Family Practice Vol. 19, No. 3, 251-256
© Oxford University Press 2002
A short-term intervention in a multidisciplinary referral clinic for primary care frequent attenders: description of the model, patient characteristics and their use of medical resources
Department of Family Medicine, Tel-Aviv University and General Health Services, Dan-Petach Tikva District, Israel.
Dr Andre Matalon, Department of Family Medicine, Tel-Aviv University, Sheba Hospital, Building 130, Tel-Hashomer, Israel.
Matalon A, Nahmani T, Rabin S, Maoz B and Hart J. A short-term intervention in a multidisciplinary referral clinic for primary care frequent attenders: description of the model, patient characteristics and their use of medical resources. Family Practice 2002; 19: 251–256.
Received 1 May 2001; Revised 22 October 2001; Accepted 7 January 2002.
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Abstract |
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Background. Frequent attenders in primary care are a professional challenge for family physicians, and the medical costs of their care can be very high. Some of them suffer from somatization and are concerned solely with their physical complaints, although somatic complaints are the most common presentation of anxiety and depression. To assess and treat these patients comprehensively, a multidisciplinary clinic was created in the community.
Methods. This study describes the first 40 patients referred to the clinic. All patients completed a mental health screening questionnaire and a functional assessment of health. The utilization of medical resources was assessed by chart review for the year before and the year after the first encounter in the clinic. The intervention consisted of a comprehensive bio-psychosocial consultation where life history and medical symptoms were woven together into a new narrative. The intervention also included pharmacological treatment and short-term psychological interventions.
Results. The majority of referred patients were women and their average age was 52 years. Headache was the leading symptom, followed by fatigue. The mean number of reported symptoms for each individual patient was 10. Mental health problems were mainly somatization, depression and anxiety. The average yearly costs per person of US$4035 were reduced to US$1161 the year following referral.
Conclusions. The integrated approach of the clinic satisfied at least three needs: of the patient, of the referring physician and of the health maintenance organization. The results of this uncontrolled pilot study suggest that this intervention helped to modify illness behaviour, decreasing the costs of medical investigations.
Keywords. Frequent attenders, primary care, referral clinic.
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Introduction |
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Between 20 and 80% of patients visiting a family physician suffer from a somatic symptom that will not be classified or defined as a disease at the first encounter.1 This will often lead doctors to perform different examinations to approach a degree of certainty that they can accept both medically and psychologically.2 They do this either to reassure their patients, and themselves, that there is no threatening underlying disease explaining their symptoms, or to alleviate their anxiety and fears. Sometimes, in functional somatic symptoms and in somatization patients, the pathway to a correct diagnosis or to an insight into their suffering is a sequence of consultations, medical examinations and tests to exclude the presence of a disease.3 Somatization is defined in this context as a medical help-seeking behaviour for stress and other emotional bodily symptoms misattributed to be of solely organic cause. Most of these patients have psychological problems, but they, and sometimes also their attending doctor, are concerned entirely with their physical complaints and have difficulties in linking emotional disturbances to their symptoms. They prefer going to doctors that tend to believe in organic causes of symptoms and they are hostile or unsympathetic to those suggesting an emotional or psychological approach to them.4 They will be the frequent attenders at primary care clinics and will refuse a psychiatric consultation or referral, although, far from being atypical, somatic complaints are the most common presentation of stress and psychiatric disorders. Social and personal distress expressed in bodily complaints is common in most cultures, especially in societies where mental problems, hypochondriasis and psychosomatic disorders are stigmatic and perceived as pejorative.5
