Canadian Emergency Physician Attitudes Toward Somatic Symptom and Related Disorders

1. Introduction

Various terms are used to describe physical symptoms and accompanying problematic thoughts, feelings and behaviours that are not believed to primarily have a medical cause, including somatoform disorder, medically unexplained symptoms, somatization and functional syndromes. The Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5-TR) uses the term ‘somatic symptom disorder’ (SSD) to describe physical symptoms lasting over six months that cannot entirely be explained by an organic medical cause, accompanied by persistent thoughts, feelings and behaviours relating to one’s health [1]. Pain is the most frequently reported symptom, but others can include shortness of breath, muscle tension and gastrointestinal or sexual dysfunction. The DSM-5-TR emphasizes that the way in which a patient interprets and presents their symptoms is a defining characteristic of SSD, rather than simply the presentation of symptoms in the absence of a clearly defined medical issue. Namely, the patient may present with concerns out of proportion to their symptoms, including a high level of anxiety regarding their symptoms, and devote significant time and energy to their symptoms [1].

Emotional or psychologically based symptoms are believed to occur in 18.5% of adult and 13% of pediatric emergency department (ED) visits, after excluding cases with physical trauma [2,3]. Despite this prevalence, SSD diagnosis is often delayed or missed and SSD has low clinical regard amongst ED physicians and nurses [4].

In a survey of over 1700 primary care physicians (PCPs) conducted by Lehmann et al., barriers to the diagnosis of SSD included the demand to relieve symptoms as well as the desire to rule out physical disease [5]. The situation regarding emergency physician (EP) attitudes and perceptions of SSD has yet to be evaluated.

The primary aim of this study is to assess Canadian Eps’ preparedness, attitudes and perceptions toward diagnosing SSD in the ED and secondarily to identify demographic trends associated therein. The relevance of these aims is highlighted by the current primary care shortage in Canada, where an estimated one in five individuals do not have a family physician, thus increasing the likelihood of patients with SSD presenting to the ED [6].

2. Materials and Methods

A voluntary and anonymous national survey was emailed to a list of 1339 EPs supplied by the Canadian Association of Emergency Physicians. Participants were excluded if they did not actively practise emergency medicine. Ethics approval was obtained from Dalhousie University on July 28 2023 (REB # 2023-6757).

Following Lehmann et al., the survey comprised two sections: one collecting demographic data (Figure A1) and a second divided into four domains, (1) EP perceptions of SSD, (2) attitudes toward patients, (3) diagnostic confidence, and (4) physician–patient communication (Figure A2) [5].

The survey was distributed on 16 October 2023, with reminders after two and four weeks, and closed on 17 November 2023.

A flow chart of the study is presented in Figure 1.

Statistical Analysis

Mean values and standard deviations for all 18 questions were calculated and responses were analyzed for associations with demographic information. A t-test was used for two-category demographics, and ANOVA was used for those with three or more categories, all at a 95% confidence interval. Bonferroni tests were conducted when necessary. Responses with fewer than six options (e.g., question 8) were scaled for comparison.

3. Results

In total, 96 participants completed the survey, of which 75 were deemed eligible.

Demographic information of the participants is presented in Table 1. Over half were male, with 53.3% trained as Fellows of the Royal College of Physicians of Canada (FRCPC), 37.3% with a certification in the College of Family Physicians (CCFP) and an additional certification in emergency medicine (CCFP (EM)), 6.7% with a CCFP alone, and 2.7% falling under ‘other’. About one-quarter had less than 10 years of experience, 32% had 10–20 years of experience, 29.3% had 21–30 years of experience and 12% had over 30 years of experience. Practice settings included urban/suburban areas (80%) and small town/rural settings (20%). Most (58.7%) practised in an academic health centre, and the remainder practised in community hospitals. The majority (69.3%) served a mixed patient demographic, while 25.3% served adults only and 5.3% served pediatric cases only.

