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      Investigación cualitativa sobre la conceptualización de la hiperfrecuentación por parte del personal médico de atención primaria Translated title: Qualitative Research on the Conceptualization around the Frequent Attendance by Primary Medical Staff

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          Abstract

          Fundamentos: La hiperfrecuentación es un fenómeno preocupante para los sistemas sanitarios occidentales, por la gran carga de trabajo que genera y sus altos costes materiales y humanos. El objetivo de este trabajo es estudiar los significados, categorías y prácticas que las médicas y médicos de Atención Primaria vivencian en torno a la hiperfrecuentación. Métodos: Estudio cualitativo basado en una aproximación sociosubjetiva, a través de entrevistas en profundidad (ocho entrevistas a médicos/as de Atención Primaria de la Comunidad de Madrid). El material discursivo se analizó desde una perspectiva pragmatista. Resultados: La figura del médico de Atención Primaria se encuentra en la intersección de lógicas profesionales-institucionales contradictorias, lo que genera niveles altos de malestar profesional. Los aspectos sociales y psicológicos aparecen de forma confusa en relación con la consideración de todo aquello que no tiene que ver con lo físico como ajeno al ámbito de actuación de la medicina. La hiperfrecuentación resulta problemática porque se sitúa en el centro de la dicotomía signo-síntoma, su manejo requiere mucho tiempo, precisa de un abordaje integral, e imposibilita el cumplimiento del rol médico como profesional que diagnostica e instaura un tratamiento etiológico. Estas dificultades terminan por traducirse en conflictos en la relación profesional-paciente. Conclusiones: Los significados relativos a la hiperfrecuentación van a variar notablemente en función de las posiciones sociosubjetivas, por lo que abordajes como el que aquí se propone ayudan a comprender la complejidad de una problemática que se construye en el seno de las relaciones entre sujetos particulares, atravesados por dinámicas institucionales, conflictos laborales, trayectorias profesionales e ideologías diversas.

          Translated abstract

          Background: The frequent attendance is a worrying phenomenon for the health systems of Western countries, due the high work load it generates and its high costs in material and human resources. This work aims to study the meanings, categories and practices that general practitioners build around the frecuent attendance. Methods: Qualitative study, based on a sociosubjective approximation, through in-depth interviews. Eight interviews were conducted with Primary Health Care physicians in Madrid. The discourses were examined from a pragmatist perspective. Results: The figure of the Primary Health Care physician is at the intersection of professional and institutional contradictory logics, which generates high levels of professional malaise. The social and psychological aspects appear in a confused way, due the consideration of the non-physical aspects as outside the realm of medicine. Frequent attendance is problematic because: it is situated in the center of the sign-symptom dichotomy. its management requires so much time. it requires a comprehensive approach. it avoids the medical performance as a professional who diagnosed and establishes an etiological treatment. These problems eventually can lead to conflict in the professional-patient relationship. Conclusions: The meanings for the frequent attendance will vary significantly depending on the sociosubjetive positions, so the approach proposed here could help to understand the complexity of a problem that is built within the relationships between particular subjects crossed by different institutional dynamics, labour disputes, career paths and ideologies.

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          Most cited references40

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          Verification Strategies for Establishing Reliability and Validity in Qualitative Research

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            Frequent attenders in general practice care: a literature review with special reference to methodological considerations.

            To describe the basis on which our knowledge of frequent attendance in general practice rests and to propose recommendations for further research on frequent attenders (FAs). The literature review (finished February 2004) encompassed peer-reviewed articles in English describing contacts with general practice in terms of frequency. Searches were performed in the Medline, CINAHL, EMBASE, PsycINFO, Social Sciences Expanded Index and ISI Citation databases with additional searches in reference lists and the 'related articles' function in the ISI Citation database and Medline. General practice. Sixty-one articles (54 studies). The articles were assessed according to the following design variables: setting; definition of FAs; sampling; sample size; control groups; study aim; study design; data sources; effect measure; and main results. There was no generally accepted definition of frequent attendance. Research designs differed substantially. Eight articles gave sufficient information on all design variables. The top 10% of attenders accounted for 30-50% of all contacts, and up to 40% of FAs were still FAs the following year. More than 50% of FAs had a physical disease, more than 50% of FAs suffered from psychological distress, social factors (low social support, unemployment, divorce) were associated with frequent attendance in more than 50% of FAs, multiproblems (physical, psychological and social) were found in one-third of FAs, and frequent attendance was associated with increasing age and female gender. The diversity of designs, definitions and methods in the current literature on FAs in general practice hampers comparison of their precision, validity and generalizability, and calls for cautious interpretation and adoption of a common, generally acceptable definition in future studies.
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              Frequent attenders in general practice: quality of life, patient satisfaction, use of medical services and GP characteristics.

              To determine the predictors of frequent attendance in general practice. A postal survey using a questionnaire including instruments for measuring patient satisfaction (EUROPEP), quality of life (EUROQOL), anxiety and depression (DUKE-AD). Primary health care in Slovenia. A representative sample of 2160 adult patients. Number of contacts with the health care services, levels of self-care, patient satisfaction scores, quality of life scores, well-being scores, presence of chronic condition. Frequent attenders were more likely to have lower educational status, were more satisfied with their GP, had higher scores of anxiety and depression, and lower perceived quality of life. They were more likely to have a chronic disease. Frequent attenders were less likely to try self-care and more likely to use health services. They were more likely to visit more experienced GPs, GPs working a greater distance from other GPs and GPs who did not use the appointment system. The multivariable modelling explained 19.7% of the variation; 16.9% was attributed to patient characteristics and 3.1% to GP characteristics. The study confirmed that lower education levels, chronicity and higher use of other health services are predictors of higher attendance.
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                Author and article information

                Journal
                resp
                Revista Española de Salud Pública
                Rev. Esp. Salud Publica
                Ministerio de Sanidad, Consumo y Bienestar social (Madrid, Madrid, Spain )
                1135-5727
                2173-9110
                December 2009
                : 83
                : 6
                : 863-875
                Affiliations
                [01] Madrid orgnameUniversidad Rey Juan Carlos orgdiv1Departamento de Ciencias de la Salud II orgdiv2Unidad Enfermería
                [02] Madrid orgnameUniversidad Autónoma de Madrid orgdiv1Departamento de Antropología Social y Pensamiento Filosófico Español
                Article
                S1135-57272009000600009 S1135-5727(09)08300600009
                3b8f143c-311b-4bf8-9e4d-8c7640e959d9

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 International License.

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                Figures: 0, Tables: 0, Equations: 0, References: 32, Pages: 13
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                SciELO Public Health

                Categories
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                Qualitative research,Physician-patient relations,Primary Health Care,Health services misuse,Investigación cualitativa,Relaciones médico-paciente,Atención Primaria de Salud,Mal uso de servicios de salud

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