Family Practice Vol. 20, No. 4, 373-375
© Oxford University Press 2003
Mental health |
Perceptions of psychological content in the GP consultation—the role of practice, personal and prescribing attributes
GKT Department of General Practice and Primary Care, King’s College London, 5 Lambeth Walk, London SE11 6SP, UK.
Correspondence to Dr Mark Ashworth; E-mail: mark.ashworth{at}gp-G85053.nhs.uk
Ashworth M, Godfrey E, Harvey K and Darbishire L. Perceptions of psychological content in the GP consultation—the role of practice, personal and prescribing attributes. Family Practice 2003; 20: 373–375.
Received 5 September 2002; Revised 12 December 2002; Accepted 28 March 2003.
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Abstract |
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Objective. The aim of the present study was to determine the relationship between the characteristics of general practices and the perceptions of the psychological content of consultations by GPs in those practices.
Methods. A cross-sectional survey was conducted of all GPs (22 GPs based in nine practices) serving a discrete inner city community of 41 000 residents. GPs were asked to complete a log-diary over a period of five working days, rating their perception of the psychological content of each consultation on a 4-point Likert scale, ranging from 0 (no psychological content) to 3 (entirely psychological in content). The influence of GP and practice characteristics on psychological content scores was examined.
Results. Data were available for every surgery-based consultation (n = 2206) conducted by all 22 participating GPs over the study period. The mean psychological content score was 0.58 (SD 0.33). Sixty-four percent of consultations were recorded as being without any psychological content; 6% were entirely psychological in content. Higher psychological content scores were significantly associated with younger GPs, training practices (n = 3), group practices (n = 4), the presence of on-site mental health workers (n = 5), higher antidepressant prescribing volumes and the achievement of vaccine and smear targets. Training status had the greatest predictive power, explaining 51% of the variation in psychological content. Neither practice consultation rates, GP list size, annual psychiatric referral rates nor volumes of benzodiazepine prescribing were related to psychological content scores.
Conclusion. Increased awareness by GPs of the psychological dimension within a consultation may be a feature of the educational environment of training practices.
Keywords. GP consultation, psychological factors, practice characteristics.
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Introduction |
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Not only do GPs routinely under-diagnose psychological illness in their patients,1 but their awareness of underlying psychological factors in the consultation varies widely.2 Is this the result of personal attributes of the GP or do external organizational factors influence the recognition of psychological factors?
We aimed to determine the relationship between measurable practice characteristics and the degree to which GPs were aware of the psychological dimension to their consultations.
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Methods |
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Sample
A group of nine practices covering a population of 41 380 registered patients in a deprived inner city area had formed a ‘locality group’ in the year before Primary Care Groups were formed in 1999. All 22 GP principals within this locality group were contacted and agreed to participate in the study.
Consultations
Each GP was given a log-diary which had been piloted on six GPs outside the study area and a format devised to maximize recording of all consultations. Every surgery-based consultation was logged over a period of one working week; home visits and out-of-hours consultations were excluded. Each GP was asked to consider the consultation in terms of its medical, psychological and social content and to indicate on a 4-point scale the ‘psychological content of the consultation’. A score of 0 indicated no psychological content; a score of 3 indicated a consultation entirely of psychological content. Additionally, a record was made of whether the GP offered counselling to the patient themselves, or referred the patient to the practice mental health worker (MHW) or a psychiatrist.
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Results |
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Consultation characteristics
A total of 2206 consultations were recorded by the 22 GPs over the study week. The mean psychological content score was 0.58 (SD 0.33). A total 1402 (64%) consultations were recorded as being without any psychological content, and 138 (6%) were described as being entirely psychological in content. Two GPs did not record a single consultation as being entirely psychological in content.
Predictors of psychological content
The variables associated with significantly higher psychological consultation scores are summarized in Table 1
. Many of these variables clustered within practices but, using linear regression analysis, only the training status of the practice independently predicted psychological consultation scores [ß = 0.53; standardized ß = 0.73; 95% confidence interval (CI) 0.30–0.77], accounting for 51% of the variance (R2 0.53; adjusted R2 0.51; SE 0.24). Within the three training practices, there were four GP trainers, but their own psychological content score was not significantly higher than that of other GPs (t = –1.28; P = 0.22).
