Feasibility of training in problem-solving treatment for general practice registrars

Introduction

In primary care, patients frequently present with emotional symptoms and/or psychosocial problems [1]. Most of these patients are treated without specialist referral [2]. Usual care by general practitioners (GPs) mostly consists of counselling and medication [2], [3]. However, medication is not always the best option [4], [5], nor does it meet patients’ preferences [6], and the effectiveness of counselling is unclear. Many GPs and GP registrars have expressed the need for more practical skills training in managing emotional symptoms [7], [8]. We therefore introduced training in problem-solving treatment (PST) into the GP residency programme. PST is a brief, psychosocial intervention teaching the patient a systematic way of dealing with problems of everyday life. The treatment has shown effectiveness in depression and other emotional symptoms [9–11], and it has also improved self-efficacy in patients with diabetes, low-back pain, and osteoarthritis [12–14]. This implies that problem-solving skills can be used as a tool for patient empowerment in general. Together with its brief character, this makes problem solving an attractive technique for GPs. In this pilot study, we assessed the feasibility of PST training in GP residency.

Methods

We performed an observational study with GP registrars in the GP residency programme in the Netherlands. We randomly selected 21 third-year GP registrars, who were in their last year of training to qualify as a GP. After training in PST, registrars selected and treated patients with emotional or psychosocial problems with PST in their teaching practice. By observation and questionnaires, we measured: registrars’ participation in the training; time spent on training, supervision, and treatment; number of patients treated with PST; registrars’ performance in treating patients; and registrars’ opinions about the training and treatment.

Problem-solving treatment and training

PST is a brief psychological treatment, derived from cognitive behavioural therapy, specifically developed for primary care [15]. Patients receive an explanation about the link between their emotional symptoms and current psychosocial problems. They learn how to use their own skills to resolve problems and improve their symptoms. PST comprises the following stages: clarification of the problems; establishing achievable goals; generating solutions; selecting and implementing preferred solution; and evaluation. The full treatment consists of four to six sessions of about 30 min (first session 60 min).

The registrars received a 2-day training by experienced PST trainers, followed by 5 months’ supervision on treatment of patients in the registrars’ practice.

Results

Twenty registrars completed the 2-day training and evaluated it as useful (see Table I). They all practised PST and treated in total 52 patients under supervision (median 2.5 patients per registrar; range 1–5). The median number of sessions per patient was 3 (range 1–6). All 20 registrars received feedback on their treatment techniques. Average attendance rate during the three group-feedback sessions (1½ hours each) was 70%. Sixteen registrars received individual feedback (5–30 min per contact). Overall, the supervisor reported good performance of PST in 18 registrars.

Table I.  Registrars’ opinions about the PST training programme.

Item of questionnaire	Average on five-point scale^a (range)
Two-day training (20 participants):	(20 respondents)
– Usefulness overall	3.8 (3–5)
– Relevance of lectures	4.0 (1–5)
– Relevance of role-play	4.2 (2–5)
– Relevance of video feedback	3.9 (1–5)
– Feeling of being sufficiently trained	3.8 (3–5)
Supervised treatment period (20 participants):	(17 respondents)
– Usefulness of group feedback	3.6 (2–4)
– Usefulness of individual feedback	3.9 (3–5)
– Difficulty with selecting appropriate patients	3.8 (2–5)
– Difficulty with patients willing to start	2.6 (1–4)
– Difficulty with defining the problem clearly	3.7 (2–5)
– Difficulty with stating achievable goals	3.6 (2–5)
– Difficulty with finding solutions	2.8 (1–4)

^a High scores indicate high usefulness, relevance, or difficulty.

At the end of the supervised treatment period, 17 registrars completed a questionnaire (see Table I). Aspects that registrars liked most included the clarifying character of the treatment (n=7), thinking in terms of practical solutions (n=7), the active role of the patient (n=4), and helping patients to increase insight in and control over their own problems (n=4). Aspects that registrars liked less included the extra time they needed for treatment (n=10) and the difficulty in defining their role as a GP whilst providing psychological treatment (n=3). Some registrars (n=4) liked the structure of the treatment; others (n=5) disliked it.

At the end of their third year, 15 registrars completed the final questionnaire: 14 assessed education in PST as positive, and 14 assessed the amount of time necessary for treatment as negative.

Discussion

This study demonstrated that training in PST is feasible during GP residency. Despite the compulsory character of the training and some critical comments, registrars stated that it brought them relevant, new skills. It met the need for practical skills training in the treatment of emotional symptoms in primary care. We therefore recommend PST training to be implemented as a core part in GP residency programmes. Experience from the US suggests that registrars will continue using PST, or parts of it, once qualified [16]. This will be primarily for patients with mental health problems. However, the skills can be used more generically for a much larger part of the primary care population. It is most satisfying that our registrars themselves stressed the generic character of problem-solving skills: they appreciated having learnt how to clarify patients’ problems, to think of practical solutions, and to activate patients. These patient-empowering skills are useful in many other patient contacts and do not have to take much time. The fact that registrars themselves expressed this potential of problem-solving skills supports our reason of introducing PST during residency.

Acknowledgements

We thank all GP registrars for their cooperation in this project. We also thank their tutors in the practices and their tutors at the Radboud University Nijmegen Medical Centre for giving the registrars the opportunity to participate in this project. We also thank ZonMw, The Netherlands Organisation for Health Research and Development, who financially supported the PST project.

Notes

Part of the data were presented as a poster titled “How is problem solving treatment received during general practice residency?” during Wonca Europe 2004 (2 June, Amsterdam, the Netherlands) and World Wonca 2004 (14 October, Orlando, USA).