Focus group interview
Interview before general practice internship. The first focus group interviews with the interns resulted in the core category ‘Can I do anything useful?’. This core category was further classified into the subcategories ‘Experience’, ‘Skills’, ‘Logistics’, ‘Confidence in other occupational groups’ and ‘Own considerations’. These categories are described in more detail below.
‘Experience’. The interns had a general belief that experience and knowledge of the patients could contribute to doctors deciding not to take part in call-outs. They drew parallels to hospital internship, where they were uncertain at first, but became more experienced during the period. The doctors were tense and nervous before heading into the new work situation, and their thoughts were filled with the responsibility they would be faced with and a fear of being superfluous.
Participation in call-outs has no doubt something to do with how much experience you have. So, I will not dare to say no. Doctors who are more experienced are, however, more likely to say, ‘no, I’ve come across this one before, I see them when they come to my practice for consultations.’ (Woman 1, Group 2)
‘Skills’. There was general agreement among the participants that they had received adequate training in most practical skills. Working with experienced ambulance personnel was considered to create a good sense of security. Nevertheless, they would like to have spent more time practising medication management, peripheral intravenous cannulation, intubation, advanced cardiopulmonary resuscitation and dealing with critically ill children prior to the general practice internship.
I think it’s fair to say that we have generally been trained well in most aspects of internship work. (Man 2, Group 2)
Before the hospital internship, we had one review of AHLR when we started the clinical internship. If we were not involved in cardiac arrest during the six-month internship, then there were no further opportunities to practise. So, in order to be better prepared, it may be beneficial to include more frequent AHLR exercises. (Woman 3, Group 1)
‘Logistics’. In Finnmark, there are major geographic and weather-related challenges. Fear of simultaneity conflicts was a key factor in decisions not to take part in call-outs. The interns believed that they had little to contribute when there was only a short distance to the accident and emergency department or hospital, and felt that the response time may be longer if they had to be collected first.
If I am notified about a patient who seems stable, I may have to assess whether the situation is serious or important enough for me to warrant letting the rest of the municipality’s population go without a doctor for two hours. (Woman 2, Group 1)
‘Confidence in other occupational groups’. Due to the ambulance personnel’s local knowledge and medical expertise, the interns had particular confidence in this group and felt a sense of security when attending call-outs with them. Several mentioned that they had little training in teamwork and team leadership. This could be a contributing factor to the uncertainty.
The little time I’ve spent working with ambulance personnel … They’ve seen everything! … Often more than once. So you really lean on them. At least when you’re out on a call. So, the medical side is not what worries me the most, because I know that they’re very good to have around! (Man 3, Group 3)
‘Own considerations’. The interns had the idea that duty doctors down-prioritise ambulance call-outs out of consideration for their own working conditions. Most hospital doctors in general practice in Finnmark have to go to work the next day and have a full list the day after their shift at the accident and emergency department. The doctors envisaged that the strain of this could make them refrain from taking part in call-outs. In addition, they had experienced episodes and heard stories about a drug and psychiatric community in the county that could be difficult to handle pre-hospital.
If I was to ask for any training, I could see myself taking a psychiatry/substance abuse course. Because that’s what I think is most uncomfortable, and we haven’t had much about that … although I covered it a bit at the hospital. But how to handle it up here and how to assess suicidality and so on is really difficult. (Woman 4, Group 3)
Interview after general practice internship. By analysing the focus group interviews conducted after the internship, ‘It all went well in the end’ emerged as a core category. This was further explained by the subcategories ‘Experience’, ‘Skills’, ‘Logistics’ and ‘Confidence in other occupational groups’.
‘Experience’. The interns described that experience had helped them to feel more confident in their clinical work, in the new role and in teamwork. The fear that the doctors held before starting the general practice internship diminished in most cases, and they felt better equipped to assess the need to participate in call-outs.
