Collaboration between family physicians and psychologists

Abstract

OBJECTIVE

To explore factors affecting collaboration between family physicians and psychologists.

DESIGN

Mailed French-language survey.

SETTING

Eastern Ontario.

PARTICIPANTS

Family physicians practising in the area of the Réseau des services de santé en français de l’Est de l’Ontario.

MAIN OUTCOME MEASURES

Physicians’ knowledge and understanding of the qualifications of psychologists and the regulations governing their profession; beliefs regarding the effectiveness of psychological treatments; views on the integration of psychologists into primary care; and factors affecting referrals to psychologists.

RESULTS

Of 457 surveys sent, 118 were returned and analyzed (27% of surveys delivered). Most family physicians were well aware that there were evidence-based psychological interventions for mental health and personal difficulties, and some knew that psychological interventions could help with physical conditions. Physicians had some knowledge about the qualifications and training of psychologists. Many physicians reported being uncomfortable providing counseling themselves owing to time constraints, the perception that they were inadequately trained for such work, and personal preferences. The largest barrier to referring patients to psychologists was cost, since services were not covered by public health insurance. Some physicians were deterred from referring by previous experience of not receiving feedback on patients from psychologists. Increased access to clinical psychologists through collaborative care was considered a desirable goal for primary health care.

CONCLUSIONS

Family physicians know that there are evidence-based psychological interventions for mental health issues. Psychologists need to communicate better about their credentials and what they can offer, and share their professional opinions and recommendations on referred patients. Physicians would welcome practice-based psychological services and integrated interdisciplinary collaboration as recommended by the Kirby and Romanow commissions, but such collaboration is hampered by the lack of public health insurance coverage.

The Romanow and Kirby reports on the future of health care in Canada recommended that the delivery of primary care services be re-examined¹ and that mental health care be community-based and accessible.^2,3 Family physicians are often the first health care providers consulted by patients with psychological problems.⁴ Such problems present in up to 70% of consultations.^5,6 In Canada, 89% of family physicians carry out psychotherapy or counseling, and 83% offer mental health assessment and prescribe drugs for mental health difficulties.^7,8 Family physicians perceive their mental health interventions to consist primarily of emotional support and counseling (listening and giving advice) rather than formal psychological treatments.⁶ Despite time constraints, feelings of being inadequately prepared for these activities, and a lack of formal training, family physicians play an important role in the diagnosis and treatment of mental health conditions.^9–13

Better use of existing regulated health professionals could relieve pressure on family physicians and help ameliorate the effects of the shortage of family physicians on health care services.^8,10 The practice of family medicine is burdened with time-consuming consultations for psychological issues⁵ for which evidenced-based psychological interventions have been proven both effective and cost-effective.^6,14–17 Most physicians do not receive formal training in medical school in providing these treatments. Psychologists, on the other hand, are professionally trained in assessing, diagnosing, and treating a range of psychological disorders and could be of use to physicians in caring for patients with these problems. Psychologists are currently underutilized in primary care.

In Canada, there is limited experience with collaboration between family physicians and psychologists, although reported experiences have been positive.^10,18–22 Studies on collaboration between nurse practitioners and family physicians have emphasized that, in order to foster trust and respect, it is important for each party to be aware of the other’s competencies, skills, and scope of practice.²³

Since family physicians are known to be the gatekeepers of primary care, it seems logical to explore factors that could influence their knowledge and attitudes regarding psychologists, as well as their thoughts about collaboration with them. Winefield et al stated that it was important to better understand the attitudes of primary care professionals in order to facilitate the introduction of mental health care services.²⁴

In this study, we surveyed a subsample of eastern Ontario family physicians to explore how much they knew about the professional training and expertise of psychologists, and their beliefs about the effectiveness of psychological treatments. We also solicited their views on the integration of psychologists into primary care and examined factors affecting referral patterns.

METHODS

Surveys were sent to family physicians who practised within certain postal codes in the area of the Réseau des services de santé en français de l’Est de l’Ontario (www.rssfe.on.ca/french/t1map-f.htm). Names and addresses of these physicians were obtained from the College of Physicians and Surgeons of Ontario. The survey was done in this region partly because funding was limited and partly because it was necessary to respect the francophone-oriented mandate of the Consortium national de formation en santé (www.cnfs.net). Ethics approval was obtained from the Ottawa Hospital Research Ethics Board, and informed consent was sought from participants completing the questionnaire.

