Family Practice Vol. 19, No. 4, 390-396
© Oxford University Press 2002
Traumatic events in a general practice population: the patient's perspective
Department of General Practice, Maastricht University, Post Box 616, 6200 MD Maastricht, The Netherlands.
Saskia SL Mol; E-mail: saskia.mol{at}hag.unimaas.nl
Mol SSL, Dinant G-J, Vilters-van Montfort PAP, Metsemakers JFM, van den Akker M, Arntz A and Knottnerus JA. Traumatic events in a general practice population: the patient's perspective. Family Practice 2002; 19: 390–396.
Received 9 February 2001; Revised 6 September 2001; Accepted 11 March 2002.
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Abstract |
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Objectives. The aim of the present study was to describe the patient's perspective on the GP's care after violent events: which role is the GP assigned; and how is the care appreciated. Events studied were serious accidents, burglary, robbery, physical and sexual abuse, disasters and war.
Method. A postal questionnaire was sent to a random sample of 2997 patients (
20 years) from the practice population of 32 GPs (67 500 patients).
Results. The response was 50%. Forty-two per cent of the respondents had experienced one or more events. Twenty-eight per cent of the victims desired some kind of professional help; more than half of them desired that care from their GP, three-quarters actually seeking it. Most frequently sought care was sympathy, "a number of good talks", and care for physical complaints. Overall, contentment with the GP's contribution was high; patients especially appreciate sympathy and support, as well as initiative on the GP's part in commencing and pursuing care. Of those who felt no need for professional help, 88% found that they could cope with the traumatic event well enough, with or without the help of family and friends. For those who did not seek help, although they did desire it, the main reasons were that they considered their problems insufficiently medical or felt that their GP lacked the time. In the case of physical and sexual abuse, feelings of guilt and issues of patient confidentiality played a role for some patients.
Conclusions. The number of events experienced by our respondents is lower than in previous studies for burglary, robbery, physical and sexual abuse (adults and children); the occurrence of accidents is similar. The majority of the people who experience traumatic events cope with them well enough without professional help. For those seeking help, the GP plays an important role. Care could be improved as follows: the GP should make it clear to patients that he/she can play a role in caring for them in the aftermath of a traumatic event and stress the confidential nature of the consultation. On the whole, GPs should be more supportive and attentive when being consulted about this topic; also patients would like their doctors to be more active in raising the subject, as well as in initiating follow-up.
Keywords. General practice, patient perspective, tramatic events.
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Introduction |
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Partners, relatives and friends can play an important part in helping someone cope with traumatic events. In addition, victim organizations, psychologists, psychiatrists, refuge homes and social workers can provide assistance. As a consequence of their central position in the health care system, caring for patients after traumatic events, as a matter of course, is a task for GPs. First, GPs can raise topics that patients may not raise spontaneously, such as abuse by relatives. Secondly, in the case of acute events, GPs, being part of the community, will often have heard about them at an early stage and, finally, GPs are able to provide patient education, help patients come to terms with what has happened or refer patients when necessary.
Which role do patients who have experienced traumatic events assign their GPs? Also, how is the care they receive appreciated by these patients? Studies on traumatic events supply insufficient answers to these questions or are irrelevant to the situation in The Netherlands.1–4 We studied the topic in a primary care population, concentrating on events that may lead to post-traumatic stress disorder (PTSD) as defined in DSM-IV (threatening a person's physical integrity, accompanied by feelings of fear, helplessness or horror).5 We investigated serious accidents, burglary, robbery, physical and sexual abuse, disasters and war, excluding witnessing of events for the sake of brevity.6
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Method |
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The study population was recruited from the Maastricht Registration Network of Family Practices (RNH), consisting of 16 GP practices in the province of Limburg, The Netherlands.7 The population in this network is representative of the Dutch population as regards age and sex, level of education, medical insurance and type of household.8 Of the 47 GPs taking part in the network, 32 (covering four rural and eight urban practices and a registered population of 67 500 patients) participated in the study. A random sample of 3200 patients aged
20 years was taken from the register. Patients suffering from dementia or acute psychosis (n = 23) and those unable to read or write Dutch (n = 46) were excluded, as were patients considered by their GPs to be too fragile to participate (terminal cancer, etc., n = 15). A further 119 had recently moved or died. A total of 2997 questionnaires were mailed to the patients' homes, by the GP. The questionnaire could be returned anonymously. After 4 weeks, those who had not yet responded, identified by a code number, received a written reminder. The questionnaire asked for demographic data and the types of events experienced, including their frequency. To ensure a representative cross-section of all degrees of severity, patients had to refer to the most recent event within that category in answering further questions. These concerned the desire for help from professionals (including the GP), whether care was actually sought and how it was appreciated. Those who did not desire or seek care were asked for their reasons. There were additional questions about PTSD symptoms and health correlates; these will be reported on in an article that focuses on determinants of PTSD.
