Qualitätssicherung in der psychosomatischen Grundversorgung - Entwicklung einer „narrativ-basierten” Leitlinie zur Diagnoseeröffnung in der Allgemeinpraxis

Zusammenfassung

Zu den schwierigsten Situationen in der Allgemeinpraxis gehört die Überbringung schlechter Nachrichten. Im Rahmen des Modellprogramms zur Förderung der medizinischen Qualitätssicherung in der ambulanten Versorgung wurde ein Leitfaden zur Eröffnung einer schwerwiegenden Diagnose entwickelt. Es handelt sich dabei nicht um eine aus einer systematischen Literaturübersicht durch Experten hergeleitete Leitlinie (evidenzbasierte Medizin), sondern um eine auf Grund Patientenvorstellungen (narrativ-basierte Medizin) in einem Qualitätszirkel entwickelte Beschreibung guter hausärztlicher Praxis. Der in der fachlichen Diskussion weitgehend vergessene Weg, aus der Praxis heraus mit qualitativen, familienmedizinischen Methoden Leitlinien zu entwickeln, verdient größere Beachtung, weil auf systematische Literaturübersichten basierende Leitlinien die Komplexität der täglichen Praxis nicht genug widerspiegeln und daher auch schwierig umsetzbar sein können.

Summary

Within a nationwide project funded by the German Ministry of Health it was found that truth telling is an important issue in patient-centered care. We describe the development of a guideline for breaking bad news in a quality circle of family physicians which is rather narrative-based than evidence based medicine (as published evidence on diagnostic disclosure was not comprehensive enough to generate a guideline). After multiple sessions of a family-medicine oriented quality circle GPs were asked to report an occasion when they had given medically related bad news to a patient. Reports were written down in the words doctors used. The stories were analyzed with a qualitative and interpretative approach and the doctors statements grouped into tentative guideline topics. The guideline was discussed in follow-up sessions of the quality circle until this „focus group" was satisfied with the result. A formal evaluation was made in a sample of vocational trainees and practicing family physicians. Both the judgement of the quality of the guideline and the result of a practice test were obtained. The following topics appeared to be common to almost all the narratives: the variety of reasons of encounters which end up in the problem of disclosure the need to cope with uncertainty, the need to find a balance between positive issues and side effects of „truth telling", the way how the truth is delivered (e.g. wording) and the coordination of medical care. Likewise the guideline contains the following sections: scenarios of reasons of encounters, examples (patient vignettes), history /diagnostics, treatment and coordination of care with respect of the disclosure of a diagnosis. The panel test showed that 80 % of all physicians valued the guideline. 21 physicians took the practice test and send back 37 patient vignettes of diagnostic disclosure. In 34 patients the guideline was helpful and manageable, in three not. In a complex task such as truth telling a bottom-up generated guideline was both helpful to vocational trainees and practicing family physicans and to those GPs who constructed it.

Key Words:

disclosure - diagnosis - truth - study guideline in general quality improvement primary care - family practice - Communication - Physician-Patient Relations - narrative - Patient Satisfaction - Patient autonomy - Adaptation - Referral and Consultation

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