In general terms, the specialized literature relates non-medically explained symptoms to mental health, more specifically to disorders such as depression and anxiety. At least one-third of patients with somatoform disorders suffer from comorbid anxiety or depressive disorders. In this regard, depression, anxiety, and somatization, with a prevalence rate of 10% each, are identified as the most common mental health disorders in PHCS. All of these are associated with fundamental functional impairment, an increased number of disability days, and high healthcare costs. Thus, psychometric scales assessing depression, anxiety, and somatization are highly related. This fact would reaffirm the overlap in diagnostic criteria and, consequently, the difficulty of classifying this phenomenon. In India, for example, somatomorphic disorders are conceptualized from CD-10 and DSM IV definitions, known as Functional Somatic Symptoms (FuSS) (5).
Internationally, the most common symptoms found in poly-consultant adults of primary care are fatigue, pain, dizziness, general malaise, gastrointestinal symptoms, abdominal discomfort, diarrhea, and constipation (5). Studies carried out in Southeast Asian countries, analyze at a global level, the concepts and mechanisms related to medically unexplained symptoms (from now on MUS) and argue that the psychological nature of somatoform disorders is due to the lack of organic origin diseases to explain them. The latter, seen from the predominant, cross-sectional biomedical viewpoint, displaces somatoform disorders to the realm of agent autonomy, where the only people responsible are the patients who suffer from them.
In this direction, research provides exciting characteristics to the hyperfrequent user profile. For example, the older the patient, the higher the healthcare services use. Also, it is noted that women between 37 and 75 have a worse subjective perception of their health, so they tend to have health services higher consumption. In short, the HF patient is characterized as a middle-aged person with a low-level education who belongs to a nuclear family, lives in the nearest central neighborhood, suffers from a chronic disease, and has a psychic dysfunction. This patient makes an average of 15 consultations a year and frequently uses the previous appointment, but also the scheduled visit by doctor and nurse (17).
In this sense, these studies indicate that the creation of a definition and clinical delimitation for those patients with hyperfrequency would directly contribute to the reduction of the overuse of Primary Care (PC) (18). Also, they suggest that the patient's type should be considered according to whether they have chronic organic or mental pathologies or both, and that the interventions should be adapted to patient type. Other strategies are those mentioned by Fuertes M, et al. (6), who infer that one of the points for reducing hyperfrequency lies in the incorporation of non-presence or telephone consultation modalities (telemedicine).
Concerning to the overlap between mental health and poly-consultation, studies in Colombia have estimated that 10% of healthcare costs can be attributed to the consultation overuse (35% and 45% of work absenteeism are due to mental health problems). The somatization disorders prevalence of almost 40% in hyperfrequenters shows that, although they are often presented simultaneously, they are not synonymous, which makes it necessary to distinguish between both terms and to search for another kind of cause beyond the disorder itself. 41% of hyperfrequency cases can be attributed to chronic diseases, 31% to mental disorders, and 15% to acute and chronic stress. Together, these three factors would explain two-thirds of the total phenomenon. In the very same sense, when analyzing most frequent mental disorders present in PC, it could be inferred that these are under-diagnosed in the clinic, by contrasting patients diagnosed with depression, anxiety or mixed anxiety-depressive disorder records, 5.6% had been diagnosed with depression, 6.3% with anxiety in the clinical history and 8.5% with mixed anxiety-depressive disorders (19).
However, after conducting a screening survey, it was revealed that 41.9% of the patients had depression symptoms or established depressive syndrome. Anxiety also occurred as a symptom or syndrome in 13.3% of the cases. On this basis, 55.2% of patients tested positive for mental symptoms or syndromes that had not been reported in clinical history (19). Clara Han (20), relates this as a depression to time to time, thinking in socio-structural perspective.
The low diagnostic capacity is especially important in the mental health field since several studies suggest that patients with anxiety and depression are twice as likely to be poly-consultants. The explanation given by the studies is that anxiety-depressive disorders can generate physical symptoms, and they may affect the health condition's self-perception. Therefore, spontaneous consultations number would increase as a result of this poor self-perception. It is, therefore, essential for the physician to consider research into the mental disorders underlying the reason for consultation (21).
Excuse me, but we have patients who are known to be poly-consultants, but they are in general, they are patients with senile dementia or people with their mental disorders as... we know them. A lady comes so much that her daughter, who comes to the doctor's attention, is torn out..
In Chile, research on poly-consultation is scant, and most relate hyperfrequency to somatization disorders. In this matter, the specialized literature estimates that somatic symptoms problem without clinical explanation represents PHC's consultations 15–25%, and up to 70% of this consultation type remains unexplained after being evaluated.
What I discovered, however, was a tense entanglement of municipal politics and health services, made even more acute by the fact that it was a munipal election year. Insecurity, fear, resentment, and frustration circulated among the local mental health workers and municipal health officers, affects in which I too became caught (20).
