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Resumen
Como
los médicos generales juegan un papel importante en la
detección y el tratamiento de los trastornos mentales,
es importante conocer sus ideas, conocimientos y concepciones
acerca de la Psiquiatría. En una encuesta realizada entre
médicos generales de Ginebra acerca de los conocimientos
y habilidades que deberían enseñarse durante la
carrera a los médicos no psiquiatras, se estudió
sus cobncepciones de la Püsiquiatría a través
del análisis factorial. Sde obtuvieron tres aproximaciones
: la clínico-biológica, la psicosocial y la psicodinámica.
La concepción psicosocial y la clínico-biológica
son sustentadas sobrev todo por los médicos generales
y los internistas quienes reconocen que tienen entre sus enfermios
un alto porcentajecon problemas existenciales o psiquiátricos-.
Los pediatras sustentan sobre todo el enfoque psicodinámico.
Un
quinto de los médicos encuestados tienen un interés
marcado por la Psiquiatría , lo que supone un porcentaje
superior al de los médicos de otras especialidades. Estos
datos llaman la atención sobre la necesidad de formar
a lois médicos generales en distintos aspectos de la
psiquiatría
Summary
Objective: As primary-care physicians play a very important
role in detecting and treating mental disorders, the different
conceptions of psychiatry they might endorse and their interest
in psychiatry need to be examined. Method: The data come
from a survey, carried out in Geneva, Switzerland, among physicians
on the psychiatric knowledge and skills which a non-psychiatric
physician should have. The main conceptions of psychiatry were
extracted by factorial analysis. Results: The three main
conceptions of psychiatry fostered by primary-care physicians
are the psychosocial, the clinical-biological and the psychodynamic
conceptions. The psychosocial conception encompasses the complex
and long-lasting problems having social implications for the
patient and effects on the physician-patient relationship. The
clinical-biological understanding of psychiatry emphasizes the
importance of differential diagnosis, treatment and medication.
These two conceptions are mainly favored by general practitioners
and general internists. Physicians fostering these conceptions
consider that they have among their patients a higher percentage
of people suffering from psychiatric or existential problems.
The third approach, psychodynamic, is principally endorsed by
pediatricians; these physicians refer a higher number of their
patients to psychiatrists. One-fifth of primary-care physicians
can be considered as having a particularly great interest in
psychiatry. Comparison with non primary-care physicians indicates
that the latter are less oriented towards psychiatry. Conclusions:
These data show the importance of the training of primary-care
physicians in different areas of psychiatry. Further research
would be necessary to delineate the type of relationship that
primary-care physicians have with psychiatrists (competition,
delegation or cooperation) according to their conception of
psychiatry.
Key words: primary health care; physicians, family; psychiatry;
knowledge, attitudes, practice.
INTRODUCTION
It
has been shown that knowledge of mental illness is poor in the
general population and recognition of mental disorders infrequent.
Recognition of these disorders is also under-estimated by the
physicians themselves, although to a lesser extent. A proportion
of psychiatric disorders are rarely recognized, rarely diagnosed
and still less often treated by primary-care physicians (Kesser
LG, Cleary PD, Burke JD, 1985) (Boardman AP, 1987) (Howe A,
1996). Üstün and Sartorius (Ustun TB, Sartorius N,
1995), reviewing research in highly developed countries, mention
that 30 to 70% of cases of mental disorder in general practice
go undetected. This underdiagnosis can lead to unnecessary medical
treatment and increase the risks of chronic illness. In order
to understand the mechanisms underlying this underestimation,
several studies have inquired into the attitudes of physicians
towards patients suffering from mental disorders, towards psychiatrists
and psychiatry (Buchanan A, Bughra D, 1992) or dealt with the
possibilities of improving physicians' knowledge in this field
(Howe A, 1996).