Differences between respondents and non-respondents in demographic characteristics were tested with chi-square tests (dichotomous variables) and t-tests (continuous variables). Relative risks were used to calculate the role of sex in lifetime experience of events. No statistical analyses could be performed on differences between the various event types regarding preferences for and appraisal of GP care, because a third of the study population had experienced more than one event, implying that the findings are probably not independent. Nevertheless, where we considered this to be justified in terms of cell size, we highlighted trends.
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Results |
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Response
Of the 2997 questionnaires, 1498 were returned (50% response). Of the respondents, 43% were male. The mean age was 50 years (SD 16). Eighty-five per cent lived with family/partner, 14% alone and 1% otherwise (e.g. student hostel). Thirty-three per cent had private health insurance and 67% had national health insurance, 44% had a low level of education, 43% had completed secondary education and 13% had completed higher education.
Regarding all demographics, except for insurance type, respondents differed from non-respondents (P < 0.05). Only several of these differences were large enough to be relevant. Of the respondents, 43% were male, while for the non-respondents this was 52% (chi-square). There were more people with a secondary or higher education among respondents than among non-respondents (56% versus 44%, chi-square). On average, the respondents were 2 years older than the non-respondents, due to an under-representation of 20–30 year olds and an over-representation of 60–70 year olds among respondents (ANOVA).
As 27 questionnaires were filled out insufficiently, further analyses were performed on 1471 questionnaires (844 women and 627 men).
Event types and number of incidents experienced
Of the respondents, 42% had experienced one or more of the types of events; of them, 70% had experienced only one, 21% had experienced two and 8% had experienced three or more. There was no significant relationships between gender and the number of event types (chi-square test). However, those who had experienced many event types were significantly older than those who had experienced few or none. Average ages ranged from 46 for no events to 53 for three or more types of events.
Burglary and serious accidents were reported most frequently, while sexual abuse as an adult was the least frequent event (Table 1
). Men were found to have a significantly higher risk of accidents and war experiences, while women proved to be at a significantly higher risk of physical and sexual abuse as adults and of sexual abuse as a child.
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Robbery and war as well as physical or sexual abuse by a stranger were mostly once-in-a-lifetime experiences. Abuse by persons known to the victim had often been experienced repeatedly. Of those who had experienced war (mostly the Second World War), 73% had undergone one of the following: injury, camps, being in hiding, and witnessing or hearing about death of loved ones.
Care seeking
Tables 2–5 list the responses to questions about the most recent event experienced within a particular event type. Table 2 shows care-seeking behaviour. Professional care was desired for 28% of the 854 events (column 2); in 64% of these (18/28%), the respondent wished for help from the GP, sometimes in combination with other sources of care. Of those desiring help from their GP, 74% had actually requested it (column 4). The GP was thus consulted for an average of 13% (74% * 18%) of the events. The flow chart (Fig. 1) illustrates the choices for care.
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The greatest desire for any assistance resulted from sexual and physical abuse (column 3). Actually seeking the GP's assistance occurred least after burglary/robbery and after childhood physical or sexual abuse (column 4).
Of all the events for which assistance from the GP was desired, sympathy was sought in 67%, while care for physical complaints was sought in 55% (particularly after accidents and war experiences; results not shown) and "a number of good talks" in 43% (especially after physical or sexual abuse). Referral was desired after 39% of events (especially after physical or sexual abuse as a child), medication in 22% of cases, a legal statement in 10% and other types of assistance after 6% of events. The wish for mental health care (including social work) —expressed by half of the 54 respondents wanting a referral—came mostly from those abused physically or sexually.
Appraisal of GPs' care
Respondents' appraisal of the GP's care was on the whole favourable (Table 3
, statements 1, 2 and 3 are stated negatively, whereas the other statements are stated positively). Opinions on the GP's invitation to express emotions and on the extent to which the consultation had helped the patient along were least positive. The most striking difference between the various events was for raising the subject: those who had been physically or sexually abused found it particularly difficult to do this (not shown in Table 5).
Respondents reported shortcomings in the GP's care for one-third of the 99 events for which they sought care. The top three shortcomings they volunteered in this open-ended question were a lack of initiative on the part of the doctor in raising the subject or reverting to it in later consultations (n = 9), lack of sympathy and support (n = 8) and not being taken seriously (n = 5). Similar topics were mentioned in answer to a question in the same section about the advice they would give a young GP on how to deal with patients like themselves. Almost half of the 108 pieces of advice given had to do with support and attentiveness: taking the patient seriously, providing support and comfort, listening attentively and questioning the patient thoroughly. In 11%, the wish was expressed for the GP to take more initiative in raising the subject and initiating follow-up. The remaining suggestions were related to taking sufficient time, referring, caring for physical complaints and improving expertise.