A study by the World Health Organization (WHO) indicates that in Santiago de Chile, there is a 17.7% prevalence of this disorder in primary care consultations (Riquelme and Schade, 2013). There is no poly-consultant patient homogeneous profile. However, several studies agree that poly-consultant users correspond mostly to women who own a home (without "formal" paid work), with an average age of 42 years, incomplete primary or average education, married, and with some chronic disease (22).
There is a "gypsy girl" who has a drug problem. A lady... several ladies, who have dementia, come here. We already know them, so at times we take blood pressure measurements to reassure them they’re OK. Then we call their children for them to come and pick the ladies up.
From the mental health area, national research has addressed the phenomenon as a depression manifestation, using as reference the fact that this disorder affects 30% of primary health level beneficiaries (7.5% of the general population) (23). In the very same direction, other studies indicate that poly-consultant patients should be treated not only themselves but also their families, since most of them present some family dysfunction, through a family therapy approach from the mental health perspective (24). Or, in Clara Hanwords, assuming that “life is by a thread” (25).
It's simple, with more than seven consultations in six months, we're on alert. Morbidity control is done with poly-consultant observation for evaluation, and we see if it is referred. If it's a chronic health problem, it's taken up by a nurse, and if you have a problem related to mental health or addictions, we refer you to the psychologist or our social worker
From the mental health units from the primary care level centers, various intervention proposals have shown high effectiveness, among which are: cognitive-behavioral therapies, psychodynamic therapies, and group therapies. However, a significant number of these patients refuse to be classified as having mental health problems, attributing the responsibility to the doctor, since he or she does not provide an adequate response to their physical affliction. It means that the doctor-patient relationship is damaged, and patients insist on the need for more evaluations and tests (1) .
And people acknowledge that it has to do with many things: the fact that nowadays both parents have to work produces a deep cut in the family dynamics, a break between getting to know each other and the relationship that can be established among parents and children.
The Brief Family Therapy (BFT) approach, whose main characteristics are to be simple, quick, to generate a greater user satisfaction and to reduce costs, aims to have patients being able to treat their own problems in their own homes through objectives set by themselves. BFT seeks to reduce the symptoms and recover the patient's autonomous functioning. With this therapy, the patient stopped using medication and did not request any more complementary examinations, thus saving on healthcare costs (26).
My idea, alongside the psychologist who set this up, is to complement this with team interventions such as home visits, family studies, and counseling.
The healthcare system provides optimal conditions for poly-consultation to be produced and perpetuated since the biomedical approach to providing care and the Cartesian legacy are still deeply rooted in the given attention. Public health administration does not adequately answer to users' demands by using indicators. Healthcare officials tend to displace the psychosocial component to a secondary concern, producing a rupture between what the services offer and poly-consultant population demands, not enabling this problem to diminish (27).
3.1- The strains of a clinical category
The "somatoform disorder" classification is, precisely, the clinical approach to capture a discomfort refractory to the most common organic diagnoses (2). Therefore, the "hyperfrequency," "somatizers" or "poly-consultants" status of those users who repeatedly come for a short period (usually six months) is recognized by its name in diagnostic manuals (2) (22) (1). However, this attempt to capture the medical device is quite questionable, as it allows neither an adequate conceptualization nor a practice around this kind of disorders.
While what is commonly criticized is the inadequate biomedical approach to this sort of phenomenon - criticism also associated with more general demands, such as a therapeutic relationship becoming more humanized (3) (23) - we are particularly interested in the "psychosocial" circumstances unspecific association which are used "to fill that space where some subjectivity is admitted" (28), becoming a "closed significance that is self-explanatory." In this direction, "professionals limit themselves to referring these patients on several occasions, as having 'psychosocial problems,' seems more to be a new effort to objectify these subjects' understanding" (28).
Instead, now, as I told you before, it is people's mental health that is relegated. And people recognize that this mental health issue is giving them a poor quality of life. It makes you get old in an awful way, along with everything else..
Moreover, from clinical experience, physical signs importance and laboratory findings are emphasized to give importance and credibility to patients with non-specific symptoms and subsequent diagnosis. Here we should ask ourselves why this phenomenon is so disregarded by professionals when it leads to a high social and economic burden. It could be explained broadly for the following reasons: 1) The conditions classification, in which people develop these non-specific symptoms, is diffuse; 2) psychiatrists do not have sufficient experience to be able to deal with these patients; 3) patients with these symptoms do not seek psychiatric help; and 4) general physicians, as well as specialists, do not refer for psychiatric help (29). Precisely, it opens an epistemic problem related to the semiology and clinic exercise (30).
