The European Journal of General Practice

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How to improve mental health competency in

general practice training?: A SWOT analysis

Harm van Marwijk

To cite this article: Harm van Marwijk (2004) How to improve mental health competency in general
practice training?: A SWOT analysis, The European Journal of General Practice, 10:2, 61-65, DOI:
10.3109/13814780409094234

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How to improve mental health
competency m general practrce I ,
A SWOT analysis
Harm van Marwijk
It is quite evident there is room for improvement in
the primary care management of common mental
health problems. Patients respond positively when
GPs adopt a more proactive role in this respect. The
Dutch general practice curriculum is currently being
renewed. The topics discussed here include the
Strengths, Weaknesses, Opportunities and Threats
(SWOT) of present primary mental healthcare teach-
ing. What works well and what needs improving?
Integrated teaching packages are needed to help gen-
eral practice trainees manage various presentations of
psychological distress. Such packages comprise train-
ing videotapes, in which models such as problem-solv-
ing treatment (PST) are demonstrated, as well as role-
playing material for new skills, self-report question-
naires for patients, and small-group video feedback of
consultations. While GP trainees can effectively mas-
ter such skills, it is important to query the level of
proficiency required by registrars. Are these skills of
use only to connoisseur GPs, or to all? More room for
specialisation and differentiation among trainees may
be the way forward. We have just developed a new
curriculum for the obligatory three-month psychiatry
Harm van Marwijk PhD, general practitioner, vocational trainer,
head Dutch diploma degree course on mental health for GPs, senior
researcher
Department of General Pra&'ce, W University Medical Centre, Institute
for Research in Extramural Health, Amsterhm, the Netberkands
Correspondence to: Harm van Marwijk
Department of General Practice, W Univcsity Medial Centre,
Institute for Research in Extramural Health, Van der Boechorststraat
7,1081 BTAmsterdam, the Netherlands
E-mail: hwi.van_marwijk.gpnb~ed.wc.nl
Submitted: 25 September 2003.
Accepted (in revised form): 1 April 2004.
European Journal of General Practice, Volume 10, June 2004
BACKGROUND PAPER
4
housemanship. It is competency oriented, self-directed
and assignment driven. This new curriculum will be
evaluated in due course.
EurJ Gen Pruct 2004;10(2):61-5.
Keywords: competency, general practice, mental
health, SWOT analysis, training
Introduction
Because of our unique position at the interface be-
tween physical and psychological problems in pri-
mary care, GPs are the most frequently consulted
professionals when it comes to mental problems. The
integrated 'two-track' approach to both physical and
mental issues offers patients a locally available
framework for both physical and mental advice,
while preventing the fragmentation of care. GPs in
training need all the encouragement and help they
can get to assist them in performing this important
but frequently difficult task.
The department of vocational training in Amsterdam
is currently reviewing mental health teaching, with a
view to possible revisions. This is therefore a good
moment to reflect on the strengths, weaknesses. op-
portunities and threats of the present curriculum, be-
fore making any changes. A process of change in
general practice training is now under way through-
out the Netherlands. After several years of instruct-
ing trainees, my general impression is that mental
health teaching may well merit a more structured
and integrated approach. It has been shown, for ex-
ample, that registrars' ability to identify signals of
depression showed no improvement from their first
year to their last.'
Although European community requirements have
reduced differences between vocational training
schemes in Europe, the European guidelines leave
61
BACKGROUND PAPER
much room for differences between countries.
Within the three-year vocational training period for
a GP in the United Kingdom, the doctor spends one
year in a training general practice as a GP registrar,
and two years in hospital training posts as a senior
house officer. The hospital posts must cover at least
two specialities relevant to general practice such as
paediatrics, general medicine, geriatrics, obstetrics,
psychiatry or accident and emergency. GP registrars
in for instance Germany and Switzerland also spend
two years doing various clinical housemanships (not
necessarily psychiatry) in hospitals, while six months
in psychiatry is obligatory in Sweden.
What are the arguments in favour of a greater em-
phasis on mental health problems?
