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Patterns of family doctor referrals for psychiatric diagnosis
Pergamon Press
Sot. Sci. & Med., 1970, Supplement 1, Vol. 4, pp. 37-42
PATTERNS OF FAMILY DOCTOR REFERRALS
FOR PSYCHIATRIC
DIAGNOSIS
l
Raymond Fink, Ph.D. and Sidney S. Goldensohn, M.D.
In October 1965 a Mental Health Center was started in the Jamaica Medical Group, largest of the 31 medical groups of the Health Insurance Plan of Greater New York. Through this Center, psychiatric therapy became available to the medical group’s 45,900 patients age 15 and older. Previously their psychiatric care in H.I.P. was limited to the diagnostic service provided by the group psychiatrist. In connection with this new psychiatric service, two programs of research are underway. The first of these is designed to determine the organization, cost and scope of a psychiatric treatment program that could be incorporated in a prepaid group practice plan through a reasonable increase in premium.“)
The second study focuses largely on the family doctor and the patterns of medical care
he provides for emotional disorders seen during his regular practice.“’ Patterns of family physician referrals to the psychiatrist are a major area of interest of the second study and the primary concern of this report. In this study of the family doctor’s care for emotional problems the impact of the psychiatric therapy service will be measured with respect to: changes in patterns of medical care provided for patients with emotional disorders; changes in the nature of those emotional conditions referred to the psychiatrist and those retained by the family physician; and differences in treatment provided for patients referred to the psychiatrist and those retained for family physician care. From the point of view of the patient, the study examines the impact of the psychiatric service on: changes in patterns of medical care and other aid sought and received for emotional disorders (as determined
through
interviews with
physicians and patients);
and social and psychological
characteristics of patients as these relate to patterns of medical care for emotional disorders and in particular changes in these patterns resulting from the introduction of psychiatric therapy. THE STUDY DESIGN Information is being obtained through interviews with both family doctors and patients of the Jamaica Medical Group conducted at two points in time. The first point covers a period immediately prior to the offering of psychiatric care on a large-scale basis. The field work for this phase has been completed and is the basis for this report. The second study period is planned for two years later. *The psychiatric demonstration program is supported in part by grants from the New York Foundation and from the Community Health Services of the U.S. Public Health Service tCH34 67). Research on the family physician and patterns of medical care for emotional problems is supported in part by research grant MH 02321-01, received from the National Institute of Mental Health, Public Health Service.
37
R. Fink and S.S. Goldensohn
38
Sample selection -
For study purposes two random samples were selected from members of the
Jamaica Medical Group 15 years of age and older who saw one of the group’s 32 family physicians in his office during the three-month period from September 1 through November 30, 1985. The first of these was a sample of patients for whom the physician reported, on a routine form, conditions classifiable according to the International Classification of Diseasesas a “mental, psychoneurotic or personality disorder.” This will be referred to as the “Psychiatric Diagnosis” sample. There was a total of 435 patients in this sample. The second sample was taken from among all other patients 15 years of age and older who saw a family physician during the study period. For these patients there was no indication of an emotional or psychiatric problem during this period. The findings which follow concern only the Psychiatric Diagnosis sample. STUDY FINDINGS During the three month study period a Psychiatric Diagnosis was reported for five per cent of all patients seen by the family doctors. Family doctor information reported here is based on 422 patients for whom adequate interview information from the family doctor was available. On the basis of these reports, patients in the psychiatric sample were classified into three groups: those who had a discussion with a family doctor about a psychiatric referral (but no referral was made); those for whom a referral was made; and those who had neither a discussionor referral. The largest of these groups consists of those for whom there had never been any discussionof a referral to the group psychiatrist - 65 percent of the sample. Next are those for whom it was reported that there had been only a discussion but no referral - 9 percent of the sample. Finally there were those who were referred to the group psychiatrist at some time either before, during or after the three month study period. This group totals 26 percent of the psychiatric sample. Forty-one percent of the patients with Psychiatric Diagnosis had conditions described by the family doctor as “acute” rather than “chronic.” In comparing those whose emotional conditions were reported as “chronic” with those described as “acute” it was found that patients with chronic emotional conditions were about twice as likely to receive a psychiatric referral as those with acute conditions. One-third of those with chronic conditions were referred as compared with 17 percent of those with acute conditions. Family doctors were asked about the extent to which the reported emotional condition interfered with the patient’s work on a job, work around the house, family life, ability to get along with others, the patient’s sex life, and his ability to enjoy himself during his free or leisure time. For each life activity the family doctor was asked if the degree of interference was a “great deal”, “somewhat”, “very little”, or “not at all”. In general, the greater the number of activities in which the emotional condition interferes, the greater the likelihood of a psychiatric referral. Among patients with no interference, 14 percent were referred-where there was reported interference in three or more life activities, 41 percent were referred. The extent of the interference is also an important consideration in the referral process Among patients who are reported by their family doctors as having emotional problems in which the extent of interference with life activities is ‘very little” or “not at all” only one in ten is referred to the psychiatrist. If there is “somewhat” interference, the likelihood of referral increasesto one in four. For those reported by family physicians as experiencing a “great deal” of interference with one or more life activities, half are referred to the psychiatrist.
Patterns Of Family Doctor Referrals For Psychiatric Diagnosis
39
The referral process was also reviewed as it relates to the care the family doctor provides for his patients before referral is made. It was found that whether or not a referral was made was importantly related to how effective the family doctor thought prescribed drugs were in helping the patient with his emotional problem and also, his judgment of the effectiveness of doctor-patient discussions in relieving the patient. Among patients for whom the family doctor thought drugs to be “very helpful”, 18 percent were referred; among those for whom the drugs provided “very little” or no help, 43 per cent were referred. In similar fashion among those for whom the family doctor described doctor-patient discussions about the emotional problem as “very helpful”, 19 percent were referred; among those for whom these discussionswere of little or no help, 39 percent were referred. CONTACT BETWEEN FAMILY PHYSICIAN
AND THE MENTAL HEALTH CENTER
As was the case before the Mental Health Center was established, patients are referred for consultation to the group psychiatrist by doctors of the Jamaica Medical Group. The medical group psychiatrist is also the Director of the Mental Health Center. It is at this diagnostic visit that the decision is made as to whether or not the patient should be seen for treatment at the Mental Health Center. If accepted for treatment, the patient is referred to a specific therapist at the Center. The group practice setting increases the opportunity for contact between therapist and family doctor. Toward this end the Mental Health Center staff conducts monthly luncheon-seminars for 8 family doctors, chosen in rotation. Thus, each family doctor is meeting with the staff twice yearly. One of the doctor’s recently discharged patients is discussed in detail. Emphasis is placed on early psychiatric diagnosis, increased sensitization to emotional problems, understanding of the nature of the illness and after-care. In addition, the patient’s personal physician is sent a written summary when the patient is discharged. The doctor is also called by the patient’s therapist a few days after discharge at which time the patient and his after-care are discussed. In selected cases, visits are made to the doctor’s office by the therapist to discussaftercare. The overall response of the group physicians and the patients has been one of pleasure and relief at having services from the Mental Health Center readily available, whereas in the past there was a dearth of psychiatric resources in the geographic area of the medical group. SUMMARY AND CONCLUSIONS From the point of view of measuring change in referral practices resulting from the introduction of psychiatric care, it is evident that the manner in which the emotional condition is viewed by the family doctor is an important determinant of whether or not a referral is made. The referred patients tend to be those who have chronic emotional problems rather than those beset by an acute episode. Further, psychiatric referrals tend to go to those with conditions regarded by the family doctor as being of importance, and those conditions which interfere with life activities. Among the research questions to be asked in later phases of this research are those touching on the manner in which the family physician may revise his perception of the emotional problems he sees. It will also be of interest to see whether the availability of psychiatric treatment and information received from the Medical Health Center on patients he has referred alters the family doctor’s referrals and management of patients with mental or emotional problems.
