Somatoform Disorders in Primary Care: CPCP by Dr. Paige Deets

This is an excellent  presentation about somatoform disorders encountered by primary care physicians, at one of our recent weekly conferences on the psychiatry consultation service. It’s part of the Clinical Problems in Consultation Psychiatry (CPCP). Appropriately, it was presented by Dr. Paige Deets, a resident physician in our Family Medicine training program. The Family Medicine residents rotate through the psychiatry consultation service, and they find it most relevant to their practice, most likely because many of the patients they see have complex, comorbid psychiatric and medical disorders which are challenging to both patients and doctors. I’m convinced that the rotation is not just a practical educational experience. I think it also provides yet another persuasive argument for the timeliness of adopting an integrated approach in health care delivery.

I think this an opportune time to point out that the need for primary care physicians is growing, especially in light of the physician shortage. A couple of articles in American Medical News highlight this challenge for American medicine. It’s getting harder to recruit primary care doctors, partly because of the aging population and partly because of the aging physician population [1]. There are not enough primary care physicians. On the positive side, American medical school graduates matched to first-year residency positions in family medicine went up by 14.4%, according to the National Resident Matching Program.

Physician shortages might reach 91,500 by 2020 according to the Association of American Medical Colleges’ Center for Workforce Studies. Half of the shortages will be in primary care. Yet many top academic medical centers still don’t have family medicine departments [2].

Primary care clinics see many patients with medically unexplained physical symptoms (MUPS), the preferred term now. In fact, some of the disorders identified by Dr. Deets may not remain in the somatoform category when DSM-5 is released, including Body Dysmorphic Disorder, Hypochondriasis, and Conversion Disorder, which may be recategorized under anxiety and dissociative labels.

Recategorization and renaming will probably not substantially change the way doctors help patients cope with these frustrating and sometimes puzzling disorders. However, an integrated care delivery system may make it easier for psychiatrists and primary care physicians to communicate about evidence-based approaches to diagnosis and management.

In order to see the picture galleries of photos or Powerpoint slides, click on the one of the slides, which will open up the presentation to fill the screen. Use the arrow buttons to scroll left and right through the slides or up and down to view the annotations.

A little more about the CPCP at Iowa:

Clinical Problems in Consultation Psychiatry (CPCP):

A weekly case conference held Wednesdays from 8:00 a.m. to approximately 8:45 a.m. Each week, a case is selected from the Daily Review Rounds Records to illustrate a clinical problem for the next week’s meeting.  The residents are assigned dates when they rotate. The medical students are welcome and even encouraged to participate as well.

This is a practical way to approach teaching the Practice-Based Learning & Improvement Core Competency. This helps develop the habit of reflecting on and analyzing one’s practice performance; locating and applying scientific evidence to  the care of patients; critically appraising the medical literature; using the computer to support learning and patient care; facilitating the education of other health care professionals. This is applying principles of evidence-based medicine (EBM) to clinical practice.

  • Evidence-based medicine is a systematic approach to use up to date information in the practice of medicine
  • Skills are needed to integrate the available evidence with clinical experience and patient concerns
  • Application and evaluation of EBM skills will provide a frame-work for life-long learning.

Self-evaluation is vital to the successful practice of EBM:

  • Am I asking answerable clinical questions?
  • Am I searching the literature?
  • Am I becoming more efficient in my searches?
  • Am I integrating my critical appraisals into my practice?

The assigned resident is responsible for searching the literature and selecting one or two teaching papers for the conference. Presentations will begin with a review of the case, followed by a summary of the references with subsequent round table discussion.

Circulate copies of 2-4 pertinent articles to team members including psychiatric nurses and faculty. A copy machine is available in the departmental administration office. Consult staff can also assist with obtaining copies.

Presentations begin with a 5-minute summary of the case with discussion of both psychiatric and medical aspects of evaluation and management. The remaining time is spent summarizing the pertinent data in the articles. Residents and medical students are encouraged to use the case conference material as preparation for submitting a case report or letter to the editor.

1. Stagg Elliott, V. (2012). It’s getting tougher to hire primary care doctors. American Medical News, American Medical Association. 55.
Positions are taking longer to fill–if they get filled at all. Recruiting in 2011 was nine percentage points behind the previous year.

2. Krupa, C. (2012). Will physician shortage raise profile of FPs? American Medical News, American Medical Association. 55.
Medical schools are working to fill gaps in primary care as more students express interest in becoming family physicians.

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