CONTINUOUS MEDICAL EDUCATION

Talking with women about personal health resources in general practice Key questions about salutogenesis
Kirsti Malterud1 and Hanne Hollnagel2
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Division for General Practice, Department of Public Health and Primary Health Care, University of Bergen, Norway, Department of General Practice, Institute of Public Health, University of Copenhagen, Denmark.

Scand J Prim Health Care 1998;16:66–71. ISSN 0281-3432 We want to share experiences from an approach for clinical communication and research, intended to identify and mobilize personal health resources in female patients, and promote strategies for resource oriented talk in general practice. We used an action research design with qualitative evaluation to summarize the process where we developed a key question about self-assessed health resources in women, based on The Health Resource/Risk Balance Model, including salutogenesis, patient-centredness and gender perspectives. From consultations with 49 female patients in our own practices, we have drawn a narrative description of the development process, a summary of issues that facilitated resource talk, and our final version of the key question. We suggest that resource talk is based on 1) an explicit shift of language from disease to health, but nevertheless recognizing the fact that illness occurs, 2) options for

answers given by the female patient and not by the doctor, 3) signification of the woman’s assessment of her own situation (in contrast to the doctor’s assessment), and 4) taking for granted that women’s personal health resources exist as numerous strategies which are utilized, and may be identified. We have learnt that communicative action can provide tools for shifting the attention of doctor and patients from risks and diseases to resources and strengths. This is an example of one way to change your practice through systematic reflection in dialogue with a colleague. Key words: communication, personal health resources, key questions, women patients, general practice, qualitative evaluation. Kirsti Malterud, MD, Di7ision for General Practice, Department of Public Health and Primary Health Care, Uni7ersity of Bergen, Ulriksdal 8C, N -5009 Bergen, Norway.

Matters like patients’ potentials and strength are still largely ignored in continuous medical education (CME) for general practitioners (GPs). Even well established references on preventive medicine seem to disregard these dimensions (1,2). More apparent is the opposite perspective, which advocates risk factor identification and intervention. The increasing number of articles including the term ‘‘risk’’ has even lead to the statement that we are confronted with a risk epidemic in medical journals (3). Antonovsky (4) suggested that it might be more significant to request the origins of health (salutogenesis), than just pursuing the origins of disease (pathogenesis). Recent empirical studies from behavioural medicine and psychoneuroimmunology confirm the fact that prevalence and progress of various diseases depend on resources as the individual’s psychic strength, the self-healing power of the body, and the social network (5–8), elements well known by the practitioner. We have previously presented The Health Resource/Risk Balance Model (9), a theoretical model intended to move the attention of the GP from objective risk factors to self-assessed health resources (Fig. 1). The model implies a dialogue where the doctor combines agendas of illness and disease as well as resources and risk factors. Such theoretical
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models may be used for reflection, understanding, thinking and research. However, more practical approaches are needed when the ideas of the model shall be applied in the clinical everyday context and used for teaching and development. We have used a communicative approach to translate theory about resource talk into clinical action and learning. We developed a key question intended to invite female patients to share knowledge and experience about their self-assessed health resources with their doctor. The outcomes of this strategy have previously been reported elsewhere (10). In this article, we shall share our practical experiences on resource talk in general practice from the process where the key question was developed and applied, emphasizing aspects significant for educational purposes. PROBLEM APPROACH The objectives of the study were
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to present a specific communicative research approach, intended to identify and mobilize personal health resources in female patients in general practice, to suggest strategies for resource oriented discourse derived from process experiences of the described approach.

