Influence of social problems on management in general practice: multipractice questionnaire survey

Subjects

Our study was approved by the regional ethics committee for medical research. We conducted the study in Buskerud county in March 1995 after a pilot study in western Norway. This county has been shown to be representative of Norway with respect to population density, distribution of employees by branch of industry, and number of residents per general practitioner.11 All the 144 doctors in Buskerud working at least half time in general practice were invited to participate in the study. Of these, 100 agreed to participate and 89 (62%) eventually did so. We recorded the doctors' age, sex, time in present practice, specialist status, type of reimbursement, and average number of patients seem each day, as well as their practice's location and type (solo or group).

Survey of consultations

The doctors were prompted to include all patients aged 16 years or over who consulted during one normal workday chosen by the doctor within a two week period. Patients in need of urgent admittance to hospital were excluded. Before their patients left the surgery, the doctors recorded their age, sex, and main reason for consulting in a separate questionnaire for each patient. The doctors had been informed of the definitions of reasons for consulting in the International Classification of Primary Care12 and instructed that the main reason should be understood and accepted by each patient as an acceptable description of his or her most important reason for contacting the doctor.

At the end of the day the doctors completed the questionnaires. by assessing their previous general knowledge of the patients on a four point scale (none, some, good, very good) and answering the other questions (see box). The management options listed resembled the list composed by Verhaak and Wennink,6 and the pilot study did not reveal a need for further alternatives.

We contacted a random sample of 13 (15%) of the participating doctors to check if the instruction procedures had been followed. These doctors reported that two eligible patients had not been included because of lack of time. The number of children they had seen approximately accounted for the discrepancy between the number of questionnaires returned and the average number of patients seen per day that had been estimated in advance.

Statistical analysis

We compared independent variables in bivariate analyses and included those with P values <0.25 in backward stepwise multiple logistic regression analyses, in which the outcome measures were whether doctors' knowledge of social problems influenced management and what types of management were chosen. We developed a two level model (level 1=patients, level 2=doctors) using the SAS macro Glimmix (generalised linear mixed model), with “doctor” as a random effect variable. We used Spearman's rank correlation coefficient to check correlations between independent variables included in the regression analyses. Interactions between the main independent variables were tested. The regression analyses were run separately with the main reason for encounter included as an independent variable. We used Spearman's rank correlation coefficient to calculate correlations between the six most common types of management.

Influence of social problems on consultations

The proportion of consultations influenced by knowledge of social problems should be interpreted as a minimum estimate of what really happened, as an exhaustive list of social problems could not possibly be composed. Advocates of the biopsychosocial model might consider this proportion, a sixth of the total number of consultations, as evidence of the substantial impact social problems have on decisions made in general practice. On the other hand, the result implies that doctors' decisions were not influenced by knowledge of social problems in more than 80% of consultations, underlining the dominance of biological science in primary medical care. Our results derive from the general practitioners' own assessments, and they might have underestimated or overestimated the influence that patients' social problems had on their decisions.

The relation between the main reasons for patients' consultations and the effect social problems have on management can be understood as a result of the doctors' or the patients' tendency to link social problems to certain symptom complexes. Verhaak and Wennink concluded that general practitioners tended not to treat psychosocial problems that were not presented directly.6 Our study generally supports their findings but indicates that, when seeing patients with general complaints, the doctors' management was often influenced by social problems.

We did not expect that doctors who had been in the same practice for longer periods would be less likely to be influenced by social problems in their management decisions. This finding could result from newly established doctors being more vigilant and interested in the social context of their practice population. Another reason may be that the newly established doctors were eager to please. Alternatively, the well established doctors might have been more biologically orientated or had more patients with clearly somatic problems. Possibly they knew their patients' problems all too well and had realised that there was little they could do about it.

Doctors' responses to patients' social problems

The doctors often allowed extra time and gave advice in response to patients' social problems. It is possible that such direct help from the general practitioners was seen as sufficient, as only nine patients were referred to or advised to contact community services. This is not necessarily a local phenomenon, and an American study has described a similar situation.9 The finding could reflect that the patients had already made such contacts themselves or intended to do so. On the other hand, the doctors could have considered cooperation with community services not to be worth while, or they could simply have been complacent. In 1980 Hookey described pervasive tensions between general practitioners and social workers stemming from differences in their treatment philosophies.23 Writing about several countries, he expected better relationships in the future because of better structural integration of these services. Our finding suggests that community services and general practice are not yet well integrated in Norway.

Time is an enabling factor for patients with social or psychological problems,10 and the doctors seemed to offer extra time immediately rather than making a new appointment. Evaluating consecutive general practice consultations, Andersson et al found that female patients had longer consultations than male patients.24 Our finding could thus reflect a general difference in consultation length between men and women, and not necessarily be related to using more consultation time when dealing with the social problems of female patients.

In Norway the authorisation of a sick leave requires a doctor's approval, and more than 90% of patients asking for a sick leave actually receive it.25 We found an association between the use of extra time in the consultation and the certification of a sick leave when a social problem influenced management. Most of the sick leaves were certified because of stressful working conditions; the doctors could have been saving time by not discussing the reality of these conditions with the patients. Among older patients, the doctors may have reasoned that they would have certified a sick leave notwithstanding the presence of social problems.

Prescribing a psychotropic drug is often considered for patients with social problems. The positive correlation with use of extra time suggests that the doctors did not save time by making such prescriptions. Morabia et al reported an increased prescription rate of psychotropic drugs by female doctors to female patients.26 That study included all general practice consultations with adult patients. In our study, however, the threefold higher prescribing rate by female doctors was not restricted to female patients. Controlling for the main reason for encounter did not reduce this odds ratio, and the female doctors were not different from the male doctors with respect to reimbursement system or number of questionnaires recorded. Thus, this finding is not likely to be explained by the female doctors being more busy or influenced by their form of income or by more social problems being presented to female physicians.27 Female doctors could, however, simply be more willing to admit making such prescriptions.

Good previous general knowledge of a patient seems to increase the odds for giving advice for social problems, while no significant effect was found for the other most common types of management. This finding supplements a previous study on the use of resources in general practice consultations28 and suggests that such knowledge facilitates communication without eliciting more expensive management decisions.