CASE Sudden weakness

Ms. G, age 59, presents to a local critical access (rural) hospital after an episode of sudden-onset left-sided weakness followed by unconsciousness. She regained consciousness quickly and is awake when she arrives at the hospital. This event was not witnessed, although family members were nearby to call emergency personnel.

EXAMINATION Unremarkable

In the emergency department, Ms. G demonstrates left facial droop, left-sided weakness of her arm and leg, and aphasia. She says she has a severe headache that began after she regained consciousness. She is unable to see out of her left eye.

Ms. G’s NIH Stroke Scale score is 13, indicating a moderate stroke; an emergent head CT does not demonstrate any acute hemorrhagic process. Tissue plasminogen activator (tPA) is administered for a suspected stroke approximately 2 hours after her symptoms began. She is transferred to a larger, tertiary care hospital for further workup and observation.

Upon admission to the ICU, Ms. G’s laboratory values are: sodium, 137 mEq/L; potassium, 5.1 mEq/L; creatinine, 1.26 mg/dL; lipase, 126 U/L; and lactic acid, 9 mg/dL. The glucose level is within normal limits and her urinalysis is unremarkable.

Vital signs are stable and Ms. G is not in acute distress. A physical exam demonstrates 4/5 strength in the left-upper and -lower extremities. Additionally, there are 2+ deep tendon reflexes bilaterally in the biceps, triceps, and brachioradialis. She has left-sided facial droop while in the ICU, and continues to demonstrate some aphasia—although she is alert and oriented to person, time, and place.

The medical history is significant for depression, restless leg syndrome, tonic-clonic seizures, and previous stroke-like events. Medications include amitriptyline, 25 mg/d; citalopram, 20 mg/d; valproate, 1,200 mg/d; and ropinirole, 0.5 mg/d. Her mother has a history of stroke-like events, but her family history and social history are otherwise unremarkable.

The authors' observations

Conversion disorder requires the exclusion of medical causes that could explain the patient’s neurologic symptoms. It is prudent to rule out the most serious of the potential contributors to Ms. G’s condition—namely, an acute cerebrovascular accident. A CT scan did not find any significant pathology, however. In the ICU, an MRI showed no evidence of acute infarction based on diffusion-weighted imaging. A head and neck MRA demonstrated no hemodynamically significant stenosis of the internal carotid arteries. An EEG revealed generalized, polymorphic slow activity without evidence of seizures or epilepsy. An electrocardiogram showed normal ventricular size with an appropriate ejection fraction.

The ICU staff consulted psychiatry to evaluate a psychiatric cause of Ms. G’s symptoms.

An exhaustive and comprehensive workup was performed; there were no significant findings. Although laboratory tests were performed, it was the physical exam that suggested the diagnosis of conversion disorder. In that sense, the diagnostic tests were more of a supportive adjunct to the findings of the physical examination, which consistently failed to indicate a neurologic insult.

Hoover’s sign is a well-established test of functional weakness, in which the patient extends his (her) hip when the contralateral hip is flexed. However, there are other tests of functional weakness that can be useful when considering a conversion disorder diagnosis, including co-contraction, the so-called arm-drop sign, and the sternocleidomastoid test. Diukova and colleagues reported that 80% of patients with functional weakness demonstrated ipsilateral sternocleidomastoid weakness, compared with 11% with vascular hemiparesis.¹

Ms. G appeared to have suffered an acute ischemic event that caused her neurologic symptoms; her rather extensive psychiatric history was overlooked before the psychiatric service was consulted. When Ms. G was admitted to the ICU, the working differential was postictal seizure state rather than cerebrovascular accident. Ms. G had a poorly defined seizure history, and her history of stroke-like events was murky, at best. She had not been treated previously with tPA, and in all past instances her symptoms resolved spontaneously.

Ms. G’s case illustrates why conversion disorder is difficult to diagnose and why, perhaps, it is even a dangerous diagnostic consideration. Booij and colleagues described two patients with neurologic sequelae thought to be the result of conversion disorder; subsequent imaging demonstrated a posterior stroke.² Over a 6-year period in an emergency department, Glick and coworkers identified six patients with neurologic pathology who were misdiagnosed with conversion disorder.³ In a study of 4,220 patients presenting to a psychiatric emergency service, three patients complained of extremity paralysis or pain, which was attributed to conversion disorder but later attributed to an organic disease.⁴

These studies emphasize the precarious nature of diagnosing conversion disorder. For that reason, an extensive medical workup is necessary prior to considering a diagnosis of conversion disorder. In Ms. G’s case, a reasonably thorough workup failed to reveal any obvious pathology. Only then was conversion disorder included as a diagnostic possibility.

EVALUATION Childhood abuse

When performing a mental status exam, Ms. G has poor eye contact, but is cooperative with our interview. She is disheveled and overweight, and denies suicidal or homicidal ideation. She displays constricted affect.

During the interview, we note a left facial droop, although Ms. G is able to smile fully. As the interview progresses, her facial droop seems to become more apparent as we discuss her past, including a history of childhood physical and sexual abuse. She has a history of depression and has been seeing an outpatient psychiatrist for the past year. Ms. G describes being hospitalized in a psychiatric unit, but she is unable to provide any details about when and where this occurred.

Ms. G admits to occasional auditory and visual hallucinations, mostly relating to the abuse she experienced as a child by her parents. She exhibits no other signs or symptoms of psychosis; the hallucinations she describes are consistent with flashbacks and vivid memories relating to the abuse. Ms. G also recently lost her job and is experiencing numerous financial stressors.