Semiology (...) was constructed by disease symptom intelligent identification and acute observation of patients' body signs (...) in the diagnosis of the disease - "clinical or morbid entities" - one must distinguish "primary or peculiar symptoms from secondary or accidental ones." It is precisely the semiological knowledge that allows us to identify the disease's different manifestations (signs and symptoms), how to look for them (semiotechnology) and how to interpret them (clinical semiology).
To address this problem, there are models used in primary care that allow us to detect, recognize, and manage non-specific symptoms. Still, the literature highlights the importance of developing customized models that meet the needs of each center due to the phenomenon of complex and multifactorial nature. An exploratory model is therefore proposed for non-psychiatric users in six specific circumstances, each one with its own considerations when dealing with these users (29).
Based on this, and around a semiological problem, we find an epistemological problem. Specifically, between biomedicine targeting the disease and the condition experienced by the patient:
Sometimes the plaque that makes the body visible shows the doctor that the patient 'has nothing’ wrong, contrary to what the latter claims, who complains of various aches and pains. The opposition between the doctor's illness and the patient's condition is therefore clear. The objective illness proof was not provided (...), so the pain is imputed to the patient's sickly fantasy. He is an imaginary patient (31).
As Canguilhem points out, "instability and irregularity are (...) the vital phenomena essential characteristics, so that forcing them into the metric relations rigid framework means denaturing them" (32). The biomedical view, while observing from interpretative frameworks that make the pathologies exclusively physiomechanical, physical, or biochemical problems, fails to reveal the seriousness that the body's interaction with its environment would have in the disease's etiology production.
Given this, life is not indifferent to the material and symbolic conditions that make it possible, hence it must be understood as a normative activity (32). In other words, life must be understood as installing normative standards that allow it to adapt to a constantly changing environment. It is why health manifests itself when the pathological, and the associated pain, impedes the individual's daily life development. The body, then, reveals its health or illness concerning the resistance and adaptation capacity towards the conditions of an environment that forces it to displace its own limits. This would explain the proposals for the biomedical model to be modified at different levels, from the "bio-psycho-social" approach development to the so-called "integrative medicine" (33) (24) (34) (35) (36) (37).
Also, this asymmetry incorporation (between the target disease and the experienced condition) to the clinic's normal functioning, either through the somatoform concept disorder development or in its association to non-specific psychosocial factors, approaches to "social determinants" currently proposed by the World Health Organization more complex (11), due to the a-criticity and non-specificity that the "social environment" acquires, and the individualizing biomedical feature that regulates its incorporation (38). This issue is crucial since it is directly linked to the social position of scientific medicine and its link to the requirements of the State and the market (39) (40). It is not surprising then that both, specialized literature and the health institutions, recognize a biomedical approach relative incapacity to face the new challenges in healthcare successfully. This is directly related to how biomedicine is presented as a technique for managing discomfort, namely: processing social problems on an individual basis.
3.2 - The Chilean healthcare system's transformations
As well as the epistemological problem that affects the care, diagnosis and treatment of conditions classified as somatization disorders, the literature reports, with a full agreement level, that such benefits generate economic disadvantages, make public care systems more expensive and more burdensome, reaching an international prevalence in primary care around 15–22% (3) (22). This global observation is particularly sensitive to Chile due to the conditions of its public health system. To highlight the importance of this point (the rise in cost and the overcharging due to hyperfrequency in Chile's public health system), it is necessary to describe the current health system characteristics and the context in which they were produced.
In 1979, twenty-seven health services and the National Healthcare Fund (FONASA, for its name in Spanish Fondo Nacional de Salud) were created to decentralize healthcare services into a National Healthcare Services System (SNSS). Later, in 1980, the Primary Health Care Clinics were transferred to local municipalities, which, according to the WHO, would have affected healthcare equity, as economic differences in the municipalities structures caused inequalities in users’ care. However, the most radical healthcare system reform took place when the Social Security Institutions (ISAPRE, for its initials in Spanish Instituciones de Salud Previsional) were created in 1981, leading to a sustained drop in public system financing, from 3.3% in 1974 to less than 2% in 1990 (41) (42). Only in 2008, the GDP percentage reserved for public healthcare reached the figures it used to have in 1974. Nevertheless, healthcare expenditure has increased significantly, even above OECD countries (7.3% of GDP), but is still far below the average for OECD countries (9.3%), and since 2013 there has been a slowdown.
The mixed provision system has produced significant inequalities between benefits and sustained pressure on the public system, as it has had to deal with increasingly scarce resources and with universal coverage that forces it to receive a significantly higher number of affiliates. By 2011, more than 80% of Chile's inhabitants are FONASA's members or beneficiaries, while only 13% are ISAPRE's. The diagnosis is even worse if we consider that the private system spends per capita exactly twice as much as FONASA (42).
