patients' intentions in primary care: relationship to physical and psychological symptoms, and...

Pergamon

Sock. Sci. Med. Vol. 38, No 4, pp. 5X5-592, 1994

Copyright :C 1994 Elsevier Science Ltd Printed in Great Rrmin. All nghts reserred

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PATIENTS’ INTENTIONS IN PRIMARY CARE: RELATIONSHIP TO PHYSICAL AND PSYCHOLOGICAL SYMPTOMS, AND THEIR PERCEPTION BY GENERAL

PRACTITIONERS

PETER SALMON,’ NARINDER SHARMA,~ ROLAND VALORI’ and NICHOLAS BELLENGER’

‘Department of Clinical Psychology, Whelan Building, University of Liverpool, P.O. Box 147. Liverpool L69 3BX, Department of Psychology, University College London, Gower Street,

London WCIE 6BT and )Gastrointestinal Unit, Middlesex Hospital, London, England

Abstract-A series of three studies of consecutive primary care patients examined their intentions when visiting a general practitioner (GP). In study 1, a principal, components analysis of responses to a specially-devised symptom check-list was used to form component-based scales on which patients’ physical symptoms were scored. Apart from a modest association of cold symptoms with seeking simple explanation, physical symptoms were unrelated to intentions. By contrast, the level of psychological symptoms correlated with the desire for support from the GP. In study 2 this result was replicated and shown to be unaffected by the amount of support which patients already experienced from family and friends. In study 3, GPs were found to be able to detect at better than chance level which patients desired support, but they were insensitive to other intentions. The results indicate that a technique for the quantification of patients’ intentions permits the formal investigation of important questions concerning primary care consultations.

Key words-general practitioner, intentions, social support, symptoms

In line with an increasing consumer-orientation in medical care, research into the doctor-patient relationship should be concerned with the patient’s active role in shaping treatment. Hitherto, attention has been focused on issues such as compliance which emphasize patients’ passivity in response to the doctor. One approach to the ‘active’ role has been to study satisfaction with care. However, satisfaction is the end-product of many factors which should be a focus of research in their own right. In particular, an appreciation of what patients desire from medical consultation is fundamental to understanding their active ‘consumer’ role. For example, the congruence between the care they desire and the care they actually receive may be one determinant of satisfaction [l].

Although the importance of patients’ intentions has been recognized for a long time, there has, to date, been little attempt to devise methods to measure them. We recently described the development of a scale which measures four independent aspects of patients’ intentions when consulting their general practitioner (GP): the desire for simple explanation and understanding, for support, for medical treatment and for more detailed information [2]. The present report describes a series of studies which explored two ways in which this instrument might be used.

Although some factors have been identified which influence the decision to consult a general

practitioner [e.g. 3-61, very little is known about the influences on patients’ intentions once they do attend. In studies 1 and 2 we focused on the severity of physical and psychological symptoms since these are the most obvious (although not necess- arily the most important) influences on the decision to consult. Physical symptoms are not perceived in isolation from each other but are generally orga- nized into a limited number of patterns [7]. For study 1, a questionnaire was therefore devised to identify these patterns in the study population.

In the third study, we examined the accuracy with which GPs perceive the different types of intention since this is likely to affect satisfaction with consultation and, in turn, compliance with GPs’ instructions [8-l I].

STUDY 1

Method

Patient samples

Patients attending two practices serving working class or lower middle class areas of London were studied. Five male GPs served 11,060 patients. 15% of patients were Afro-Caribbean and the remainder white. Of 170 questionnaires issued, 144 were com- pletely answered. Mean age of the patients complet- ing all questionnaires was 37 yr; 40% were male; 59% of patients were in employment; 10% were in pro-

585

586 PErnit SALMON el al.

fessional or managerial work; 56% were married or cohabiting.

Questionnaires

Physical symptoms. Items were drawn from the Pennebaker Inventory of Limbic Languidness [7], and supplemented with advice from participating GPs as to the commonest presenting symptoms and on the basis of interviews with 10 patients drawn at random from attenders at one session in each practice. After redundant, ambiguous or idiosyncratic items were removed, the final questionnaire contained 35 items. Patients were asked to describe, for each symptom, ‘how much you have experienced it in the past week’ by marking a 4-point scale (not at all, slightly, quite a lot, a great deal). Scores were standardized.