The process was closed when the question frequently in both practices lead to disclosure of useful knowledge about Scand J Prim Health Care 1998. both of us women GPs working in Norway and Denmark. The answers were noted. as well as our reflection on expressions that seemed to respectively facilitate or obstruct the intended channels. which has previously been presented in more detail (13). By constant comparison the level of theoretical saturation was assessed (13. A key question is a focused and problemoriented speech act. While Denmark has a list system. It is the endpoint of a specific systematic heuristic development procedure. Malterud K. including rephrasing of the uttering and strategies for locating the question optimally during the consultation through gradual adjustment and elaboration according to responses from patients These reflections and decisions were also included in the field notes. 2. The practices therefore cannot be described in terms of comparable list characteristics. 1. we shall here distinguish between the process (the communicative approach represented by the key question) and the outcome or product (what the women answered when the question was posed). Fig. Which of these strong sides do you normally use to stay (or become) well?’’ COMMUNICATIVE APPROACH – KEY QUESTION The key question is the vital component of our communicative strategy. The Health Resource/Risk Balance Model. Each of these elements was evaluated separately. and is based on experiences from encounters with 23 + 26 female patients aged 18–85 years who consulted for various problems. designed to increase the doctor’s understanding of medically unexplained disorders in women patients (13). Then the next steps were decided jointly. 16 . (Revised from Hollnagel H. The development procedure lead to the following key question: ‘‘We cannot talk only about problems. Norway has not. and the product evaluation has previously been reported (10). The development process proceeded through the planning steps presented in Fig. The development process took place December 1994–February 1995. which in this setting were found to promote resource discourse with female patients. DEVELOPMENT PROCEDURES The key question about women’s self-assessed health resources was developed in the context of ordinary consultations by the two of us. In this study we developed a key question about women’s self-assessed health resources. Shifting attention from objective risk factors to patients’ selfassessed health resources. A clinical model for general practice. Here we shall present and discuss the process evaluation. Material for documentation of this process was field-notes taken by us as doctors/researchers during and immediately after consultations. which we have systematized. For the purpose of clarity. reporting responses from the patients when various versions of the question were posed. We shall present and discuss them below. I also want to hear about your strong sides. The strategy was originally The process evaluation from the development procedure provided access to discourse experiences. However. both of us are experienced practitioners in stable practices with a varied patient population. Fam Pract – 9). emphasizing talk experiences. intended to invite the patient to share with the doctor her conception of illness and health within a specific theme.Talking with women about personal health resources in general practice 67 DESIGN – MATERIAL – METHOD The study was designed as an action research project (11) where experiences were systematized according to principles of qualitative evaluation (12).14). in order to inspire colleagues who want to develop their skills on talking with women patients about resources.

ANALYSIS When the key question was reached and the process closed. and the final version of the question. and could be expressed as an uttering which could be naturally integrated in the clinical conversation. Speech Scand J Prim Health Care 1998. Our theoretical frame of reference was The Health Resource/Risk Balance Model. Transforming tacit skills into a clinical method. (Elaborated after Malterud K. patient-centredness (17) and gender perspectives (18).68 K.12:121–7). 16 act theory (16) supported the analysis by helping us to ask what was going on by means of talk. self-assessed resources. . we did a qualitative analysis of the material. Hollnagel Fig. H. which includes salutogenesis (4). The experiences are presented as narrative description of the development process. Key questions – a strategy for modifying clinical communication. 2. We searched for experiences representing critical incidents (15) assessed as decisive turning points to enhance the intended kind of knowledge from the patients. Scand J Prim Health Care 1994. Developing the key question. a summarized list of the powerful linguistic and contextual elements that seemed to facilitate resource talk. Malterud. intended as an example of how the experiences above could be expressed.

The key question was seldom relevant in brief consultations about simple medical problems. Further elaboration was needed. the question had to be posed after the clinical interview and examination. the two of us identified the following common point-of-departure: ‘‘But in order to find out what to do with this. and worked out systematically elaborated versions of the question while seeing our regular patients. 16 . which has been identified intuitively through introspection and not yet further refined. but the outcome of a systematic heuristic process of refinement. When we changed from ‘‘…what to do …’’ to ‘‘…which ingredients of yourself do you apply …’’. which actually opened up when we switched to the more general term ‘‘…when you feel bad …’’. the connotation to disease obviously still was too strong. However. The initial ‘‘…to find out what to do with this …’’. their usual strategies were not sufficient to keep them healthy. Presenting the phrase ‘‘…suffered from something similar …’’ seemed to narrow the options of experiences. We started with the point-of-departure question referred above. I also want to hear about your strong sides. the key question finally was articulated in this version: ‘‘We cannot talk only about problems. However. we co-ordinated our experiences. the questioning in different versions was applied in 49 consultations. not only about their maneuvers. expecting the same outcome as when used by the authors. we said ‘‘…which of your strong sides …’’. that these may be numerous and that this is a relevant matter when we are discussing health. However. The key question From these experiences. In a more brief version we asked for ‘‘…what you use to do when …’’. These contextual matters seemed to be important: In order to provide information. and we wanted to expand the usefulness – the pragmatic validity (19) – of the question. we also added the phrase ‘‘normally ’’. which proved necessary to move the perspective of the conversation. For I am sure that you have useful and important experiences which we can use now. we knew that its effect probably was confined to a very specific context. and preferred the latter one in the subsequent stage. while ways of questioning which seemed to block this kind of communication. However. Linguistic and contextual elements facilitating resource talk From process analysis we identified contextual and linguistic issues which incorporate the essence of a key question intended to facilitate talk about women’s self-assessed personal health resources. The initial version of the utterance was applied in subsequent consultations. The key question is the endpoint of an elaborative process starting from this way of asking – the point-of-departure. At the same time the introduction. but before management is considered. We realized that we had to decide to go for information about respectively actions or personal strategies. I need that you tell me about your strength – about what you did the last time you suffered from something similar. By means of frequent telephone conferences. which apparently presupposes – without discussion – that women have strengths. either medical (as paracetamol) or lay (as garlic) items. We summarize these by suggesting the subsequent issues to be followed for promotion of resource talk beyond the natural language of the authors – as represented by the specific key question phrase above. at least when used in cases with simple medical problems. after the diagnostic conclusion has been presented. Altogether. and gradually adjusted due to the responses. even in consultaScand J Prim Health Care 1998. because some patients remarked that just now.’’ A key question is not just an ingenious way of asking. but this phrase turned up to release information about particular treatment. The utterance presented above might have been efficacious in a particular situation. Triggered by getting closer to resources through this way of asking. Which of these strong sides do you normally use to stay (or become) well?’’ The quoted version of the key question we have developed is not intended to be replicated verbatim by some other doctor. (which probably originally was meant to signal a pragmatic application of the information for management of the presented problem) was dropped when we realized that several consultations in general practice actually did not include action events. the patients told about themselves as persons. which promoted resource talk in different patients consulting for various problems. and we aimed for a key question. We soon realized that the initial question was too lengthy. and the patients gave more imaginative answers when we instead shifted to ‘‘…become healthy …’’ or ‘‘…stay healthy …’’ or ‘‘well ’’. which helped you to recover.Talking with women about personal health resources in general practice 69 EXPERIENCES AND RESULTS Narrating the path of de6elopment Together. became ‘‘We cannot talk only about problems …’’. were abandoned. The phrase represents an example of a speech act where some level of ‘‘translation’’ always will be needed if it shall fit the personal style of the individual doctor. We therefore warn the reader against regarding this as a key question. We pursued ways of questioning which indicated potentials for resource talk.

