Liaison psychiatry in general practice: a comparison of the liaison-attachment scheme and shifted outpatient clinic models.

Most psychiatrists who visit health centres use the shifted outpatient clinic model, the main aim of which is to improve secondary care by providing it in the primary care setting. For five years we have employed a liaison-attachment scheme in which support and advice from the psychiatrist enables general practitioners to improve their care of patients with psychiatric and psychological problems. One of the advantages of the latter model is that the psychiatrist can contribute to the care of patients not seen by the specialist psychiatric service and also to the development of the primary care team. The scheme is cost effective as psychiatrists can advise on the care of far more patients than they could see in formal referrals, fewer patients are taken on for a course of psychiatric treatment that could be provided by general practitioners and the skills of general practitioners and their trainees are enhanced. It is hoped that more general practitioners will adopt this pattern of working so that it can be fully developed and evaluated.     

Unravelling referrals to medical outpatients

Little is known about the process of referral to Irish hospital outpatient medical clinics. We analysed pre-referral management, information quality and communication to a general medical outpatient clinic. 100 consecutive attendee referral letters were prospectively assessed for information, appropriateness, legibility and pre-referral management. Patients underwent a questionnaire. We documented the final diagnosis and management patterns. 16% of letters were largely illegible, Only 47% of letters gave examination findings and of those, 40% omitted significant details. Appropriate pre-referral investigations were performed in 55%. Where performed, results were not enclosed in 32%. In 61% of cases therapy could have been instituted prior to referral, of these treatment was not started in 36%. 16% of patients did not understand the reason for referral. 10% of referrals were inappropriate. In this limited study there were substantial communication deficiencies in patient referral. If standard criteria were set (e.g. by proforma) before a referral is accepted perhaps the quality of patient care might improve especially if treatment could be initiated earlier by referring doctors.     

Improving psychiatric consultation to nonpsychiatrist physicians

Nonpsychiatrist physicians were surveyed regarding problems that they had experienced when seeking a psychiatric consultation or treatment referral. They gave three main reasons for not referring more patients to psychiatrists: a belief that other mental health professionals could do as well at less cost, that psychiatrists were less available to discuss patients, and that greater stigma was attached to seeing a psychiatrist than seeing other mental health professionals. Psychiatrists might improve their consultation and referral networks by addressing the misperceptions of their nonpsychiatrist physician colleagues.     

Psychiatric teaching and consultation in a primary care clinic

Basing their report on an 11-month experience as members of a primary care team in an outpatient municipal hospital setting, the authors identify six major presenting problems in consultation requests: functional complaints, noncompliance, depression, chronic psychosis, alcoholism, and physician role conflicts. The primary care physician's multiple roles, the content of general medical practice, and the ambulatory setting all colored these consultation requests and shaped the ways in which psychiatrists could be most helpful as consultants. Consulting psychiatrists should have special expertise in several specific clinical areas that are common in primary care practice. They can help primary physicians become more effective clinically by encouraging them to heighten their personal and interpersonal sensitivities and to think through their own values and beliefs about medical practice.     

Improving communication between physicians and patients who speak a foreign language.

BACKGROUND: Communication between physicians and patients is particularly challenging when patients do not speak the local language (in Switzerland, they are known as allophones). AIM: To assess the effectiveness of an intervention to improve communication skills of physicians who deal with allophone patients. DESIGN OF STUDY: 'Before-and-after' intervention study, in which both patients (allophone and francophone) and physicians completed visit-specific questionnaires assessing the quality of communication. SETTING: Two consecutive samples of patients attending the medical outpatient clinic of a teaching hospital in French-speaking Switzerland. METHOD: The intervention consisted of training physicians in communicating with allophone patients and working with interpreters. French-speaking patients served as the control group. The outcomes measured were: patient satisfaction with care received and with communication during consultation; and provider (primary care physician) satisfaction with care provided and communication during consultation. RESULTS: At baseline, mean scores of patients' assessments of communication were lower for allophone than for francophone patients. At follow-up, five out of six of the scores of allophone patients showed small increases (P < 0.05) when compared with French-speaking patients: explanations given by physician; respectfulness of physician; communication; overall process of the consultation; and information about future care. In contrast, physicians' assessments did not change significantly. Finally, after the intervention, the proportion of consultations with allophone patients in which professional interpreters were present increased significantly from 46% to 67%. CONCLUSIONS: The quality of communication as perceived by allophone patients can be improved with specific training aimed at primary care physicians.     

