Objectives: To find how often social problems influence clinical management in general practice, how management is changed, and how the characteristics of patients, doctors, and the doctor-patient relationship influence this management.
Design: Multipractice survey of patients consulting general practitioners. Doctors completed a questionnaire for each patient.
Setting: General practices in Buskerud county, Norway.
Subjects: 1401 consecutive adult patients attending 89 general practitioners.
Main outcome measures: How often management of patients was influenced by different types of social problem and main reasons for consultation; frequency and intercorrelation of different types of management applied; odds ratios for social problems' influence on management, controlled for by characteristics of doctors, patients, and their relationship.
Results: In 17% of all consultations the doctors' knowledge of patients' social problems influenced their management, stressful working conditions being the most frequent influencing type of problem. Knowledge of social problems influenced management more often when the doctor knew a patient well, but less often the longer a doctor had worked in a practice. When social problems influenced management, the commonest types of management offered were extra time for consultation (51%), advice (42%), authorisation of sick leave (28%), and prescription of a psychotropic drug (20%), while referral to community services was used in 2.6% of these consultations. Prescription of a psychotropic drug was positively correlated with use of extra time, and was made more often by female doctors.
Conclusions: Patients' social problems influenced choice of management in at least a sixth of consultations. Prior knowledge of the patient, the doctor's time in present practice, age and sex of the patient, and sex of the doctor significantly influenced management of patients.
Disease and illness cannot be viewed in isolation. Personal care includes understanding the person and the world in which he or she lives. Information about a patient's environment is necessary, not only for establishing the correct diagnosis, but in order to choose the right management.[2 3] More than a decade ago, Brooke and Sheldon pointed out that, although the prominence of psychosocial problems is one of the distinguishing features of general practice, we do not know much about what influence such problems have on general practitioners' decisions. In an extensive study of more than 7000 patient contacts from his own practice, Essex identified 93 different factors affecting decisions in general practice. Reviewing his list of factors, we found that 16 could be classified as related to the patient's social situation, but the study did not quantify these factors. Verhaak and Wennink showed that, even if they were recognised, 40% of psychosocial problems did not lead to treatment. One study used videotapes to analyse the impact of non-medical problems on patient consultations, but the study was restricted to 149 patients with chronic diseases. We have found no study that evaluates how often patients' social circumstances influence their management in general practice.
One problem a doctor may face when taking a patient's social circumstances into account is the limitations of his or her therapeutic armamentarium. Nevertheless, two studies indicate that general practitioners seldom refer patients with social problems to other community services.[8 9] Recently, Howie et al reported that longer consultations are enabling for patients with a combination of psychological and social problems, The aims of this study were to estimate how often social problems influence management in general practice, to describe what kind of management this leads to, and to examine how management is affected by the characteristics of patients, doctors, and their relationship.
Subjects and methods
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. 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' …