1. Are patients with chronic diseases a new challenge to general practice? Organizing preventive health services to patient with chronic diseases Why do clinics not follow the same code of practice? Loni Ledderer Research Unit of General Practice, Institute of Public Health, University of Southern Denmark lledderer@health.sdu.dklledderer@health.sdu.dk. Loni Ledderer 1

2. Are patients with chronic diseases a new challenge to general practice? Organizing preventive health services to patient with chronic diseases Existing Interventions focus on – Medical treatment – New technology – Clinical procedures Existing Interventions neglect – Cultural rules – Collective meaning Loni Ledderer2

3. Are patients with chronic diseases a new challenge to general practice? Organizing preventive health services to patient with chronic diseases Rules and interaction about – Receptionist’s duties – The consultation routine – Blood tests Give collective meaning to medical practice Loni Ledderer3

4. Are patients with chronic diseases a new challenge to general practice? Organizing preventive health services to patient with chronic diseases 4 Motivational Interviewing (MI) Organizing MI into patient care Preventive Health Project 2005-2006 10 general practices Voluntary participation

5. Are patients with chronic diseases a new challenge to general practice? Organizing preventive health services to patient with chronic diseases Loni Ledderer5 The resources in the clinic. Consultation room Appointment system Trained staff

6. Are patients with chronic diseases a new challenge to general practice? Organizing preventive health services to patient with chronic diseases Loni Ledderer6 Medical assessment We have to be physicians; we form an estimate of biochemical profile from patients’ blood test….. We shall devote our time to the sick people. (clinic 4, GP) Talk I ask patients about their motives, what is valuable to them, try to figure out, what they think is most important. I also inquire about the reason for the decision they have made to visit the clinic, what kind of behavior change they expect to obtain... (Clinic 10, nurse)

7. Are patients with chronic diseases a new challenge to general practice? Organizing preventive health services to patient with chronic diseases Loni Ledderer7 Biomedical approachPsychological approach Producing variation in medical practices

8. Are patients with chronic diseases a new challenge to general practice? Organizing preventive health services to patient with chronic diseases Conclusion Variation in clinics’ understanding of new interventions produces substantial variation in the form of health service offered to patients. Loni Ledderer8

9. Are patients with chronic diseases a new challenge to general practice? Organizing preventive health services to patient with chronic diseases Implication Change in medical practice depends on healthcare organizations’ ability to put forward a new collective meaning to what is considered an appropriate health service. – No intervention fits equally into every clinic – Purely technical, instrumental and practical issues are inadequate Loni Ledderer9