which would normally not have appeared in the consultation. but to focus on specific and reproductive segments of the consultation. Hollnagel tions dealing with clear-cut somatic problems. In the design of this project. but nevertheless recognizing the fact that illness may occur options for answers given by the female patient and not by the doctor signification of the woman’s assessment of her own situation (in contrast to the doctor’s assessment) taking for granted that women’s personal health resources exist as numerous strategies which are utilized. In the design of the project we therefore decided not to study phenomena which required intensive interpretation of the doctor’s action. The doctor therefore must be prepared to spend some more time. Doing research in own practice might actually represent a potential for burnout prevention in busy practitioners. It should therefore not be reserved for application with psychosocial problems or preventive matters. The key question as we have presented it here should only be considered as a personal version. Malterud. as observant participators we will not be able to describe our own actions in a distant and objective manner. Gender In this project. There are probably overlapping fields which can be applied for both genders.70 K. where the researchers are identical with the doctors under study. Two other doctors might have reached other conclusions or interpreted the responses and processes otherwise. Transferability Although one doctor might accomplish this process and get to an efficacious key question. and whether these are considered as relevant for another context than the original one. we surprisingly frequently acquired new knowledge from asking the key question. To develop a common question about self-assessed health resources intended to cover male as well as female patients seemed like a contradiction in terms. In a case study like this. Such an approach will very seldom lead to the intended result. An ongoing project on self-assessed health resources in male patients will demonstrate whether communicative strategies within this field can be more specific when we relate to male and female patients in different ways. However. In this project we wanted to identify and demonstrate this process in a systematic and scientific manner. We would also mention the joys of curiosity and enthusiasm. an example of the words embracing the speech act of its designer. This is the reason why the process of developing a key question should not only aim for a successful question. we clearly admit a considerable level of subjectivity during this process. but also include the analysis of the linguistically powerful elements of this question. The question may open up for discussion. but can be reached by conscious introspection. the researcher is always a participant who in some way or other influences the material and interpretations. empirical and theoretical references indicate clearly that coping strategies as well as communication in many ways differ in women as compared to men (20. we needed first hand access to the internal reasoning of the doctors. We cannot state that the process presented here regards women and only women. the same uttering should therefore not be expected to have an identical effect when another doctor repeats the same words literally. We do not know for sure whether the key question and the answers are gender specific. and the doctor does not perceive the nuances of the replies of the patient. H. we have only studied conversations with female patients. because we wanted to demonstrate explicitly the process of elaborating a specific way of questioning. However. the patient does not understand what the doctor means. These arguments are meant to counteract a rather popular belief in which the doctor is repeating the words of the key question as a parrot.21). However. the external validity or transferability of the Scand J Prim Health Care 1998. this is even more candid. The conversation becomes rigid and mechanical. Asking the same patient this key question again after a short time should not be expected to provide new material. The transferability or external validity of a speech act requires more than a set of words. This kind of processes are normally tacit and implicit. and how it works. We therefore chose a design where the key questions were developed separately for men and women. emerging from taking a systematic look on what we do and say. Of course. Summarizing our processual experiences. Every step of this process was of course based on our interpretation of why it worked or not. and may be identified DISCUSSION Research in own practice In qualitative research designs. 16 . “ “ “ explicit shift of language from disease to health. regarding this as a long term investment. we find that the powerful linguistic elements of the key question are these: “ findings depends on whether the inter-subjectivity of the presentation gives the reader sufficient access to the logic of the conclusions.

