The medical profession has been aware that psychosocial issues can lead to physical symptoms at least since the days of Hippocrates about 2500 years ago. Yet diagnosis and treatment for the pain and other symptoms lag far behind nearly every other form of illness. In thinking about this I began to recognize several challenges to improving the quality of care for this condition.
1. Too few trained professionals. One in six adults suffers from a Psychophysiologic Disorder (PPD). That is around 40 million in the U.S. and 8 million in the U.K. The number of practitioners skilled in PPD work is on the order of two or three per million patients at best.2. Most health care professionals and most of the public are not even aware of PPD, its range of symptoms and potential for severity or long duration. Most of the few health care professionals who have heard of PPD are skeptical since it was not part of their formal training. How can we best gain acceptance for the PPD approach?3. Most PPD sufferers do not adequately recognize the psychosocial or mental health issues with which they are afflicted. Therefore they focus on finding an organic or structural cause for their pain or other symptoms. Most will not make or keep an appointment with a mental health professional for assessment of a physical symptom.4. Many medical professionals were trained to use diagnostic and treatment techniques for symptoms due to PPD that are significantly less effective and carry greater risk than a PPD approach. For example, there are many examples of people having spine surgery for pain despite minimal to non-existent abnormalities on MRI.5. The value of the PPD approach has not (yet) been supported by randomized controlled trials though it is supported by extensive experience of PPD-trained clinicians from a wide range of specialties. How best to improve the science supporting the PPD approach?6. Most mental health professionals are not familiar with the concept of relieving physical symptoms using psychological treatment and feel uncomfortable with patients whose primary problem is pain or another physical symptom.7. Many US physicians are compensated significantly more for their current approach to PPD symptoms than they would be for a PPD approach. (In my case, the ratio of payment for procedures to payment for a discussion with the patient ranged from three to six times as much per hour for procedures.) This leads me to a quote from the journalist Upton Sinclair: “It is difficult to get someone to understand something, when their salary depends on not understanding it.” Fortunately, financial incentives for care in the U.S. are changing from procedure-based to population-based. How can we best leverage that change into greater use of the PPD approach?
Tags: challenges, medical education, mental health education, psychophysiologic disorders