Reasons for not seeking help
The reasons for not seeking help from the GP amongst respondents preferring help from a professional other than the GP, and the respondents who did not consult their GP even though the GP was their preferred caregiver, were similar; the answers of both groups are summarized in Table 4. The most frequent reason for not asking the GP's help was that the patient thought the problem was not really a medical one (mostly after burglary/robbery, disaster or war). Lack of time was mentioned in one-fifth of the events. The items "I'm afraid my GP will tell someone else" and "my GP knows the person guilty of the event" were ticked almost exclusively by those who had been sexually or physically abused. Of the 64 reasons under the heading ‘other’, 26 fell under the GP's influence: lack of trust in the GP, feelings of shame, etc.
The most common reasons given by respondents for not seeking any professional help, except in cases of child abuse, was having been able to cope well enough without this help (Table 5). When combining the two options "got over it without help" and "got over it with help of family or friends", 88% found they had got over it without professional help. For almost half of the events experienced, respondents indicated that professional care would not help them, or that they thought they should work it out themselves. Although the numbers are small, the trend that emerges from the data is that feelings of guilt and shame are more often the reason for not seeking professional help after abuse than after other types of events.
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Discussion |
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This is the first Dutch study on the lifetime prevalence of a range of traumatic events in the open population and on the victims' perspective of the role of the GP in their aftermath. The prevalences we found are systematically lower than those found in American, British and Australian studies for burglary, robbery, adult physical and sexual abuse and childhood physical and sexual abuse.6,9–16 International comparison of war and disaster experiences is not useful, as these events are specific for each country. The numbers we found for accidents are comparable with those found in the USA.6,10 The sex differences we found per type of event are comparable with those found elsewhere.
The lower prevalences found in our study may be due to selective non-response. Our response, at 50%, was reasonable and not unusual, taking into account the taboo surrounding some of the topics and the length and difficulty of the questionnaire.9 Our non-respondents were less well educated than the respondents. Although there is conflicting evidence about this, on the whole, lower socio-economic status is considered a risk factor for experiencing traumatic events.6,9,17 This may have contributed to the lower prevalences found in our study.
Other Dutch studies on prevalence of sexual abuse of girls and of physical abuse of children show higher prevalences than ours, possibly because the data were collected by interview, rather than by written questionnaire.1–3,18 In an interview, one can enhance recall of past experiences by detailed questioning and stepwise cueing.19 Another benefit of interviewing is that with a complex questionnaire like ours, with many references to questions further on, the number of missing answers can be minimized. However, we felt that the anonymity of a postal questionnaire when studying a sensitive topic outweighed the advantages of interviewing patients.
Of all the events for which no care was sought (72%), 88% of the respondents felt they were able to cope well enough without professional care, with or without the help of family or friends. This means that after some 60% of all events, people come to terms with the event without professional help, a considerable amount.
Of those who did want professional care, 62% chose the GP's care. Patients mostly seek understanding, care for physical complaints and "a number of good talks", care that is typical for general practice. Whether or not the GP is able to select patients that need more specialized care or whether there are interventions for patients with PTSD feasible in the general practice setting are topics for further study.
Although, on the whole, our patients were positive about their GP's help, one-third reported shortcomings. They would appreciate a more listening attitude, more sympathy and support, more initiative in informing how the patient is coping with the trauma and in initiating "a number of good talks". These aspects, related to the GP's attitude and communication skills, would merit extra attention in medical training and continuing medical education (CME) courses.
In an international study on GP care in general, being given sufficient time was found to be the patients' top priority.20 Of our patients, one-fifth thought that the GP had too little time to help them with coping with traumatic events. Whether GPs have insufficient time or not, it is important to realize that looking busy keeps patients from consulting.21
Even though it is considered the GP's task to help people cope with a traumatic experience,22 patients themselves often perceive their problem as insufficiently medical to consult their GP about. This matter would deserve attention in patient education.
Although the data on sexual and physical abuse, both in childhood and as an adult, should, due to the small numbers, be interpreted with care, they do show a trend. They were the events for which the patients considered their capacity to cope with the aftermath more often insufficient than for other events. This led to a higher desire for care, care that was not always sought. As was found in earlier studies, difficulty raising the topic, feelings of guilt and shame as well as the fact that the GP knows the perpetrator and fears regarding confidentiality were reasons for not seeking care.12,23,24 Therefore, to enhance the care of patients who have been abused, GPs should be taught how to facilitate disclosure of abuse while patients should be educated about rules of confidentiality.
In summary, patients who want professional care in getting over a traumatic event assign their GP an important role in helping them cope with its aftermath. Our data provide a basis for improvement in the care of these patients, in both the areas of patient education and the GP's attitude and communication skills. For optimal implementation of the suggested changes, the barriers GPs themselves perceive in bestowing help on this group of patients should also be taken into consideration.21
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Acknowledgments |
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We would like to thank the following for their contribution to this article: Professor BPR Gersons, Mrs V Pigmans, Dr G Hutschemaekers and W van Duin (the Achmea Foundation Victim and Society). We are also thankful to the patients for filling out the long and complicated questionnaire.
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