Psychological symptoms. The General Health Questionnaire (GHQ) [12, 131 measures neurotic ‘caseness’. The need to maximize acceptability and brevity of the questionnaires necessitated the 12-item version. The GHQ is often used in two ways; first, to identify a group of extreme scorers (i.e. ‘cases’); second, to provide a continuous measure of disturbance. In the present study, data were recorded in both forms. Likert scoring provided a continuous distri- bution for correlational analysis, and the GHQ, binary scoring was used to identify ‘cases’ (see later).

Patients’ intentions. The Patient Requests Form [2] was designed for the measurement of patients’ intentions on visiting the GP; a principal components analysis has been used to define subscales measuring the extent to which a patient seeks: (i) medical treatment, (ii) simple explanation and understanding, (iii) detailed information, and (iv) emotional support. Because of the limited time available for questionnaire completion before consultation, the Patient Requests Form was shortened. Only the 22 items loading at 0.55 or more in the original validation study [2] were included. As a check on the validity of this shortened scale, data from study 3 which included the full scale were used to calculate correlations between the short and full scoring. Correlations between shortened and full scales were: explanation and understanding, 0.95; detailed information, 0.70; support, 0.95; medical treatment, 0.98. Scores were standardized.

Procedure

Consenting patients attending to see a GP for their own problems were given the questionnaires immediately after reporting to the receptionist and asked to complete them before being called. Occasionally, patients completed a few questions afterwards. It was explained that the questionnaire would ‘help us to understand better the needs of patients coming to see their GP’. The anonymity of the questionnaire was stressed.

Statistical methods

Principal components analysis was used to reduce responses to the physical symptoms questionnaire to a few dimensions for entry into subsequent analyses; the correlation matrix was analysed so as to standard- ize the scores. The number of components to retain for Varimax rotation was determined with the help of a scree test. Loadings 20.40 were used to define the components. Component-based scale scores were then calculated for each patient by summing scores on items loading on the respective component. Scores were standardized for inclusion in subsequent analyses.

The main analyses were product-moment correlations used to assess the relationship of physical symptom and GHQ scores with patients’ intentions. In addition, so as to check whether patients reporting extreme levels of physical or psychological symptoms differed in intentions from the remainder (a relationship which linear correlations might not detect) analyses of variance compared, for each intention, groups formed by dichotomizing the sample on the basis of the physical symptom and GHQ scores. For the latter, scores exceeding four were regarded as indicating distress at a ‘case’ level; this relatively stringent criterion identified about 25% of patients as cases. For each physical symptom scale, the division was at a standardized score of 0.50. In addition, the group who exceeded a standardized score of zero on every physical symptom dimension was compared to the remainder. In every case the analysis of variance was significant only when the corresponding correlation was significant; therefore only the latter are presented.

Additional analyses of variance assessed whether male and female patients differed in their intentions.

Results

Physical and psychiatric symptoms

Four principal components were identified, ac- counting for 41% of the total variance (Table 1). Component I described abdominally-focused

symptoms; component II clearly described symptoms associated with common cold or influenza; musculoskeletal symptoms loaded on component III. Symptoms loading on component IV characterized somatic presentation of anxiety. GHQ score correlated with each type of physical symptom except cold (Table 2).

Patients’ intentions

Physical symptoms were unrelated to intentions, except for a marginal correlation of cold symptoms with seeking explanation and understanding (Table 2). The only clear predictor of intention was the GHQ which correlated with desire for support (Table 2). The sexes did not differ on any intention.

