Family Practice Advance Access originally published online on May 16, 2005
Family Practice 2005 22(4):419-427; doi:10.1093/fampra/cmi033
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A randomised controlled trial of brief training in assessment and treatment of somatisation: effects on GPs' attitudes
a Quality Improvement Committee for General Practice in Vejle County, b Research Unit and Institute for General Practice, Aarhus University, c Research Unit for General Practice, University of Southern Denmark and d Research Unit for Functional Disorders, Aarhus University Hospital
Correspondence to Marianne Rosendal, Research Unit for General Practice, Aarhus University, Vennelyst Boulevard 6, DK-8000 Aarhus C, Denmark; Email: m.rosendal{at}dadlnet.dk
Received 3 December 2004; Accepted 1 April 2005.
Rosendal M, Bro F, Sokolowski I, Fink P, Toft T and Olesen F. A randomised controlled trial of brief training in assessment and treatment of somatisation: effects on GPs' attitudes. Family Practice 2005; 22: 419–427.
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Abstract |
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Background. Somatising patients frequently present in primary care but GPs often express frustration in dealing with them. A negative attitude may result in missed diagnoses and ineffective treatment.
Objective. This study aimed to evaluate the effect of a novel, multifaceted training programme on GPs' attitudes towards somatisation.
Methods. The study was performed as a cluster randomised controlled trial with practices as randomisation unit and with a follow-up period of 12 months. Forty-three GPs from 27 practices in Vejle County, Denmark participated. The intervention consisted of a cognitive-oriented educational programme on assessment, treatment and management of somatisation (The Extended Reattribution and Management Model). Outcome measures were GPs' attitudes toward somatoform disorder and somatisation in general measured by the means of questionnaires at baseline and follow-up. The primary outcome was a change in response.
Results. Baseline values confirmed previous findings that GPs find it difficult to deal with somatising patients. Compared with the control doctors, intervention doctors' attitudes towards patients with somatoform disorders had changed significantly 12 months after training on the parameters enjoyment (P = 0.008) and anxiety (P = 0.002). Doctors also felt more comfortable in dealing with somatising patients in general (P = 0.002). Attitudes about other parameters related to the doctors feelings, aetiology and course of somatisation changed in the expected direction, but these changes were not statistically significant.
Conclusion. A brief multifaceted training programme focussing on somatisation was accompanied by a significant change in GPs' attitude towards patients with somatoform disorders.
Keywords. Education—continuing, health personnel attitude, primary health care, randomised controlled trial, somatoform disorders.
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Introduction |
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Somatising patients frequently present in primary care (20–30% of visiting patients)1 and GPs often express their frustration in dealing with them. A negative attitude, missed diagnoses and lack of treatment not only frustrate GPs, but may also affect patient care.2
GPs rate about 15% of all patient encounters as being difficult.3,4 Reported predictors for difficulty have included somatisation and a poor GP attitude towards psychosocial issues.4–6 Nevertheless, most GPs believe that patients with medically unexplained symptoms should be managed in primary care.7
Previous intervention studies focusing on doctor–patient relationships or common psychiatric disorders have explored various ways of changing GPs' attitudes. A pilot study of five GPs participating in a Balint group for 13 weeks demonstrated a positive effect on GPs' attitudes towards patients with somatoform disorders. GPs in the Balint group were significantly less likely to feel that somatising patients took up too much of their time, they showed a decline in anger and feeling unsure and their enjoyment increased.8 Long training may also improve GPs' attitudes towards psychiatric disorders in general on parameters such as confidence and comfort.9 Brief training increased GPs' confidence in dealing with depression in a before-and-after study of 20 GPs,10 but a recent randomised controlled trial of cognitive behavioural therapy taught to 42 GPs showed no major effect on GPs' attitudes towards depression.11
The present intervention study targeted somatisation defined as the broad spectrum of medically unexplained symptoms seen in general practice. However, owing to the questionnaires available, GPs were presented with two definitions of medically unexplained symptoms: Somatoform disorder and somatisation. Somatoform disorder was defined according to WHO's International Statistical Classification of Diseases and Related Health Problems (ICD-10) as ‘physical symptoms or illness worry without organic explanation and not explained by depression, anxiety, psychosis, medical side effects or abuse; affected functional level or social functioning and a duration of at least 6 months’. The concept of somatisation was defined more broadly as ‘a tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness and to seek medical help for them’, according to Lipowski's definition.12 This definition of somatisation is purely descriptive and covers the whole spectrum of disorders encountered in general practice. It also includes patients with somatoform disorders. The term somatisation defined in this way is used synonymously with the terms ‘Medically Unexplained Symptoms’ and ‘Functional Somatic Symptoms’.