40
R. Fink and S.S. Goldensohn
Table Grand Score and Individual Correlation
I la Correlates of Knowledge
Ratioes Squared
n
etaL -
beta2
,091
,047
Recency of graduation .258
.275
Length of Residency
.041
Specialization
.I24
.393
Table Ilb n
etaL
beta2
.388
.260 b/
attendance
.I52
.054c/
Specialty journal reading
,128
.019d/
County
.lll
.046el
R2
Age-Specialization Typology (Combination of the three above factors Postgraduate course
a/ Holding constant, b/
.475
in each case, the other two factors
Holding postgraduate courses, specialty journals, and county constant
c/ Holding age-specialization
typology,
specialty journals, and county constant
d/
Holding age-specialization
typology,
postgraduate courses and county constant.
e/ Holding age-specialization
typology,
postgraduate courses and specialty journal reading constant.
The second column different
keeping-up
reduced.
The
contribution
The
addition
Ilb shows the independent
are introduced.
of post graduate
The
training
initial
effect
of age and specialization
relationship
and specialty
with
journal
after
levels of information
is
reading shows independent
to levels of knowledge.
initial
predictive
regression coefficient between
in Table
activities
power
of age and specialization
is indicated
by the squared
of .390. This means that the three variables of age and specialization
a third and a half of the variance in our original grand score. Introduction
increases our predictive
power somewhat
(from
greater clarity the major correlates of knowledge,
393
to .475).
specialization
multiple
account for
of other factors
It also allows us to interpret
and age.
with
Patterns Of Family
FAMILY EMOTIONAL
Doctor
DOCTOR
CONDITION
Referrals For Psychiatric
REPORTS AND
ON PATIENT’S
PSYCHIATRIC
REFERRALS
PER CENT Sample Size*
Family Doctor Reports on Emotional
U’Jo.)
Condition TOTAL
A.
41
Diagnosis
OF PATIENTS
Neither Discussed Nor
Discussed Referral
Psych iatric
Referred
Only
Referral
422
65
9
26
167 239
78 55
5 12
17 33
178
81
6
13
74
65
5
26
Two
50
46
Three or more Don’t know
86 33
47 67
14 12
40 41
6
27
Acute vs. Chronic Acute Chronic
8. Number of Life Activities with which Patient’s Emotional Condition Interferes None One
*The total of each of the distributions and unclassifiable
replies.
may not come to 422 due to the exclusion of “No Answers”
R. Fink and S.S. Goldensohn
42
C. Maximum Interference in One or More of Patient’s Life Activities Great deal Somewhat Very little or Not at all Don’t know D. Drugs Very helpful Somewhat helpful Very little or not at all helpful Don’t know E. Discussions Very helpful Somewhat helpful Very little or not at all helpful
126 84
38 65
12 11
50 26
178 33
84 67
6 6
10 27
119*+
73
9
18
111
59
12
29
42 57
48 83
9 5
43 12
126””
71
10
19
152
67
7
26
94
49
12
39
**Excludes patients for whom no drugs were prescribed for an emotional condition. l**Exludes patients for whom the family doctor reports no doctor-patient discussionsabout an emotional condition.
REFERENCES (1) Goldensohn, S.S.; Daily, E.F.; Shapiro, S. and Fink, R.; “Referral and Utilization Patterns in the First Year of a Mental Health Center in a Prepaid Group Practice Medical Program,“Medica/ Care, Vol. 5, No. 1. (2) Fink, R.; Goldensohn, S.S.;Shapiro, S. and Daily, E.F.: “Characteristics of Patients Designated by Family Doctors as Having Emotional Problems,” American Journal of Public Health (In press). Check this reference with authors.