Patients’ intentions in primary care

Table I. Results of principal components analysis of responses to symptom questionnaire. Orthogonally rotated loadings >0.40 are shown. The following items did not load: indigestion/heartburn, diarrhoea,

constipation, skin problems, blurred vision, ringing in ears, chest pains, sprain or other injury

Compo”e”ts

587

Abdominal Cold/influenza Musculo-skeletal Somatic anxiety

Upset stomach 0.75 - -

Stomach pain 0.73 -

Being sick 0.71 - -

Feeling sick 0.66 -

Headache 0.42 -

Sore throat/cough 0.80 -

Runny nose 0.76 - -

Temperature - 0.64 - -

Short of breath - 0.53 - -

Difficulty swallowing 0.51 -

Difficulty breathing 0.49 -

Feeling stiff - 0.78 -

Pains in amx./legs - 0.77 -

Swelling - 0.56 -

Cannot sleep 0.55 -

Aches all over - 0.55 -

Cramps - 0.45 -

Tired - 0.44 -

Back pain 0.43 -

Weak 0.42 0.43 -

Heart irregular 0.71 Eyes watering - - 0.58 Shaking/trembling - 0.52 Dizzy - 0.52 Cold all over 0.46 - 0.47

STUDY 2 Questionnaires

Method

Patient samples

Three practices were studied. Two were based in a single health centre, serving a working class area of London, where eight male GPs and one female served 18,200 patients. About 20% of patients were Afro-Caribbean; fewer than 1% were Asian; the remainder were white. Out of 150 patients approached, 131 questionnaires were fully completed. Mean age of these patients was 38 yr; 26% were male; 68% were employed; 10% were in professional or managerial work; 74% were married or cohabiting. In the third, rural, practice a single female GP served 2200 patients involved in local agricultural work or small industries or who were commuters. All but a few (< 1%) patients were white. Out of 330 patients approached, 312 fully completed questionnaires. Mean age was 48 yr; 35% were male; 45% were employed; 70% were married or cohabiting.

The 12-item GHQ [12, 131 was used, as before, to measure psychiatric distress. Patients’ intentions were measured by the Patient Requests Form [2] which was shortened by including the 30 items reaching a loading of 0.50 in the original validation study [2]. To check that this preserved the validity of the full scale, data from study 3 were used, as above, to calculate correlations of the short with the full scale. These were: explanation and understanding, 0.98; detailed information, 0.97; support, 0.96; medical treatment, 0.98. The Perceived Social Support Questionnaire [ 141 was also used, which contains 12 items measuring the perceived availability of emotional support from friends and family.

StatisticaI analysis

Product-moment correlations assessed the relationship of social support and GHQ scores with intentions. Additional analyses of variance assessed whether the sexes and patients attending the rural and

Table 2. Study I. Correlation coefficients showing relationship of physical and psychological symptoms with patients’ intentions: *P < 0.05; **f < 0.01

Intentions

Physical symptoms Abdominal Cold/flu’ Musculoskeletal Anxiety

GHQ

GHQ

0.36” 0.00 0.40” 0.25”

-

Detailed Medical Explanation infoormation treatment Support

-0.01 0.05 0.03 -0.01 0.19. -0.12 0.12 -0.04

-0.08 0.05 0.00 -0.05 -0.02 -0.02 -0.04 -0.08 -0.01 0.01 0.07 0.2v*

588 Pm-m SALMON et al.

Table 3. Study 2. Correlation coefficients showing relationship of patients’ psychological distress (GHO1 and exaerience of sumort with their intentions: l P < 0.05; **P i 0.01

Intentions

Detailed Medical

GHQ Explanation information treatment Support

Perceived support -0.1 I 0.03 -0.02 -0.01 -0.08 GHQ - 0.01 -0.05 -0.05 0.30.’

urban practices differed in intentions, GHQ score and perceived social support.

Results

Availability of support

Rural patients experienced more support than suburban patients [mean scores: 69.3, 64.5; F(1,440) = 11.59, P c O.OOl], but the sexes did not differ (F < 1.0). GHQ was unrelated to the amount of support experienced (Table 3).

Predictors of intentions

As in study 1, GHQ scores correlated with desire for support but with no other intention (Table 3). A multiple regression analysis confirmed that this relationship did not differ between the practices. Support presently experienced did not cor- relate with support desired from the GP-or, indeed, any other intention. Intentions did not differ between the rural and urban practices. The only effect of sex was a slightly greater desire for medical treatment by men than by women [mean standardized scores: 0.16 vs -0.09; F(1,434) = 5.69, P < 0.051.

