Editorials - March 1, 2000 - American Academy of Family Physicians

Editorials

Early Diagnosis and Empathy in Managing Somatization

KATHERINE L. MARGO, M.D., and GEOFFREY M. MARGO, M.D., P.H.D.
Harrisburg Family Practice Residency Program
Harrisburg, Pennsylvania

See article in this issue.

A two-part article on somatization, one part appearing in this issue of American Family Physician¹ and the other appearing in the previous issue,² examines diagnosis and treatment of this illness in primary care. Somatizing patients have symptoms caused by emotional distress rather than physiologic dysfunction. Anne Fadiman's fascinating book The Spirit Catches You and You Fall Down³ tells the true story of the relationship between physicians from a family practice residency in California and a Hmong family. Somatization is a common diagnosis in the Hmong people when they are seen by American physicians. Fadiman sees this as an expression of conflict with what the Hmong perceive to be a hostile American culture. In Fadiman's book, the American physicians report that they dread seeing the Hmong patients because they take a lot of time and then refuse to follow physicians' recommendations.

Somatization is also common among native-born Americans. Many patients struggle within a hostile environment, and many do not have the tools to survive. Suffering with pain that has no obvious pathophysiologic source is one response to a world that is fast-paced and competitive. This psychic pain is real but has no relief.

Where does that leave family physicians? Somatizing patients are difficult. They take a lot of time, they are rarely satisfied with our treatments, they are demanding and they make us feel uncomfortable because we clearly see their suffering but cannot help them. When we are pushed to see as many patients as possible and when capitation creates a disincentive to see patients frequently, it is no wonder that family physicians have little patience with somatizing patients. Like the physicians who dreaded seeing the Hmong patients, we all may be secretly glad when somatizing patients leave to seek care elsewhere.

So what can we do to help these patients? Servan-Schreiber and colleagues^1,2 have many good suggestions. We would like to give special emphasis to two of these ideas. The first recommendation is to recognize somatization early in the physician-patient relationship. The authors suggest a process for making a positive diagnosis of somatization, rather than having it become a diagnosis of exclusion after many rounds of unhelpful, frustrating office visits, tests and even invasive procedures. When the diagnosis is made promptly, realistic expectations and appropriate management plans become clear. Then it is possible to begin collaborative work with the patient using approaches that have received mutual agreement from the patient and the physician.^2,4,5 The authors' emphasis on less restrictive diagnostic criteria for somatoform disorders than that used for somatization disorder is in keeping with current opinion in primary care.^5,6

The second point to emphasize is the importance of developing empathy for these patients. We know that they suffer, and understanding some of the psychologic or cultural stresses in their lives allows us to see their suffering in a context we can understand. Servan-Schreiber and associates^1,2 refer to the BATHE technique⁷ as a structured way of learning about patients' current difficulties in an empathetic but time-sensitive way. If we can understand and know our patients, we often can offer more effective treatment. Also, understanding that patients may be unaware of their effect on physicians is a useful tool for developing the empathy necessary to care for them.

How do we manage ourselves so that we can survive our hectic days yet keep our humanity when treating these difficult patients? Some physicians find that working in teams can be helpful. Because psychodynamic and cognitive-behavioral psychotherapies can be effective for somatizing patients, having a good therapist available to the team can be helpful for the patient and supportive for the family physician. Balint group work⁸ is specifically geared toward understanding the use of the physician-patient relationship in troublesome interactions such as these. Even referral to a colleague for a short break may be a legitimate alternative. Caring for ourselves allows us the energy to give the compassionate care these patients deserve.

Katherine L. Margo, M.D., is associate residency director of the Harrisburg Family Practice Residency Program and medical director of the Harrisburg Family Practice Center. Geoffrey M. Margo, M.D., Ph.D., is director of behavioral medicine at the Harrisburg Family Practice Residency Program and president of the American Balint Society.

Address correspondence to Katherine L. Margo, M.D., Harrisburg Family Practice Residency Program, 205 S. Front St., Harrisburg, PA 17104.

REFERENCES

1. Servan-Schreiber D, Kolb NR, Tabas G. Practical diagnosis of somatizing patients. Am Fam Physician 2000;61:1423-8,1431-2.

2. Servan-Schreiber D, Tabas G, Kolb NR. Practical management of somatizing patients. Am Fam Physician 2000;61:1073-8.

3. Fadiman A. The spirit catches you and you fall down: a Hmong child, her American doctors, and the collision of two cultures. New York: Noonday Press, 1998.

4. Margo KL, Margo GM. The problem of somatization in family practice. Am Fam Physician 1994;49:1873-9.

5. Walker EA, Unutzer J, Katon WJ. Understanding and caring for the distressed patient with multiple medically unexplained symptoms. J Am Board Fam Pract 1998;11:347-56.