Questionnaire

The questionnaire was written in French and could be completed in approximately 5 minutes. Questions were generated by the research team based on a literature review that revealed common themes in collaboration between psychologists and family physicians.^10,18–22 and on the principal investigators’ earlier experiences with collaboration. The questionnaire was reviewed by an external consultant and pilot-tested on 6 physicians. Revisions were made in accordance with their comments before the questionnaire was mailed.

Outcome measures

Questions explored physicians’ knowledge about the training, roles, and skills of psychologists; their willingness to collaborate with psychologists; their level of comfort with treating psychological problems; and their past experiences in working with psychologists. Demographic data were also collected.

Mailings

To maximize response, a modified version of the Dillman total survey method was used.²⁵ The questionnaire and an addressed, stamped return envelope were mailed to each potential participant. A reminder postcard was sent to all nonrespondents 2 weeks after the initial mailing. Two weeks later, a second questionnaire was sent to those who had not yet responded. If necessary, a third questionnaire was sent 2 additional weeks later. Questionnaires were mailed in May, June, and July 2005. To protect respondents’ anonymity, a code was used on mailing and return labels.

Data analysis

Descriptive statistics were used to summarize respondents’ answers.

RESULTS

The addresses of 457 family physicians practising in francophone areas of eastern Ontario were provided by the College of Physicians and Surgeons of Ontario. A total of 126 of these family physicians returned completed surveys: 76 (16.6% of those mailed) were returned after the first mailing, 21 (4.6%) after the second mailing, and 29 (6.4%) after the third mailing. Fifteen surveys were undeliverable. Among the 126 respondents, 8 declined consent to share their answers, so 118 surveys were included in the analyses (27% of delivered surveys). Table 1 summarizes respondents’ demographic and practice characteristics.

Table 1.

Demographic characteristics of family physicians: N=118.

CHARACTERISTICS	N (%)
Male sex	59 (50)
Age (y)
• 25–34	17 (14)
• 35–44	42 (36)
• 45–54	43 (36)
• ≥55	16 (14)
No. of years in practice
• 0–4	13 (11)
• 5–9	19 (16)
• 10–14	18 (15)
• 15–20	27 (23)
• ≥21	41 (35)
Type of practice*
• Hospital	36 (31)
• Private solo	34 (29)
• Private group	56 (47)
• Community clinic	20 (17)
• Other†	6 (5)

^*Respondents checked all applicable categories

^†Occupational health (2), research clinic (1), university clinic (2), home visits (1).

Table 2 shows the linguistic and cultural backgrounds of participants. Nearly half of respondents were francophone (48%) or had a strong French linguistic background; about 40% were anglophones. Almost all their services were offered in French, English, or both.

Table 2.

Language background and use of language in practice: N = 118.

LANGUAGE	%
Mother tongue
• French	49
• English	37
• French and English	5
• Other	9
Culture and identity
• Francophone	48
• Anglophone	41
• Allophone	11
Language of services*
• French	31
• English	38
• French and English	28
• French, English, and other languages	4

^*Respondents could check more than 1 answer.

Family physicians’ knowledge of psychologists’ training and profession is summarized in Table 3. About 59% of respondents knew that a doctorate was required to practise as a psychologist in Ontario, while the remainder believed that lesser academic training was required. A similar number were aware that psychologists had to complete a period of supervised practice not unlike a medical residency. Almost all respondents correctly indicated that psychologist is a protected and regulated title. It was less clear to them what distinguished psychologists from psychotherapists.

Table 3.

Family physicians’ knowledge of psychologists’ training and expertise

ASPECTS OF TRAINING AND EXPERTISE	NO. OF RESPONDENTS	% WHO AGREED
Studies required to be a psychologist
• Doctorate	109	59
• Residency (yes/don’t know)	109	58/28
• Master’s degree	109	28
• Baccalaureate	109	13
• College certificate	109	0
Psychologist is a title that is …*
• Protected and regulated	108	93
• Given to any professional with advanced knowledge in psychology	99	18
• Equivalent to psychotherapist	100	11
• Equivalent to psychoanalyst	100	5
A psychotherapist …*
• Must legally have advanced training in psychotherapy	106	49
• Adheres to a professional code of ethics	103	45
• Is a member of a professional college	101	38
• Is qualified to formulate and communicate a diagnosis	102	33

^*Responses agreed with answers to true/false questions; N varied because some respondents did not answer.

