Dealing with the doctor shortage: a qualitative study exploring French general practitioners' lived experiences, difficulties, and adaptive behaviours

CONTEXT

The shortage of general practitioners (GPs) is a growing concern in Europe, especially in France. This problem is likely to continue until the end of the 2020s.

OBJECTIVES

To study the GPs' perceptions of access to care in medically underserved areas (i.e. with low physician density), its consequences on their working conditions, and how they cope with the resulting difficulties.

METHODS

Semi-structured individual interviews were conducted between May and August 2021 of 29 GPs practising in areas of southeastern France with a low physician density or at risk of a doctor shortage. Purposive sampling was used to include profiles of diverse physicians and diverse rural and urban areas. The interviews, conducted with an interview guide, were transcribed and analysed thematically.

RESULTS

The participants described a serious degradation of access to care in their areas. These issues also concerned urban areas, where they were, according to the participants, underrecognized. The participants' workloads were rising, at a rate often perceived as unsustainable: many participants, including the youngest group, reported they were exhausted. Their principal source of dissatisfaction was their impression that they could not do their work correctly. Participants reported that these difficulties required them to improvise and adapt without any official or formal method to keep their practice manageable.

CONCLUSION

These GPs were worried about the future of their profession and their patients. They expected strong measures by public policymakers and officials, but paradoxically seemed to have little interest in the solutions these officials are promoting.

A methodological support to set up multidisciplinary group practices in Southeastern France

Issue/Problem

Despite high medical densities in Southeastern France, access to prevention and care is difficult in some territories due to a lack of health professionals. The Regional Council supports multidisciplinary group practices (MGP) to improve primary care access and quality. When developing them, health professionals have to propose a health project addressing population health needs in the area.

Description of the problem

Two complementary resource centres -the Southeastern Regional Health Observatory and the Regional Committee for Health Education- collaborate to provide support to health professionals in the creation of MGP. The process includes a territorial assessment based on quantitative indicators about various environmental and socio-economic determinants, morbidity, mortality, and health-seeking behaviours. Stakeholders then discuss the results of this assessment in order to confront it to their experiences, identify priorities and design the health project: it defines the forms according to which professionals will work together and set specific objectives and activities to cover main public health needs in the corresponding territory.

Results

Since 2011, our methodological support has benefited 45 MGP projects: 19 were successful, 13 are still in progress and 13 projects were not completed. It helped decision-makers in the identification of priority territories in terms of prevention and care; it also presented outlooks of the current and coming health needs of various areas.

Lessons

Levers to the MGP setting up have been identified: a project is more successful when it is initiated by health professionals supported by local authorities, and up for discussion. On the contrary, preconceived ideas about the MGP project complicate the assessment’s appropriation.

Key messages

Taking into account the results of the assessment helps to propose MGP projects that better match population needs. It also improves collective knowledge of public health issues between health professionals and various local stakeholders.

Opinions of general practitioners about psychotherapy and their relationships with mental health professionals in the management of major depression: A qualitative survey

Background

French general practitioners (GPs) refer their patients with major depression to psychiatrists or for psychotherapy at particularly low rates.

Objectives

This qualitative study aims to explore general practitioners' (GP) opinions about psychotherapy, their relationships with mental health professionals, their perceptions of their role and that of psychiatrists in treating depression, and the relations between these factors and the GPs' strategies for managing depression.

Methods

In 2011, in-depth interviews based on a semi-structured interview guide were conducted with 32 GPs practicing in southeastern France. Verbatim transcripts were examined by analyzing their thematic content.

Results

We identified three profiles of physicians according to their opinions and practices about treatment strategies for depression: pro-pharmacological treatment, pro-psychotherapy and those with mixed practices. Most participants considered their relationships with psychiatrists unsatisfactory, would like more and better collaboration with them and shared the same concept of management in general practice. This concept was based both on the values and principles of practice shared by GPs and on their strong differentiation of their management practices from those of psychiatrists,

Conclusion

Several attitudes and values common to GPs might contribute to their low rate of referrals for psychotherapy in France: strong occupational identity, substantial variations in GPs' attitudes and practices regarding depression treatment strategies, representations sometimes unfavorable toward psychiatrists. Actions to develop a common culture and improve cooperation between GPs and psychiatrists are essential. They include systems of collaborative care and the development of interdisciplinary training common to GPs and psychiatrists practicing in the same area.