1 Such problems result in considerable disability.
The World Health Organisation Global Burden of
Disease Survey identifies these disorders as the
leading cause of the worldwide disability burden
(http://www.who.int/whr2001/200l/main/en/chapter2/tifying the strengths and weaknesses, and of examin-
OO2d.hm1).~-~ Comorbidity with somatic illness is
very common in general practice, and it further in-
creases the disability experienced by sufferers.
2 Managing mental health problems is a complex
and growing task. WHO projections indicate that
the burden of suffering will increase to 15% in the
year 2020. Depression is already the third most
common reason for consultation in UK general
p r a c t i ~ eEighty
.~ percent of such patients visit their prehensive, personal, longitudinal and local nature
GI’ because of physical complaints, not for depres-
sion. There is also the issue of poor acceptance and
compliance with existing treatments. At least 50%
of patients who receive an intervention for depres-
sion (i.e. antidepressants) stop within one month.‘j
An extra bottleneck results from the high level of
advisory skills needed by those treating people
with mental problems. A nationwide evaluation of
vocational training curricula, which was carried
out a few years ago in the Netherlands, revealed an
adequate improvement in most of the skills re-
quired by general practice trainees. Surprisingly,
however, their consultation skills showed little im-
provement over the three years.’ Much of the ef-
fort invested in Dutch general practice training
over the past thirty years has focused on teaching
these very skills. Since consultation skills are a
GP’s most important tools for dealing with psycho-
logical problems, extra teaching emphasis in this
area would seem to be appropriate.
3 There is a great deal of evidence that the quality of
primary care mental health management can be im-
proved by relatively simple interventions at the
level of the organisation of care, such as structured
telephone f ~ l l o w - u p It
. ~ has also been shown that
patients respond positively when GPs adopt a more
proactive role in this r e ~ p e c t . ~More
, ~ structured
forms of proactive care, referred to as ‘disease
management’, or ‘collaborative care’ may offer a
62
way forward, not only for mental problems but
also for chronic illnesses such as diabetes melli-
tus.l0J1Chronic care models retain the important
role of the primary care physician as the frontline
worker with the patient and thus the important
place as the professional who can deal with both
psychological and physical symptoms together.
The models share the need to alter reactive acute
care-oriented practice to accommodate the pro-
active, planned, patient-oriented longitudinal care
required for both prevention and chronic c a ~ e . ’ ~ , ~ ~
Pure disease management models carve out the
care of individual problems away from the GP and
are much less appealing.
SWOT
SWOT analysis is a model that is widely used in
business consulting. It was originally described by
Ansoff.l4 SWOT analysis is an effective way of iden-
ing the opportunities and threats an organisation
faces. Carrying out an analysis using the SWOT
framework helps to focus activities into areas where
one is strong and where the greatest opportunities
lie.
Strength
The strengths of current teaching stem from the com-
of general practice. The training course currently
consists of integrated learning and working in prac-
tice, a weekly course in the Department of
Vocational Training, and private study. Students in
all years put in a four-day week, either in a practice
or in a clinical setting. During the first year, the
trainee works in the GI? trainer’s practice, and is
taught primarily by the latter. The general aim is to
make the learning process and feedback as specific
and targeted as possible. One way in which this is
done is by using the videotapes that trainees make of
their own consultations. The trainees study in groups
of 10 to 12 within the department for one day every
week. These group sessions are supervised by a psy-
chologist and a GP. Weekly supervision by a psy-
chologist appears to be unique for the situation in
the Netherlands.
There is a range of tried and tested teaching pro-
grammes covering subjects such as anxiety, depres-
sion and problematic alcohol use. Second-year
trainees take up housemanships outside general prac-
tice for a maximum of 12 months. During this time
they work in emergency wards, nursing homes, and
mental healthcare institutions. In the third year,
trainees return to general practice in a GP trainer’s
practice. At this stage, extra emphasis is given to
chronic conditions and psychiatric problems. The use
of a group teaching structure results in enhanced
safety and improved communication skills. The close
European Journal of General Practice, Volume 10, June 2004