The views of family physicians on the effectiveness of psychological interventions and collaboration with psychologists are shown in Table 4. Most family physicians were aware that there were evidence-based psychological interventions. Virtually all respondents agreed that psychological interventions would be useful for patients with mental and emotional disorders or personal difficulties, and 78% thought these interventions might be beneficial in the context of some physical problems. The most common reasons for referring to psychologists included the belief that psychologists’ services would be appropriate (84%) and patients’ requests for referral (62%). The most important reason for not referring to psychologists was patients’ economic constraints (95%).

Table 4.

Family physicians’ views on collaboration with psychologists

ASPECTS OF COLLABORATION	NO. OF RESPONDENTS	% WHO AGREED
Do evidence-based psychotherapies exist? (yes)	110	95
Psychological intervention will help with	110
• Mental and emotional problems		100
• Personal problems		98
• Physical problems (eg, chronic pain, fatigue, and disease)		78
Reasons to refer to a psychologist	117
• Belief that psychotherapy is appropriate		84
• Patient’s request		62
• Acquaintance with psychologists in the community		49
• Lack of time to counsel patients oneself		45
• To gain support for diagnosis and management		44
• Lack of interest in practising psychotherapy		19
Reasons not to refer to a psychologist	110
• Patient’s economic constraints		95
• Lack of feedback from psychologists in the past		22
• Lack of psychologists in the neighbourhood		21
• Can offer an equivalent service		9
• Negative experiences with psychologists in the past		4
• It will not help or I do not refer patients		3
• Other*		11
Integration of psychologists into primary care would	118
• Improve the quality of services offered to patients		76
• Be a complementary addition		59
• Be an effective collaboration		56
• Be an essential addition to care		52
• Allow for a useful exchange of knowledge between professionals		49
• Increase patients’ satisfaction with care		47
• Not be useful		1

^*Lack of knowledge of psychologists in area (3), difficulties with access or long wait times (5), perception that psychologists are prejudiced in favour of insurance companies (1), lack of follow-up from psychologists (1), and psychiatrist available on site (1).

About 75% of family physicians believed that integrating psychologists into primary care would improve the quality of services. More than half stated that collaboration with psychologists would be a desirable addition to medical practice, and half felt that such collaboration would lead to a useful exchange of knowledge and increased patient satisfaction.

Physicians’ prior experiences with psychologists were explored by asking them to rate their agreement with statements using ordered response categories. Physicians placed the highest importance on receiving feedback from psychologists on their clinical findings and recommendations. They did not think psychologists provided adequate feedback when patients had been referred to them. There was strong agreement that psychologists offer effective treatments that some patients need, but a mixed response regarding ease of access to psychologists. Physicians also acknowledged that they had received insufficient training in psychological treatments while in medical school and residency, scoring the adequacy of their training as 2.28 (standard deviation 1) on a scale of 1 (very inadequate) to 5 (very adequate).

DISCUSSION

These eastern Ontario family physicians were aware that there are evidence-based psychological interventions for common mental health problems.¹⁷ They acknowledged to a lesser extent the effectiveness of psychological interventions for dealing with health conditions, such as chronic pain, cardiovascular diseases, chronic fatigue, and insomnia.^26–31 It is clear that physicians need to be better informed about how psychology could contribute to health promotion and management of chronic illnesses.

Most physicians thought they had received insufficient information and training in medical school and residency to treat patients with psychological problems. This is consistent with results of previous reports noting that family physicians perceive that their mental health interventions consist primarily of emotional support and counseling rather than formal psychological treatments.⁶

Although physicians knew that psychologists belonged to a regulated health profession, they seemed to be ill-informed about psychologists’ training. Many physicians were unclear as to the distinctions between psychologists and other of mental health workers, such as psychotherapists, who are sometimes unregulated, have varying levels of training, and are sometimes not trained in psychology at all. This confusion about the credentials and scope of practice of psychologists might pose a barrier to collaboration that does not exist for many other health professionals. Fostering interprofessional relations between psychologists and family physicians through shared training opportunities could be considered as a way to begin interdisciplinary collaboration. It might allow each to know more about the other’s expertise and understand the other’s work styles and conventions.