These frequent attenders at primary care with somatic symptoms are generally a burden on the health care system and may be seen as a professional challenge for family physicians. They will anxiously pursue a fantasy of finding an organic disease that will explain their suffering by visiting emergency rooms and specialists, and will undergo any medical examination that they read about or which is proposed by one of the different doctors visited.6 In doing so, they explore the doctor's fear of misdiagnosis of cancer or other serious disease. In a study of medical malpractice suits against doctors in the Israeli courts, it was found that most of them were for tests that were not ordered, but none were for unnecessary tests.7 On the other hand, overinvestigation of common physical symptoms can lead to ‘somatic fixation', reinforce anxiety, and deepen depression and isolation, leading to a delay in the appropriate treatment.8,9
For bodily symptoms and ‘unexplained' physical symptoms, when the initial assessment does not suggest a physical cause, an organic diagnosis is very improbable. In a prospective study of patients with unexplained physical symptoms, an organic diagnosis was demonstrated in only 16% in 3 years follow-up. The costs of the search for an organic diagnosis, particularly for certain symptoms such as headache or backache, were especially high.10
Mayou et al. reported that the ideal treatment for somatization is a multidisciplinary team where the patient can receive a comprehensive assessment.11 Following their recommendations, the General Health Services (formerly Kupat-Cholim Klalit; the General sick fund), the largest health maintenance organization (HMO) in Israel, established a multidisciplinary clinic in the community in the district of Petach-Tikva. The hypothesis underlying the creation of this clinic was that it would reduce health care costs, reduce patients' consultations and improve physician satisfaction with the doctor– patient relationship. In this paper, we describe the intervention model and characterize the frequent attenders in general practice, chosen by their family physicians to be referred to this clinic. We also compare their overall medical expenditures 1 year before and 1 year after the intervention.
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Methods |
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Subjects
All the 45 family physicians of the region were informed by letter of the opening of a multidisciplinary ‘Consultation Clinic' and were invited to refer their difficult patients, the frequent attenders and heavy users of medical examinations and procedures. We decided to let the physicians decide which patients to refer, as for each physician difficult patients could be those with a different problem or personality, but we prompted them to choose especially those with multiple somatic complaints in different sytems or multiple psychological symptoms without acceptance of this interpretation. Excluded were patients with anorexia nervosa, Alzheimer's disease, mental retardation, patients on active treatment for cancer, schizophrenia or other psychotic patients and those who were already receiving treatment within the mental health network. Following receipt of the letter, the physicians were invited to a lecture on somatization and functional somatic symptoms, and after that we offered our new service. This study reports on the first 40 patients referred to the clinic in the first months of its establishment.
Setting
The multidisciplinary clinic was called the ‘Consultation Clinic' in order that it would be accepted by all patients and to overcome the pejorative stigma in Israeli society of the term psychosomatic or psychiatric consultation. The clinic was located in the community specialist clinic of the region. The team comprised a family physician (AM) with training in psychotherapy, working in this clinic 16 hours a week, and a medical social worker (TN) working 6 hours a week. A senior psychiatrist (BM) served as a supervisor for the team, without directly seeing the patients. The clinic functioned 2 days a week, and one new patient was examined each day by the family physician. This interview lasted for 2–3 hours and was followed by an ‘integrative interview', with the participation of the social worker. Both the physician and the social worker, acting as ‘case manager', allocated afternoons for the follow-up encounters.
Intervention
All patients completed three short questionnaires at the first encounter: (i) a mental health screening questionnaire (Prime MD);13 (ii) the Dartmouth COOP charts for health and functional assessment;14 and (iii) the MOS SF-36, for health and functional assessment.15 All the questionnaires have been validated in Hebrew. The Dartmouth COOP charts and the MOS SF-36 currently are being repeated 1 and 2 years after the intervention, and will be presented in a further study.