This study was conducted as part of a larger randomised controlled trial on the effect of a novel, multifaceted training programme targeting GPs.13,14 The trial aimed at an evaluation at several levels: GPs, patients and health care costs. This article presents the effect of training on GPs' attitudes towards chronic patients with somatoform disorders and towards somatising patients in general. Results concerning the effects on GPs' diagnoses have been published previously.14 Analyses of patients' self-perceived health and health care costs have not been completed at the time of writing.
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Methods |
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Setting
The study was conducted in Vejle County, Denmark, which is a mixed rural and metropolitan area served by 121 practices (227 GPs). The assessment of GPs' attitudes was performed as part of a larger study examining the effects of the educational training programme ‘The Extended Reattribution and Management Model’.13,14
GPs and randomisation
All GPs registered with the Vejle County health insurance were invited in November 1999. Inclusion criteria were: participation of at least 50% of GPs from a practice and minimum working hours of 2.5 day per week. Enrolled practices were stratified by number of GPs per practice (1–4) and by proportion of participating GPs in relation to the total number of GPs in practices (0.5, 0.75, 1.0). After inclusion was completed, the practices in each stratum were allocated to intervention or control (block randomisation of clusters of GPs) (Fig. 1, Table 1). A person not involved in the study performed the randomisation by drawing non-transparent lots containing code numbers for practices. GPs were informed about their randomisation group.
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Sample size
Power analyses were performed for the entire study.14 These analyses resulted in a desired sample size of 22 GPs in each arm to show a minimal required difference of 20% (type 1 error 0.05 and type 2 error 0.20) and the study may have been underpowered.
Intervention
Intervention consisted of a multifaceted educational programme on assessment, treatment and management of somatisation described in detail in a previous publication (The Extended Reattribution and Management Model).13 The programme had three main aims: 1) to mediate evidence about somatisation; 2) to give GPs proficiencies in general interview techniques and specific principles for treatment of somatisation with a focus on cognitive, behavioural and ‘administrative’ techniques; and 3) to initiate a change in GPs' attitudes towards somatising patients. The main elements in the model were to make the patient feel understood, then to broaden the agenda and finally to negotiate a new, shared understanding of the physical symptoms. The programme also offered a set of management principles for severe cases of somatisation. In relation to the items presented in the questionnaires, the programme included sessions on classification of somatisation, the differential diagnoses between somatisation and physical disease, different aetiological aspects including biological components and stress reactions, current treatment possibilities, and the importance of correct diagnosis and treatment provided by GPs. Training started in April 2000 and several strategies were applied as described in Figure 2
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During the trial control GPs were only informed about the definitions of ‘Somatisation’ and ‘Somatoform disorder’. They were offered training after completion of the trial.
Outcome measures
We evaluated GPs' attitudes towards somatisation using a self-administered questionnaire consisting of two parts (Table 2). Part one was based on a previously used questionnaire concerning somatoform disorders and consisted of 9 items and a 7-point Likert scale.8 Part two was based on a validated questionnaire dealing with depression.15 The questions from this part were adapted to the broad definition of somatisation generating 20 items with 10 cm visual analogue scales (VAS). The entire questionnaire was pilot tested by GPs not otherwise involved in the study. Five items were removed either because they were repeated within the questionnaire or because they seemed incompatible with the concept of somatisation.
