RESEARCH. For Cecilia Björkelund, dialogs with patients have been a common thread in both research and care. Now she is investigating how care coordinators, who keep in close contact with the patient, can improve the treatment of psychiatric illness.
A serious health problem in her hospital’s own catchment area is what got Cecilia Björkelund, then the district medical officer at the hospital in Strömstad, to begin her research. In the early 80s a public health survey showed that the death rate from cardiovascular disease was significantly elevated among women in northern Bohuslän province.
“At the care center and hospital, we realized that it was time to do something,” she says. “So we sought and received money for a study, which then became a successful intervention project.”
A benefit of following the women
All women in the municipality from age 45 to 64 were offered free monitoring of factors such as blood pressure, body mass index, blood sugar and lipoproteins. Those deemed to be at risk received an offer for group training in maintaining a healthy diet as well as help in quitting smoking and starting to exercise.
“It was a really enjoyable period. I had the benefit of meeting middle-aged women whom I could follow closely for many years. It was very instructive,” Cecilia says.
The Strömstad project demonstrated that this type of intervention can improve the health of a large group of people, both short and long term, and the results were published in Cecilia Björkelund’s doctoral dissertation in 1990. While working on her dissertation at the Department of Public Health and Community Medicine at the University of Gothenburg, Cecilia was helped by Calle Bengtsson, who conducted a population study beginning in 1968 known as the Study of Women in Gothenburg. He was a professor in general medicine and, like Cecilia Björkelund, combined his research with service as a district medical officer. Calle suggested that she continue to do research at the department and further advance the women’s population study, among other things.
“It’s the only study of its kind in the world, one of the very few that has followed a large number of women for a long time. It is still being updated and keeps generating new knowledge and new research projects,” says Cecilia Björkelund, who became a professor in 1999, head of the Department of Public Health and Community Medicine in 2001 and manager of the General Medicine unit in 2008, where she remained until 2015.
Better physical health – but more stress
The women’s study has helped researchers find a series of links between women’s lifestyle and health, and through the years they have been able to see a positive trend, especially among middle-aged women. Fewer of them are smoking and more exercise and eat healthier food – and this shows up as improved physical health. At the same time, the stress they experience has increased significantly. According to the Swedish Social Insurance Agency, stress is the most common cause of psychiatric illness, which in turn is the most common cause of prolonged sick leaves.
“Psychiatric illness is a major challenge for primary care. For those afflicted, continuity is especially important, and that is insufficient today,” Cecilia says. After the first doctor’s visit, a patient may have to wait for months to see a psychologist or therapist. During the waiting period, care centers do not always have regular contact with the patient. Being on the waiting list is not good care; rather it’s non-care.”
Continual contact with patients
Since 2014 she has been working on a project that amounts to testing the efficacy of special care coordinators for people seeking treatment for depression, anxiety and stress-related illness at the care center. The coordinator may be a district nurse or a welfare officer who follows up an initial meeting in person by keeping in touch with the patient through weekly phone calls. The task involves finding out how the patient is feeling, drawing up a care plan with the patient and, if necessary, planning extra visits with the doctor or therapist.
“Above all, it’s about providing support and demonstrating that the caregiver is concerned, but it’s also about using primary care resources more effectively. In addition, knowing that someone is keeping track of how the patient is doing provides support for the doctors.”
Earlier return to work
The project was tested first at 19 care centers in Region Västra Götaland and four in Dalarna. Now there are care coordinator at about a hundred care centers in Västra Götaland, and the ongoing evaluation indicates, among other things, earlier return to work for patients on sick leave due to depression, Cecilia notes.
“Both doctors and care center managers are happy to have a care coordinator, and above all, patients are happy, which is the most important thing.”
Patients have always been the focus of Cecilia Björkelund. She thinks that longstanding relationships with them are part of the allure of being a doctor in general practice. In the 90s she was involved in designing a new part of the medical education program in which students practice talking to patients – what is known as consultation methodology.
“At first there were colleagues who had a negative view of patient-centered methodology, but nowadays it is accepted practice to base treatment on the patient’s experiences, apprehensions, expectations and desires, so that the patient participates in managing the illness.”
Better self-care – fewer emergencies
Cecilia Björkelund mentions the care of asthma, chronic obstructive pulmonary disease, diabetes and cardiovascular disease as examples of how those affected now often keep track of their illnesses and are good at managing their maintenance treatment, which has led to fewer emergency situations. The same trend has led to a number of tasks being moved from hospitals to primary care. Instead of long hospital stays, patients can go home rather quickly after a hospital visit and manage the aftercare in cooperation with their care center.
“This is a major change that has occurred during my time as a doctor and that places many new demands on primary care. Unfortunately, resources are scarce and the time that the doctor spends with the patient is short. But the doctor still must be sure to ascertain what the patient wants to achieve with the visit. And that doesn’t have to take very long. Often you get the most important information a few minutes into the conversation. But to perceive it, it’s a matter of being interested in the patient as a person and really listening.”
TEXT AND PHOTO: MALIN AVENIUS/FREELANCE JOURNALIST