Primary care access to computed tomography for chronic headache

Background

The diagnostic yield of neuroimaging in chronic headache is low, but can reduce the use of health services.

Aim

To determine whether primary care access to brain computed tomography (CT) referral for chronic headache reduces referral to secondary care.

Design of study

Prospective observational analysis of GP referrals to an open access CT brain scanning service.

Setting

Primary care, and outpatient radiology and neurology departments.

Method

GPs in Tayside and North East Fife, Scotland were given access to brain CT for patients with chronic headache. All referrals were analysed prospectively over 1 year, and questionnaires were sent to referrers to establish whether imaging had resulted in or stopped a referral to secondary care. The Tayside outpatient clinic database identified scanned patients referred to the neurology clinic for headache from the start of the study period to at least 1 year after their scan.

Results

There were 232 referrals (55.1/100 000/year, 95% confidence interval = 50.4 to 59.9) from GPs in 59 (82%) of 72 primary care practices. CT was performed on 215 patients. Significant abnormalities were noted in 3 (1.4%) patients; there were 22 (10.2%) non-significant findings, and 190 (88.4%) normal scans. Questionnaires of the referring GPs reported that 167 (88%) scans stopped a referral to secondary care. GPs referred 30 (14%) scanned patients to a neurologist because of headache. It is estimated that imaging reduced referrals to secondary care by 86% in the follow-up period.

Conclusion

An open access brain CT service for patients with chronic headache was used by most GP practices in Tayside, and reduced the number of referrals to secondary care.     

Should we train psychiatrists as primary care providers?

The author discusses the proposition that psychiatrists would be appropriate primary physicians for specific types of patients. The author reviews the arguments for and against psychiatrists as primary care providers, proposes questions that must be addressed in training for such a role, and describes current models of primary care education and practice for psychiatrists. The author believes that primary care may be an appropriate career track within psychiatry and suggests that the development of family medicine may provide useful guidance in incorporating primary care functions into psychiatry.     

Non-attendance at psychiatric outpatient clinics: communication and implications for primary care.

BACKGROUND: What should happen when an outpatient fails to attend a psychiatric clinic? Guidelines from the General Medical Services Committee suggest that general practitioners (GPs) have no further responsibility of care for a patient once a referral to a psychiatrist has been made. This raises questions about the formulation of effective management plans for those patients with whom psychiatric services find it difficult to engage due to non-compliance with assessment and follow-up. AIMS: To investigate communication between GPs, patients, and psychiatrists at referral and following attendance or non-attendance at outpatient appointments. METHOD: A prospective study of a random sample of attenders and non-attenders at psychiatric outpatient clinics. Patients and GPs were interviewed to obtain data about the referral process. GPs' views on communication from psychiatrists and the appropriate course of action following clinic non-attendance were investigated. The quality of referral and clinic letters for attenders and non-attenders was compared. RESULTS: There was no difference in the quality of referral letter for attenders and non-attenders. Psychiatrists were less likely to write to GPs about follow-up patients' appointments than new patients' appointments; communication was least likely when a follow-up patient missed their appointment. GPs considered follow-up non-attenders were more likely to need a further appointment than new patient non-attenders, but did not identify a role for themselves in engaging with follow-up non-attenders. CONCLUSION: Communication between GPs and psychiatrists about new patients seems adequate. However, there are important deficits in communication from psychiatrists to GPs about follow-up patients, especially non-attenders who are often more severely ill and difficult to engage. An effective response for this group is likely to need cooperative health and social service action rather than rigid guidelines concerning clinical responsibility.     

