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versión impresa ISSN 0213-6163
Eur. J. Psychiat. vol.20 no.4 nov./dic. 2006
M. González, MD, PhD, J. Calderón, MD, MRCPsych (UK), P. Olguín, MD, J.L. Flores, MD, S. Ramírez, MD
Consultation-Liaison Unit, Hospital Clínico Pontificia Universidad Católica de Chile
Psychosocial factors play an important role in the clinical practice in the general hospital. The main objective of this study is to evaluate the relevance assigned by non psychiatry physicians who work in a teaching general hospital, to psychosocial factors in the context of their day-to-day clinical practice, and the coping strategies they adopt to deal with them. A second objective is to assess the evaluation of the Consultation-Liaison (C-L) service in a teaching hospital.
Method: A previous questionnaire about perception of psychosocial factors in the general hospital (1) was adapted. Our questionnaire consists of 3 sections. A first section gathers socio-demographic information of surveyed physicians; a second section evaluates the relevance assigned by non psychiatry physicians to psychosocial factors, and their coping strategies, and finally, a third new section designed to provide an evaluation of our C-L unit service provision by non psychiatry physicians.
Results: Of a total of 219 non specialty physicians responding to the survey, 35.5% stated they had adequate knowledge of psychiatric disorders, 87.3% considered that psychosocial factors influence the origin and prognosis of physical illnesses and 99.5% considered that social and emotional aspects play an important role in their clinical practice. 79.6% considered psychiatrists to be essential for the care of hospitalized patients. Statistical significance was set at 5%.
Conclusion(s): This paper highlights the relevance attributed to psychosocial factors in clinical practice and the importance assigned to the C-L services by non specialty physicians of a teaching general hospital.
Keywords: Consultation-Liaison services, General Hospital, Social and Psychological Factors, Perception.
Consultation psychiatry is a subspecialty within the field of psychiatry that serves as a liaison with the rest of the medical field. It is assigned an important role in the development and education of psychosocial aspects towards other medical specialties2. C-L services operate in general hospitals where mental disorders have been reported to be present in as much as a 25% of inpatients3. These units help to increase treatment adherence, reduce the time of hospitalization and medical resources burden, and improve life expectancy4,5,6,7. Moreover, the interaction between the psychiatrist and non psychiatrist physician contributes to the implementation of better psychosocial educational programs.
The focus of the studies that scrutinize the more relevant aspects of the clinical practice of psychiatry in a general hospital has been set upon two main aspects. On one hand, some studies have described the general aspects of C-L services such as demographic characteristics of the assisted population, reason for referrals, and the results obtained by C-L services8,9. On the other hand, other studies have studied the perception that different specialists have of psychiatric services within the general hospital10.
More recently and complementing the original paper1, a study has focused its interest on the coping strategies used by non psychiatric physicians when dealing with mental disorders in hospitalized patients11.
In this paper, we have adapted the questionnaire designed by Mayou and Smith, incorporating a new section that introduces a feedback evaluation of our C-L unit service provision.
The study of the perception that non psychiatry physicians have about the importance of psychosocial factors in their medical practice, contributes to a better definition of the psychiatric practice boundaries within the general hospital, and therefore optimizes the implementation of C-L services in hospitals.
The study was designed between July and December 2004. The physicians surveyed work in the Catholic University of Chile's teaching hospital in Santiago. This is a 536-bed hospital that covers an extended area of the city. Although an informal consultation service was implemented 12 years ago, a formal C-L service unit, with 3 full-time psychiatrists, was only established 3 years ago.
We adapted a questionnaire on mental health perception for non psychiatry physicians who work in a hospital setting. This consisted of a modification of the original questionnaire designed by Mayou and Smith, in order to include a section that incorporates an evaluation by non psychiatry physicians of our C-L unit service provision.
A pilot study was conducted among a consecutive sample of 30 non-psychiatrist residents, with views to improve the wording of the questions and the length of the questionnaire. During the pilot study we realized that a feedback evaluation of our C-L service provision from non-psychiatrist physicians was needed, in order to inform a strategy for further developments of the unit. Hence we decided to include a whole new section for this purpose. The questionnaire is self-administered and was sent out via internal email to all non psychiatry physicians (residents and staff) working in the hospital. Prior to this, permission had been granted by the hospital board to carry out the survey. As in previous studies1,11, paediatric services and those services that do not have direct contact with patients were excluded.
The surveys were filled out anonymously, but were coded in order to specify response rates within each service. A total of 357 physicians received the questionnaire. Copies of the surveys are available for those interested.
The first and second section of our questionnaire are very similar to the one designed by Mayou and Smith, with a first section dealing with socio-demographic data and specialty of the physician surveyed, and a second section enquiring about general physicians´ knowledge and skills on psychosocial factors involved in their day to day clinical work. From a total of 5 questions of this second section, the first 3 ones deal with general knowledge about psychiatric disorders, and the perceived influence of psychosocial factors on prognosis of medical conditions and on physicians' daily clinical practice. In turn, the last 2 questions focus on perceived prevalence of psychosocial factors and related coping strategies used by surveyed physicians. The third section gathers information about perception of non-psychiatrists about our C-L unit service provision. It includes 4 questions and a space for comments. The issues surveyed are: need of psychiatrists in the general hospital, promptness and adequacy of service provided.
The results of the questionnaire were used to obtain univariate comparisons using chi-square or Fisher's exact tests, as appropriate. As in previous studies, statistical significance was set at the 5% level.
From a total universe of 357 non-psychiatry physicians, 59 were excluded from the sample for being out of the hospital during the study period. This makes up a total of 298 surveyed, 73.5% of which (n = 219) responded to the survey. The 38.8% of the sample corresponded to surgical specialty physicians, 88% were male, 56% were staff, and 51% were between 30 and 45 years old.