Psychotherapy for depression in primary care: a panel survey of general practitioners' opinion and prescribing practice

PURPOSE

Psychotherapy is recommended as first-line treatment in patients presenting with mild-to-moderate depression. Although this disorder is mostly managed in primary care, little is known about General Practitioners' (GPs) practice of prescribing psychotherapy. The objectives were to explore GPs' opinion on psychotherapy for depression, and the personal and professional characteristics associated with reported strategies for prescribing psychological therapy and/or an antidepressant in mild-to-moderate depression.

METHODS

A cross-sectional survey was carried out among participants in a panel of randomly selected GPs (2,114/2,496 participated: 84.7%). GPs were interviewed using a standardized questionnaire covering their professional and personal characteristics, their practices and opinions in the area of depression management. A multi-model averaging approach was used to explore the characteristics associated with practice of prescribing psychological therapy in mild-to-moderate depression.

RESULTS

Most GPs had a favourable opinion regarding the efficacy of psychotherapy in depression. Slightly more than one out of four reported prescribing psychological therapy alone often/very often in mild-to-moderate depression. These GPs were more likely to be female (OR = 1.56, 95% CI 1.24; 1.97), to have a personal history of psychotherapy (OR = 1.76, 95% CI 1.31; 2.38), no history of depression in someone close (OR = 0.80, 95% CI 0.65; 0.99), and to consider that antidepressants are over-prescribed (OR = 2.02, 95% CI 1.63; 2.49). No association was found with professional characteristics.

CONCLUSIONS

GPs' personal experience has a greater impact on psychological therapy prescription than professional characteristics. This finding suggests that educational efforts are required for providing GPs decision-making skills regarding psychological therapy prescription, based upon evidence-based medicine rather than subjective factors.

Physicians' characteristics associated with exploring suicide risk among patients with depression: a French panel survey of general practitioners

Background

General practitioners (GPs) have a key role to play in suicide prevention, but the rates at which they question patients with depression about suicidal thoughts and plans are rather low. Little is known about GPs' characteristics associated with such inquiries. Our objectives were to describe GPs' attitudes, perceived barriers, and self-reported practices in this questioning of these patients and to analyze factors associated with these practices.

Methodology

This cross-sectional survey was conducted among participants in a panel of randomly selected French GPs (1249/1431 participated: 87.3%). GPs were interviewed with a standardized questionnaire covering their professional and personal characteristics, attitudes, and practices in exploring the suicide risk of their patients with depression. We built a suicide inquiry score by summing the responses to 5 items and used a multiple linear regression analysis to explore the characteristics associated with this score.

Principal Findings

Most GPs reported inquiring about the presence of suicidal ideation often or very often; less than 30% reported that they frequently explored signs of a specific suicide plan. The mean suicide inquiry score was 12.4 (SD, 2.9; range, 5–20). False ideas, such as thinking that patients who report suicidal ideas do not often commit suicide, were frequent (42.3%). Previous continuing medical education on suicide, participation in a formal mental health network, and patients who committed suicide in the past 5 years were associated with a higher score. Reluctance to question patients about suicide and perception of insufficient skill were associated with a lower score.

Conclusions/Significance

This study showed great variability in French GPs' practices in exploring suicide risk in patients with depression. Interventions aiming at improving GPs' initial training and continuing medical education in suicide and/or depression, and their collaboration with mental health specialists should be developed, and their impacts assessed.

General practitioners' choices and their determinants when starting treatment for major depression: a cross sectional, randomized case-vignette survey

Background

In developed countries, primary care physicians manage most patients with depression. Relatively few studies allow a comprehensive assessment of the decisions these doctors make in these cases and the factors associated with these decisions. We studied how general practitioners (GPs) manage the acute phase of a new episode of non-comorbid major depression (MD) and the factors associated with their decisions.