Patient proactivity enhancing doctor-patient-family communication in cancer prevention and care among the aged

This paper presents a comprehensive conceptual model of health care communication involving three key health care partners: patients, physicians, and significant family members (health significant other, HSOs). A unique feature of this model is its focus on proactive roles played by elderly patients in information gathering and communication with health care partners regarding both cancer prevention and cancer care. We outline how proactive initiatives by health care consumers and involvement of their HSOs can enhance patient outcomes (satisfaction with physician, adherence to preventive and corrective practice recommendations, and quality of life). Finally, we also note primary antecedents of health care partner communication in terms of both medical care context and patient characteristics. We hope that this testable causal model will inform future research in the field of health communication.     

The hospitalized psychiatric patient and the primary care physician

Patients admitted to a general hospital psychiatric service were divided into two groups depending on whether they had primary care physicians. Significant differences were found in age, sex, psychiatric diagnoses, and incidence of active medical problems. The primary care physicians said they were aware of these patients’ psychiatric problems and had treated them in their offices, but were reluctant to participate in medical care during psychiatric hospitalization. The reasons for this are dis cussed, and a model for collaborative treatment by primary care physicians and hospital-based psychiatrists is presented.     

Physicians at the medicine/psychiatric interface: what do internist/psychiatrists do?

Studies have convincingly demonstrated that some 50% of patients in primary care settings have both medical and psychiatric diagnoses requiring dual treatment. The concept of primary care psychiatry has emerged in recent years as one way to address this problem. In 1979 the first combined medicine-psychiatry residency was formed. There are now over 20 such programs, but there is little information on how these doubly trained physicians actually practice. In 1997, the authors surveyed the 268 physicians with board certification in both internal medicine and psychiatry that were listed with the American Board of Medical Specialties. Only 15% practiced any type of medicine at all; the rest were involved only in the practice of psychiatry. Although 75% identified themselves only as psychiatrists and worked predominantly in psychiatry, 95% reported using both their medical and psychiatric training in their professional work. They reported that the dual training made them better physicians, improved their professional credibility, and enhanced their diagnostic skills. Several significant barriers were discovered that directly affect the ability of physicians to practice in two fields. Findings, study limitations, and potential implications for the field and its patients are discussed.     

Changes in the scope of care provided by primary care physicians

BACKGROUND: Strategies to control medical costs and improve the quality of care often translate into decisions affecting the range of services primary care physicians provide to patients, which patients are referred for specialty care, and the points in disease processes at which referrals are made. This study focused on physicians' assessments of changes in the scope of care provided by primary care physicians and their assessments of the appropriateness of the scope of the care that primary care physicians are expected to provide. METHODS: We analyzed data from the 1996-1997 Community Tracking Study Physician Survey. Telephone interviews were conducted with 12,385 physicians (reflecting a response rate of 65 percent) who were drawn from a representative random sample of physicians providing direct patient care in the continental United States and not employed by the federal government. The analysis was based on responses from the 7015 primary care physicians and 5092 specialists who had been in practice for at least two years. RESULTS: Thirty percent of the primary care physicians and 50 percent of the specialists reported that the scope of care provided by primary care physicians had increased during the previous two years. Twenty-four percent of the primary care physicians and 38 percent of the specialists reported that the scope of care expected to be provided by primary care physicians was greater than it should be. According to multivariate analysis, primary care physicians other than general or family practitioners (i.e., pediatricians and general internists), those who were in one- or two-physician practices, those who received revenues from capitation, and those who served as gatekeepers for their patients' care were significantly more likely to report that the scope of care they were expected to provide was greater than it should be. CONCLUSIONS: The finding that nearly one in four primary care physicians reported that the scope of care they were expected to provide was greater than it should be arouses concern about the potential impact of changes in the delivery of health care. The associations we found between financial and administrative aspects of managed care and physicians' concern about the scope of care they provide to their patients deserve careful consideration.     