6. Escobar JL, Waitzkin H, Silver RC, Gara M, Holman A. Abridged somatization: a study in primary care. Psychosom Med 1998;60:466-72.

7. Stuart MR, Lieberman JA. The fifteen minute hour: applied psychotherapy for the primary care physician. 2d ed. Westport, Conn.: Prager, 1993.

8. Brock CD, Salinsky JV. Empathy: an essential skill for understanding the physician-patient relationship in clinical practice. Fam Med 1993;25:245-8.

Options and Issues in Managing Menopause

JANE L. MURRAY, M.D.
University of Kansas Medical Center
Kansas City, Kansas

See article in this issue.

With the advent of unprecedented numbers of women baby boomers now entering the perimenopausal and menopausal years, family physicians will increasingly be called on to discuss options and issues concerning menopause. Information that is widely available in the popular press, women's magazines, the Internet and even television commercials makes the physician's role as "information interpreter" especially crucial.

More patients than ever are armed with books, articles and computer printouts about menopause options when they visit their family physicians. Patients have many questions about the risks and benefits of hormone replacement therapy (HRT) and increasingly ask about nonpharmacologic treatment possibilities. What was once a fairly straightforward discussion about the benefits of HRT for most women has become a lengthy visit in my practice. Women want to live as long and healthy a life as possible. They want to introduce minimal health risks into their lives and feel great. They want energy, clear thinking, a vigorous sex life, a stable mood and a good night's sleep.

I enjoy discussing menopause with patients. This is an area with few absolutes and many controversies. It is a grand opportunity to explore a woman's personal health goals and beliefs, her fears and hopes. It is a chance to review individual risk factors and lifestyle choices and practices. A woman experiencing life and physical changes provides physicians an excellent opportunity to help her prepare for the future, with optimal health as an attainable goal.

As Cutson and Meuleman¹ point out, not all women wish to "medicalize" a normal physiologic process. And, many women fear the potential risks of conventional HRT. Increasing numbers of patients are seeking "natural" alternatives--be that through phytoestrogens, herbal supplements or compounded isomolecular hormone formulations by physician prescription.^2-4 Because patients are asking about these approaches, more physicians are seeking to become educated about such options.

Controversy abounds in the medical literature about the possible risks of breast cancer in women taking HRT. Now, the possibility that HRT may actually promote cardiovascular disease in some women--as reported in the recent Heart and Estrogen/progestin Replacement Study (HERS)⁵--confounds not only patients but physicians as well. No wonder women are seeking advice and treatment from a variety of nonconventional practitioners.

I believe that what patients want is advice from their family physician. This includes an individualized discussion of risks and benefits with an emphasis on the challenges of compliance, side effects and their management. Different preparations and methods of delivery should be offered, especially in conjunction with the mention of new products (e.g., vaginal capsules, combination patches and progesterone delivery through intrauterine devices).⁶ If a patient opts against HRT or "natural" alternatives, a careful plan should be constructed to ensure adequate weight-bearing exercise, calcium supplementation, cholesterol-lowering and other preventive measures. Patients want the ability to arrive at a reasonable decision for themselves, with the help of a caring and informed physician.

We do need to learn more about herbal approaches, phytoestrogens and so-called "natural" or isomolecular HRT. Much more research in women's health is imperative. We need good studies that are not funded by commercial interests and that compare various treatment options across a broad spectrum of women. Our patients deserve no less.

Jane L. Murray, M.D., is clinical professor in the Department of Family Medicine at the University of Kansas Medical Center, Kansas City, Kan. She is also medical director of the Sastun Center of Integrative Health Care in Mission, Kan., and has a practice emphasizing women's health care.

Address correspondence to Jane L. Murray, M.D., Sastun Center of Integrative Health Care, 5509 Foxridge Dr., Mission, KS 66202.

REFERENCES

Cutson TM, Meuleman E. Managing menopause. Am Fam Physician 2000;61:1391-400,1405-6.

Murray JL. Natural progesterone: what role in women's health care? Women's Health Prim Care 1998;1:671-87.

Northrup C. Menopause. Prim Care 1997;24:921-48.

Taylor M. Alternatives to conventional hormone replacement therapy. Compr Ther 1997;23:514-32.

Herrington DM. The HERS trial results: paradigms lost? Heart and Estrogen/progestin Replacement Study. Ann Intern Med 1999;131:463-6.

Tuimala RJ, Vihtamaki T. Individual hormone replacement therapy. Maturitas 1996;23(suppl): S87-90.

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