STUDY 3

Method

Patient samples

The sample in the rural practice, above, provided data for this study (n = 312). An additional sample was drawn from a practice run by two male and two female GPs, serving ca 7000 patients in a middle class urban area. Fewer than 1% were non-white. Out of 196 patients approached, 179 completed questionnaires. Mean age was 45 yr; 3 1% were male; 77% were employed; 25% of patients were in managerial or professional jobs; 7 1% were married or cohabiting.

Questionnaires

Patients’ intentions. The Patient Requests Form [2] was used in the rural practice, as described for study 2. In the urban practice, this was the only questionnaire to be completed by patients and the full-length form was therefore used.

GPs’ perception of patients’ intentions. Before the

study began, the GPs were given a description of the intentions defined by each of the subscales in the Patient Requests Form and based on the items loading on the relevant subscale. For each patient, the GP completed a simple evaluation immediately after the consultation. In the rural practice this was to allocate the patient’s main intention to one of four categories, each corresponding to one of the subscales: simple explanation and understanding, social support, medical treatment and information seeking. Lest this forced choice distorted the results, the procedure was modified for the second practice. For each type of intention, the GP assessed whether it applied to the consultation using a 3-point scale: ‘yes’, ‘unsure’ or ‘no’. In practice the ‘unsure’ category was neglected; the few such responses were recorded as ‘yes’.

Statistical analysis

In the rural practice, canonical variate (discriminant) analysis was used to compare the patient’s principal intention as identified by the GP (response variable) with the patients’ actual scores on each intention (predictor variables). This technique identifies whether the GPs’ allocation of principal intention is related to a linear combination of the patients’ actual scores. In the urban practice, the GPs rated patients on each intention. How these ratings compared with the patients’ own ratings was therefore assessed by canonical correlation analysis. This identifies whether any linear combination of the patients’ ratings correlates with any linear combination of the GPs’ ratings.

In each practice, univariate analyses of variance were also performed as a check on the multivariate results. In the rural practice, mean ratings of each intention (made by the patients) were compared between the four groups (formed by the GP’s assessment of principal intention). In the urban practice, the GPs’ ratings of the presence or absence of each intention formed pairs of groups. For each pair, the groups were compared on patients’ own ratings of each intention. Groups distinguished by GPs were found to differ in the level of support sought. These analyses of variance were repeated using GHQ score as a covariate; this was to check whether GPs’ discrimination of need for support could be accounted for merely by their detecting emotional disturbance, since this (i.e. GHQ) proved to be consistently correlated with seeking support.

Patients’ intentions in primary care 589

Results

GPs’ perception of patients’ intentions

Rural practice. The GP allocated the patients’ main intention as follows: medical treatment, 182; support, 68; simple explanation and understanding, 49; detailed information, 13. Two discriminant functions were significant b * for dimensionality > 1 = 20.4, d.f. 6, P c 0.01; x * for dimensionality >2 = 6.5, d.f. 2, P > 0.051. The corresponding canonical correlations were 0.46 and 0.22 and they accounted for 16 and 17%, respectively, of the between-group variability. The first is clearly defined by patients seeking support, and this function discriminates the patients whom the GP allocated to the support category (Table 4); that is, patients whom the GPs thought were primarily seeking support were, indeed, seeking more support than others. The second function is less clear. It indicates that the group seen by the GP as seeking detailed information really wanted simple explanations and reassurance rather than detailed information or medical treatment.

In the univariate analyses, two comparisons were significant. The first bore out the first discriminant function; groups allocated by the GP differed accord- ing to the level of support sought [F(3,308) = 11.56, P < 0.001; Fig. 11; patients thought to seek support primarily did seek more support than any other group (minimum t = 2.52, P -=z 0.05). This difference remained significant after allowing for the covariance of GHQ score with the level of support sought [F(3,307) = 6.20, P < O.OOl]. The second significant comparison partially bore out the second discriminant function; the extent to which medical treatment was sought differed between the groups [F(3,308) = 2.86, P < 0.05; Fig. 11; patients thought by the GP to seek primarily information were characterized not by a particular desire for information, but merely by less desire for medical treatment than any other group [only the comparison with group ‘Expla-

nation’ was significant: t = 3.00, P < 0.01; other comparisons just fell short of significance: minimum t = 1.91, P > O.OS]. Figure 1 suggests that the desire for information was least in the group thought by the GPs primarily to want information, but there was no statistical support for this.

