The workload of general practitioners does not affect their awareness of patients’ psychological problems

https://doi.org/10.1016/j.pec.2007.02.006Get rights and content

Abstract

Objective

To investigate if general practitioners (GPs) with a higher workload are less inclined to encourage their patients to disclose psychological problems, and are less aware of their patients’ psychological problems.

Methods

Data from 2095 videotaped consultations from a representative selection of 142 Dutch GPs were used. Multilevel regression analyses were performed with the GPs’ awareness of the patient's psychological problems and their communication as outcome measures, the GPs’ workload as a predictor, and GP and patient characteristics as confounders.

Results

GPs’ workload is not related to their awareness of psychological problems and hardly related to their communication, except for the finding that a GP with a subjective experience of a lack of time is less patient-centred. Showing eye contact or empathy and asking questions about psychological or social topics are associated with more awareness of patients’ psychological problems.

Conclusion

Patients’ feelings of distress are more important for GPs’ communication and their awareness of patients’ psychological problems than a long patient list or busy moment of the day. GPs who encourage the patient to disclose their psychological problems are more aware of psychological problems.

Practice implications

We recommend that attention is given to all the communication skills required to discuss psychological problems, both in the consulting room and in GPs’ training. Additionally, attention for gender differences and stress management is recommended in GPs’ training.

Introduction

Recognition of a patient's psychological problems by a general practitioner (GP) is important because it is the first critical step towards finding the appropriate care for the patient. The GP is the person assigned to provide integrated care for both patients’ somatic problems and their psychological complaints, or psychological aspects of their somatic complaints. However, a lack of available time has been reported by GPs as an important barrier against involvement in patients’ psychological problems [1], [2]. It has been shown that patients with mental health problems contact their general practice more often than patients with physical problems [3]. Moreover, it has been demonstrated that consultations with patients who suffer from mental health problems take more time [4], [5], [6], [7], [8], [9] and leave the GPs more often with the subjective experience of a lack of time [7].

Investing extra time in a patient's psychological problems can be a problem, because GPs already complain about their increasing workload [10], [11], [12]. One of the reasons for the GP's investing extra time is the entanglement of mental health problems with somatic problems [6], [13] resulting in longer consultations covering more than one topic. Additionally, discussing a patient's mental health problems requires specific communication skills that encourage the patients to disclose their psychological problems [14], [15]. This also requires extra time in the consultation.

Patients with psychological problems often offer cues that are indicative of their distress [15], [16]. GPs can use their communication techniques to influence the rate at which their patients offer cues [15], [17]. The more cues the patient offers, the greater the chance that the GP identifies the patient's psychological problems. It is demonstrated that if a GP adopts a more patient-centred style of consulting this will lead to the patient offering more cues [17] and in turn a greater tendency by the GP to identify the patient's problems as psychological [14], [18].

A patient-centred consulting style is characterised by a GP paying attention to patients’ problems, ideas, concerns and preferences. Other aspects of GPs’ verbal communication that might contribute to patients offering more cues, and in turn more psychological evaluations by GPs are showing empathy [17], [18], and asking questions about psychological issues [15], [17], [18]. Eye contact is an important non-verbal communication skill that is associated with GPs’ identification of psychological problems [19], [20].

Investing extra time in a patient's psychological problems will be a problem especially at moments when the GP's workload is high. We expect that in order to gain time, busy GPs will be less inclined to encourage their patients to disclose their psychological problems. This can result in GPs being less aware of psychological aspects in their patients’ complaints.

Our assumption is that a GP's workload is not constant over time. Workload can fluctuate during working days, but also within the working day. We differentiate therefore between ‘overall’ and ‘situational’ workload, following a study of Hutten [21]. The GPs’ overall workload indicates how busy the GPs are in general, because of their practice size. Whereas the situational workload is the GPs’ workload at a specific moment. We expect that GPs with a higher overall or situational workload will adapt their communication to elicit less patient disclosure regarding their psychological distress. These GPs will be less aware of their patients’ psychological problems. It is further expected that the characteristics of both the GP and the patient can affect the GP's awareness of the patient's psychological problems, and the GP's communication. It is demonstrated that female [22], [23] and younger GPs [5], [24] are more inclined toward psychological assessment of patients’ health problems. Additionally, it is known that women and older patients more often have psychological problems [5], [24]. Communication patterns may also differ according to the age and the gender of GPs and their patients [25], [26], [27], [28], suggesting more affective GP communication in female and younger GPs and female and older patients. Therefore the GP's and the patient's age and sex are included in this study.

The general question of this study is: how does the GPs’ workload influence the GPs’ awareness of a patient's mental distress? We will answer the following questions in more detail:

  • Do GPs’ workload and their communication style affect their awareness of patients’ psychological problems?

  • Does GPs’ workload influence the GPs’ communication that is visible in the medical consultation?

Section snippets

Design

Secondary analyses were performed from data from the second Dutch National Survey of General Practice, a cross-sectional study conducted in The Netherlands in 2000–2002 [29]. To this National Survey participated 195 GPs in 104 general practices. Data are derived from a video registration that was part of the National Survey of General Practice. A sample of 142 of the 195 GPs gave permission to videotape consultations during one or more days. These 142 GPs were representative of the Dutch

Results

In Table 2 the results of multilevel regression analyses are presented with the GP's awareness of the patient's psychological problems as an outcome measure.

Table 2 shows that the GP's workload does not affect the GP's awareness of psychological problems (steps 1–3). On the other hand, it is demonstrated that the GP's awareness of psychological problems is in particular predicted by the patient's feelings of distress. Subsequently it is shown that female GPs are more aware of psychological

Discussion

Against our expectation, the GPs’ workload is not related to their awareness of psychological aspects in the patient's complaints. GPs with a high workload, indicated by having a large list size or a subjective feeling of a lack of time at the moment of the consultation, are not less aware of psychological aspects in the patient's problems, compared to GPs with a lower workload. The presence and severity of a patient's mental distress are more important reasons for a GP to take psychological

Acknowledgements

The Second Dutch National Survey of General Practice is mainly sponsored by the Dutch Ministry of Health, Welfare and Sports. The authors would like to thank the general practitioners and patients for their participation in the video registration.

References (36)

  • J. Cape

    How general practice patients with emotional problems presenting with somatic or psychological symptoms explain their improvement

    Br J Gen Pract

    (2001)
  • E.M. Zantinge et al.

    The workload of general practitioners: consultations of patients with psychological or somatic problems compared

    Br J Gen Pract

    (2005)
  • S.O. Andersson et al.

    Factors associated with consultation length and characteristics of short and long consultations

    Scand J Prim Health Care

    (1993)
  • J. Howie et al.

    Long to short consultation ratio: a proxy measure of quality of care for general practice

    Br J Gen Pract

    (1991)
  • I. Morrison et al.

    Hamster health care

    BMJ

    (2000)
  • M.D. Burdi et al.

    Physicians’ perceptions of autonomy and satisfaction in California

    Health Aff. (Millwood)

    (1999)
  • G. Huby et al.

    Morale among general practitioners: qualitative study exploring relations between partnership arrangements, personal style, and workload

    BMJ

    (2002)
  • T. Millar et al.

    Link between the ability to detect and manage emotional disorders: a study of general practitioner trainees

    Br J Gen Pract

    (1991)
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