Both groups GPs stated that after their participation in the clinical trial, they perceived the patients as true suffering persons; their relationship with the patients had improved, although there continued to be complicated cases and the doctors still preferred attending to other types of patient.
Reasons for taking part in the training program
Doctors fundamentally gave two reasons for agreeing to participate in the study. Firstly, the necessity of finding a useful tool to help them work with this type of patient, characterised as complicated and problematical, and secondly, confidence in the research team.
'Personally, what brought me here was to see whether I could learn something about how to manage these patients. These patients are a real problem in my surgery really, so I thought, let's see what they're offering, whether there's anything... here that can be used, (I wanted) to learn how to deal with this problem better, that's all' (NIG1).
'For me specifically, it was the researchers, in other words the, well... more than being a question of motivation, for me it was one of participating, of collaborating with a colleague, José Mari Aiarzaguena, who was planning a project that I thought was serious - that was really my only motivation' (ACG2).
'I have the problem, but no answer' (ACG1).
1. The intervention is clearly structured.
Physicians assigned to the intervention group rated the experience positively mainly because it provided them with a road map, a guiding line or frame of reference in their surgeries. "So, as well as having a protocol for hypertension, or a problem, isn't that so? I know that... now we've also got a method, so the consultation appears to have a thread, a connecting thread, doesn't it? (NIG1)
'Before, when you wanted to enter the psychosocial world, the consultation turned into a chat session, you never knew where you were going and the... the fact of participating here gives you... at least it gives you a road map...' (NIG2).
2. Participation in the training afforded doctors in both groups a better understanding of somatising patients. It facilitates a more comfortable relationship.
Both groups highlight this as a positive point. Somatising patients are difficult to deal with and can elicit contempt, but after spending time with them doctors become aware that they are people who are suffering and have problems. Despite this, they still prefer to attend to other types of patient.
'I understand them better, I now believe these patients and I also believe in all the... in all this somatic suffering that they have, right? I mean I understand them, whereas before I saw them as real fakers' (NIG2).
' ... I think that it's a question of valuing them for what they are. I mean, and maybe I'm going to exaggerate here, but before the trial, I'm going to exaggerate, eh? They were annoying - what I wanted was to get rid of them - so with a new focus, something which would never have occurred to me, I value them more as persons, not only as patients [...] I'm more comfortable in the relationship' (NIG2).
'Because they are people that seemed annoying before, and obsessive, and now having an explanation for the whole cycle, I want to say that... that there is something that makes you understand all these people a bit more' (ACG1).
Since the trial, they are less afraid of consultations with somatising patients, due to the fact that they have a better relationship with the patients.
'Change is something that has taken place in us, more than in the patients' (NIG2).
'I feel more comfortable taking care of them [...] communication with these patients has clearly improved, there is more empathy' (NIG2).
3. It may be used with other patients with psychosocial problems, not only patients with medically unexplained symptoms.
This opinion was only expressed by the doctors in the intervention group. It seems that once the tool has been learned, it is then useful for attending to grieving patients, or those suffering from depression or anxiety. The doctors suggest using specific aspects of the DEPENAS proposal.
'It has even changed how I work with grieving patients, for example, support, and little things that, without applying the complete, systematic Depenas method; it's enough to apply some of the things that we have learned in the training, isn't that right? And wham! You know that it... that it works, or at least that it is... that it's gratifying...' (NIG1).
'Personally, I believe that for seventy percent of my cases, it could be an extremely useful technique' (NIG2).
Limits and barriers
1. Patient's change is more complicated than previously thought
Doctors from both groups consider that change on the part of the patients is necessary (that they learn to put things in perspective, look after themselves, etc.), but that it is extremely difficult to achieve. Those who took part in the intervention group put a higher priority on their feeling comfortable with the relationship themselves, than on patient results.
'I don't know, the change that, that we were aiming for, right? Or that we... it's not, it's not clear to me that this was achieved in my patients' (NIG1).
'Almost nobody wants to change. I mean, if you can change them yourself, without them making an effort, that's wonderful; but a personal effort from them... that's difficult, very difficult' (NIG2).
'We still don't know how it might have affected the patients, but for me, brilliant... If on top of that the results are good then... then that's the icing on the cake' (NIG2).
2. The shortage of Time is still a problem in primary care consultations
Both groups mentioned the amount of time that they needed to dedicate to these patients. They raised the question of whether, if this is a common problem in primary care, it makes sense to dedicate so much time to this type of patient, given that they perceive the patient care situation as being under pressure. This led into a debate over which type of patient should be given time. Why this time should not be dedicated to somatising patients? Why are they considered as a different category of patient, with differing needs from those of hypertensive patients, diabetics, etc.? The GPs considered the time required for managing them to be beyond their capacity in primary care consultations.
'Why should we give priority to hypertensive patients, just because they are hypertensive, and not to those people for whom unhappiness is the underlying cause of it all? So it doesn't seem to me that we are giving them priority; but now I will be able to say to them that you are in the same category, or have the same rights as someone who comes in with a cold, or for haemorrhoids, or with hypertension...' (ACG2).
They are already considered by the doctors as people with the same rights as those whose symptoms can be explained medically - as we mentioned above - but both groups concur in stating that the time that they have to dedicate to them is excessive and it is apparent that this technique may not be applicable outside the investigation, in everyday clinical practice.
'Well, it's all the same whether instead of five half-hour sessions... all the same with one or two sessions, it could still be enough; I mean, there's no need for five sessions, is there? Or however many there are' (NIG2).
'As a protocol it's very long, I mean in time, not in importance, in time' (NIG2).
3. Medical training and its usefulness in primary care
In the interviews, doctors in both groups raise topics related to general practitioner training and a lack of relevant training. 'We are neither psychiatrists, nor psychologists... but family physicians, we need answers to give these patients' (ACG2).
Finally, participants in both groups affirm that their relationships with these patients are now easier and that they consider their participation in the study to have had positive effects.