Appendix 2

The ‘7 hypothesis + team’ intervention.

  • Hypothesis generation: analysis of available information

    GPs analyse all the available information about possible reasons for frequent attendance from clinical charts using a standardised questionnaire designed to facilitate analysis of this information.3234

    This questionnaire prompts analysis of the following: (1) category of visits and their frequencies; (2) type of frequent attender according to the first point; (3) family and personal history, and biopsychosocial problem list that needed follow-up; (4) searching for common factors for frequent attendance from the previous points; (5) feelings and thoughts questionnaires, ‘In most interviews with this patient I think …’ (11 items), ‘I feel …’ (13 items)34; (6) rethinking issues of GP capacity (and processes) to resolve the frequent attendance in this patient; and (7) analysing the different professionals who intervened in patient care and their contribution to resolving or continuing frequent attendance.

    Finally, GPs indicate the type of hypothesis from a list of seven that they believe made the patient a frequent attender: biological, psychological, social, family, cultural, administrative-organisational, or related to the doctor–patient relationship.

  • Hypothesis confirmation

    The decision to accept or refute each hypothesis is based on the GP's interpretation of the data (cognitive component) and the self-perception about feeling sure (emotional component). When necessary, the GPs can try out the hypothesis with one or more of the following strategies: another interview with the patient, biological and psychosocial tests, and/or asking for the opinion of other professionals.

  • Planning

    The GP makes plans for each frequent attender based on the confirmed hypothesis and available resources. There are many possible plans, examples of which include: making longer intervals between medical revisits for stable chronic patients, and asking for collaboration with nurses; looking for possible causes of the unstable physical chronic illness and intervening accordingly; scheduling an interview to search for a psychological, family or/and, social diagnosis; suppressing unnecessary face-to-face medical revisits for repeat prescriptions in stable chronic patients, and asking the health centre administrative staff for collaboration; asking the social worker at the health centre for help; referring to community resources if necessary; and being more realistic about the type of doctor–patient relationship expected.

    These plans are then commented on at the group meeting, after which the GP negotiates the plan with the frequent attender. The GP should never suggest to the patient: ‘You have to attend less frequently’. This would be too aggressive and the patient might react with anger or guilt. It is better to offer a search for solutions to the patient's health problem from both points of view.

  • Team

    GPs hold meetings to share analyses and reflections on their frequent attenders and make plans for each frequent attender. Moreover, the GP team provides emotional support to each GP and generates strategies to deal with frequent attenders from a more neutral perspective. The time spent sharing each reflection about a frequent attender ranges from 5 to 35 minutes. The GP team sets regular meetings to discuss (and possibly coming to a consensus agreement about) the hypotheses and plans for all the patients included in the intervention group.

    More detailed information on the 7H+T intervention can be obtained from the corresponding author.