Methodology/Principal Findings

In this cross-sectional telephone survey, professional investigators interviewed an existing panel of randomly selected GPs (1249/1431, response rate: 87.3%). We used case-vignettes about new MD episodes in 8 versions differing by patient gender and socioeconomic status (blue/white collar) and disease intensity (mild/severe). GPs were randomized to receive one of these 8 versions. Overall, 82.6% chose pharmacotherapy; among them GPs chose either an antidepressant (79.8%) or an anxiolytic/hypnotic alone (18.5%). They rarely recommended referral for psychotherapy alone, regardless of severity, but 38.2% chose it in combination with pharmacotherapy. Antidepressant prescription was associated with severity of depression (OR = 1.74; 95%CI = 1.33–2.27), patient gender (female, OR = 0.75; 95%CI = 0.58–0.98), GP personal characteristics (e.g. history of antidepressant treatment: OR = 2.31; 95%CI = 1.41–3.81) and GP belief that antidepressants are overprescribed in France (OR = 0.63; 95%CI = 0.48–0.82). The combination of antidepressants and psychotherapy was associated with severity of depression (OR = 1.82; 95%CI = 1.31–2.52), patient's white-collar status (OR = 1.58; 95%CI = 1.14–2.18), and GPs' dissatisfaction with cooperation with mental health specialists (OR = 0.63; 95%CI = 0.45–0.89). These choices were not associated with either GPs' professional characteristics or psychiatrist density in the GP's practice areas.

Conclusions/Significance

GPs' choices for treating severe MD complied with clinical guidelines better than those for mild MD; GPs rarely recommended psychotherapy alone but rather as a complement to pharmacotherapy. Their decisions were mainly influenced by personal life experience and attitudes regarding treatment more than by professional characteristics. These results call into question the methods and content of continuing medical education in France about MD management.

[Occupational physicians and occupational cancers: attitudes, opinions, practices. A qualitative study in South Eastern France]

BACKGROUND

A qualitative study was conducted in 2008 of occupational physicians (OPs) in south-eastern France to document their attitudes, opinions and practices on prevention and screening of occupational cancers. This was done to provide elements to prepare the questionnaire of a quantitative study in 2009.

METHODS

Semi-structured interviews were conducted using a structured interview guide with 20 OPs. The data collected were subjected to an analysis of thematic content type.

RESULTS

The analysis revealed that OPs face many difficulties when preventing occupational cancers. For most of OPs, these difficulties appeared related to "external factors": lack of involvement of employers and minimization of risks by employers and employees. Lack of time, overload and, for some OPs, perceived lack of independence towards employers, were also mentioned as barriers to cancer prevention. This study also suggested hypotheses related to OPs themselves (internal factors): perceived lack of effectiveness and, trend to minimize the risks of occupational cancer in their geographical area. Finally, the results suggest a significant heterogeneity of OPs' practices regarding occupational cancer screening.

CONCLUSION

These results raise several hypotheses that will be addressed further in the quantitative survey. They warn about the difficulties of a profession that seems to encounter a demographic and identity crisis.

Public awareness campaigns about depression and suicide: a review

OBJECTIVE

Numerous institutions, including the World Health Organization, recommend education campaigns targeted at the general public to improve awareness of suicidal crises and, more broadly, of depression; to improve access to care; and to combat the stigma associated with these illnesses and discrimination against people who have them. The purpose of this literature review was to gather information on campaigns about depression or suicide awareness and summarize data on the impact and effectiveness of these campaigns.

METHODS

A search was conducted of MEDLINE, the Cochrane Library, PsycINFO, HDA (Health Development Agency) Evidence Base, DARE (Database of Abstracts of Reviews of Effects), and the ISI Web of Science to identify articles written in English and published between 1987 and 2007 that described depression or suicide awareness programs that targeted the public.

RESULTS

Among the 200 publications for which references were found, 43 publications that described 15 programs in eight countries met inclusion criteria. Comparing the programs was difficult because of the diversity of their objectives and the methods used to deliver the programs and to evaluate them. Results suggest that these programs contributed to a modest improvement in public knowledge of and attitudes toward depression or suicide, but most program evaluations did not assess the durability of the attitude changes. No study has clearly demonstrated that such campaigns help to increase care seeking or to decrease suicidal behavior.

CONCLUSIONS

Developing guidelines for assessment of public education campaigns to improve knowledge about suicide and depression is essential for the sharing of knowledge among scientists and stakeholders.