Psychiatric consultation in general practitioners' daily practice: a qualitative study on the experience of consultation-liaison psychiatry interventions in primary care settings in French-speaking Switzerland.

BACKGROUND: Mental disorders are frequent in primary care settings, which is challenging for primary care physicians. In Neuchâtel (Switzerland), a Consultation-Liaison psychiatrist integrated three primary care group practices, proposing both clinical interventions and supervisions/psychiatric training. Primary care physicians' experience regarding this collaboration was investigated. METHODS: A qualitative study was conducted. Three focus groups were organized in each primary care group practice involved in the project (10 primary care physicians participated in focus groups). Data were analysed with thematic content analysis. RESULTS: Six major themes emerged from our analysis, describing primary care physicians' collaboration with psychiatrists: 1) Impact on a difficult to reach and "reluctant to consult" population; 2) Fluidity of the intraprofessional collaboration; 3) Influence on the doctor-patient relationship; 4) Positive emotional experiences; 5) Psychiatric counselling and training; 6) Long-term prospects for the project. CONCLUSIONS: Consultation-Liaison psychiatrist's presence came as a relief for participating primary care physicians, facilitating accessibility to mental healthcare, introducing a common culture of care, and offering "in-situ" psychiatric training. Primary care physicians felt that their relationships with patients benefited from such interventions, being better able to deal with complex emotional experiences and found patients more confident regarding proposed care. Models of psychiatric intervention provided in primary care must establish settings of collaboration that reinforce relationships between primary care physicians, psychiatrists, and patients.

[«â€ Group medical practices†¼ project†: collaboration between primary care medicine and institutional public psychiatry]. / Projet «â€ cabinets de groupe†¼â€ : collaboration entre médecine de premier recours et psychiatrie.

Collaboration between primary care medicine and psychiatry is a well-known challenge. In order to improve access to psychological care for patients undergoing primary care, the «â€…group medical practices ¼ project proposes a collaborative care model in which a psychiatrist employed by a public psychiatric institution integrates group medical practices in order to provide assistance to primary care physicians. It is thus able to evaluate patients directly in the practices and to offer supervision and consilium spaces to primary care physicians.

La collaboration entre la médecine de premier recours et la psychiatrie représente une difficulté bien connue. Pour améliorer l'accès aux soins psychiques des patients suivis en médecine de premier recours, le projet «â€…cabinets de groupe ¼ propose un modèle de soins collaboratifs dans lequel un psychiatre employé d'une institution psychiatrique publique intègre des cabinets de groupe afin d'apporter son aide aux médecins de premier recours (MPR). Il est ainsi en mesure, d'une part, d'évaluer les patients directement au sein des cabinets et, d'autre part, d'offrir des espaces de supervision et de consilium aux MPR.

General practitioners referring patients to specialists in tertiary healthcare: a qualitative study.

BACKGROUND: There is a large and unexplained variation in referral rates to specialists by general practitioners, which calls for investigations regarding general practitioners' perceptions and expectations during the referral process. Our objective was to describe the decision-making process underlying referral of patients to specialists by general practitioners working in a university outpatient primary care center. METHODS: Two focus groups were conducted among general practitioners (10 residents and 8 chief residents) working in the Center for Primary Care and Public Health (Unisanté) of the University of Lausanne, in Switzerland. Focus group data were analyzed with thematic content analysis. A feedback group of general practitioners validated the results. RESULTS: Participating general practitioners distinguished two kinds of situations regarding referral: a) "clear-cut situations", in which the decision to refer or not seems obvious and b) "complex cases", in which they hesitate to refer or not. Regarding the "complex cases", they reported various types of concerns: a) about the treatment, b) about the patient and the doctor-patient relationship and c) about themselves. General practitioners evoked numerous reasons for referring, including non-medical factors such as influencing patients' emotions, earning specialists' esteem or sharing responsibility. They also explained that they seek validation by colleagues and postpone referral so as to relieve some of the decision-related distress. CONCLUSIONS: General practitioners' referral of patients to specialists cannot be explained in biomedical terms only. It seems necessary to take into account the fact that referral is a sensitive topic for general practitioners, involving emotionally charged interactions and relationships with patients, colleagues, specialists and supervisors. The decision to refer or not is influenced by multiple contextual, personal and clinical factors that dynamically interact and shape the decision-making process.

[From a different angle : supervision of general internal medicine practitioners by psychiatrists and its benefits]. / Déplacer le regard : apports de la supervision psychiatres/médecins généralistes.

The supervision of general internal medicine practitioners by psychiatrists is an opportunity to take a step back from the daily medical practice. In this article, we adopt an interdisciplinary perspective on these supervisory practices, combining a number of insights and perspectives from both psychiatry and sociology. We aim at initiating a broader and more rigorous reflection on such supervisions, which remain little theorized although they are clearly appreciated by those who benefit from them.

Les supervisions de médecins généralistes/internistes par des psychiatres sont l'occasion de prendre du recul par rapport à la clinique quotidienne. Dans cet article, nous adoptons une perspective interdisciplinaire sur ce dispositif, en mobilisant conjointement certains apports et perspectives issus de la psychiatrie et de la sociologie. L'enjeu est d'entamer une réflexion plus ample et rigoureuse sur ces pratiques de supervision qui, si elles sont manifestement appréciées de ceux qui en bénéficient, restent peu théorisées.

[Assumption of sincerity in medicine]. / Postulat de sincérité en médecine.

Medical practice is always embedded in time and space, whatever its scientific and technical progress could claim as universal truths. The postulate of sincerity is one those contextual elements but it has become so pervasive that a gloss of evidence surrounds it. This situation is at risk of loosing its depth, as much as its limits. By bringing closer together sincerity with more usual notions (transparency, confidence, uncertainty), one could get more insight into these matters of concern in medical practice.

La pratique médicale est toujours ancrée dans un temps et un lieu, quelles que soient les avancées scientifiques et techniques auxquelles elle a contribué et qui peuvent prétendre à une reconnaissance universelle. Le postulat de sincérité fait partie de ces déterminants contextuels, mais son statut contemporain « d'évidence ¼ risque de faire oublier sa profondeur, tout comme ses limites. En rapprochant la sincérité d'autres notions plus couramment évoquées (transparence, confiance, incertitude), nous verrons dans quelle mesure elle permet de les questionner à nouveaux frais.