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Participating GPs were asked to answer this questionnaire one month before training (March 2000) and 12 months after training (April 2001). Non-responders were reminded after two weeks, and if they still did not respond they were reminded again by telephone.
Questionnaires were rated for each item. Items were analysed for all GPs before training to obtain baseline values. Then differences between follow-up and baseline data were assessed for every GP and randomised groups were compared.
Statistics and software
Questionnaire data were processed using TELEform (version 6.1). Baseline values were compared using Chi-square tests and Mann-Whitney's U test.
In order to assess changes in attitudes we chose to analyse the differences in values for each GP, that is the value before training was subtracted from the value one year after training. Per-protocol analyses are presented as the main result but have been supplemented by ‘intention to treat’ analyses on GPs who provided baseline information. In the ‘intention to treat’ analyses we assigned the value zero to differences for lost GPs and missing questionnaire items (last observation carried forward, that is no change).
Although randomisation was carried out at practice level, individual GPs were chosen as the primary analytic unit because the intervention was targeted at individual GPs and because GPs within practices were found to change attitudes differently. Randomised groups were compared using Mann-Whitney's U test in part one and t-test in part two of the questionnaire. In order to account for a possible cluster effect, additional analyses were performed at practice level using mean values for partnership practices (Mann-Whitney's U test and t-test, respectively). The results did not allow for valid estimations of intra class correlation coefficients due to the small sample size and the few measurements per participant. Finally, p-values were corrected according to Bonferroni's procedure due to the large number of tests performed. Statistical analyses were completed using SPSS 10.0 and STATA SE 8.0.
Ethics and approvals
This study was approved by the local Ethics Committee, the Data Surveillance Authority and the Scientific Research Evaluation Committee of the Danish College of General Practitioners.
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Results |
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Enrolment comprised 27 practices (43 GPs) randomised to intervention or control (Fig. 1). Two practices dropped out before answering any questionnaires. They were solo practices with male GPs older than other participants (mean 57 years). Participants did not differ from non-participants on the parameters presented in Table 1, except for urban doctors being in majority.
Randomised groups did not differ significantly on selected parameters (Table 1). Training was completed by 22 of 23 GPs in the intervention group (participation in the residential course and minimum 2 follow-up meetings) and 20 GPs accepted the outreach visit.
GPs' attitudes towards somatisation before training
GP attitudes did not differ significantly between randomisation groups before training. GPs generally scored low on attitudes on the Likert scale in part one of the questionnaire (Table 2, first column). However, the score reached at least 4 (= some) for 51% on the statement ‘these patients take up too much of my time’, for 44% on ‘feeling unsure’, 37% on ‘enjoyment’, 24% on ‘worry’, 17% on ‘anxiety’, and 13% on ‘anger’. In part two of the questionnaire, the 95% confidence intervals (CI) were placed outside the 5 cm marking on the 10 cm VAS for a number of items: GPs agreed to the influence of ‘life conditions’ and some of the proposed aetiologies (items 9, 14 and 15), but they disagreed on the existence of biochemical abnormality, that psychotherapy would be more beneficial than current treatments, that psychotherapy should be left to specialists, and that somatisation was not amenable to change. GPs found it difficult to differentiate between self-limiting somatisation and somatisation requiring treatment. A score above 5 cm was seen in 90% of GPs for the statement ‘working with somatising patients is heavy going’.
Effects of training on GPs' attitudes
Intervention entailed a decrease in GPs' negative attitudes towards patients with somatoform disorders and an increase in their professional satisfaction (Table 2, Fig. 3A). Only the items about anxiety and enjoyment were statistically significant when corrected for multiple testing, but all answers changed in the expected direction. Supplementary analyses at practice level (n = 13 and n = 10 in the intervention and control groups, respectively) revealed equivalent differences with P values: 1.00, 0.462, 0.007, 0.024, 0.021 and 0.078. However, the very limited number of practices weakened the statistical tests at this level.