After filling in these questionnaires, the patients completed a medical and a psychosocial interview with the family physician. The medical interview was detailed, exploring each of the symptoms presented, and was followed by the psychosocial interview tracing the family genogram. The medical history of the family and the personal and family life history were examined, with special attention paid to stressful life events. The family support system was assessed by Smilsktein's model.12 The interview was followed by a physical examination. After its conclusion and a coffee break, the medical narrative interweaved with the personal and family biography were presented to the team's social worker in the presence, and with the active participation, of the patient. There were no more dichotomies between the medical and the personal narratives. This narrative technique was adapted from Viederman's psychodynamic life narrative originally viewed in the frame of psychotherapy as an intervention to alleviate depression and to create a powerful bond between patient and physician in order to relieve symptoms and influence the patient's behaviour.16 The symptoms were presented to the patient, reframed in their life context, generally a context of prolonged suffering or misery, or as part of a general stress response or depression. After the completion of all stages of the interview and with the active participation of the patient, an individually tailored therapeutic strategy was adopted, according to the patients' preferences, acceptance and cultural or personal beliefs. The treatment, or combination of treatments, was proposed within the framework of a short-term intervention, ~10 encounters of 1 hour each, once a week or once every 2 weeks. It included simple counselling for maladaptive health behaviours (special attention was directed towards implementing physical exercise, mainly daily walking) and pharmacological treatment for anxiety, depression or panic disorder and for any other diagnosed medical condition or functional somatic symptom. Apart from the pharmacological treatment, we offered short-term psychological interventions such as cognitive–behavioural therapy, relaxation techniques, guided imagery or supportive treatment. Sometimes we functioned as an integrative ‘reframing' team and referred the patients to more specific psychiatric or psychological treatments in mental health clinics when prolonged psychotherapy was indicated or when suicidal thoughts were present. Some of the patients were referred to physiotherapy or to complementary/alternative medicine not covered by HMO (biofeedback, acupuncture or body massage). Sometimes, after the integrative interview at the first encounter, there was no need for further treatment. The patients were surprised as there was enough time to deal with their body feelings and their emotions. Their symptoms were respected and their fears addressed therapeutically.
Patients' family doctors were invited to take part in the integrative interview to foster the understanding of the context in which the frequent complaints took place and to involve him/her in the new ‘contract', to create a new partnership in treatment and ensure continuity. As part of the contract, it was stressed that during treatment, the patient had to inform the ‘case manager' (AM or TN) of each medical examination they had undergone or tests for which they had been referred by other physicians, or that they themselves wanted to suggest. At the end of the first interview and again at the end of the intervention, with the consent of the patient, a letter was sent to the referring physician, with a synthesis of the consultation and the recommendations for further treatment or follow-up.
Outcome measures
Measures of outcome were: health care utilization, health care costs and physician's satisfaction with the doctor–patient relationship.
Health care costs were standardized measured with the same ‘price list for services' of the HMO calculated for each medical resource utilization and the number of visits to physicians and hospitals. This was assessed by chart review of the primary care medical file, and of records in the four general hospitals and the specialist clinics of the HMO in the surrounding neighbourhood. The chart review was performed for the year before and the year after the date of the first encounter in the counselling clinic.
Family physicians were asked to rate their satisfaction with the doctor–patient relationship on a linear scale from 0 to 10 (0 being the lowest and 10 the highest satisfaction), before the intervention and 1 year later. Patients' satisfaction ratings with the service were not addressed as we did not want to add another research questionnaire.
Data on the first 40 patients referred to the counselling clinic were analysed at least 1 year after the date of their first encounter.
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Results |
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The majority of the referred patients were women (77.5%) with an average age of 52 years (range 22–72) and median age of 50. The age and gender distribution is given in Table 1
. Thirty-five per cent had an education of <8 years; 22.5% had completed college or technical studies; and 10% had academic degrees.
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The symptoms that disturbed the patients in the previous month, as they were reported in the Prime MD questionnaire, are displayed in Table 2
. Headache was the leading symptom that bothered almost 85% of patients, followed by fatigue (in 82.5%). Sixty-two per cent had feelings of being depressed or hopeless, and 65% thought that they had an underlying serious disease that had not yet been diagnosed. The mean number of reported symptoms in each individual patient in the previous month was 10. Seventy-two per cent of the patients stated that their overall health was poor, and the rest stated that their health was just fair. No patients chose to rate their health as good, very good or excellent.
