DISCUSSION

· Three conceptions of psychiatry

The secondary analysis of the data covering the knowledge and expertise deemed necessary to the practice of medicine allows us to delineate three different types of understanding of psychiatry in primary-care physicians: the psychosocial, the psychodynamic and the clinical-biological conceptions. The first type corresponds to a set of difficulties for the patients which are often hard to bear and in general long-lasting, with consequences on their social life and important implications for the relationship between the physician and the patient. For the second, on a clearly more psychological level, the necessity of having psychological knowledge, or even psychoanalytical skill, is linked to an interest in normal personality development and disorders in early life. The third underlines the importance for physicians of knowing how to diagnose and treat, mainly through drugs, the principal psychiatric disorders. These three conceptions, which can be considered as an expression of attitudes towards psychiatry and as corresponding to three types of needs concerning problems of a psychiatric nature, present an analogy with the orientations described for psychiatrists themselves. A survey carried out among Swiss psychiatrists (Guimon J, Fischer W, Goerg D, Zbinden E, 1997) showed the existence, though founded on very different data, of these main theoretical orientations.

Important differences exist in the conceptions of psychiatry physicians favor according to their specialization. Among primary-care physicians, it is general practitioners and general internists who adhere most strongly to a psychosocial understanding on the one hand and a clinical-biological one on the other. Internists with subspecialization (cardiology, rhumatology, etc.) and pediatricians have a lower profile in these two types of understanding. On the contrary, pediatricians appear to endorse most clearly a psychodynamic conception. The degree to which primary-care physicians are interested in psychiatric matters is variable. It can be considered that slightly more than one-fifth of these physicians show a high degree of interest in psychiatry. It is particularly the case for general practitioners who display this tendency more frequently than do other primary-care physicians. These different references are probably linked, among others, to the training and education they have received, to the particularities of their patients and to the physician's specific fields of activity (long-term treatment vs. evaluation, or general care vs. treatment of specific disorders, for example).

Specialized physicians who do not handle primary-care differ from primary-care physicians. They have, in general, little attraction to any type of psychiatric understanding, and surgeons even less than most other specialists. These observations resemble those of other studies undertaken with physicians of various specialties. Thus, Cohen-Cole & Friedman (Cohen-Cole SA, Friedman CP, 1982) note that hospital specialists in family medicine and internists consider that their patients suffer from illnesses with an important psychological element more often than do surgeons, pediatricians or gynecologist-obstetricians. Among physicians working in private practice, internists consider, more often than surgeons, that an important proportion of their clients suffer from psychiatric disorders (Fauman MA, 1983). In a study undertaken with hospital physicians, it appeared that surgeons were much less interested than other physicians in the emotional problems of their patients and felt less responsible for their treatment (Mayou R, Smith EBO, 1986).

We noted that internists with subspecialization ranked in an intermediate position between general internists, who were often closer to general practitioners, and specialized physicians who did not work in primary care. It seems that in a region with a very high medical population those doctors might as well work as general practitioners or as super-specialists. Their position on psychiatric orientation, with regard to the ways in which different patients are viewed, would indicate that both types of functioning exist, either among physicians, or for the same physician.

· Consequences on referral to psychiatry

The aim of this study was not to examine the relationship that primary-care physicians have with psychiatry or psychiatric services as these relationships have already been the object of research in certain specific contexts. Some results, however, can indirectly suggest the existence of differing mind-sets, needs and expectations in physicians towards this discipline. Thus, physicians with a strong psychodynamic tendency, i.e. those who appear to have the greatest affinities with one of the predominant tendencies of Swiss psychiatry, refer a higher number of their patients to psychiatrists. It would be important to know whether, in these cases, the motivation behind these referrals is a desire to delegate authority or to cooperate.

Physicians who favor a psychosocial conception of psychiatry and who attach great importance to the doctor-patient relationship, emphasize the difficulties that patients face coping with everyday problems as well as the psychiatric disorders of their patients, but do not refer more patients to psychiatrists than those physicians without a marked psychosocial orientation. The same applies to physicians who foster a biological approach to psychiatry. In the first case, the question arises as to whether physicians are prepared to cope with their patients' difficulties through improving their own methods of handling interpersonal relationships, for example Balint groups, which might help them to better assess the treatment to be given to their own patients and to decide when to refer them to psychiatrists. In the second case, it is possible that physicians think themselves better able to treat certain psychiatric disorders, often through the use of drugs.

· Scope and limitations

Our data do not permit a more in-depth study of these different questions. This is one of the constraints placed upon a secondary analysis of data, which were not expressly gathered for a certain purpose and which were limited in nature. Other studies will be necessary to ascertain the conceptions physicians have of psychiatry and how they interpret their relations to it : as partners, as proxies or as competitors. The current outcry to reduce health-care costs and the increasing pressure brought to bear by insurance companies might also modify the relations physicians working in different fields of specialization have to psychiatry.

These results have implications for the training of physicians in the field of psychiatry since it can be considered that the vast majority of patients suffering from psychiatric disorders are to be found in primary-care medicine. According to Shepherd et al. (Shepherd M, Cooper B, Brown AC, Kalton G, 1981), among the patients of general practitioners, one patient out of seven shows symptoms of psychiatric disorder. The World Health Organization Collaborative Study on psychological problems in general health care shows that 24% (on average) of all patients contacting general health services, in a wide range of health-care settings and cultural contexts, have current mental disorders. A certain proportion of patients (9%) suffer from a sub-threshold condition that has clinically significant symptoms and functional impairment, while 31% have a few mental disorder symptoms (Goldberg DP, Lecrubier Y, 1995). Thus primary-care physicians are de facto an essential resource of the mental health-care system (Regier DA, Goldberg ID, Taube CA, 1978) and their training in mental health should be improved.

As knowledge of diagnosis and treatment of the most frequent psychiatric disorders is already included in the undergraduate curriculum, the interest displayed in the development of learning how to cope with interpersonal relationships and the expansion of psychodynamic knowledge which appear in this report indicate that these subjects should form an integral part of the undergraduate, postgraduate and professional training of physicians.

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