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The GPs' attitudes to somatisation defined broadly did not change to the same degree (Table 2, Fig. 3B). The largest observed difference in the control group was 0.7 cm, whereas differences in the intervention group exceeded 0.7 cm and went in the expected direction for 7 of 17 items. The largest and only statistically significant change was found in item 16 showing that GPs felt more comfortable in dealing with somatising patients after training. When this item was tested at practice level we found a larger difference between groups (3.3 cm, 95% CI 1.2–5.4). The P value was 0.004 but not statistically significant when corrected for multiple testing (the P value should be less than 0.0029 according to the Bonferroni correction). Again the statistical tests were impaired by the few test units.
Items 8 and 18 may not have been relevant in relation to the accomplished training. ‘Intention to treat analyses’ gave virtually identical results for both part one and two of the questionnaire.
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Discussion |
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Summary of main findings
GPs expressed worry, uncertainty and frustration in relation to patients with somatoform disorders and they found working with these patients hard. Brief multifaceted training of GPs induced a positive change in attitudes. In particular, GP attitudes saw a decline in negative and a rise in positive feelings.
Strengths and limitations of this study
Randomisation of practices combined with assessment of attitudes before and after training provides strong evidence that the observed changes in attitudes were related to the intervention. There was no indication of selection bias as only few GPs dropped out, and randomisation was successful according to baseline values on selected parameters and attitudes. The time period of 12 months from training to evaluation ensured that the measured outcome reflects a sustained effect of training and not just a short-lived rapture.
Participating GPs amounted to 20% of the GPs practicing in Vejle County and they were representative of the county's GPs, which would seem to indicate that results may be generalised to general practice in similar settings. We can, however, not rule out that enrolled GPs took greater interest in somatisation than non-participants. Such a selection would not affect the overall conclusion on the effect of intervention because of the randomised design, but it would bias baseline values and could question the generalisability of the effect size. A fact speaking against selection is that no difference was found between participants and non-participants on previous training in communication and psychiatry, though information was available for 60% of non-participants only.
The questionnaires used in this study were not validated in Denmark, but they were based on questionnaires used in previous studies of GPs' attitudes and many questions were directed at themes that were raised in the training programme. Furthermore, the validity of the results was supported by a concomitant qualitative study of participating GPs.16
Multiple testing of the questionnaire items posed a problem of possible mass significance, but was adjusted for by correction of the P values. Furthermore, the limited number of partnership practices impeded a valid estimation of the cluster effect and reliable statistical testing at the practice level. However, results at practice level did not differ substantially from the results at the GP level. Finally, the study may have been underpowered due to the low number of participants, the large variations in GP attitudes, the small changes observed and the correction of significance levels. Nevertheless, the response changes were statistically significant for a few items and many of the remaining item responses were found to change in the expected direction according to the content of the training programme. The trend in these changes supports the importance of the final results.
Comparison with existing literature
Our study agrees with previous studies that GPs find it difficult to handle somatising patients3–5 and with the few studies that have indicated an effect of training on GPs' attitudes.8,9 It also corroborates the findings of a qualitative study, in which the GPs generally expressed increased ease in coping with difficult patients after training.16 However, a recent randomised controlled study in the UK showed no effect on attitudes towards depression six months after training.11 The second part of our questionnaire was developed from the questionnaire used in that study and demonstrated a possible significant change in only one item. Thus, our data would seem to largely corroborate those of the British study. The one change found in our study concerned the GPs feelings, and the reasons for this discrepancy between our study and the British study may be rooted in the different disorders targeted and differences in interventions in the two studies.
Implications for future research and clinical practice
According to this study, a short-term multifaceted training programme is able to produce a change in GPs' attitudes towards somatisation. GPs become more confident and find it less frustrating to deal with medically unexplained symptoms. Seen in the light of problems with burnout in primary care, this is an important result. An altered and more positive attitude towards somatising patients is also a necessary step in the direction of better patient care. Future research would gain from larger studies on GPs' attitude changes in relation to somatisation and should also look at the impact of such a change on doctor–patient interaction and patient care.
