Medical Education, 1981,15, 340-345

Attitudes of house-phy sici ans to wards self-poisoning patients

F. H. CREED7 A N D J. M. PFEFFER

Department of Psychiatry, The London Hospital

S-Y Eighty-two housephysicians filled in a question- naire concerning the care of self-poisoning patients with special emphasis on training and attitudes. These recently qualified doctors dealt with large numbers of such patients and expressed dissatis- faction with their training in this respect. Hostile attitudes towards these patients developed most clearly at those district hospitals where psychiatrists are rarely available. During their 6 months as a house-physician, doctors at the teaching hospital became more interested in making a full assessment of these patients whereas those at other hospitals became less so.

Better training at both undergraduate and pre- registration level is needed to make house-physicians more able and more willing to fully assess these patients.

Key words: *ATTITUDE OF HEALTH PERSONNEL; *IN- TERNSHIP; POlSONING/*pSyChOl; HOSPITALS, TEACH-

ther; GREAT BRITAIN ING ; HOSPITALS, DISTRICT ; HOSTILITY ; POISONING/

Introduction

Several papers have recently questioned the recom- mendations made by the Department of Health and

Correspondence.: J. M. Pfeffer, Department of Psychiatry, The London Hospital, Whitechapel Road, London El IBB.

tPresent address: Deoartment of Psychiatry. Universitv Hospital of South Manihester, West Didsbury; ‘Manchestei M20 8LR. 0308-01 10/81/0900-0340 S02.00 0 1981 Medical Education

Social Security in 1968 that all self-poisoning patients admitted to hospital should be seen by a psychiatrist (Anon., 1979). It has been implied that since under- graduate education in psychiatry has improved and more emphasis has been placed on psychosocial aspects of illness, junior medical staff are now better equipped to assess these patients (Blake & Bramble, 1979).

In a prospective trial at Cambridge, Gardner et al. demonstrated that providing doctors are properly trained they are as competent as psychiatrists in assessing self-poisoning patients (Gardner er al., 1977, 1978). However, Sir Denis Hill, who chaired the DHSS committee of 1968, has warned that not all doctors would be as well motivated and suitably trained for this task as those involved in a prospec- tive trial (Hill, 1978).

Adequate assessment of self-poisoning patients begins with a clear history being taken by the pre- registration house-physician (Stengel, 1963). Gardner er al. stressed that further training was necessary at this stage because that received at undergraduate level was inadequate. However, Patel (1975) demon- strated clear hostility to these patients among junior hospital doctors and we have therefore attempted to assess the relationship between attitudes to self- poisoning patients and previous training of pre- registration house-physicians.

Previous studies of this topic have been performed at teaching hospitals but it is at the less well staffed District General Hospitals that the vast majority of self-poisoning patients are seen. We therefore included those house-physicians who worked in the latter type of hospital and compared their attitudes with those of their colleagues who worked in the teaching hospital.

340

Attitudes towards self-poisoning patients 34 1

Subjects and method

We studied two consecutive cohorts of pre-registra- tion house-physicians who had graduated from the same Medical School in 1977/78. Of the eighty-eight house-physicians, forty held posts at the teaching hospital and forty-eight at district general hospitals.

Attitudes were measured with a modified version of the questionnaire designed by Patel (1975), which included an 8-point self-rating scale. The 3 points at either end were used to designate the attitude as ‘hostile’ or ‘sympathetic’ and the middle points as neutral. The questionnaire was administered at the end of the first month of the house job and again during the last month. In addition, one house- physician at each district hospital was interviewed in some detail (by telephone) to determine the availability of the psychiatrists for assessment of self-posioning patients. Statistical comparisons were made using the Chi square test (with Yates correc- tion where appropriate) applied to the raw data but percentages have been used in the tables for clarity.

Results

The response rate was similar from teaching and district hospitals; seventy out of a possible eighty- eight house-physicians filled in both questionnaires and a further twelve filled in the first questionnaire only. The figures given in the text below refer to the initial questionnaire unless otherwise stated.

(1) Treatment ofself-poisoning patients (Table 1)

Few house-physicians felt that the stay in a general medical ward helped self-poisoning patients and

many felt that such patients ought to be admitted to specialized units although only two house-physicians worked in hospitals where such a unit exists. The proportion of patients who were considered ill enough to warrant admission to a psychiatric hospital was much larger than is actually admitted. A vast majority of the house physicians were of the opinion that the general attitude of the medical and nursing staff towards self-poisoning patients was one of hostility in marked contrast to the other conditions listed (Table 2).

(2) House-physicians’ personal involvement with the treatment of self-poisoning patients

Only five house-physicians (6.5%) found the majority of self-poisoning patients personally satis- fying to treat while forty-seven (62%) felt that few or none were satisfying to treat. Although 65% felt they should always take a brief psychiatric history before referral to a psychiatrist, examination of the notes of these patients demonstrated that this was rarely the case in practice. Similar results were recorded on these items at the end of the house job.