Urban practice. The GPs divided patients accord- ing to whether they did/did not seek each service as follows: medical treatment, 136/42; support, 64/l 14; explanation and reassurance, 50/128; detailed information, 33/145. The first canonical correlation was 0.39; only this was significant [with all four canonical variates included, F(16,520) = 2.47, P < 0.001; with the first excluded, F(9416) = 1.20, P > O.lO]. In both the patients’ and GPs’ ratings, the corresponding canonical variates were defined primarily by the desire for support (Table 5); that is, patients seeking support were identified as such by the GP. The univariate analyses were consistent with this. Only two reached significance; patients seen by the GP as wanting support did seek more support than others [mean standardized scores: 0.30 vs -0.21; F(1,176) = 10.63, P < O.Ol]. This remained significant after adjustment for covariance with GHQ scores [F(1,175) =4.12, P < 0.051. In addition, patients said by the GP to want medical treatment sought less detailed information (mean: -0.10) than did others [mean: 0.26; F(1,176) = 4.26, P < O.OS].

Discussion

Apart from a marginal association of cold symptoms with a desire for explanation and understanding, the general types of physical symptom which our questionnaire quantified failed to predict what patients intended from their consultation. This nega- tive result emerged whether correlations were used to test the relationship across the range of symptom scores or whether extreme scorers were compared to the rest. It is possible that specific, isolated symptoms give rise to a distinctive pattern of intentions, since

Table 4. Study 3, rural practice. Results of canonical variates analysis are shown. Standardized coefficients and correlations relate patients’ intentions (as the predictor variables) to canonical variates (upper panel). Centroids are shown for each variate for groups formed by GPs’ categoriz-

ation of principal intention (lower panel)

Canonical variate

I II

Coefficient Correlation Coefficient Correlation

Patients’ intention Explanation/understanding SUPport Medical treatment Detailed information Variance (%)

-0.19 0.02 1.50 0.19 I .40 0.75 -0.07 -0.24

-0.74 -0.07 -0.82 -0.42 -0.11 -0.05 -0.91 -0.41 75.05 16.08

Canonical variate

Intention allocated by GP Explanation/understanding

SUPport Medical treatment Detailed information

I II

-0.41 0.08 0.84 -0.04

-0.21 -nnx _.__ 0.07 0.99

590 Pm-m S~~fd01-4 et al.

Explanation 0

-0.5 J

0.5

support

Medical 0 treatment

Information 0

Explanation Support Medical Information Treatment

Principal intention as identified by GP

Fig. 1. Mean standardized scores on each intention for each of the groups allocated by the GP in the rural practice (study 3). Bars show SED for comparisons between groups.

our technique would not have identified such relationships. Nevertheless these results indicate that, to understand how intentions are shaped, knowing the level of the main types of physical symptom is not useful. Beliefs about symptoms may prove to be better predictors of intentions than the symptoms themselves [15, 161. Most of the evidence about people’s beliefs about symptoms is qualitative; only a

generally applicable instrument to identify and quantify the main types of belief will allow the quantitative testing of this prediction [17].

The physical symptom dimensions identified by the principal components analysis were readily inter- pretable (with the exception that ‘headache’ was marginally associated with gastrointestinal symptoms), corresponding to physical or psychological

Patients’ intentions in primary care 591

systems responsible for the majority of symptoms presented to general practitioners. The resulting subscales therefore provide a way of quantifying such symptoms in future research. To reduce the risk that unreliable dimensions would be identified from our modest sample, a relatively stringent criterion was used [18]. In consequence, over half the variance remained unexplained. Only use of a larger sample would show whether additional dimensions can be reliably identified.

By contrast with physical symptoms, psychological symptoms did predict intentions; the greater the symptoms, the more support was sought. It is not a new suggestion that patients who are emotionally

distressed seek more help from their GP. The importance of the present results is to show that this is specific to support. Emotionally distressed patients do not seek more medical treatment or information than do others. That many nevertheless go on to receive inappropriate medical investigation and treatment [ 191 must therefore be attributed to the inappropriate response of general practitioners rather than to the intention of the patients. As discussed later, GPs were unable to detect the extent of patients’ intentions concerning medical treatment and information and such misperception helps to account for inappropriate treatment and referral.