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Declaration |
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Funding: The Quality Improvement Committee for General Practice in Vejle County (Q2), The Foundation for Medical Science in Vejle County ('Vejle amts laegevidenskabelig forskningsfond) (20/99, 3/2002), The Danish National Research Foundation for General Practice (‘Fonden vedr. finansiering af forskning i almen praksis og sundhedsvaesenet i oevrigt’) (FF-2-01-314), The Regional Health Insurance in Vejle County, The General Practitioner's Foundation for Education and Development (‘PLU-fonden’), the Foundations of Sara Kirstine Dalby Krabbe, Else Nicolajsen and Dr K. Rasmussen.
Ethical approval: this study was approved by the local Ethics Committee, the Data Surveillance Authority and the Scientific Research Evaluation Committee of the Danish College of General Practitioners.
Conflicts of interest: none.
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Acknowledgments |
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We thank all the GPs in Vejle County who took part in this study.
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References |
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1 Toft T, Fink P, Christensen KS, Oernboel E, Frostholm L, Olesen F. Prevalence and comorbidity among mental disorders in primary care. Results from the FIP study. Psychol Med (in press).
2 Fink P. Surgery and medical treatment in persistent somatizing patients. J Psychosom Res 1992; 36: 439–447.[CrossRef][ISI][Medline]
3 Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS. The difficult doctor–patient relationship: somatization, personality and psychopathology. J Clin Epidemiol 1994; 47: 647–657.[CrossRef][ISI][Medline]
4 Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med 1999; 159: 1069–1075.
5 Lin EH, Katon W, Von Korff M, Bush T, Lipscomb P, Russo J et al. Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med 1991; 6: 241–246.[ISI][Medline]
6 Barsky AJ, Wyshak G, Latham KS, Klerman GL. Hypochondriacal patients, their physicians, and their medical care. J Gen Intern Med 1991; 6: 413–419.[ISI][Medline]
7 Reid S, Whooley D, Crayford T, Hotopf M. Medically unexplained symptoms—GPs' attitudes towards their cause and management. Fam Pract 2001; 18: 519–523.
8 Hartmann PM. A pilot study of a modified Balint group using cognitive approaches to physician attitudes about somatoform disorder patients. Int J Psychosom 1989; 36: 86–89.[Medline]
9 Rittelmeyer LF, Jr. Continuing education in psychiatry for physicians. Report of a four-year experience. J Am Med Assoc 1972; 220: 710–714.[CrossRef][Medline]
10 Gask L, Usherwood T, Thompson H, Williams B. Evaluation of a training package in the assessment and management of depression in primary care. Med Educ 1998; 32: 190–198.[CrossRef][ISI][Medline]
11 King M, Davidson O, Taylor F, Haines A, Sharp D, Turner R. Effectiveness of teaching general practitioners skills in brief cognitive behaviour therapy to treat patients with depression: randomised controlled trial. Br Med J 2002; 324: 947–950.
12 Lipowski ZJ. Somatization: the concept and its clinical application. Am J Psychiatry 1988; 145: 1358–1368.
13 Fink P, Rosendal M, Toft T. Assessment and treatment of functional disorders in general practice: the extended reattribution and management model—an advanced educational program for nonpsychiatric doctors. Psychosomatics 2002; 43: 93–131.
14 Rosendal M, Bro F, Fink P, Christensen KS, Olesen F. Diagnosis of somatisation: effect of an educational intervention in a cluster randomised controlled trial. Br J Gen Pract 2003; 53: 917–922.[ISI][Medline]
15 Botega N, Mann A, Blizard R, Wilkinson G. General Practitioners and Depression—First use of the Depression Attitude Questionnaire. Int J Methods Psych Res 1992; 4: 169–180.
16 Christensen KS, Rosendal M, Nielsen JM, Kallerup HES, Olesen F. [Outreach visits. Choice of strategy for interviewing general practitioners]. Ugeskr Laeger 2003; 165: 1456–1460.[Medline]
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