ABSTRACT

The PhD study was conducted in general practice in Vejle County in cooperation with the Quality Improvement Committee for General Practice in Vejle County, the Research Unit for General Practice, Aarhus University, and the Research Unit for Functional Disorders, Aarhus University Hospital.

The dissertation is based on five articles describing the development and evaluation of a new evidence based training programme for general practitioners (GPs) focusing on assessment and treatment of somatising patients. The effects of the programme were evaluated in a cluster randomised controlled trial with practices as randomisation units.

Somatisation may be defined in numerous ways. An overview of the various concepts is given in the dissertation. We based our concept on a descriptive definition of somatisation proposed by Lipowski as "a tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness and to seek medical help for them". Among patients in general practice 30% fulfil diagnostic criteria for somatoform disorder. Despite a high frequency, somatisation often goes unrecognised. This may lead to chronification and iatrogenic harm of the patients and unnecessary expenditures for the health care system.

The new cognitively oriented treatment model is described in detail in the first part of the dissertation. It was named `The Extended Reattribution and Management Model'.

The evaluation trial was conducted in year 2000-2001 by 37 GPs from Vejle County, Denmark, and 2880 of their patients, of whom 916 patients had a high screening score for somatisation. Patients and GPs were followed for one year using questionnaires.

The GPs' attitudes towards patients with somatoform disorders improved significantly in the intervention group during 12 months follow-up, whereas the attitude of control GPs remained unaltered. The intervention GPs diagnosed somatisation more frequently than the control GPs, but the difference fell short of significance at a 5% level (p=0.094). However, the subclass "medically unexplained physical symptoms" was diagnosed twice as often in the intervention group as in the control group. Diagnostic rates of somatisation varied much between doctors. Finally, the effect of training of GPs was evaluated at patient level. Questionnaires addressing the patients' health and satisfaction showed no statistically significant differences between randomised groups at follow-up, but patients in the intervention group were generally more satisfied than control patients.

There is a considerable need for research and education in somatisation in general practice. It is essential to clarify the concept and further investigate the effects of GP training at patient level.