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The suggested Prime MD mental health diagnosis is revealed in Table 3
. Eighty-seven per cent of the patients suffered from somatization; 85% suffered from depression, both major and minor; and 75% suffered from anxiety. Twenty per cent suffered from panic attacks and another 20% from hypochondriasis. There were no cases of alcoholism. The great majority of patients (77.5%) suffered from a combination of depression, anxiety and somatization, and only one patient suffered from somatization, without any other accompanying mental diagnosis. There were 138 other non-mental diagnoses, with an average of 3.45 non-mental diagnoses per patient. Other prevalent non-mental health diagnoses were fibromyalgia (47.5%) and irritable bowel syndrome (30%), followed by hypothyroidism (25%) and hypertension (15%). In one patient, we diagosed multiple myeloma.
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The psychosocial interview assessed the context of symptoms: 40% of patients had experienced the death of one of their parents before the age of 8 years. Another 40% experienced childhood neglect or abandonment. Thirty-nine per cent of the Ashkenazi Jews had survived the Holocaust of the Second World War or were first-generation descendants of survivors. Thirty per cent of the patients experienced violence in the family or spousal alcoholism.
All 40 patients completed all phases of the intake interview. Sixty-five per cent (26) of them were accepted for further treatment in our unit. Of the other 14, four patients were referred to mental health clinics or other private psychological or psychiatric treatment, and four were referred to the care of the family physician. For three patients, we thought that there was no need for further treatment, and three refused any treatment even though we thought it appropriate.
The medical costs in terms of consultations, emergency room visits, in-hospital days and diagnostic tests were estimated as US$161 400 for the 40 patients the year before the intervention. These are summarized in Table 4 and compared with the costs 1 year later. This estimate did not include costs of the drugs and laboratory tests, as the data were not available. The average yearly costs per person were US$4035. One year after the intervention, the costs were reduced to US$46 448 for the 40 patients (an average of US$1161 per patient). The yearly costs of our clinic were US$13 680. The yearly average of 14.5 visits to their family physician fell to 8.4. Their visits to specialists decreased from an average of 7.4 to 4.9. These 40 patients made 53 visits to the emergency room of the neighbouring hospitals the year before the intervention, which went down to 23 the year after. They had 41 days of in-hospital stay for investigations the year before and 17 the year after. The striking differences in cost before and after the intervention were made up of decreasing the number of tests performed (X-rays, computerized tomography, magnetic resonance imaging, ultra-sonography, isotope mapping, cardiological tests such as stress test, echo-cardiograph and Holter ECG tracing, gastroscopy or colonoscopy, electro-encephalography or electro-myography and lung function tests) from US$73 337 to US$5830.
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The doctors' mean satisfaction score for the doctor– patient relationship was 4.7 (on a scale from 0 to 10) before the intervention, and increased to 8 one year later.
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Discussion |
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We have presented the results of an uncontrolled pilot study on the effects of a short bio-psychosocial intervention that, given certain limitations, seems to modify illness behaviour, decreasing the number of consultations and the costs of medical investigations, referrals and hospitalizations. In this context, the integrated ‘Consultation Clinic' possibly satisfied at least three needs:
- Of the patients, who suffered from several somatic symptoms. Although they were not assessed objectively, their narratives reflected the fear of serious diseases; they felt misunderstood and sometimes rejected and were often depressed since so many consultations and hospitalizations had not been helpful.
- Of the referring family physicians, who often felt helpless after multiple referrals to specialists and hospitals, and the failure of the treatments. They often experienced these patients as demanding and bothersome. Even if they had a strong intuition that these patients had psychosocial problems, the patients refused to be referred to a mental health professional. The physicians sometimes felt exhausted and were relieved that a colleague showed interest in seeing these patients, so that they could take temporary leave of them.17
- Of the HMO, that for many years had to cover the costs of these ‘heavy users'. Now there was an additional resource, within the framework of the HMO, to which these patients could be referred, with a hope that costs in the future would drop.