Only a quarter of the house-physicians agreed with the suggestion that physicians might assume total responsibility for a large number of self-poisoning patients. This proportion increased to 35% at the end of the 6 months.

The house-physicians rated their own personal reactions to patients with different illnesses similarly to the general attitudes of medical and nursing staff. Once again patients who had taken an overdose evoked strikingly more hostility than those with other diagnoses (Table 2) .

TABLE 1. House-physicians’ opinions regarding the treatment of self-poisoning patients (number of respondents and the results of the second assessment in brackets)

All/nearly All (%) Few/none ( %)

The cases admitted benefit from their stay in hospital n=76 (72)

24 (19) 34 (29) 42 (52)

Yes ( %) No ( X ) Don’t know (%)

Overdose patients should be admitted to specialized units rather than general medical wards 58 (48) 25 (30) 17 (22)

n=79 (67) All/nearly all Half Few/none

The cases are psychiatrically ill enough to warrant admission to mental hospital 3 (4) 45 (35) 52 (61) n=78 (71)

342 F. H. Creed and J. M. Pfefer

TABLE 2. Attitude scores according to diagnosis

Number (%) of responses scored as ‘hostile’

House-physicians assessment of the general attitude of medical and nursing staff (n=78) Self-poisoning 63 (80.8)t Other diagnoses* 2 (2.5) x2=98.3, d.f.= 1

House-physicians own attitude (n= 75) Self-poisoning 37 (49.3)t Other diagnoses* 2 (2.7) x2=4244, d.f.=l

*These figures represent the average score for the following diagnoses: cerebro-vascular accident, myocardial infarction,

t Difference between self-poisoning and other diagnoses, P< 0.001. asthmatic attack, pneumonia, diabetic ketosis and terminal cancer, which were scored separately on the questionnaire.

(3) Training

Only 18% of these doctors had been closely in- volved with the care of a self-poisoning patient while a student, and only 27% felt that they had been adequately trained while students to make a full assessment of such patients. This point was probably brought home during their first month as house- physicians during which time 90% had looked after at least one such patient, 53% had looked after at least five such patients and 25% at least ten.

Relationship between attitude and other variables (Table 3)

Not surprisingly those house-physicians who rated themselves as hostile in their attitude towards self-poisoning patients were those who did not find them satisfying to treat. They had treated signifi- cantly more such patients since qualifying compared to those whose attitude was not hostile, but were

somewhat less likely to have been closely involved with one during their student training. Their hostile attitude was demonstrated in a reluctance to take a brief psychiatric history from such patients prior to referral for a psychiatric opinion.

Teaching versus District Hospital (Table 4)

By the end of the 6 months those house-physicians who worked at the district hospitals felt significantly more hostile towards self-poisoning patients than those at the teaching hospital. The reluctance of house-physicians working at district hospitals to take a brief psychiatric history from these patients in- creased during the pre-registration period while the tendency at the teaching hospital was in the opposite direction. The number of individual house-physicians who changed their views between the two assessments (Table 5) confirms this result.

Of those house physicians at the district hospitals,

TABLE 3. House-physicians’ responses according to their own attitude towards self-poisoning patients (the number and

‘Hostility’ ‘Neutral/sympathy’

percentages in parentheses, of doctors whose answers correspond with agreement of each statement)

group group

The majority of cases are satisfying to treat

Houseman should always take a brief psychiatric history before referral

Training as a medical student was satisfactory for assessment of these patients

Closely involved with overdose patients while a student

7/36 (19) 27/38 (72) x2= 17.7*

21/37 (57) 30/36 (83) XZ=6.12t

13/38 (34)

d.f. = 1

d.f.= 1

d.f.= 1 8/38 (21) xa= 1.64

4/36 (11) 11/39 (28) x2=3.42

Seen more than ten cases in first month as a house-physician

._ d.f. = 1

d.f. = 1 13/37 (35) 2/37 ( 5 ) x’= 10.12*

. .

*Difference significant at P<O.OOl. tDifference significant at P < 0.02.

Attitudes towards self-poisoning patients 343

TABLE 4. House-physicians’ responses according to hospital (the number and, in parentheses, percentage of doctors whose answers correspond with agreement of each statement regarding cases of self-poisoning)

First assessment (1st month) Second assessment (6th month)

Teaching District X2 Teaching District X2 hospital hospital (d.f.= I ) hospital hospital (d.f.= I )

~~ ~ ~

(1) The majority of cases are

(2) Housemen should always take a

(3) Since qualification:

satisfying to treat 15/35 (43) 14/41 (34) 0.6 16/30 (53) 8/41 (19.5)* 8.85

brief psychiatric history before referral to a psychiatrist 27/38 (71) 28 41 (68) 0.07 26/31 (84) 21/40 (5.25)t 7.68

Cared for more than five self- poisoning patients 11/30 (29) 33/44 (75)$ 17.39 23/31 (74) 41/41 (loo)$ 11.90 Cared for more than ten self- poisoning patients 4/38 (10.5) 17/44 (39)’ 8.49 11/31 (35.5) 38/41 (93)t 26.57

(4) Own attitude ‘hostile’ 14/37 (38) 25/42 (59.5) 3.7 11/31 (35.5) 27/40 (67.5). 7.2

Difference between Teaching & District Hospital significant at *P< 0.01 ; t P < 0.02; $P<O.OOI.