The main reported obstacle to referring patients to psychologists was financial. The relative scarcity of psychologists and not knowing when they were in a community also limited referrals. These results are consistent with other findings that financial and logistical factors limit referrals to psychologists.⁶

It is both good medical practice and professional courtesy to provide feedback on clinical impressions and recommendations when patients are referred. Physicians said lack of clinical feedback was a negative experience in dealing with psychologists. They did acknowledge, however, that there are potential benefits to collaborating with psychologists.^{6,10,12,13,19,21,32,33}

Limitations

The results of this survey are consistent with those of previous studies. The low response rate (28%), however, limits their representativeness and generalizability. Physicians are known to have the lowest response rates to mailed surveys.^34,35

Detailed demographic information regarding the mailing list was not accessible due to privacy issues, so only demographic data collected from respondents were available. Our respondents’ profile was different from that of respondents to the 2004 National Physicians Survey (NPS). Our sample was younger (72% versus 57% in the 35- to 54-year-old stratum),³⁶ and women were more highly represented (50% versus 40%).³⁶ As with NPS respondents, most family physicians responding to this survey worked in private practice (76% versus 77%). Of our respondents, 38% had academic responsibilities compared with 10% of those in the NPS.³⁶ These differences in demographic characteristics might have affected our survey’s results. Given that our sample had a greater proportion of women, was younger, and had more academic affiliations than the NPS respondents, we might have expected greater knowledge of other professions and more openness to interdisciplinary collaboration. Also, our results might overestimate family physicians’ knowledge and beliefs about psychologists.

Due in part to funding constraints, this survey was written only in French and administered to physicians offering services in francophone areas of eastern Ontario. This might have deterred physicians less comfortable with French from participating, although about 40% of respondents considered English their first language, and a similar proportion used primarily English during patient care.

Physicians responding to this survey might have been biased by their language, age, sex, or academic interests, but their readiness to collaborate and their perceived need for support in the area of mental health care despite limited understanding of psychologists’ background is consistent with the findings of previous studies.^10,18–22

Conclusion

This survey suggests that family physicians are receptive to collaboration with psychologists. Family physicians need to be better informed about the training and credentials of psychologists, however, and psychologists need to better communicate their professional opinions and recommendations on referred patients. This is professional courtesy, and it might foster professional collaboration and increase physicians’ understanding of the roles and contributions of psychologists. Although physicians were aware of the existence of evidence-based psychological interventions, they felt ill-prepared to treat patients with psychological problems, other than to provide them with basic counseling and support. As regulated professionals with training in assessing and diagnosing a range of psychological disorders and the ability to provide evidence-based psychological treatments, psychologists could well complement the skills of physicians in family practice and might be called upon to play a role in the health care system that emerges from primary care reform.

EDITOR’S KEY POINTS

• This study explores physicians’ knowledge of psychologists’ training, roles, and skills; their willingness to collaborate with psychologists; their level of comfort in treating psychological problems; and their past experiences in working with psychologists.

• The most common reasons for physicians to refer to psychologists were the belief that psychologists’ services were appropriate and patients’ requests for referral. The most important reason for not referring patients to psychologists was that public health insurance did not cover the cost of visits to psychologists.

• Physicians placed the highest importance on receiving feedback from psychologists on their clinical findings and recommendations and did not think that psychologists provided adequate feedback when patients had been referred to them.

POINTS DE REPÈRE DU RÉDACTEUR

• Cette étude explore les connaissances que les médecins ont de la formation, des rôles et des compétences des psychologues; leur propension à collaborer avec eux; leur niveau de confort pour traiter des problèmes psychologiques; et l’expérience qu’ils ont du travail avec des psychologues.

• Deux raisons principales amenaient les médecins à diriger un patient en psychologie: l’idée que ce type de service était approprié et la demande du patient pour une telle consultation. La principale raison pour ne pas demander une telle consultation était que le système public d’assurance santé public ne défrayait pas les visites chez le psychologue.

• Les médecins jugeaient primordial de recevoir des psychologues un rapport sur leurs observations cliniques et leurs recommandations, mais ils disaient que les psychologues ne leur avaient pas fourni de tels rapports dans le passé pour leurs patients.