Sot. Sci. & Med., 1970, Supplement 1, Vol. 4, pp. 37-42
PATTERNS OF FAMILY DOCTOR REFERRALS
FOR PSYCHIATRIC
DIAGNOSIS
l
Raymond Fink, Ph.D. and Sidney S. Goldensohn, M.D.
In October 1965 a Mental Health Center was started in the Jamaica Medical Group, largest of the 31 medical groups of the Health Insurance Plan of Greater New York. Through this Center, psychiatric therapy became available to the medical group’s 45,900 patients age 15 and older. Previously their psychiatric care in H.I.P. was limited to the diagnostic service provided by the group psychiatrist. In connection with this new psychiatric service, two programs of research are underway. The first of these is designed to determine the organization, cost and scope of a psychiatric treatment program that could be incorporated in a prepaid group practice plan through a reasonable increase in premium.“)
The second study focuses largely on the family doctor and the patterns of medical care
he provides for emotional disorders seen during his regular practice.“’ Patterns of family physician referrals to the psychiatrist are a major area of interest of the second study and the primary concern of this report. In this study of the family doctor’s care for emotional problems the impact of the psychiatric therapy service will be measured with respect to: changes in patterns of medical care provided for patients with emotional disorders; changes in the nature of those emotional conditions referred to the psychiatrist and those retained by the family physician; and differences in treatment provided for patients referred to the psychiatrist and those retained for family physician care. From the point of view of the patient, the study examines the impact of the psychiatric service on: changes in patterns of medical care and other aid sought and received for emotional disorders (as determined
through
interviews with
physicians and patients);
and social and psychological
characteristics of patients as these relate to patterns of medical care for emotional disorders and in particular changes in these patterns resulting from the introduction of psychiatric therapy. THE STUDY DESIGN Information is being obtained through interviews with both family doctors and patients of the Jamaica Medical Group conducted at two points in time. The first point covers a period immediately prior to the offering of psychiatric care on a large-scale basis. The field work for this phase has been completed and is the basis for this report. The second study period is planned for two years later. *The psychiatric demonstration program is supported in part by grants from the New York Foundation and from the Community Health Services of the U.S. Public Health Service tCH34 67). Research on the family physician and patterns of medical care for emotional problems is supported in part by research grant MH 02321-01, received from the National Institute of Mental Health, Public Health Service.
37
R. Fink and S.S. Goldensohn
38
Sample selection -
For study purposes two random samples were selected from members of the
Jamaica Medical Group 15 years of age and older who saw one of the group’s 32 family physicians in his office during the three-month period from September 1 through November 30, 1985. The first of these was a sample of patients for whom the physician reported, on a routine form, conditions classifiable according to the International Classification of Diseasesas a “mental, psychoneurotic or personality disorder.” This will be referred to as the “Psychiatric Diagnosis” sample. There was a total of 435 patients in this sample. The second sample was taken from among all other patients 15 years of age and older who saw a family physician during the study period. For these patients there was no indication of an emotional or psychiatric problem during this period. The findings which follow concern only the Psychiatric Diagnosis sample. STUDY FINDINGS During the three month study period a Psychiatric Diagnosis was reported for five per cent of all patients seen by the family doctors. Family doctor information reported here is based on 422 patients for whom adequate interview information from the family doctor was available. On the basis of these reports, patients in the psychiatric sample were classified into three groups: those who had a discussion with a family doctor about a psychiatric referral (but no referral was made); those for whom a referral was made; and those who had neither a discussionor referral. The largest of these groups consists of those for whom there had never been any discussionof a referral to the group psychiatrist - 65 percent of the sample. Next are those for whom it was reported that there had been only a discussion but no referral - 9 percent of the sample. Finally there were those who were referred to the group psychiatrist at some time either before, during or after the three month study period. This group totals 26 percent of the psychiatric sample. Forty-one percent of the patients with Psychiatric Diagnosis had conditions described by the family doctor as “acute” rather than “chronic.” In comparing those whose emotional conditions were reported as “chronic” with those described as “acute” it was found that patients