TABLE 5. Number of house-physicians whose views changed between first and last months ofjob, by type of hospital

Teaching District hospital hospital

(1) Self-poisoning patients satisfying to treat: More satisfying Less satisfying No change

x2=15,9O7 d.f.=2 P<O.O1

7 1 4 5

1 s 30

(2) ‘H-P should take brief psychiatric history from self-poisoning patients’ More agree 8 3 Less agree 2 10 No change 20 22 x2= 1 1:46 d.f. = 2 P < 0.01

(3) H-P’s own attitude towards self-poisoning patients More ‘sympathetic’ 7 2 More ‘hostile’ 4 5 N o change 16 28

x2=7.092 d.f.=2 P < 0 . 0 5

twenty-six worked at hospitals where a psychiatrist was available every day and ten at hospitals where a psychiatrist was available only twice a week. Amongst the former group, there was a slight f d l over the 6-month period in the proportion who rated their attitude as one of hostility (62 to 54%). Amongst the latter group, however, there was a marked increase in hostility (40 to 80%).

Discussion

Our study confirms the presence of hostile attitudes to self-poisoning patients found in previous papers (Ghodse, 1978; O’Brien & Stoll, 1977; Patel, 1975;

Ramon, Bancroft & Skrimshine, 1975). Like Ghodse (1978) we have found that one of the correlates of hostility is the number of self-poisoning patients that a house-physician deals with. However, if this were the most important factor in determining attitudes one would expect there to be an increase in hostility for all house-physicians by the end of their house jobs. Our results show clearly that this is not the case but that hostility increases most in those district hospitals where the psychiatrist is rarely available, and even falls slightly at other hospitals. The importance of this change lies in the housemen’s readiness to take a proper history from self-poisoning patients. The psychiatrists at the teaching hospital

344 F. H. Creed and J . M. Pfefler

are readily available and discuss the case in detail with the housemen, which is presumably why they develop more interest in making a full assessment.

In contrast, the referral process at some of the district hospitals included little or no feedback to the house-physicians from the psychiatrist. This was often because the psychiatrist visited the ward in the evening by which time the house-physician was either off duty or involved in emergency work. At those hospitals where a psychiatrist was available only twice a week the house-physicians described that it was sometimes necessary to detain a patient for 5 days on the general ward. It became clear that this situation contributes to the development of unfavourable attitudes.

Apart from the larger number of self-poisoning patients and the relative lack of available psychiatric expertise the house-physician at a district hospital faces an additional overall work-load which reduces the time he has to interview patients and may con- tribute to the prevailing attitude. This situation is analogous to that described by Morris (1973) in relation to the higher mortality rate of surgical cases outside the teaching hospital. Unlike Morris’s illustration, however, there is no evidence that self- poisoning patients seen by the house-physicians at the district hospitals are more seriously ill than those at the teaching hospital. The reverse may be true as drug addicts are the group of patients who are most likely to generate hostile attitudes in this context (Ghodse, 1978) and are relatively more common at the teaching hospital than the district hospitals (Collier, Cummins & Hamilton, 1976).

It is desirable that the training of medical students to assess self-poisoning patients should be improved as only a quarter of these recently qualified doctors felt that their undergraduate training was quite satis- factory in this respect and only one-fifth had been closely involved with the care of such a patient while a student. Those who had been so involved expressed much more satisfaction with their training and were also much less likely to feel hostile towards these patients after qualifying (though this trend just failed to reach statistical significance).

Students who acquire the necessary skills to assess self-poisoning patients during their psychiatric clerkship may lose them during their final year through disuse and lack of emphasis on their importance. An integrated approach is therefore necessary; students should initially be taught the technique of assessment by psychiatrists. A second

stage would be the supervision of the student by a doctor and a psychiatrist in collaboration on the medical firms. Fortunately the assessment of self- poisoning patients is a clinical skill that lends itself to a variety of audio-visual aids and should be amenable to some degree of automation.

Although it is probably desirable that doctors should gradually take over from psychiatrists the responsibility for the assessment of self-poisoning patients this can only be done with the extra teaching described by Gardner et al. (1978). Better provision for the teaching and supervision of house-physicians at some district general hospitals is necessary before a change in DHSS policy is made and until training at undergraduate level is improved.

Acknowledgments

We thank the consultants in the Department of Psychiatry, the London Hospital, for their help, the consultant physicians who allowed us to study their house-physicians, and all those doctors who com- pleted the questionnaires. We thank Mrs Jo Laird, Mrs Anne Heys and Ms Barbara Lawrence for their secretarial help. This research was undertaken while F.H.C. held a Mental Health Leverhulme Fellow- ship.

References

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Attitudes towards self-poisoning patients 345

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Received 26 August 1980; accepted for publication 23 February 1981