Seeing Skin Disease From Both Sides

“It is easy to label a patient with high symptom burden as having a low threshold for discomfort, or for a patient to presume that the doctor is unempathetic,” say Valencia Long, M.B.B.S., and colleagues from University of Singapore. A mismatch between the patient’s assessment of disease and the physician’s can hamper treatment and frustrate both parties. They suggest, though, that it’s possible to bridge the perception gap.

Quantitative studies may not have adequately explored the interrelated psychological and behavioral constructs of the phenomenon, which is called discordant severity grading, the researchers say. So they took a “mixed-methods” approach, starting with a qualitative study involving interviews with 18 patients and 12 physicians. That study, they say, suggested the causes of discordant severity grading are “nuanced and multifactorial.” Using findings from the qualitative research, they developed a comprehensive model to help explain discordant severity grading and confirmed its clinical validity and applicability in a quantitative study.

That study, published today in JAMA Dermatology, involved 1,053 pairs of patients treated for psoriasis or eczema in three Singapore outpatient tertiary dermatological centers and their physicians. Both patients and physicians completed a questionnaire after a consultation. Although more than half of the pairs were in agreement about severity, 447 (42.4%) scores were “positively discordant” — that is the patient graded severity worse than did the physician.

Differences in scoring stemmed from differing perspectives. While physicians emphasize the visible physical signs and biomedical aspects of disease, the researchers say, patients focus on the functional and emotional impact. Positive discordance was more likely with patients who felt more impairment of quality of life, higher symptom expression and lower objective disease severity. In turn, higher QOL impairment was associated with less stable personality, poorer resilience, higher anxiety, increased negative social comparisons and lower self-efficacy (i.e., poorer control and understanding of the disease).

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Many of those factors are modifiable, the researchers note. For instance, cognitive behavioral therapy, education and counseling for stress management can bolster resilience and self-efficacy.

An accompanying editorial by John S. Barbieri, M.D., MBA, of Brigham and Women’s Hospital in Boston, and Karen MacDonald, Ph.D., an associate editor at JAMA Dermatology and a principal at Matrix45, a evidence-based medicine consulting firm in Earlysville, Virginia, cites research that found patients who received cognitive behavioral therapy reported greater improvements not only in stress and depression, but also in Patient-Oriented Eczema Measure scores and itch intensity.

Long and colleagues note that physicians tend to compare the patient’s severity relative to other patients while patients may compare themselves with peers and their social circle. They suggest “leveraging the human tendency to compare” by harnessing social media to educate and inspire patients to accept their skin condition and live their best lives.

Equally as important, they conclude, is the need to acknowledge the “crucial contribution of physicians to the phenomenon of discordance, rather than viewing it as a patient problem.” Medical training, which focuses on objective and physiological aspects of disease, “often overlooks the patient’s subjective experience, such as the itch and functional impairment that even a small patch of rash can cause.” It is important, they add, to “prioritize patient-focused outcomes and cultivate effective communication habits that allow us to elucidate values that are important to the patient.”