Figure 2 shows the average responses to Section 2 (Figure A2) of the survey. Questions 8 and 9 are not included in this figure as the responses to these are not on a Likert scale. In question 8, when asked about the proportion of patients whose symptoms were thought to be primarily caused by emotional stress, 44% indicated 11–20%, while 40% indicated less than 10%. In response to question 9, 90% of respondents felt that SSD was occasionally, often, or very frequently missed rather than over-diagnosed. For all other questions, a mean response above 3.5 indicated agreement on average and a mean response below 3.5 indicated disagreement, with scores closer to 6 showing stronger agreement and those closer to 1 showing stronger disagreement.

Significant statistical tests relating demographic information from Section 1 (Figure A1) to responses in Section 2 (Figure A2) are displayed in Figure 3. Demographic associations with significance include male respondents being more likely than females to express the belief that there are clear enough signs and symptoms of SSD to make a presumptive ED diagnosis. Participants with a FRCPC certification were on average more likely than those with a CCFP(EM) to claim to never have made a definitive diagnosis of SSD. Participants with 10–20 years of experience were more likely than those with >30 years of experience to believe that there is rarely time in the ED to broach this topic with patients. Those with <10 years of experience were least likely to have made a definitive diagnosis of SSD. Respondents in urban/suburban settings were significantly more likely than those in rural/small town settings to believe patients would be insulted if a non-organic origin of their symptoms was suggested.

4. Discussion

This study aimed to evaluate EPs’ attitudes and comfort in managing patients with suspected SSD and identify demographic factors associated with their responses.

Most respondents felt that SSD is common and underdiagnosed, acknowledged the existence of effective therapies to treat SSD and acknowledged their role in diagnosing it. Respondents perceived the need for extensive testing before diagnosis. While this is understandable considering the imperative in EM to consider acutely life-threatening diagnoses, male respondents were more likely to believe there are clear enough signs of SSD to make a presumptive diagnosis.

EPs’ concerns about missing organic disease and meeting patient expectations to alleviate symptoms match those of PCPs described by Lehmann et al. [5]. Respondents in our study acknowledged that patients might not accept non-organic diagnoses, and that time constraints and managing patient’s emotions are challenging. They also expressed concerns about the medico-legal implications of SSD diagnoses. Although our surveys were not identical, EPs appear to experience greater frustration and difficulty dealing with emotions in this population than PCPs [5]. This may be due to the more familiar and trusting relationships between PCPs and their patients, and due to the higher levels of stress associated with acute presentations. Other studies have indicated low clinical regard for disorders of medically unexplained symptoms [4]. While our results support this, some EPs do report confidence broaching SSD with patients.

CCFP(EM)-trained EPs were more likely to report having made a diagnosis than FRCPC physicians. This difference may be explained by a CCFP(EM) physician’s greater exposure to SSD patients in primary care training, and by the possibility that FRCPC-trained EPs are more likely to work in higher-acuity EDs, thus having an appropriately higher index of suspicion for acute life-threatening illness.

Physicians with >30 years of experience were more likely to believe there is time in the ED to broach this topic. This finding may align with the suggestions by Chao-Jui et al.: that experienced physicians spend more time interacting with patients [7]. Greater experience also correlated with the likelihood of having made a SSD diagnosis, potentially reflecting the increased familiarity with and likelihood of encountering SSD given the length of clinical time.

Rural physicians were less concerned than urban-based physicians about insulting patients by suggesting a non-organic diagnosis, possibly due to differences in physician–patient relationships. One study comparing communication styles of urban and rural physicians found that rural physicians may generally ease patient anxiety and increase patient trust more than urban physicians [8].

Our study suggests that there is room for improvement in EPs’ diagnostic confidence in SSD and the role for education on communication techniques to minimize the likelihood of patients feeling insulted. This may include structured communication techniques, encouragement of empathy and reassurance that organic illnesses have been adequately considered, with adherence to established guidelines for the treatment of SSD [9,10]. EPs’ awareness of effective SSD treatments suggests that there would be greater willingness to make referrals for further assessment and treatment if services were more readily available. Examples of ED-based psychology clinics demonstrating effectiveness in treating SSD are reported in the literature [11].

Limitations of this study include the small sample size, affecting its generalizability. The survey was shortened to encourage participation and reminders were sent; nevertheless, the response rate was disappointing. There was likely selection bias amongst those who responded. This survey likely selected EPs more interested in or aware of SSD, and perhaps those with a more favourable perception thereof. Data on awareness of SSD amongst EP are sparse, though a study amongst physicians in Sweden found that 71% of physicians across various specialties were aware of the diagnosis but only 7% were aware of the diagnostic criteria [12]. To align with the survey of Lehmann et al., most survey statements were framed negatively, which may have influenced responses.