with chronic emotional conditions were about twice as likely to receive a psychiatric referral as those with acute conditions. One-third of those with chronic conditions were referred as compared with 17 percent of those with acute conditions. Family doctors were asked about the extent to which the reported emotional condition interfered with the patient’s work on a job, work around the house, family life, ability to get along with others, the patient’s sex life, and his ability to enjoy himself during his free or leisure time. For each life activity the family doctor was asked if the degree of interference was a “great deal”, “somewhat”, “very little”, or “not at all”. In general, the greater the number of activities in which the emotional condition interferes, the greater the likelihood of a psychiatric referral. Among patients with no interference, 14 percent were referred-where there was reported interference in three or more life activities, 41 percent were referred. The extent of the interference is also an important consideration in the referral process Among patients who are reported by their family doctors as having emotional problems in which the extent of interference with life activities is ‘very little” or “not at all” only one in ten is referred to the psychiatrist. If there is “somewhat” interference, the likelihood of referral increasesto one in four. For those reported by family physicians as experiencing a “great deal” of interference with one or more life activities, half are referred to the psychiatrist.
Patterns Of Family Doctor Referrals For Psychiatric Diagnosis
39
The referral process was also reviewed as it relates to the care the family doctor provides for his patients before referral is made. It was found that whether or not a referral was made was importantly related to how effective the family doctor thought prescribed drugs were in helping the patient with his emotional problem and also, his judgment of the effectiveness of doctor-patient discussions in relieving the patient. Among patients for whom the family doctor thought drugs to be “very helpful”, 18 percent were referred; among those for whom the drugs provided “very little” or no help, 43 per cent were referred. In similar fashion among those for whom the family doctor described doctor-patient discussions about the emotional problem as “very helpful”, 19 percent were referred; among those for whom these discussionswere of little or no help, 39 percent were referred. CONTACT BETWEEN FAMILY PHYSICIAN
AND THE MENTAL HEALTH CENTER
As was the case before the Mental Health Center was established, patients are referred for consultation to the group psychiatrist by doctors of the Jamaica Medical Group. The medical group psychiatrist is also the Director of the Mental Health Center. It is at this diagnostic visit that the decision is made as to whether or not the patient should be seen for treatment at the Mental Health Center. If accepted for treatment, the patient is referred to a specific therapist at the Center. The group practice setting increases the opportunity for contact between therapist and family doctor. Toward this end the Mental Health Center staff conducts monthly luncheon-seminars for 8 family doctors, chosen in rotation. Thus, each family doctor is meeting with the staff twice yearly. One of the doctor’s recently discharged patients is discussed in detail. Emphasis is placed on early psychiatric diagnosis, increased sensitization to emotional problems, understanding of the nature of the illness and after-care. In addition, the patient’s personal physician is sent a written summary when the patient is discharged. The doctor is also called by the patient’s therapist a few days after discharge at which time the patient and his after-care are discussed. In selected cases, visits are made to the doctor’s office by the therapist to discussaftercare. The overall response of the group physicians and the patients has been one of pleasure and relief at having services from the Mental Health Center readily available, whereas in the past there was a dearth of psychiatric resources in the geographic area of the medical group. SUMMARY AND CONCLUSIONS From the point of view of measuring change in referral practices resulting from the introduction of psychiatric care, it is evident that the manner in which the emotional condition is viewed by the family doctor is an important determinant of whether or not a referral is made. The referred patients tend to be those who have chronic emotional problems rather than those beset by an acute episode. Further, psychiatric referrals tend to go to those with conditions regarded by the family doctor as being of importance, and those conditions which interfere with life activities. Among the research questions to be asked in later phases of this research are those touching on the manner in which the family physician may revise his perception of the emotional problems he sees. It will also be of interest to see whether the availability of psychiatric treatment and information received from the Medical Health Center on patients he has referred alters the family doctor’s referrals and management of patients with mental or emotional problems.