Differential use of available genetic tests among primary care physicians in the United States: results of a national survey

PurposeThis study assesses primary care physicians' experience ordering and referring patients for genetic testing, and whether minority-serving physicians are less likely than those serving fewer minorities to offer such services.MethodsSurvey of a random sample of 2000 primary care physicians in the United States (n = 1120, 62.3% response rate based on eligible respondents) conducted in 2002 to assess what proportion have (1) ever ordered a genetic test in general or for select conditions; (2) ever referred a patient for genetic testing to a genetics center or counselor, a specialist, a clinical research trial, or to any site of care.ResultsNationally, 60% of primary care physicians have ordered a genetic test and 74% have referred a patient for genetic testing. Approximately 62% of physicians have referred a patient for genetic testing to a genetics center/counselor or to a specialist, and 17% to a clinical trial. Minority-serving physicians were significantly less likely to have ever ordered a genetic test for breast cancer, colorectal cancer, or Huntington disease, or to have ever referred a patient for genetic testing relative to those serving fewer minorities.ConclusionsReduced utilization of genetic tests/referrals among minority-serving physicians emphasizes the importance of tracking the diffusion of genomic medicine and assessing the potential impact on health disparities.     

Attitudes of referring physicians regarding total joint replacement: a preliminary report.

More than 800,000 artificial hip joints have been implanted in Americans. Similarly, a large and increasing number of artificial knee joints are being implanted. The successful replacement of deteriorated and severely injured joints permits continued mobility and independent living for many patients who would otherwise be disabled. Recent changes in the delivery of health care raises certain questions regarding access to specialty care. These questions may be even more critical in the African-American community where recent studies have shown that hip and knee replacement are underused in African Americans. This article describes a study undertaken to ascertain the attitudes of referring physicians (primary care) regarding joint replacement.     

Future directions in consultation-liaison psychiatry

Consultation-liaison psychiatry in the United States has had to reassess its priorities with the change in health care economics in the 80 s. Liaison programs and educational programs for primary care staff are jeopardized. The emphasis has shifted from liaison to reimbursable consultation activities. Hospital stays are shorter with emphasis on outpatient and prepaid settings. Less expensive health care professionals are often asked to see patients previously evaluated by psychiatrists. This paper will discuss the need for focused cost-effective liaison services in this climate. Funding strategies for consultation-liaison programs, models of staffing consultation-liaison services, continuity of care from inpatient to outpatient services, integration of consultation-liaison psychiatrists in prepaid health care settings, primary-care educational programs, and psychosocial intervention programs for high-risk primary-care patients will be discussed.     

Links between mental health care professionals and general practices in England and Wales: the impact of GP fundholding.

BACKGROUND: Fundholding general practitioners are able to determine the type of contracts they place with providers of mental health care, and are able to employ some categories of mental health care professionals directly. The impact of this on the care of the mental health of patients in non-fundholding practices is not yet fully known. AIM: A survey was undertaken of 100 fundholding general practices and 100 similarly sized non-fundholding practices in order to investigate the changes in mental health provision made by general practitioners. METHODS: A sample of 100 fundholding general practices in England and Wales was randomly chosen from the list supplied by the Association of Fundholders and matched to a similarly randomly chosen sample of non-fundholding practices. Postal questionnaires were sent to the senior partner and to the practice manager in each practice. RESULTS: The number of mental health care professionals who are either employed by or attached to general practices, or who visit the general practice on a regular basis appears to have increased substantially since 1991. This increase was particularly marked in fundholding practices. The results suggest that general practitioners with specific links to particular mental health care providers were more satisfied with the service provided by the mental health care team, and more likely to increase referrals to that service in the last 2 years, than general practitioners without such links. There was little evidence to suggest that increasing the number of mental health care professionals in primary care had brought about a major reduction in referrals to psychiatrists. CONCLUSION: General practitioners, particularly fundholders, are increasing their links with mental health professionals, and community psychiatric nurses, psychiatrists, psychologists and counsellors are spending more time either based in general practice or visiting regularly. While the shift of resources to primary care, particularly to fundholders, may increase the treatment options available to patients with less severe illnesses, this may have the effect of reducing the services available for the long-term and severely mentally ill.     