supervision of trainees by behavioural scientists/ psy-
chologists and experienced GPs also serves to facili-
tate learning.
Various guidelines drawn up by the Dutch College of
General Practitioners (on dementia, depression, anx-
iety, delirium, problematic drinking), together with
implementation packages, are available for the sup-
port of vocational trainees. Every six months, the vo-
cational trainees take a national continuation test,
which gives them additional, specific feedback on
their strong points and areas of weakness. Learning
is already largely student-centred.
The setting of a GP’s practice is potentially an ideal
teaching environment in which to learn the profes-
sion, provided that adequate learning conditions are
met. For instance, the practice should not be deluged
with work, and video equipment, books and Internet
facilities should be available on-site. Most patients
see their GI’ on a regular basis. The latter is a locally
available, well-trained professional who offers a
stable, longitudinal, comprehensive approach. The
GP usually has an adequate working alliance with
most patients. Practices are generally well managed
(Dutch GPs have no waiting lists). One of the more
appealing aspects of the profession is that it allows
physicians to adopt an autonomous and individu-
alised approach to healthcare. Departments of voca-
tional training have also put considerable effort into
teaching GP trainers.
Weaknesses
The literature shows that it is generally more diffi-
cult to take comprehensive responsibility for mental
issues than for physical One reason is
that psychosocial consultations tend to require con-
siderably more time than other interview~.~*J~ GP’s
consultations with their patients are generally dom-
inated by pain, anxiety and depression, themes that
frequently display a degree of overlap. A trainee’s
ability to learn to make accurate ratings of such psy-
chological distress is determined by the rate at which
patients provide cues that are indicative of such dis-
tress. There is a higher rate of cue provision in inter-
views that are ‘patient-led’ than in those that are
‘physician-led’.15J0,21
Regarding everyday mental healthcare needs in the
community, a wide body of research shows that
there is still plenty of room for improvement (WHO
Health Report 2001). This is hardly surprising, since
GPs manage over 90% of all health problems in the
community during their regular ten-minute consult-
ations. Even the most complex issues are generally
dealt with inside this short t i r n e f ~ a m e . ~
Research
,~~
has been carried out into vocational trainees’ levels
of proficiency in consultation skills and their ability
to recognise mental health problems. The results
show that while, on a theoretical level, trainees may
be better qualified at the end of their training, this is
European Journal of General Practice, Volume 10, June 2004
BACKGROUND PAPER
not always reflected in their actual behaviour in the
practice.’Js An important barrier may be the ten-
minute consultation. Trainees need to focus less on
practising the content of their psychosocial consult-
ations and more on training with new formats and
consultation styles, such as PST. A style of problem-
solving better adapted to the constraints of general
practice might be a solution. An international work-
ing party is therefore currently trying to define the
content of what they call brief problem-solving and
will organise a workshop at the next WONCA meet-
ing in Amsterdam in June 2004 (Van Weel-
Baumgarten and Mynors-Wallis, personal communi-
cation). Most trainees could learn some of the basic
skills of problem-solving in order to improve the
quality of what they do in everyday opportunistic
consultations with patients in which mental health
problems will come up (such as activity scheduling:
‘a treat a day’). Trainees must also learn to take their
time. The physician’s characteristics, rather than
those of the patient, have the greatest influence on
the degree to which patients use frank presentation
rather than signal behaviour to provoke discussion
of psychosocial problems.24
Opportunities
The basic idea of the new Dutch curriculum is that it
is competency driven. Competency is ‘the personal
capacity to select and apply behaviours for relevant
knowledge and/or skills required for given situations
in professional activities according to the statutory
regulations and standards’. During the first 15 to 18
months of the training course, the trainees design
their own approaches to a wide spectrum of the most
frequently occurring complaints and illnesses. This is
followed by a period of three to six months in which
they strengthen their clinical ‘secondary care’ skills.
Finally, the trainees have 12 months of general-prac-
tice study which is aimed at improving their ‘intake,
diagnosis, therapeutic policy and related communica-
tive skills’. After that, they broaden and deepen their
skills in dealing with more complex complaints and
illnesses. Training is aimed ‘at the development,
broadening and deepening of broad, professionally
oriented competencies’.
Given the complexities associated with mental prob-
lems, trainees should be given the opportunity to
learn to cooperate closely with mental health profes-
sionals early on in their medical careers. Perhaps
even more importantly, they must learn to organise
such cooperation in their ultimate place of work.
In the teaching of primary mental healthcare, it is
important to invite vocational trainees to reflect
upon the scope and limits of their responsibility as a
gatekeeper to mental health. Dutch general practice
teaching has traditionally focused on the clarification
of patients’ actual demand for care, within the pa-
tient-centred paradigm.25 As GPs are the first (and
63
BACKGROUND PAPER
frequently last) port of call for patients with a multi-
tude of mostly self-limiting health problems, an em-
phasis on patient-led care and autonomy is under-
standable. For mental conditions, however, this
paradigm limits the potential quality of care. Many
of the improvements that have been developed for
general practice are not used systematically. More
importantly, in the context of this paper, many are
not even being taught. Those that are being taught
have not been integrated into current training mate-
rials in a way that invites trainers and trainees to use
them often enough to become familiar with them.9
The new curriculum offers a unique opportunity to
try and implement a quality system for improving
mental healthcare facilities in general practice. If
various Dutch and, possibly, British departments of
general practice were to cooperate on teaching pro-