40
R. Fink and S.S. Goldensohn
Table Grand Score and Individual Correlation
I la Correlates of Knowledge
Ratioes Squared
n
etaL -
beta2
,091
,047
Recency of graduation .258
.275
Length of Residency
.041
Specialization
.I24
.393
Table Ilb n
etaL
beta2
.388
.260 b/
attendance
.I52
.054c/
Specialty journal reading
,128
.019d/
County
.lll
.046el
R2
Age-Specialization Typology (Combination of the three above factors Postgraduate course
a/ Holding constant, b/
.475
in each case, the other two factors
Holding postgraduate courses, specialty journals, and county constant
c/ Holding age-specialization
typology,
specialty journals, and county constant
d/
Holding age-specialization
typology,
postgraduate courses and county constant.
e/ Holding age-specialization
typology,
postgraduate courses and specialty journal reading constant.
The second column different
keeping-up
reduced.
The
contribution
The
addition
Ilb shows the independent
are introduced.
of post graduate
The
training
initial
effect
of age and specialization
relationship
and specialty
with
journal
after
levels of information
is
reading shows independent
to levels of knowledge.
initial
predictive
regression coefficient between
in Table
activities
power
of age and specialization
is indicated
by the squared
of .390. This means that the three variables of age and specialization
a third and a half of the variance in our original grand score. Introduction
increases our predictive
power somewhat
(from
greater clarity the major correlates of knowledge,
393
to .475).
specialization
multiple
account for
of other factors
It also allows us to interpret
and age.
with
Patterns Of Family
FAMILY EMOTIONAL
Doctor
DOCTOR
CONDITION
Referrals For Psychiatric
REPORTS AND
ON PATIENT’S
PSYCHIATRIC
REFERRALS
PER CENT Sample Size*
Family Doctor Reports on Emotional
U’Jo.)
Condition TOTAL
A.
41
Diagnosis
OF PATIENTS
Neither Discussed Nor
Discussed Referral
Psych iatric
Referred
Only
Referral
422
65
9
26
167 239
78 55
5 12
17 33
178
81
6
13
74
65
5
26
Two
50
46
Three or more Don’t know
86 33
47 67
14 12
40 41
6
27
Acute vs. Chronic Acute Chronic
8. Number of Life Activities with which Patient’s Emotional Condition Interferes None One
*The total of each of the distributions and unclassifiable
replies.
may not come to 422 due to the exclusion of “No Answers”
R. Fink and S.S. Goldensohn
42
C. Maximum Interference in One or More of Patient’s Life Activities Great deal Somewhat Very little or Not at all Don’t know D. Drugs Very helpful Somewhat helpful Very little or not at all helpful Don’t know E. Discussions Very helpful Somewhat helpful Very little or not at all helpful
126 84
38 65
12 11
50 26
178 33
84 67
6 6
10 27
119*+
73
9
18
111
59
12
29
42 57
48 83
9 5
43 12
126””
71
10
19
152
67
7
26
94
49
12
39
**Excludes patients for whom no drugs were prescribed for an emotional condition. l**Exludes patients for whom the family doctor reports no doctor-patient discussionsabout an emotional condition.
REFERENCES (1) Goldensohn, S.S.; Daily, E.F.; Shapiro, S. and Fink, R.; “Referral and Utilization Patterns in the First Year of a Mental Health Center in a Prepaid Group Practice Medical Program,“Medica/ Care, Vol. 5, No. 1. (2) Fink, R.; Goldensohn, S.S.;Shapiro, S. and Daily, E.F.: “Characteristics of Patients Designated by Family Doctors as Having Emotional Problems,” American Journal of Public Health (In press). Check this reference with authors.