Lazarus RS. 7. Physician stereotypes about female health and illness: a study of patients’ sex and the informative process during medical interviews. 15. which the question is supposed to explore. Action research – a strategy for evaluation of medical interventions. 2nd ed. As experienced practitioners. Wallen J. Chicago: Aldine Publishing. The critical incident technique.Talking with women about personal health resources in general practice 71 How then can the transferability of a key question be taken care of? How can one doctor who made a brilliant question share this knowledge with her colleague? Leaning to the specifications regarding intentional and contextual matters. editor. Scand J Prim Health Care 1994. 6. stress and coping. Waitzkin H. Soc Sci Med – 96. This is necessary to perceive and interpret the replies from the patient. Strategies for qualitative research. Anson O. Malterud K. Oxford: Oxford University Press. Fam Pract 1995.4:135 – 46. 17. Health. 1991. Oxford: Oxford University Press. Fam Pract 1995. 8. Fowler G. 16 . 20. The procedure of development can be transferred.51:327 – 58.14:293– 318. et al. Strauss AL. McWhinney IR. 1993. The intention of repeatability focuses on the interactional consequences of the speech act – that is what we want to repeat and transfer. Psychoneuroimmunology: interactions between the nervous system and the immune system. We argue that the strategy presented here. Structures and processes of social support. Hollnagel H. the colleague can establish a real understanding of the substantial matters.12:476 – 81. Psychol Bull 1954. Malterud K. Hollnagel H. sense of coherence and health: Gender differences on the Kibbutz. 3. NY: Cornell University Press. Washington. Malterud K. 1982. In: Kvale S. Felten D. Carmel S. Prevention in general practice. 14. Goldstein MG.35:873 – 8.12:121– 7. Austin JL. 5. Beardsley G. 1989:73 – 92. We do not recommend a mechanical way of using this strategy. Psychological factors affecting physical condition. A clinical model for general practice. Coping theory and research: past. We shall then expect a related. To validate is to question. Skolbekken JA. 18. Life events.40:291 – 305. 1979. The art of general practice. Flanagan JC. Newbury Park: Sage Publications. 1967.a strategy for modifying clinical communication. 13. developed deliberately within a framework of patient-centredness and salutogenesis. 2. 1991. Scand J Prim Health Care 1998.55:234 – 47. Cohen N. 2nd ed. New perspectives on mental and physical well-being. present and future. Lancet 1995. Ann Rev Sociol 1988. as the method is described in detail. but suggest it as a tool for shifting the attention of doctor and patients from risks and diseases to resources and strengths. Psychosom Med 1993. Are we on the brink of a major transformation of clinical method? CMAJ 1986. The risk epidemic in medical journals. Anderson P. 12. we know very well that every medical conversation is stuffed with implicit structuring and ritual questioning. 1990. Issues of validity in qualitative research.345:99 – 103. Ader R. may very well complement our more or less conscious strategies for communication.12:423 – 9. 9. 16. DC: Jossey-Bass Publishers. Scand J Prim Health Care 1997. Women’s self-assessed personal health resources. 19. Ithaca.15:163 – 8. Kvale S. Lund: Studentlitteratur. The discovery of grounded theory. Morrell D. Shifting attention from objective risk factors to patients’ self-assessed health resources. House JS. Soc Sci Med 1995. Glaser BG. Antonovsky A. Women Health 1979. which certainly incorporates potential disturbances and pitfalls. Endocrine disease literature review. Psychosomatics 1993. 10. Oxford: Oxford University Press. but very seldom an identical key question as the outcome of this transfer operation. Umberson D. Code L. 11. The key question approach represents a way of structuring the communication. Stoeckle JD. Why not just speak? It might be objected that the best medical communication evolves when doctor and patient have a conversation based on naturally occurring associations and expressions. Transforming tacit skills into a clinical method. Levenson A. REFERENCES 1. Qualitative evaluation and research methods. Malterud K. Taking the uttering delivered by the designer as her point of departure. 21. Gray M.34:12 – 9. What can she know? Feminist theory and the construction of knowledge. Landis KR. How to do things with words. the colleague can use the specification of the linguistically powerful elements of the question as guidelines when she adjusts the uttering according to her own natural language. 4. Key questions . Patton MQ.