grammes and if rigorous evaluations were to be car-
ried out, this might help to ensure the highest stan-
dards of teaching.
Threats
The strength of Dutch general practice lies in its autono-
my, but this could well become a threat in periods of ris-
ing work pressures. Unlike the situation in the UK, no
immediate low-threshold psychological help (such as
counselling) is available to patients in the Netherlands.
As patients with mental health problems are frequently
reluctant to ask for help, there is a danger that GP train-
ers will focus exclusively on the more pressing somatic
problems, and that regstrars will get too little opportu-
nity to learn new roles.
Reforms towards a more market-oriented approach are
being explored in the UK and the Netherlands. This may
amplify unmet needs, a process which is described as the
‘inverse care law’,2h and many of the more vulnerable
patients will not receive the structured care they need.
Many patients with mental illness define their prob-
lems in physical terms, such as fatigue. This example is
illustrated by the large numbers of laboratory tests re-
quested for healthy people complaining of tiredness. In
such cases, the patient’s mental illness can easily re-
main undetected and unmanaged. In the training situa-
tion, the structured use of psychological questionnaires
instead of laboratory forms may help future GPs to be-
come more aware of mental problems. Another type of
diagnostic confusion involves incidental co-occurrence
with a physical problem, such as a myocardial infarc-
tion. We can instruct the trainers to give these issues
more structured attention.
A mental health diagnosis is often negotiated in prima-
ry care. Only when both the patient and the GP agree
on the psychological nature of the problem does it be-
come acknowledged as More often than not,
when the GP detects signs of a mental problem, the pa-
tient remains unconvinced. Fortunately, the more
chronic and serious problems such as major depression
are eventually acknowledged.‘
64
GPs also vary in their willingness and ability to detect,
diagnose and treat mental illness. The use of guidelines
is meant to reduce such variation. Although major dif-
ficulties arise when introducing evidence and clinical
guidelines into routine daily practice, in vocational
training, the Dutch guidelines for general practice are
actually an invaluable help and trainees use them ex-
tensively. It may also help to stress what GP registrars
can personally achieve and gain from improving their
mental health skills.
General practice has to play an important role in under-
graduate education. Many of the attitudes towards men-
tal healthcare were established while GP registrars were
medical students and if they observe as medical students
that GPs do not spent much time with their patients
with mental health problems, it is likely that they will
carry those same attitudes throughout their career.
Discussion
To summarise the SWOT analysis: a strong and rich
teaching environment is present, the weakness is that
the current primary mental health teaching is not
specific and competency oriented enough, the oppor-
tunity is the revision of the curriculum, and the
major threat is the lack of time of GPs. Integrated at-
tractive teaching packages are needed to help general
practice trainees manage various presentations of
psychological distress, and to help them learn to co-
operate with professionals of other disciplines, such
as nurses. Such packages comprise training video-
tapes, in which models such as problem-solving
treatment are demonstrated, as well as role-playing
material for new skills, and small-group video feed-
back of consultations. While GP trainees can effect-
ively master such skills, it is important to query the
level of proficiency required by registrars.28Are these
skills of use only to connoisseur GPs, or to all? The
latter option is not very attractive. It is difficult to
teach professionals skills that they d o not want to
learn. More room for specialisation and differenti-
ation among GPs is required. Diploma/degree cours-
es for GPs are in keeping with this development. One
such course, a national diploma/degree training
course for mental healthcare, is being hosted by our
department, and the first group of trainees has just
commenced their studies.
We have just rewritten the curriculum for the psych-
iatry housemanship in the second year to provide the
registrars with a good base in mental health skills,
with the opportunity for those who are interested in
developing further skills to learn where and how to
obtain such training. It started in March 2003. This
will be evaluated in due course. An important new
element is that it is student-centred, self-directed and
assignment driven. Previous studies in the UK have
shown that the advisory skills for dealing with
people with mental problems can be effectively
learned. The structured use of questionnaires on
European Journal of General Practice, Volume 10, June 2004

psychological distress, for patients with ill-defined
problems, may also help such patients to acknowl-
edge the issue of mental dy~function.~
W 2002;288:1909-14.
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Royal College of General Practitioners International Travel Scholarships
International Travel Scholarships assist any general
practitionerfiamilydoctor in the world to undertake
personal study of an aspect of primary health care in an
international context. The awards are open to both
members and non-members. They enable GPs to travel
to and from the United Kingdom to study an aspect of
primary health care internationally that is relevant to their
country’s needs, or for overseas doctors to help develop
their own systems of primary care. The value of each
scholarship may range from f2OO to f 1000.
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Maeseneer J. Consultation length in general practice: cross sectional
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WW, et al. The impact of patient-centeredcare on outcomes.J Fum
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The following award will also be made:
The John J Ferguson Award
The John J Ferguson award is awarded each August
for the most outstanding internationaltravel scholarship
application submitted.
Next closing date: Friday 13 August 2004
For further information and an application form:
lnternational Department Royal College of General Practitioners;
14 Princes Gate, Hyde Park, London, SW7 lPU, UtC tel.. 4 - 2 0 7581 3232
ext 289; fax. 4 - 2 0 7973 0056; email: international@rcgp.org.uk;
website: http:llwww.rcgp.o g .uk
65