In this month’s Hospital Pediatrics, Ibeziako et al1 present a clinical pathway for hospital-based management of somatic symptoms and related disorders (SSRDs). SSRDs include psychiatric diagnoses outlined in the Diagnostic and Statistical Manual, Fifth Revision, such as conversion disorder, factitious disorders, and illness anxiety disorder, as well as other medical conditions, such as functional gastrointestinal disorders, amplified pain syndromes, and “psychogenic” conditions such as nonepileptiform seizures and syncope. This new pathway outlines principles of managing SSRDs in hospitalized patients and provides resources to aid hospital teams in effective management.
Although mental health conditions are among the most common reasons for pediatric hospitalization2 and are a common comorbidity in medical and surgical hospitalizations,3 few clinical pathways exist to guide hospital management of mental health concerns. The SSRD pathway breaks new ground by providing standards to guide the care of a complex group of disorders requiring collaboration across medical and psychosocial disciplines. Given the complexities of managing SSRDs, hospital teams will likely experience challenges implementing the guidelines provided in the SSRD pathway. We have drawn from our own experiences caring for patients with SSRDs to outline likely difficulties and suggest strategies that might help address each one.
How the SSRD pathway is implemented will vary depending on hospital setting and resources. Determining which clinicians have familiarity in treating SSRDs is essential to creating hospital-specific guidelines. In hospitals with robust behavioral health teams, psychologists, psychiatrists, and social workers will be important members of the team. In addition, physical therapists, occupational therapists, and child life specialists, among others, can offer services for SSRD diagnosis and treatment. Positive and trusting relationships among clinicians from different specialties can enable understanding about each discipline’s contributions. Exchanging clinical experiences and providing education in venues such as case conferences and other recreational team-building activities (anything from brown-bag lunches to an off-site retreat) can help to facilitate trust and communication within teams.4
Physicians might disagree on what constitutes the “complete but judicious medical workup” recommended by the pathway. Several factors can contribute to overtesting. Clinicians might experience pressure from other providers or families to perform diagnostic testing or to refer a patient for a subspecialty evaluation. Multiple subspecialists can offer differing opinions about what workup is indicated. Simultaneously pursuing both a medical and behavioral health workup early in an evaluation of a patient with suspected SSRD, as the pathway recommends, instead of thinking of SSRDs as a “diagnosis of exclusion” can help minimize unnecessary testing. In our experience, patients and families underestimate the risks and unintended consequences of diagnostic tests and overestimate the certainty that an “answer” can come from diagnostic testing. Conversations with patients, families, and clinicians to explore possible test outcomes (normal, equivocal, abnormal) and how each outcome would change management can help focus the workup and avoid exposing patients to unnecessary risk.
Communication With Families
Involvement of specialists from multiple disciplines in the care of a patient with SSRD opens opportunities for team members to inadvertently communicate different messages to families. When families perceive nonalignment between different members of the clinical team, teams are prone to being split. Family meetings can help ensure that all team members communicate the same message to patients and families. Family meetings also offer patients and families opportunities to ask questions that might require input from >1 team member. Several clinical events should prompt clinicians to consider a family meeting: initial suspicion of an SSRD, confirmation of the diagnosis, and new serious symptoms or changes in functioning. The comprehensive materials created with the pathway give excellent examples of how to explain SSRD to patients and their families, scripting a shared message that all providers can use regardless of previous experience. An initial family meeting to introduce the concept of an SSRD using language recommended by the pathway can help ensure that clinical team members, patients, and families remain on the same page when they discuss symptoms and management.
Clarifying Clinical Accountability
Clear communication is closely tied to clear lines of authority and accountability. Identifying a lead clinician, the “captain of the ship” so to speak, who can resolve clinical differences of opinion and has authority over difficult decisions or communication points can help teams maintain a clear message. The lead clinician might be different in the inpatient and outpatient setting (eg, a pediatric hospitalist during a hospitalization and a primary care physician [PCP] outside the hospital). When that is the case, a warm handoff at hospital admission and discharge that includes relevant medical information, a plan for future decision-making, and a plan for postdischarge follow-up can help maintain positive therapeutic relationships with the family across settings. Team-based care might require the lead clinician to be tied to a role (eg, the attending hospitalist physician) as opposed to a single individual. For shorter hospitalizations, this arrangement might serve patients well; however, for patients who are hospitalized frequently or for long periods, teams can consider identifying a continuity clinician to participate in longitudinal care decisions in partnership with the rotating lead clinician.
Transitions in Care
This SSRD treatment pathway is concentrated on inpatient management. Hospitalizations for SSRD symptoms that are not manageable in the outpatient setting represent a crisis for many patients and families. This poses several complications. First, families may have difficulty accepting the SSRD diagnosis from unfamiliar inpatient providers. Involving outpatient providers (eg, the PCP and outpatient subspecialists) via phone or in person for team and family meetings helps preserve continuity between outpatient to inpatient care and ensures the patient and family receive information in the presence of familiar, trusted providers. Second, the majority of the patient’s care to restore functioning will need to occur outpatient. Establishing appropriate outpatient follow-up, especially for mental health, can be difficult,5 and enlisting the PCP to help locate resources near the patient’s home can be instrumental in a successful discharge.
Pathway Uptake and Maintenance
Uptake of pathway recommendations and determining what constitutes pathway success requires buy in from clinicians caring for patients with SSRDs. Because these clinicians are likely to represent a wide range of clinical disciplines, it can be helpful to identify a clinical champion from key stakeholder disciplines. These clinicians can serve as local experts on the pathway among their colleagues and can help assess what constitutes improvement or success in the care of patients with SSRDs. Quality metrics that could be useful in pathway evaluation might include some traditional hospital quality measures, such as inpatient length of stay, patient adverse events, and patient and caregiver satisfaction, as well as less commonly used measures such as patient quality of life or global assessment of functioning.
The SSRD pathway gives pediatric hospital clinicians a framework for optimizing care for a patient population that many teams struggle to diagnose and treat effectively and efficiently. Emphasis on improving functioning instead of symptom resolution provides a realistic goal of care. Championing a team approach helps patients and families receive consistent messaging from all clinicians.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Dr Doupnik was supported by grant K23MH115162 from the National Institute of Mental Health. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2019 by the American Academy of Pediatrics