Original articleRisk factors of symptom underestimation by physicians
Abstract
Objective
The aims of this study were to characterize patient–physician agreement on various psychological and somatic symptoms in internal medicine inpatients and to identify predictors of symptom severity underestimation by physicians.
Methods
Consecutive adult inpatients of two internal medicine wards of a university hospital completed visual analogue scales (VASs) for severity of disability, anxiety, depression, somatic symptoms, and pain at the time of admission (n=639, participation rate=70%) and 5 days thereafter (n=401, participation rate=82%). In addition, the Patient Health Questionnaire 9 (PHQ-9) depression scale and the Clinical Global Impression Scale—Revised were used. At the same time, the six treating physicians independently rated the complaints of their patients using the same VAS. Rates of overestimation, concordance, and underestimation of symptom severity were analyzed. Logistic regression analyses were used to identify predictors of symptom underestimation by physicians.
Results
Concordance between patients and physicians regarding disability, anxiety, depression, somatic symptom severity, and pain reached 50–60%. Symptom severity of patients suffering from major depressive episode was significantly more often underestimated than that of nondepressed patients (all P<.01). Of all the variables, greater depression on the PHQ depression score was the most important risk factor for symptom underestimation by physicians (OR ranging from 1.29 to 1.57; all P<.05, except underestimation of disability). Symptom underestimation of pain severity was also associated with panic disorder symptoms (odds ratio, 2.44; P=.01).
Conclusion
Depressed patients seem to be at greater risk of symptom underestimation by their physicians—a finding bearing implications for avoidance of underdiagnosis and insufficient treatment. Mutual understanding could be improved by better doctor–patient communication skills. Brief self-report depression screeners might help to reliably identify patients at risk for symptom underestimation by physicians.
Introduction
Agreement between physician and patient assessments of the most relevant clinical symptoms appears as an important prerequisite for both patient satisfaction and treatment outcome [1], [2], [3], [4]. It has been reported that practitioner–patient agreement on the types of medical problems requiring follow-up care is associated with better outcomes for reported health-problems [5]. Establishing an agreed upon agenda has been called a key therapeutic process[6]. Still, unanimous understanding of symptom-suffering and underlying causes is achieved infrequently.
The importance of concordance is especially obvious in comorbid conditions when physical and mental factors contribute to patients' subjective health to varying degrees. Psychiatric comorbidity is common among inpatients and outpatients and causes substantial functional impairment [7], [8], [9], [10], [11]. At the same time, psychiatric comorbidity is often underdiagnosed and inadequately treated in inpatient settings not specializing in psychosomatic medicine or psychiatry [12], [13]. The sensitivity and specificity of validated psychometric questionnaires are significantly higher than the ones of the correlating doctors' clinical assessments [14], [15], [16], [17], [18], [19], [20], [21].
Research has sought to identify predictors of deficient physician/patient concordance and has pointed out that misunderstandings can be related to discrete features of symptom intensity, etiology, and need for follow-up. There are notable differences between physicians and patients about what they rate as the most important elements of care [22]. Patient–physician concordance is less probable if the main problem is psychological in nature [23], [24], [25], [26], [27]. Depression has been shown to influence the assessment of the medical status of physically ill patients and thus is a candidate when looking for predictors of concordance, underestimation, or overestimation of symptoms [28]. Female sex of the patient seems to be an additional risk factor for disagreement in a general practitioner primary care setting [29]. Disagreement concerning symptom etiology has prognostic implications because disagreeing patients are in turn perceived as less cooperative [30]. So we hypothesized that psychiatric comorbidity leads to less concordance between the patient and the treating physician and bears an increased risk of misunderstandings.
This study sought to answer the following questions in a naturalistic setting. First, what is the amount of agreement between patients' and doctors' assessments? Second, which factors predict patients at higher risk of having their complaints underestimated? Third, are there systematic biases concerning patients' and physicians' ratings of disability, anxiety, depression, somatic symptom-severity, and pain?
Section snippets
Sample
Our patient sample included consecutively admitted adult (age 18+) inpatients from two wards (cardiology and gastroenterology) of the University Hospital of Heidelberg. Psychosomatic treatment was provided as necessary, in the framework of an integrated internal medicine and psychosomatic setting. The study design was naturalistic and prospective. The inclusion criteria for our study were admission to one of the two participating wards and written informed consent. The exclusion criteria were
Sample characteristics
Fifty-three patients were too ill to take part, and 23 were insufficiently accustomed to the German language. Exclusion criteria were met by 79 (7.9%) patients at T0 and 7 (1.4%) patients at T1. Seventy-six patients (8.1%) at T0 and 25 patients (5.1%) at T1 explicitly refused to participate. Two hundred three questionnaires (22.1%) at T0 and 65 (13.2%) at T1 were not returned for unknown reasons. Data were returned from 639 of 918 eligible patients at T0 and from 401 of 491 eligible at T1.The
Discussion
The major finding of our study is that depression severity seems to be an important risk factor for symptom underestimation by the treating physician. This result was found for several outcomes–anxiety, depression, physical symptom severity, and pain—substantiating the importance of depression as a risk factor for symptom underestimation. We emphasize underestimation of symptom severity as a clinically important factor, possibly leading to underdiagnosis of disease, incomplete treatment, and
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