General practitioners' experiences of managing patients with chronic leg ulceration

Genevieve M Sadler, Grant M Russell, Duncan P Boldy and Michael C Stacey
Med J Aust 2006; 185 (2): 78-81. || doi: 10.5694/j.1326-5377.2006.tb00476.x
Published online: 17 July 2006


Objective: To understand general practitioners' experiences of managing patients with chronic leg ulceration, thus informing future strategies to improve leg ulcer care in general practice.

Design: Qualitative study using phenomenology and in-depth interviewing.

Participants and setting: Maximum variation sample of 12 GPs working in the Perth and Hills Division of General Practice between September and December 2004.

Main outcome measure: Themes in participants' experiences of leg ulcer care.

Findings: Participants regarded leg ulcer management as an integral part of general practice. They expressed a desire to maintain their involvement, yet relied on nursing assistance. They perceived that ulcer care was usually straightforward and successful. Approaches to management appeared to differ significantly from that outlined in current guidelines. Instead, participants valued accessibility of care for the patient, awareness of patient context and regular review. Occasional problems with non-healing ulcers were experienced, and, in these situations, specialist opinion was appreciated.

Conclusion: This study highlights fundamental differences between GP and specialist conceptualisation of leg ulcer care. For GPs, it identifies key areas of ulcer management that could be improved. For specialists, it suggests that widespread implementation of traditional guidelines may not be appropriate or acceptable. New approaches to leg ulcer management in general practice are likely to need a combination of education, human resources and practical support.

Chronic leg ulceration affects 1% of the Australian population.1 It significantly impairs quality of life and is responsible for about $400 million annually in health care costs.1,2 Most patients with leg ulcers are managed in primary care, where wound dressings represent the second most frequent procedural treatment.3

International guidelines for treatment of leg ulcers recommend evaluation of ulcer aetiology, treatment of the underlying cause, management of the wound, and ongoing monitoring of healing.4-6 As venous disease is a sole or contributory cause of many leg ulcers, optimal treatment frequently includes compression therapy.7

Several studies have identified deficiencies in general practice management of leg ulceration, specifically the underuse of ankle–brachial pressure measurements, over-reliance on dressings, and lack of understanding of compression therapy.8,9 Specialists attribute these problems to practitioner disinterest10,11 and uncertainty as to whether leg ulcer care is a medical or nursing responsibility.12 However, general practitioners’ perspectives have not been articulated.

This study aimed to understand GPs’ experiences of managing patients with leg ulceration, thus informing future strategies to improve leg ulcer care in general practice.


This study used the qualitative approach of phenomenology. A glossary of qualitative research terms is shown in Box 1. In-depth interviews were conducted with a maximum variation sample of GPs in the Perth and Hills Division of General Practice.15 An initial list of potential participants was created from expressions of interest canvassed in a GP survey on leg ulcers16 and from discussions with stakeholders. Potential participants were contacted by mail, then telephoned by the principal investigator (G M S, a registrar working in a tertiary hospital leg ulcer clinic). Additional participants were identified through snowball sampling.

Data were collected in semi-structured interviews based on an interview guide. Interviews were conducted by G M S between September and December 2004 and took place in the GP’s surgery. They continued until the investigator had gained a clear understanding of the participant’s experience, lasting 45–60 minutes. Interviews and field notes were audiotaped and transcribed verbatim.

Transcript data were coded and connected using the computer program QSR N6 (Qualitative Solutions and Research, La Trobe University, Melbourne, VIC, 1997) and further explored using an immersion–crystallisation technique.13 Throughout the analysis, G M S regularly met with an academic family practitioner (G M R) to discuss emerging themes. Several additional techniques reinforced the trustworthiness of the findings. Interviews were led by the participants rather than the interviewer. While theme saturation was reached at the 10th interview, two additional interviews allowed for member checking, and all participants were invited to respond to an interview summary. The analysis team (G M S and G M R) independently reviewed transcripts and explicitly reflected on their pre-existing and evolving perspectives of the topic.

The Curtin University Human Research Ethics Committee approved the study. Participants were reimbursed $75 for time spent in the interview.