In
a more general fashion, the question of the connection between
primary-care medicine and psychiatry is dealt with. According
to country and region, observations were made on the extent
of the primary-care physician's role as "gatekeeper"
for mental health-care services, under various systems of insurance,
as well as on the increase in the number of psychiatrists working
in the primary-care field of medicine, in various forms of cooperation
(liaison psychiatry, for example). A proposal to extend the
role of psychiatrists in the somatic treatment of chronic psychiatric
patients is even foreseen to provide improved care for this
group of under-served patients and to counteract the influence
of general practitioners in this field (Shore JH, 1996). To
cooperate or to compete: this is the question which arises,
with all the resulting implications for training and subspecialization,
the organization of services, relations with insurance systems
and public authorities.
We
have made a secondary analysis of data from a study on the knowledge
and skills in psychiatric matters that a non-psychiatric physician
should possess. The first analysis had shown that, when asked
about the knowledge of and expertise in psychiatry that is necessary
for all medical practitioners, physicians mainly insisted on
several items referring to the doctor-patient relationship,
to the detection of the principal psychiatric disorders and
the risks that might be linked to them, and finally to psychosocial
aspects of some psychiatric or somatic disorders (Goerg D, De
Saussure C, Guimon J, 1999).
The
objective sought here is to examine, more specifically, the
three following questions:
- Does
there exist, among primary-care physicians, different conceptions
of psychiatry?
- What
factors may be linked to these conceptions of psychiatry or
contribute to explaining them?
- How
great is the interest of primary-care physicians in psychiatry?
The
different conceptions of psychiatry might also be considered
as different needs expressed by doctors towards psychiatry or
psychiatric training. The analysis focuses on primary-care physicians.
A comparison between them and specialists who do not work in
the primary-care field will allow us to discern elements which
are specific to the former.
METHODS
Sample
A
brief questionnaire was sent out, in 1995, to Geneva physicians,
both in private practice and the public sector. In all, 1593
questionnaires were sent out and 697 analyzable questionnaires
were returned (reply rate 43.8%). Since the characteristics
of the reference population are not accurately known, it was
not possible to determine whether our sample was representative.
Primary-care physicians represented 53.1% of the sample. Other
medical specialists (surgeons, gynecologists, neurologists,
etc.) represented 26.4% of the total, psychiatrists 20.5%.
Questionnaire
The
questionnaire asked for some indications on the physician's
background, specialization, training in the psychiatric field
(courses, group training in interpersonal relationships), an
estimate of the percentage of their patients suffering from
psychiatric or existential problems, as well as an estimate
of the number of patients that they refer to psychiatrists.
It
included a list of 23 psychiatric topics generally taught during
undergraduate training; they correspond to the psychiatric knowledge
and skills which a non-psychiatric physician should possess
(such as an awareness of when and how to refer a patient to
a psychiatrist, an understanding of the emotional aspects of
the chronically ill or dying patient, a basic knowledge of current
psychiatric treatment modalities, etc.). To the list used by
Johnson & Snibbe in the United States (Johnson W, Snibbe
J, 1975) and by Guimón et al. in Spain (Guimon J, Totorica
K, Villasana A, Ozamiz A, 1980), we added two new aspects: psychiatric
aspects of molecular biology and neuroimagery and knowledge
of both the normal and pathological processes of mental aging.
Each field had to be evaluated between 0 "not at all important
" and 3 " essential/ indispensable".
Statistical
methods
A
factor analysis was undertaken on 22 of the 23 items concerning
the information about, and the expertise on, psychiatry necessary
for any physician. One item, concerning the ability to talk
with patients about their personal problems, was not included
since most physicians gave it a very high rating. The factor
analysis explained, with six factors, 58.1% of the variance.
The first three factors are used in the following analysis.
For each of the underlying dimensions, an additive index was
created using the values of the items with factor loadings equal
to or greater than .50.
The
usual statistical tests were used (x2 for dichotomic
or dichotomized variables, t-test, respectively Mann-Whitney
U test, or variance analysis (anova) for continuous variables).
Only the results presenting statistically significant differences
will be presented here.
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