These numbers must also be contrasted with healthcare financing ways. In most OECD countries, public spending on this item exceeds 70% as an average, with Chile and the United States as exceptions. Chile barely reaches 49% of public expenditure, a heavy burden on households that are responsible for financing almost a third of the cost, compared to the average for OECD countries, which barely reaches 20%. This last point implies a noticeable healthcare problems individualization kind of management and the correlative market liberalization. Moreover, the number of health professionals is also noticeably lower than the other countries of the international organization, placing Chile in the last place next to Turkey in the physicians quantity, with 1.7 per 1000 inhabitants, well below the 3.3 OECD average in 2012 (not even reaching the standard of 2000 which was 2.7). Similarly, in the nursing professionals case in Chile, it reaches 4.2 per 1000 inhabitants in 2012, compared to an average of 8.8 for the organization's member countries. These structural pressures and limitations are transferred to Chilean public healthcare professionals, imposing on them a competitive market model that installs life just as any other commodity (38) (43).
It is within this framework -which imposes extreme resources rationalization and optimization (1) - that the recognized burdens that hyperfrequent patients represent for the health system take on particular relevance.
If we are responsible for people in their lives progress, by helping them at the right moments, we can prevent them from becoming poly-consultants and sick.
It is estimated that 30% of users consume 80% of healthcare resources, and it is estimated that unexplained somatic symptoms problem fluctuates around 15–25% total consultations in Primary Health Care (PHC), which would imply a broad impact of this sort of conditions in the full benefits of primary healthcare services, constituting between 60% and 80% of users' total demand who attend to those centers (22).
Based on international studies, it is estimated that users characterized as hyperfrequent users cause twice the cost of any other type of patient, due to the number of examinations requested and medicines administered. Considering the figures already mentioned, the specialized literature agrees on the need to improve the resolution of this sort of disorders, as well as the need to discuss the allopathic, orthodox, scientific or biomedical medicine limitations (2) (4) (22) (28) (1). In this direction, it is necessary to have a profile that allows us to know who these hyperfrequent patients are beyond the limited case studies that have been carried out in our country. A poly-consultant general profile would enable us to rethink, among other things, the management mechanisms of these patients in the public healthcare system.
3.3 A way of understanding social relations: collective problems managed as individual problems
A third problem overlapping with the previous ones has deserved -and still deserves- an in-depth study that shows its importance in the more or less global matrix of assessment deployment make up what has been called "connectionist world" (44). In this regard, the socio-economic transformations that Chile has undergone in the last 40 years have produced a particular way of understanding social relations (45). This series of reforms -which broadly contained fiscal discipline, macroeconomic stabilization, price, and market liberalization, state enterprises and social services privatization, and finally, the reduction of State intervention in capital markets and economy in general (46) (47) (45) -, would be at the base of a new institutionality associated with generalized privatization that allows the action of free agents as a base element for the management of their lives (38) (48) (49). The first result of Chile's transformations is that, in less than two decades, went from being "a closed economy with a high level of state intervention to being one of the most, if not the most, open and market-based economies in the world" (45), whose main support point is individual modulation.
Since the 1990s, governments have not (yet) substantially amended any of these reforms, keeping in line with world trends. On the contrary, it could be said that the country intensified possibility conditions for individuals exposed to general habitat modification, could assume this as natural, and renewed society, freedom, politics conceptions imposed by the weight of the immutable, having modified the public administration own logic, and committing individuals to manage their lives based on their personal projects, quite far from community logics (46) (48).
In this direction, we are currently witnessing a highly individual way of experiencing inter-subjective relations (50), which has made possible the transition to a new way of understanding the overlap between State, market and society, and the role that each of these has in the management of social problems. Generalized privatization of social affairs emerges in which "freedom of agents" operates as the basis for the management of their environment and their lives, thus transferring the structural inequality burden and the competitivity demands to "citizens" who must, from now on, individually manage their precariousness and their lack of certainties (51) (52) (25) .
This crosses over the possible answers to the two previous points, namely the "burden" imposed by non-specific somatic consultation and the limits of biomedicine in this regard. It also conditions the understanding that individuals themselves have of their discomforts and how they deal with them. It is precisely at the intersection of these problems that our research is focused, unraveling from a sociological perspective who the hyperfrequent patients are (sociodemographic characterization), how their care is managed (the governmental rationalities behind the logics of care plans and programs expressed in specific protocols), and what obstacles and possibilities people face in a deeply individualized healthcare system such as the Chilean one (the daily and symbolic construction of healthcare service conditions).
So the ones from [territory] are different, so in general, people here are like quiet. There are city neighborhoods that we have known all our lives, as I said, the ones that slip through our fingers, are from that area where we should work more. Over there, we have to act differently, have a particular family doctor, a team that goes frequently enough. We make different strategies to deal with them.