To the Editor: We strongly agree with the reasons to improve training in nonpsychiatric medicine for psychiatrists that were outlined in Wright’s (1) commentary in the May-June issue. This training is particularly important because of the high numbers of comorbid general medical illnesses that often go undetected and untreated (2, 3). These illnesses are often “hidden” or unrecognized and mistakenly attributed to psychological problems. In fact, several studies have indicated that undiagnosed medical illnesses may either directly cause or exacerbate psychiatric disorders (4–6). Moreover, conservative estimates suggest that at least 10% of all psychiatric illness may have general medical sources (7, 8).
Failure to recognize psychologically masked general medical illness results in a clinical assessment that is inaccurate and a treatment plan that is both misguided and potentially harmful to the patient. One investigation (9) found that mental health providers with no medical training demonstrated substantially less knowledge of common medical illnesses that masquerade as psychological problems than did medically trained providers. However, no studies have specifically compared the ability of psychiatrists with that of physicians in other medical specialties to recognize masked general medical illness in patients presenting with what appears to be primarily a mental health disorder.
In this pilot investigation, we compared psychiatrists with primary care physicians regarding their abilities to identify common medical illnesses that often masquerade as psychological problems. We hypothesized that psychiatrists and primary care physicians would demonstrate equivalent ability to recognize masked medical illnesses.
Data for this study were taken from an earlier investigation (9) comparing the abilities of providers from a spectrum of health care-related disciplines to identify psychologically masked illnesses. In supervised test administration settings, 24 psychiatrists and 20 primary care physicians completed a questionnaire (9) consisting of 10 clinical vignettes in which patients seek treatment for psychological symptoms that are caused by unrecognized medical illnesses. For each vignette, physicians were asked to choose the correct medical illness from four medical disorders. In addition, participants were asked to indicate their medical specialty, gender, age, and years of clinical experience.
The sampled physicians practiced in the following clinical settings: a Veterans Affairs medical center, a state psychiatric hospital, a university teaching hospital, and a primary care clinic affiliated with an academic medical center. SPSS software, version 16.0 (SPSS Inc., Chicago), was used for statistical analysis. Student’s t test was used for comparing groups of independent samples.
No significant differences were found between primary care physicians and psychiatrists in age (t=0.71, df=33, p=0.48) or clinical experience (t=0.70, df=40, p=0.48). However, the mean questionnaire score of the primary care physicians (mean=9.35) was significantly higher (t=2.97, df=42, p<0.01) than the mean questionnaire score of the psychiatrists (mean=8.33).
Unexpectedly, psychiatrists scored significantly lower on the questionnaire than did primary care physicians. Although a majority of psychiatrists did well on the questionnaire, almost one-third of psychiatrists (29%) obtained a score of 7 or below. In contrast, nearly all primary care physicians did well on the questionnaire, with only one earning a score of 7.
These findings should be viewed with caution because of the small sample sizes. Clearly, further studies with larger sample sizes and more diverse practice settings are needed to confirm these findings. However, these results do lend preliminary support to Wright’s (1) arguments for improved training in nonpsychiatric medicine. Improved proficiency in nonpsychiatric medicine for psychiatrists would result in improved detection and more timely treatment of psychologically masked medical illness. Moreover, improved fluency in nonpsychiatric medicine would improve psychiatrists’ ability to effectively communicate and collaborate with physicians in other specialties (1).
By establishing close, continuous working relationships with internists, family practice physicians, and physicians in other medical specialties, psychiatrists can remain knowledgeable about the ongoing health status of their patients (10, 11). This provides an opportunity for the treating psychiatrist and primary care physician to discuss, in a timely fashion, clinical concerns that might suggest an underlying or contributing medical illness.
At the time of submission, the authors declared no competing interests.