Substantial differences in perception of disease severity between post COVID-19 patients internists & psychiatrists or psychologists…, 2023, Ruzicka+

SNT Gatchaman

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Substantial differences in perception of disease severity between post COVID-19 patients, internists, and psychiatrists or psychologists: the Health Perception Gap and its clinical implications
Ruzicka, Michael; Ibarra Fonseca, Gerardo Jesus; Sachenbacher, Simone; Heimkes, Fides; Grosse-Wentrup, Fabienne; Wunderlich, Nora; Benesch, Christopher; Pernpruner, Anna; Valdinoci, Elisabeth; Rueb, Mike; Uebleis, Aline Olivia; Karch, Susanne; Bogner, Johannes; Mayerle, Julia; von Bergwelt-Baildon, Michael; Subklewe, Marion; Heindl, Bernhard; Stubbe, Hans Christian; Adorjan, Kristina

Patient-reported outcome measures (PROMs) such as the Numeric Pain Rating Scale (NPRS) or Likert scales addressing various domains of health are important tools to assess disease severity in Post COVID-19 (PC) patients. By design, they are subjective in nature and prone to bias.

Our findings reveal substantial differences in the perception of disease severity between patients (PAT), their attending internists (INT) and psychiatrists/psychologists (PSY). Patients rated almost all aspects of their health worse than INT or PSY. Most of the differences were statistically highly significant. The presence of fatigue and mood disorders correlated negatively with health perception. The physical health section of the WHO Quality of Life Assessment (WHOQoL-BREF) and Karnofsky index correlated positively with overall and mental health ratings by PAT and INT. Health ratings by neither PAT, PSY nor INT were associated with the number of abnormal findings in diagnostic procedures. This study highlights how strongly perceptions of disease severity diverge between PC patients and attending medical staff. Imprecise communication, different experiences regarding health and disease, and confounding psychological factors may explain these observations.

Discrepancies in disease perception threaten patient-physician relationships and pose strong confounders in clinical studies. Established scores (e.g., WHOQoL-BREF, Karnofsky index) may represent an approach to overcome these discrepancies.

Physicians and psychologists noting harsh differences between a patient’s and their own perception of the patient’s health should apply screening tools for mood disorders (i.e., PHQ-9, WHOQoL-BREF), psychosomatic symptom burden (SSD-12, FCV-19) and consider further psychological evaluation. An interdisciplinary approach to PC patients remains imperative.

Link | PDF (European Archives of Psychiatry and Clinical Neuroscience)
 
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One possible explanation for the dissonant disease perceptions between PAT, INT and PSY may lie in different experiences regarding health and disease. Individuals with professions outside the medical field commonly have less frequent exposure to severely ill patients. It seems fair to assume that our cohort of relatively young PC patients (Mdn age of 39 years), most of whom have had non-severe courses of COVID-19, may never or just rarely have experienced critical disease by themselves or in their social environment.

Physicians, on the other hand, are frequently exposed to critically ill patients (i.e. in the context of intensive, intermediate or palliative care settings). This may shape their individual grading of health categories differently. Different patient collectives and clinical entities might also explain the differences when comparing INT and PSY health assessments. Taken together, personal experiences regarding health and disease may account for different interpretations of both the Likert scales and the NPRS, explaining some of the discrepancies between medians of health ratings by different observers.
 
It should be stated (restrictively) that at the time of writing, no biomarkers have yet been identified to objectively confirm the presence of a PC condition. Most abnormal diagnostic findings were of subordinate clinical relevance (e.g. lack of vitamin D or folic acid, hypercholesterinemia; data not shown) and unlikely to cause or significantly contribute to the patients symptoms. Consequently, the number of pathological findings correlated strongly with the number of diagnostic procedures performed but did not translate into high numbers of relevant findings likely to account for the patients’ complaints.

(Received 2 Jul 2023, prior to publication of eg Distinguishing features of Long COVID identified through immune profiling)
 
Individuals with professions outside the medical field commonly have less frequent exposure to severely ill patients. It seems fair to assume that our cohort of relatively young PC patients (Mdn age of 39 years), most of whom have had non-severe courses of COVID-19, may never or just rarely have experienced critical disease by themselves or in their social environment.

And yet in Healthcare employment as a risk factor for functional neurological disorder: A case–control study (2023, European Journal of Neurology) we have —

This case–control study found significantly more healthcare professionals (18%) among 186 FND subjects than among a group of 189 age- and gender-matched controls (10.6%) who had another neurological disease. This confirms a link between employment in a healthcare profession and FND and we suggest that working as a healthcare professional is a risk factor for the development of FND, possibly due to exposure to a “model” of neurological symptoms, either in the healthcare professional's daily work life or during their training/education.
 
I think the fact that they call chronic fatigue syndrome a psychiatric condition tells us all we need to know. Not to mention that their internists apparently thought more than half of the patients in the study, who were at an LC clinic, had excellent or good physical health.
 
We need a rebuttal of this article done by someone like Leonard Jason. They would get similar findings--that doctors rate LC patients' health much better than the patients themselves. But they would explain it as due to doctors' ignorance.
 
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In a study based on the HUNT cohort in mid Norway, it was found participants that rated their health as bad had higher mortality even when controlling for typical confounders (though in my opinion HUNT has a only a short list of acute and/or chronic health conditions that can be controlled for). I haven’t read the study but it was used in a lecture as a way to indicate people know their health even if they on paper «should be» healthier than they say they are.

I don’t even know where to begin with my opinions on the interpretation by the authors of this new study..
 
Physicians and psychologists noting harsh differences between a patient’s and their own perception of the patient’s health should apply screening tools for mood disorders (i.e., PHQ-9, WHOQoL-BREF), psychosomatic symptom burden (SSD-12, FCV-19) and consider further psychological evaluation.

Perhaps they should apply those screening tools and consider further psychological evaluation on themselves. I'm sure it's very common for doctors--and really anyone other than the patient--to immediately think "I know what fatigue feels like. Just get over it lazybones." So, if there's a discrepancy between how the patient rates their symptoms and how the doctor does, the doctor should re-evaluate their own biases and judgement.

Do psychiatrists/psychologists apply the findings from psychiatrist/psychologist research papers on themselves? Do they cherrypick the ones they apply to themselves? There are so many contradictory theories, so they can't apply them all, so what method do they use to select theories?
 
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