There are two ways to view the relationship between psychological distress and the desire for support from the GP. Conventionally, it would be attributed to the seeking out of emotional support in an effort to ameliorate psychological distress. How- ever, the amount of support already experienced from family and friends was unrelated to the further support sought from the GP. Similarly, in study 2, although rural patients already experienced more support than the urban ones, they desired no less support from the GP. One response to this is to argue that a nonspecific concept of support is invalid [20,21]. The support already experienced from family and friends may be different in nature from that sought from the GP; it may even be counterproduc-

Table 5. Study 3, urban practice. Results of canonical correlation analysis are shown, describing relationships between ratings of patients’ intentions made by patients themselves and by their GPs: correlations with first canonical variate and standardized canonical coefficients are shown, together with % variance explained in each

set

Patients’ ratings Explanation/understanding Support Medical treatment Detailed information Variance (%)

GPs’ ratings Explanation/understanding support Medical treatment Detailed information Variance (%)

Coefficient

0.01 0.86 0.66

- 1.32 10.53

-0.57 0.74 0.23

-0.33 24.62

Correlation

-0.15 0.48 0.26

-0.32

-0.54 0.74 0.13

-0.35

tive [22]. An alternative explanation for the pattern of findings is that to express a need for support may be one way in which people signal distress and vice oersu. On this reasoning, there is no reason to expect that, at a given level of distress, relatively well-supported people should seek less support than poorly supported ones.

The only intention to which GPs could be shown to be sensitive was the seeking of support. This was a reliable finding: it emerged whether they revealed their assessment by merely choosing the patient’s principal intention or by independently rating each type of intention. One explanation arises from the evidence that GPs are able to detect patients’ level of psychological distress [23]. The GPs in the present study, therefore, might simply have identified patients who were distressed and designated them as in need of support, rather than perceiving patients’ requests for support ‘directly’. The analyses of covariance disproved this: GPs were sensitive to patients’ desire for support even after controlling their psychological distress. Our technique does not show the level of accuracy of the GPs’ assessments. To quantify this, both GPs and patients would have to be asked to record their assessments using exactly the same scales.

Despite this one area in which some sensitivity was demonstrated, the general finding was that GPs were remarkably insensitive to their patients’ intentions. Since patients look to their GP specifically for explanation and reassurance [2, 51 GPs’ apparent inability to recognize which patients seek this, in particular, is a serious deficit. Such insensitivity may be a cause of patient dissatisfaction and non-compliance as well as inappropriate investigation, treatment and referral.

In part, GPs’ insensitivity probably reflects their bias to see the function of the consultation in terms of medical treatment: in both practices in study 3, the overwhelming majority of patients were thought by their GPs to be primarily concerned with medical treatment. This conflicts with previous evidence that medical treatment is generally a lower priority for general practice patients than is the receipt of information or support [2, 3,8]. In addition to this general bias, it is also possible that specific distortions occur in GPs’ perceptions. In the rural practice in study 3, the second discriminant function described patients who sought simple explanation and reassurance rather than detailed information or medical treatment. However, patients who were high on this dimension were seen by the general practitioner as mainly wanting detailed information. It would be premature to attach weight to this discrepancy, since it did not emerge when using a different procedure to study a different general practice. Specific distortions in general practitioners’ perception of patients are probably of more limited generalizabihty than our main finding: that GPs are largely insensitive to their patients’ intentions.

In conclusion, our findings have shown how a technique for quantitative assessment of patients’

592 PETER SALMON et al.

intentions permits the formal investigation of import- 8. ant questions concerning the consultation process that it would otherwise not be possible to answer. First, they have shown that emotionally-distressed patients attend primarily to seek support but that 9. they do not seek greater levels of medical treatment or information than other patients. Secondly, the IO. main types of physical symptom are not associated with any particular intention; other factors, such as patients’ beliefs about the origin of their symptoms, Il.

may be more important determinants of what such

patients seek from the GP. Finally, we have described 12. a technique which can be used to study discrepancies between patients’ intentions and GPs’ assessments of 13. these. In future, this could be used as part of a training or advisory procedure designed to improve

14. the matching of health care provision to patients’ needs.

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