5. Conclusions

EPs recognize that, while ruling out life-threatening illness is crucial, SSD is common and underdiagnosed. They believe effective therapies exist and see SSD as a legitimate ED diagnosis. However, they remain concerned that patients may react negatively to non-organic explications, reported struggling with managing patient’s emotions, and reported that there is often a lack time to address the diagnosis. Opportunities remain to improve care for SSD and reduce the associated suffering.

Author Contributions

Conceptualization, J.H.W. and S.G.C.; data curation, J.H.W.; formal analysis, J.H.W., J.M.T. and S.G.C.; funding acquisition, J.H.W.; investigation, J.H.W.; methodology, J.H.W. and S.G.C.; project administration, J.H.W.; resources, J.H.W.; supervision, S.G.C.; visualization, J.H.W.; writing—original draft, J.H.W.; writing—review and editing, J.H.W., J.M.T. and S.G.C. All authors have read and agreed to the published version of the manuscript.

Funding

We received financial support in the form of a CAD 5000 bursary from the Dalhousie University Faculty of Medicine Ross Stuart Smith RIM Summer Studentship.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Dalhousie University (REB # 2023-6757, 28 July 2023).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors upon request.

Conflicts of Interest

The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Abbreviations

The following abbreviations are used in this manuscript:

SSD	somatic symptom disorder
ED	emergency department
EP	emergency physician
FRCPC	Fellows of the Royal College of Physicians of Canada
CCFP	Certification in the College of Family Physicians
CCFP-EM	Certification in the College of Family Physicians with additional certificate in Emergency Medicine
PCP	primary care physician

Appendix A

Figure A1.
Section 1 of the survey collecting demographic information.

Figure A2.
Section 2 of the survey collecting the survey response data.

References

American Psychiatric Association (Ed.) Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR, 5th ed.; Text Revision; American Psychiatric Association Publishing: Washington, DC, USA, 2022; p. 1. [Google Scholar]
Alsma, J.; van de Wouw, J.; Jellema, K.; Coffeng, S.M.; Tobback, E.; Delesie, L.; Brand, C.L.V.D.; Vogelaers, D.; Mariman, A.; Paepe, P.; et al. Medically unexplained physical symptoms in patients visiting the emergency department: An international multicentre retrospective study. Eur. J. Emerg. Med. 2019, 26, 249. [Google Scholar] [CrossRef] [PubMed]
Virk, P.; Vo, D.X.; Ellis, J.; Doan, Q. Pediatric somatization in the emergency department: Assessing missed opportunities for early management. Can. J. Emerg. Med. 2020, 22, 331–337. [Google Scholar] [CrossRef] [PubMed]
Howard, S.; Akhlaghi, H.; Watson, T.; O’Reilly, G.M.; Karro, J. Attitudes and regard for specific medical conditions among Australian emergency medicine clinicians. Emerg. Med. Australas. 2022, 34, 812–817. [Google Scholar] [CrossRef] [PubMed]
Lehmann, M.; Pohontsch, N.J.; Zimmermann, T.; Scherer, M.; Löwe, B. Diagnostic and treatment barriers to persistent somatic symptoms in primary care—Representative survey with physicians. BMC Fam. Pract. 2021, 22, 60. [Google Scholar] [CrossRef] [PubMed]
Duong, D.; Vogel, L. National survey highlights worsening primary care access. CMAJ 2023, 195, E592–E593. [Google Scholar] [CrossRef] [PubMed]
Li, C.J.; Syue, Y.J.; Tsai, T.C.; Wu, K.H.; Lee, C.H.; Lin, Y.R. The Impact of Emergency Physician Seniority on Clinical Efficiency, Emergency Department Resource Use, Patient Outcomes, and Disposition Accuracy. Medicine 2016, 95, e2706. [Google Scholar] [CrossRef] [PubMed]
Desjarlais-deKlerk, K.; Wallace, J.E. Instrumental and socioemotional communications in doctor-patient interactions in urban and rural clinics. BMC Health Serv. Res. 2013, 13, 261. [Google Scholar] [CrossRef] [PubMed]
Epstein, R.M.; Hadee, T.; Carroll, J.; Meldrum, S.C.; Lardner, J.; Shields, C.G. “Could this Be Something Serious?”: Reassurance, Uncertainty, and Empathy in Response to Patients’ Expressions of Worry. J. Gen. Intern. Med. 2007, 22, 1731–1739. [Google Scholar] [CrossRef] [PubMed]
Roenneberg, C.; Sattel, H.; Schaefert, R.; Henningsen, P.; Hausteiner-Wiehle, C. Functional Somatic Symptoms. Dtsch. Ärztebl. Int. 2019, 116, 553. Available online: https://www.aerzteblatt.de/10.3238/arztebl.2019.0553 (accessed on 10 August 2024). [CrossRef] [PubMed]
Town, J.M.; Abbass, A.; Campbell, S. Halifax somatic symptom disorder trial: A pilot randomized controlled trial of intensive short-term dynamic psychotherapy in the emergency department. J. Psychosom. Res. 2024, 187, 111889. [Google Scholar] [CrossRef] [PubMed]
Iloson, C.; Praetorius Björk, M.; Möller, A.; Sundfeldt, K.; Bernhardsson, S. Awareness of somatisation disorder among Swedish physicians at emergency departments: A cross-sectional survey. BMC Psychiatry 2024, 24, 223. [Google Scholar] [CrossRef] [PubMed]

