A General Practitioner intervention on frequent attenders

Hypothesis generation: analysis of available information. The General Practitioners (GPs) analyse all the available information from clinical charts using a standardised questionnaire designed to facilitate analysis of this information. 1) The GPs count different types of patient visits in mutually exclusive categories and make a flow diagram of the relationships between the number of visits and time (months). 2) The GPs study the individual and family clinical history, as well as bio-psycho-social problems from the problems list. 3) Under the heading “In most interviews with this patient I feel …” the questionnaire provides a list of 12 emotions and feelings that the GPs are asked to rate on a 5-point Lickert scale. In the following section, headed “In most interviews with this patient I think …” the GPs are asked to indicate which of the different options apply (yes/no) from a list of 10 thoughts. 4) Other information obtained includes how the visits finished, giving prescriptions, ordering complementary tests, referring to consultants and/or whether another appointment was made by the GP. 5) The GPs are also asked to indicate their perceived capacity to solve the patient’s problems. 6) Other information gathered concerns whether the patient was referred during the preceding year for nursing care, social assistance, mental health care or any community resource. 7) The GPs then try to find common factors from the above six points. 8) Finally, the GPs indicate the type of hypothesis that they believe made the patient a frequent attender: biological, psychological, social, familial, cultural, administrative or related with the doctor-patient relationship. Hypothesis confirmation When necessary and in order to dispel uncertainty, the GPs can try out the hypothesis through three different strategies: another interview with the patient, biological and psychosocial tests, and/or asking for the opinion of other professionals. Planning The GPs make plans for each frequent attender on the basis of the confirmed hypothesis and available resources. The plans can be proposed previously by a specific GP or generated by any member of the GP team at the meetings. After obtaining consensus about the plan, the relevant GP negotiates it with the frequent attender, who may disagree with the proposals. The GP team contributes to modulate the GP’s expectations about the proposed interventions. Intervention on professional and doctor-patient relationship These processes of analysis enable the GPs to be aware of their emotions, thoughts and reactions when interviewing frequent attenders. Such introspection and awareness prepares them to accept that a good relationship with each patient is perhaps not a realistic goal, particularly with some frequent attenders. The reduction in emotional uncertainty also contributes to improving a dysfunctional relationship with the frequent attender. In addition, it gives them the chance to change their emotions, thoughts, attitudes and reactions. Moreover, the GP team gives emotional support to each GP and generates strategies to deal with frequent attenders from a more neutral perspective. “T” (Team) ingredient The three intervention GPs who received training form the “T” (Team) ingredient. They hold meetings to share analyses and reflections on their frequent attenders and make plans for each FA. Normally, the proposed plan is drawn up by each GP and explained to the Team using the GP’s personal structured analysis of his or her frequent attender candidates. The other members of the GP Team help, with comments about the data analysis of the frequent attender and sometimes suggesting different plans. The decision on a definitive plan is often taken by consensus. The time spent sharing each reflection about a FA ranges from 5 to 35 minutes. The mean is 20-25 minutes for most cases. The GP Intervention Group undertake an interactive work-shop training session (15 hours) on the intervention "7 Hypothesis + Team" (“7H+T”). The GPs randomly assigned to GP intervention group offer to their frequent attenders randomly selected the new intervention, and these give theirs consents. Therefore both GPs and frequent attenders are not blind. The GPs allocated to GP Control Group are not informed of the identity of the frequent attenders randomly selected to the Patient Control Group, and these FA neither are informed that they belong to the Patient Control Group, because of this the GP Control Group and the Patient Control Group are blind. From the list of frequent attenders belonging to the GP Intervention Group, we randomly select a new group of FAs who receive usual care (Patient Control Group 2), these frequent attenders are not informed of that and their GPs neither are informed of the identity of this second Patient Control Group. Therefore, there is a crossover design for GPs (the GP group do, in the same time, as GP intervention and GP control), whereby the three groups of frequent attenders (Intervention Group, Control Group 1, and Control Group 2) are in a parallel design. No frequent attender is informed on our primary outcome (number of visits post-intervention). The overall duration of the study is for one year.