For each question, inter-group differences were sought out: male/female, residents/staff, and surgical/non-surgical specialties (from now on, surgeons/physicians).
Non psychiatric physicians and psychosocial factors: general knowledge and coping strategies
87.3% of surveyed physicians considered that psychological factors play a role in the aetiology and prognosis of physical diseases, and 99.5% thought that social and emotional factors are important in their clinical work, results which are in line with those described by Morgan and Killoughery in 2001. On the other hand, 35.5% believed to have adequate knowledge of psychiatric disorders. Surgeons felt less confident in this respect, when compared with doctors from other specialties. Interestingly, younger doctors (residents), ascertained a higher degree of perceived knowledge of psychiatric disorders when compared to older doctors (staff). (Table I).
With regards to the perceived prevalence of psychiatric disorders and psychosocial problems encountered in their clinical work, the surveyed listed anxiety disorders (93.5%), depression (80.4%), giving bad news (78.5%), insomnia (71.8%), conflictive or hostile patient or relative (58.9%) and delirium (53.1%) as the most frequently faced with. (Table II).
Table III shows the coping strategies displayed by surveyed doctors to deal with psychosocial problems. Psychosis, suicide attempt, substance use, phobias, and patients with a history of psychiatric disorders, were considered more troublesome and to request psychiatric assessment.
On the other hand, problems considered not requiring specialized management were: giving bad news, insomnia, hostile patient or relative, and anxiety. Only a minority considered psychiatric disorders as irrelevant for their clinical practice.
When asked whether they would treat psychiatric disorders and psychosocial problems themselves, surgeons were less keen than other physicians, although most coincided in that they would make a attempt to cope with insomnia, giving bad news, and conflictive/hostile patients. (Table IV)
The Role of Psychiatry in the General Hospital
79.6% of those surveyed considered psychiatrists highly necessary in the general hospital. In our study, only 18.9% pointed out that psychiatrists although necessary in general terms, were not indispensable in the hospital setting.
Around 2/3 of those surveyed considered the hospital liaison unit to provide an adequate clinical service, while 61.1% of those surveyed considered that a 24-hrs on call psychiatrist was essential for the hospital daily functioning.
Psychosocial factors are known to be relevant to the general hospital physicians in their clinical practice. Although many of these factors are dealt with by the medical team, others tend to overwhelm their intervention capability. Specifically trained psychiatrists and other members of the mental health team are in a suitable position to intervene along with non-psychiatry physician in the most difficult areas, namely diagnosing and treating severe psychiatric disorders, assessing suicidal patients, addressing issues such as agitation within the general hospital settings, among others.
The obstacles encountered for the implementation of liaison units are still too many, and it has become urgent to persuade physicians and health organisers about the need of an integration of psychiatry in the mainstream of hospital service provision12,13.
Unfortunately, the paucity of evidence-based successful interventions in this area14 still limits a more rapid integration, despite the now well established relation between psychological factors and length of admission, co-morbidity and quality of life.
Nevertheless, the process of implementation of a liaison unit requires, a thorough knowledge of the specific characteristics of the environment where it will develop. The perceptions of non-psychiatry physicians about psychosocial factors can be argued to be of paramount importance for the success of such an enterprise. In fact, it is most likely that these physicians will be involved in health plan developments at any time.
The aim of this study was firstly to inform a further development of our relatively new unit, and secondly to contribute to the discussion about research in the area of perception of psychosocial factors in the general hospital. This study provides a representative sample of physicians in a teaching hospital. The sample is similar in size in relation to other studies and there was a high rate of response. Interestingly, the survey showed that non psychiatry physicians perceived that social and emotional factors have a significant influence in their clinical practice. Surgical specialists seemed less confident in the recognition and management of these factors, as did older doctors compared to younger ones. Suicide attempt, psychosis, substance use, phobias and previous psychiatric history were found to require psychiatric assessment, where only a half of surveyed felt confident in treating delirium. Of note is the fact that the great majority felt at ease treating anxiety and insomnia. The survey also conveyed the importance that physicians grant to the C-L service provided by our unit.
The data collected in our study is comparable to the Morgan and Killoughery study, with reference to the influence of psychosocial factors in the origin and prognosis of physical illness, as well as to the importance of social and emotional aspects in clinical practice. The similarity between both studies may be explained by the current emphasis given to the psychosocial factors in undergraduate curriculum and the progress made in the integration of social and behavioural sciences15. This is in line with the fact that our hospital was accredited by the American Association of Medical Colleges in 1997, where the need to incorporate these aspects was explicitly pointed out16. On the other hand, 66.6% of academics working within the hospital have spent at least one year in hospitals and universities abroad, which allows for the standardization with highly prestigious centres. Another factor to be considered is that, despite a short 3-year history of a formal C-L unit in our hospital, there is a 12-year history of an informal consultation service, with a larger experience than other centres in the country, with no consultation or C-L service17.
The main limitations of our study are, firstly, the difficulty in extrapolating the data obtained in our survey to clinical practice. As pointed out by Morgan and Killoughery, the effect of the normative social influence ("social desirability bias") continues to be a non resolved problem. Secondly, the results are not necessarily representative of other general hospitals in Santiago, particularly the ones with no C-L services. Nevertheless, our results are comparable to previous surveys mentioned in this paper.
The subsistence and further development of C-L services will depend on high quality research in this area, and the perception of non-psychiatry physicians about psychosocial factors will be a relevant area to be addressed. Methodological issues related to normative social influence need to be dealt with in order to extrapolate the findings to clinical practice. Qualitative methodology seems more suitable for forthcoming research in this area.
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Received 29 December 2005
Accepted 16 May 2006