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Psychological consultation scores and their relationship to consultation activity
GPs who had recorded a higher psychological consultation content were both more likely to have offered counselling themselves (Pearson’s r = 0.65; P = 0.001) and to have referred more patients to the on-site MHW (Pearson’s r = 0.58; P = 0.005) but were not more likely to have made a psychiatric referral during the study period (mean recorded psychiatric referrals were 1.09 per GP; SD 1.54).
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Discussion |
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GPs working in training practices were more likely to report higher psychological content scores for their consultations. Training practices account for
20% of all general practices nationally. Training emphasizes the importance of the consultation seen from a medical, psychological and social perspective.3,4 Adoption of this perspective in the consultation by the whole training practice, rather than by an individual GP, may account for the higher reported psychological consultation scores by all GPs within training practices, not just the GP appointed as a GP trainer. On-site MHWs are known to sensitize GPs in the same practice to patients with psychosocial problems,5 and their influence may explain the higher psychological content scores that we observed in practices where they were employed. However, it was unlikely that their presence selectively attracted a large proportion of psychologically unwell patients, since this factor was not predictive of higher scores. The finding of higher antidepressant prescribing in practices reporting higher psychological content scores adds to the face validity of the results, suggesting that higher psychological awareness levels might translate into increased diagnosis of depression, which in turn may result in more prescribed courses of antidepressants. The lack of a relationship to the other psychotropic medication, benzodiazepines, is unsurprising because higher prescribing levels are not generally considered to be an indicator of good mental health care.6
This study has a number of limitations. Only three of the practices were training practices, although these did contain 73% of the GPs, and the confidence interval of the main finding on regression analysis did not span unity. Self-report by GPs was not corroborated by patient interviews, limiting the interpretation of results. For example, we do not know the clinical significance of low reported psychological content in the consultation and whether this translates into greater levels of undetected and untreated mental illness. The Hampshire Depression Project gathered validated data on >20 000 patient consultations and reported increased detection of depression by GPs with the MRCGP qualification, but data on training practices were not reported.7 Our study was open to bias, the tendency of GPs to either over- or under-identify psychological problems,2 which only a study with patient-validated measures could quantify. Bias is itself related to factors which are likely to have varied widely in our study, such as the empathy of the consultation style, sensitivity to verbal cues and the frequency with which questions with a psychological content are asked.2 Finally, the validity of a 4-point scale for self-reporting has not yet been formally tested, although face validity is supported by the strong relationship between higher psychological consultation scores and GPs’ reports that they had offered counselling themselves or had referred to on-site MHWs.
Further qualitative study could be used to explore factors located in training practices that may enhance awareness of the psychological problems that patients bring to the consultation and the reasons why almost two-thirds of consultations were reported as being without any psychological content.
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Acknowledgments |
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We would like to thank Professor Tom Craig for advice at the study design stage of this work, Sarah Clement for advice on the research protocol, and all the GPs who took part in the study. This work was part funded through the South Thames Research Network (STaRNet), London. StaRNet London is funded by the NHS Directorate of Health and Social Care (DHSC) for London. MA is one of the STaRNet lead GPs.
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References |
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1 Telford R, Hutchinson A, Jones R, Rix S, Howe A. Obstacles to effective treatment of depression: a general practice perspective. Fam Pract 2002; 19: 45–52.
2 Goldberg D, Huxley P. Common Mental Disorders: A Bio-social Model. London: Tavistock/Routledge; 1992.
3 Olesen F, Hjortdahl P. CME in primary care: the way forward. Scand J Prim Health Care 1999; 17: 131–134.[Medline]
4 Bower P, Gask L, May C, Mead N. Domains of consultation research in primary care. Patient Educ Counsell 2001; 45: 3–11.
5 Sibbald B, Addington-Hall J, Brenneman D, Freeling P. Investigation of whether on-site general practice counsellors have an impact on psychotropic drug prescribing rates and costs. Br J Gen Pract 1996; 46: 63–67.[ISI][Medline]
6 British National Formulary 36. British Medical Association and the Royal Pharmaceutical Society of Great Britain; 1998.
7 Thornett AM, Pickering RM, Willis T, Thompson C. Membership of the Royal College of General Practitioners and recognition of depression in primary care. Br J Gen Pract 2002; 52: 563–566.[Medline]
8 Ashworth M, Clement S, Sandhu J, Farley N, Ramsay R, Davies T. Psychiatric referral rates and the influence of on-site mental health workers. Br J Gen Pract 2002; 52: 39–41.[Medline]
9 Prescribing Measures and Their Application. Leeds: Prescribing Support Unit; 1999.
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