Figure 1.
Study flow chart.

Figure 2.
Mean responses to questions in Section 2 (Figure A2) of the survey. Questions are subdivided into four domains and ordered from highest average level of agreement to highest average level of disagreement. Mean responses are displayed beside the statement. The value 3.5 is represented by the dotted reference line. The closer the mean is to 6, the stronger the agreement. The closer the mean is to 1, the stronger the disagreement. Error bars represent 95% confidence intervals.

Figure 3.
Bar graph showing mean responses in Section 2 (Figure A2) of the survey when significant differences existed based on demographic variables collected in Section 1 (Figure A1). Only significant differences are shown. Question number is indicated on the x axis along with the demographic variable. Error bars represent the standard deviation. * p < 0.05 ** p < 0.01 *** p < 0.001.

Table 1.
Personal and practice characteristics of participants, n = 75.

	Level	Responses
Gender	Male (%)	44 (58.7)
	Female (%)	31 (41.3)
Training Path	FRCPC (%)	40 (53.3)
	CCFP (EM) (%)	28 (37.3)
	CCFP (%)	5 (6.7)
	Other (%)	2 (2.7)
Years Spent Practising Emergency Medicine	>10 years (%)	20 (26.7)
	10–20 years (%)	24 (32)
	21–30 years (%)	22 (29.3)
	>31 years (%)	9 (12)
Geographic Population Served in Practice Setting	Urban/Suburban (%)	60 (80)
	Small Town/Rural (%)	15 (20)
	Geographically Isolated/Remote	0
	Cannot Identify a Primary Geographic Location	0
Primary Work Setting	Community Hospital (%)	31 (41.3)
	Academic Health Centre (%)	44 (58.7)
	Private Office/Clinic	0
	Prefer Not to Answer	0
Primary Patient Demographic	Adult Only (%)	19 (25.3)
	Pediatric Only (%)	4 (5.3)
	Mixed (%)	52 (69.3)

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© 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

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Canadian Emergency Physician Attitudes Toward Somatic Symptom and Related Disorders

1. Introduction

2. Materials and Methods

Statistical Analysis

3. Results

4. Discussion

5. Conclusions

Author Contributions

Funding

Institutional Review Board Statement

Informed Consent Statement

Data Availability Statement

Conflicts of Interest

Abbreviations

Appendix A

References

Greenberg

1. Introduction

2. Materials and Methods

Statistical Analysis

3. Results

4. Discussion

5. Conclusions

Author Contributions

Funding

Institutional Review Board Statement

Informed Consent Statement

Data Availability Statement

Conflicts of Interest

Abbreviations

Appendix A

References

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