Major themes

This is the first study, to our knowledge, that explores GPs’ experiences of dealing with leg ulceration. The findings support interventions based on primary care: GPs are keen to be involved, benefits of community care are highlighted, and scope for improvement is evident. The challenge is the fundamental difference between GPs’ attitudes and those previously articulated by specialists.10,11 Future strategies will need to bridge the gap between what is practical and what is ideal.

Study participants appeared to risk losing track of certain aspects of ulcer management as they balanced diverse treatment goals. Better appreciation of the healing times achievable with optimal treatment and close monitoring may clarify expectations for acceptable patient outcomes. GPs could be reassured that selecting the type of dressing is only one part of ulcer management, leaving attention to be focused on ulcer aetiology. The lack of confidence in compression therapy is of special concern, given strong evidence that compression improves venous ulcer healing.7 These specific areas for improvement in leg ulcer care warrant reiteration.

However, broad implementation of traditional leg ulcer guidelines may be neither appropriate nor acceptable in general practice. Participants perceived that most patients progressed smoothly towards healing, suggesting that their patient population differed from that in specialist clinics. They also embraced a “gatekeeper” role of protecting patients from the risk and discomfort of unnecessary interventions.17 It would be an oversimplification to assume guideline dissemination alone will improve community leg ulcer care.

Our findings suggest three areas for future intervention:

It is likely that a combination of interventions will be required to significantly improve community leg ulcer care.

The main limitation of this study is the transferability of its findings. We sampled GPs in a range of practices, and our study design acknowledged the need to seek alternative and disconfirming cases; however, different attitudes may be shared by GPs who were not involved in this study. Further, the method of in-depth interviews, although ideally suited to the exploration of experience, does not capture participant behaviour.

Despite these limitations, our study highlights the scope for optimising leg ulcer management, while it also suggests that traditional ulcer guidelines may not be appropriate or acceptable in general practice. Both GP and specialist perspectives will need to be considered when developing leg ulcer management strategies.

1 Glossary of qualitative research terminology13,14

Phenomenology: Research tradition that aims to understand the essence of a lived experience. It involves methodologically capturing and describing how people experience a phenomenon — how they perceive it, feel about it, and make sense of it.

Maximum variation sample: Purposeful sampling technique that selects a wide range of cases to gain broad perspectives. The emphasis is on finding information-rich cases, from which one can gain greatest insight into the topic.

Snowball sampling: Participants identify potential new cases for inclusion in the study.

In-depth interviews: Data collection tool using open questions to elicit detailed and vivid narratives.

Interview guide: Outline of topic areas to be explored in the interview. In our study, this was informed by the investigators’ experience, a literature review and two pilot interviews.

Study stakeholders: Key organisations in our study were the Silver Chain nursing association, Perth and Hills Division of General Practice and University of Western Australia’s Primary Health Care Research, Evaluation and Development Unit.

QSR N6: Computer program facilitating coding and connection of qualitative data.

Immersion–crystallisation: Analysis technique in which thorough reading of the data, reflection and intuition produce insight into the research topic.

Themes: Core meanings and consistencies in qualitative data.

Theme saturation: Point at which new information fails to emerge from interviews, signalling that an adequate sample size has been reached.

Member-checking: Process of confirming findings with participants.

  • Genevieve M Sadler1
  • Grant M Russell2
  • Duncan P Boldy3
  • Michael C Stacey4

  • 1 Department of Dermatology, Royal Perth Hospital, Perth, WA.
  • 2 Department of General Practice (Primary Health Care Research, Evaluation and Development Unit), University of Western Australia, Perth, WA.
  • 3 Department of Health Policy and Management, Curtin University of Technology, Perth, WA.
  • 4 School of Surgery and Pathology, University of Western Australia, Perth, WA.


We thank the clinicians who were interviewed, the Perth and Hills Division of General Practice and the Silver Chain nursing association.

Competing interests:

Smith & Nephew Pty Ltd provided an unrestricted donation for this study but did not influence its design, analysis or publication.

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