Telling “the truth” in dementia-Do attitude and approach of general practitioners and specialists differ?

OBJECTIVE: The prevailing opinion in the literature that disclosing the diagnosis of dementia to patients is important is not always put into practice. The purpose of this study was to investigate differences between GPs and specialists (neurologists and psychiatrists) in the German ambulatory care system concerning the disclosure of the diagnosis of dementia. METHODS: Thirty in depth interviews with randomly selected GPs were conducted. On this basis a standardised questionnaire was developed and sent to 389 GPs and 239 neurologists and psychiatrists. RESULTS: The postal survey revealed only minor differences between GPs and specialists, both groups being equally in favour of a timely disclosure. For example, 70% of the GPs and 77% of the specialists strongly agreed that "patients with dementia should be informed early because of the possibility to plan their lives". This positive attitude is pronounced among younger physicians, but is somewhat contradicted by difficulties in the communication with patients expressed in the interviews. In the interviews, what may be described as a "double taboo" emerges, in that GPs describe taboo topic areas related to dementia for them and for their patients. CONCLUSION: The postal survey shows the two professional groups to be very much in favour of a timely disclosure--an attitude that is pronounced among younger physicians. These findings can be interpreted as a recent change of attitudes regarding the disclosure of the diagnosis of dementia in the medical profession. PRACTICE IMPLICATIONS: Training opportunities are needed in order to overcome communication obstacles in the doctor-patient-communication about dementia.     

“There's no cure for this condition”: How physicians discuss advance care planning in heart failure

Objective

To evaluate the extent to which physicians engage in recommended elements of advance care planning (ACP) communication during outpatient clinic visits with heart failure (HF) patients.

Methods

We conducted a qualitative content analysis of 71 audio-recorded and transcribed outpatient visits with 52 patients ≥65 years recently hospitalized for HF and their physicians (n = 44).

Results

We identified 25 instances of ACP-related communication over 15 of the 71 visits: in 17 instances, physicians explained the nature of HF but only once was the life-limiting potential of HF mentioned. Physicians discussed goals of care in 6 instances but elicited their patients’ preferences in only 2 of those instances. Finally, physicians encouraged documentation of preferences in 2 instances.

Conclusions

Despite recommendations for early ACP with HF patients, physicians rarely engaged in fundamental elements of ACP discussions during outpatient visits. We suggest a stepwise approach to supporting the process of ACP communication in practice.

Practice implications

Given the importance of ACP in helping patients plan for their future care, outpatient clinicians should be helped to incorporate these discussions in the routine care of their HF patients. Using a simple heuristic might help physicians engage in fundamental elements of ACP during busy outpatient visits.     

Why physicians fail to tell patients a psychiatrist is coming

A survey of 103 psychiatric referrals in a medical center showed that 68% of the patients had not been informed by their physicians that psychiatric consultations had been requested for them. To understand this phenomenon, the authors inter viewed the patients, their referring physicians, and a random sample of 30 other physicians. The most prevalent reason for the physicians’ failure to inform their patients about psychiatric re ferrals was the physicians’ misperception that laymen have negative attitudes toward psychiatry. In fact, approximately two thirds of the patients had positive or uncommitted attitudes about the psychiatric interviews before they occurred. Imparting psychological skills to referring physicians would improve their preparation of patients for psychiatric consultation.