A high percentage of the frequent attenders of primary care services suffer from psychiatric distress.18 Data from the Prime MD study in the USA showed that 14% of primary care patients meet the criteria for somatoform disorders.13 In the UK, most of these patients suffer from problems, symptoms or disorders belonging to the spectrum between depression and anxiety, with or without somatization.19 In a WHO international study of psychological problems in primary care, it was found that 10.1% of screened patients in 14 different countries met the criteria for major depression, and half of them had multiple unexplained somatic symptoms.20 The prevalence of patients with depression who reported only somatic symptoms varied between 45 and 95%. Our data using the Prime MD questionnaire support these findings; somatic symptoms co-existed with depression and/or anxiety. The impact of early parent death in mental illness is well known,21 and most of our patients had experienced such severe stress in their childhood or had experienced childhood neglect. Community studies have shown that childhood maltreatment, stressful life events, psychological stress, anxiety or depression are assossiated with somatic symptoms without identified pathology, and increased health care utilization and costs.22 The diagnosis of multiple myeloma in one patient and the association of mental health problems with other chronic disorders and multiple somatic symptoms as shown in our results makes these patients especially suited to be assessed integratively by a family physician with the help of a mental health professional, or by their own personal family physician, although some of them feel they lack the skills and time to treat such patients.11 Sometimes, when they are especially difficult, the patients nibble at the doctor–patient relationship to a point where physicians are unaware of its negative effects, affecting good management. Not only is the patient ill, but the relationship is as well. It is therefore not surprising that the physicians rated their satisfaction with the doctor–patient relationship low. The intervention in our ‘Consultation Clinic' thus also served as a remedy for this problem. Through experiencing the bio-psychosocial model, our patients could become less demanding and more comfortable with words such as distress or depression. The integrated new narrative, the medical anamnesis interwoven with life history, presented to the social worker, with the patient's attendance, suggested the patient's pain and suffering as a ‘logical' and ‘inevitable' consequence of previous life stresses and experiences. This by itself creates a ‘corrective emotional experience'; a therapeutic intervention in which the patient feels understood and accepted, and it is suggested that he could then transfer this cognitive and emotional insight to a new satisfactory relationship with his family physician.
Although this pilot study was uncontrolled, our results suggest that this short bio-psychosocial intervention modifies illness behaviour, and decreases the costs of medical investigations, referrals and hospitalizations. These results are in accordance with previous findings in Germany,23 where a study of a short psychosomatic intervention showed a change in health behaviour and reduced health care costs. The investigators suggested that this kind of integrated intervention was usually carried out very late, after patients had been complaining for many years of the same symptoms.
We cannot rule out the effect of time on the decrease in use of health care resources. Further randomized studies comparing referred frequent attenders with matched controlled patients, who were not referred, may clarify this point.
We also do not know how long the described improvement of the integrated intervention lasted. It is possible that after a longer period of follow-up (longer than 1 year), some of the patients' symptoms may return, and they may revert to being ‘heavy users' of medical care. We therefore do not claim to have ‘cured' these patients. Follow-up of these patients in a further investigation will show whether additional integrated interventions are necessary, but, even a temporary improvement, with its previously outlined benefits, is certainly very encouraging for the patient, the referring doctor and the health care system in general.
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Acknowledgments |
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We thank Dr John Yaphe and Professor Michael Weingarten for their comments and help in preparing the manuscript. We also thank the General Health Services and all the family physicians that referred their patients and gave us access to the clinical records.
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References |
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1 Kelner R. Functional somatic symptoms and hypochondriasis. Arch Gen Psychiatry 1985; 42: 821–833.
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