Much of it is like an algorithm, so once you’ve been exposed to it you’re slightly more relaxed the next time. (Woman 1, Group 3)
I used to think, if someone takes ill on the plane, what would I do? But now I’m more inclined to think that it will be okay. So I feel that I have learned something … (Woman 2, Group 3)
Some of the local authorities in Finnmark have local guidelines stipulating that duty doctors must take part in call-outs when the doctor-ambulance alarm is raised. The interns in these municipalities therefore participated on all call-outs where the level of urgency was acute. This applied to a few of the interns. Others received requests from the Emergency Medical Communication Centre to attend and had to make an independent decision.
Some of the interns reported that they had occasionally refrained from taking part in call-outs, but nevertheless thought they had a lower threshold for attending than the more experienced doctors, who have more knowledge about the patients.
We notice that we have a much lower threshold for going on call-outs than the other doctors who are in permanent positions. Some of these others never participate in call-outs. (Man 1, Group 2)
I have opted not to take part, and prefer for the patients to be brought to the acute admissions ward for examination. But these are often patients that you have in ten times with the same symptoms, and each time it’s been shown that there is no somatic illness. (Woman 1, Group 1)
‘Skills’. The doctors learned that the role of a medical officer outside hospitals was very time-consuming. They also found that participation in specific treatment was less of a requirement. This meant a reduced need for practical skills.
Good training was needed in skills in connection with abuse and rape, and how to handle patients in the most vulnerable situations was something that they lacked.
Often, if there is a situation where a lot of things need to be done at once; a catheter needs to be fitted, and blood tests taken … If you had to do all the practical things, it would take a very long time. And there are other things that you need to do first, like taking the patient’s anamnesis, taking written notes, making some phone calls … (Man 1, Group 3)
‘Logistics’. Challenging weather and geographic conditions combined with a lack of resources meant that it was difficult to solve logistical problems. The doctors therefore had to work with several different services in the area. On short call-outs, several of the doctors chose instead to examine the patients at the accident and emergency department rather than taking part in the call-out, with a view to shortening the call-out time and because they felt that they had nothing more to contribute before and during transportation to the accident and emergency department.
Administration and logistics … It’s hard … It’s perhaps the most difficult thing about the whole job. It takes such a long time. If the patient is severely ill and you have to wait, that’s stressful. That’s the worst thing about being a duty doctor I think. (Woman 3, Group 3)
Where I work, I have had to request a snow plough to get us to a call-out. (Man 2, Group 2)
Several of the interns found that their main job on call-outs was to talk on the phone. Nevertheless, some of them considered logistics to be part of the clinical assessment, where one is dependent on the other.
You need to explain the background to their condition at least three times; first to the Emergency Medical Communication Centre in Kirkenes, then the one in Tromsø, and then a duty doctor in Kirkenes, maybe the University Hospital of North Norway, and then maybe you need to tell a duty medical officer as well as a surgeon. That’s how the story can start to change … You spend a lot of time on the phone. (Woman 2, Group 3)
‘Confidence in other occupational groups’. The interns reported that they were surprised at how well the cooperation with the ambulance personnel went. They felt they had the competence to contribute beyond the level of the ambulance personnel and that they were respected for this.
I was really surprised how well it went and how well they accepted a younger doctor, an inexperienced doctor. I expected to be a bit railroaded, but once I showed that I was getting a handle on things and I started giving a few orders, it went really well! (Man 2, Group 2)
The cooperation with the Emergency Medical Communication Centre was a challenge – both cases of communication failures and cases where the operators railroaded the interns on issues regarding transport and call-outs.
I have had to argue once with the Emergency Medical Communication Centre. But ultimately, you need to establish who is in charge. I don’t remember exactly what was wrong with the patient, but I wanted air transport. Then there was another operator who became very argumentative. So I said I cannot force them to send a helicopter, but I said I would enter in the medical record that they had responsibility for the patient in that case. No, I couldn’t do that. So I got a helicopter in the end. (Man 1, Group 2)
In some places in Finnmark, the police are not available in the community around the clock. Long call-out times led to difficult situations in connection with the work of the interns. Having to wait for the police in situations that involve people with substance abuse and psychiatric issues represented a challenge to the personal safety of the doctors and other parties involved.
We had to wait for the police from somewhere else. A man was threatening to shoot himself, and said that if we approached him he would shoot everyone in sight. So we sat there and waited for the police. Not very cool. (Woman 2, Group 1)