The authors' observations

There are many examples in the literature of patients with conversion disorder (Table 1),⁴ ranging from pseudoseizures, which are relatively common, to intriguing cases, such as cochlear implant failure.⁵

Some studies estimate that the prevalence of conversion disorder symptoms ranges from 16.1% to 21.9% in the general population.⁶ Somatoform disorders, including conversion disorder, often are comorbid with anxiety and depression. In one study, 26% of somatoform disorder patients also had depression or anxiety, or both.⁷ Patients with conversion disorder often report a history of childhood physical or sexual abuse.⁶ In many patients with conversion disorder, there also appears to be a significant association between the disorder and a recent and distant history of psychosocial stressors.⁸

Ms. G had an extensive history of abuse by her parents. Conversion disorder presenting as a stroke with realistic and convincing physical manifestations is an unusual presentation. There are case reports that detail this presentation, particularly in the emergency department setting.⁶

Clinical considerations

The relative uncertainty that accompanies a diagnosis of conversion disorder can be discomforting for clinicians. As demonstrated by Ms. G, as well as other case reports of conversion disorder, it takes time for the patient to find a clinician who will consider a diagnosis of conversion disorder.⁹ Largely, this is because DSM-5 requires that other medical causes be ruled out (Table 2).¹⁰ This often proves to be problematic because feigning, or the lack thereof, is difficult to prove.⁹

Further complicating the diagnosis is the lack of a diagnostic test. Neurologists can use video EEG or physical exam maneuvers such as the Hoover’s sign to help make a diagnosis of conversion disorder.¹¹ In this sense, the physical exam maneuvers form the basis of making a diagnosis, while imaging and lab work support the diagnosis. Hoover’s sign, for example, has not been well studied in a controlled manner, but is recognized as a test that may aid a conversion disorder diagnosis. Clinicians should not solely rely upon these physical exam maneuvers; interpreting them in the context of the patient’s overall presentation is critical. This demonstrates the importance of using the physical exam as a way to guide the diagnosis in association with other tests.¹²

Despite the lack of pathology, studies demonstrate that patients with conversion disorder may have abnormal brain activity that causes them to perceive motor symptoms as involuntary.¹¹ Therefore, there is a clear need for an increased understanding of psychiatric and neurologic components of diagnosing conversion disorder.⁸

With Ms. G, it was prudent to make a conversion disorder diagnosis to prevent harm to the patient should future stroke-like events occur. Without considering a conversion disorder diagnosis, a patient may continue to receive unnecessary interventions. Basic physical exam maneuvers, such as Hoover’s sign, can be performed quickly in the ED setting before proceeding with other potentially harmful interventions, such as administering tPA.

Treatment. There are few therapies for conversion disorder. This is, in part, because of lack of understanding about the disorder’s neurologic and biologic etiologies. Although there are some studies that support the use of cognitive-behavioral therapy (CBT), there is little evidence advocating the use of a single mechanism to treat conversion disorder.¹³ There is evidence that CBT is an effective treatment for several somatoform disorders, including conversion disorder. Research suggests that patients with somatoform disorder have better outcomes when CBT is added to a traditional follow-up.^14,15

In Ms. G’s case, we provided information about the diagnosis and scheduled visits to continue her outpatient therapy.

Bottom Line

Conversion disorder is difficult to diagnose, and can mimic potentially life- threatening medical conditions. Conduct a thorough medical workup of these patients, even when it is tempting to jump to a diagnosis of conversion disorder. The use of physical exam maneuvers such as Hoover’s sign may help guide the diagnosis when used in conjunction with other testing.

Related Resources

• Conversion disorder. www.nlm.nih.gov/medlineplus/ency/ article/000954.htm.
• Couprie W, Wijdicks EF, Rooijmans HG, et al. Outcome in conver- sion disorder: a follow up study. J Neurol Neurosurg Psychiatry. 1995;58(6):750-752.

Drug Brand Names

Amitriptyline • Elavil       Citalopram • Celexa

Ropinirole • Requip         Valproate • Depakote

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE Sudden weakness

Ms. G, age 59, presents to a local critical access (rural) hospital after an episode of sudden-onset left-sided weakness followed by unconsciousness. She regained consciousness quickly and is awake when she arrives at the hospital. This event was not witnessed, although family members were nearby to call emergency personnel.

EXAMINATION Unremarkable

In the emergency department, Ms. G demonstrates left facial droop, left-sided weakness of her arm and leg, and aphasia. She says she has a severe headache that began after she regained consciousness. She is unable to see out of her left eye.

Ms. G’s NIH Stroke Scale score is 13, indicating a moderate stroke; an emergent head CT does not demonstrate any acute hemorrhagic process. Tissue plasminogen activator (tPA) is administered for a suspected stroke approximately 2 hours after her symptoms began. She is transferred to a larger, tertiary care hospital for further workup and observation.

Upon admission to the ICU, Ms. G’s laboratory values are: sodium, 137 mEq/L; potassium, 5.1 mEq/L; creatinine, 1.26 mg/dL; lipase, 126 U/L; and lactic acid, 9 mg/dL. The glucose level is within normal limits and her urinalysis is unremarkable.

Vital signs are stable and Ms. G is not in acute distress. A physical exam demonstrates 4/5 strength in the left-upper and -lower extremities. Additionally, there are 2+ deep tendon reflexes bilaterally in the biceps, triceps, and brachioradialis. She has left-sided facial droop while in the ICU, and continues to demonstrate some aphasia—although she is alert and oriented to person, time, and place.

The medical history is significant for depression, restless leg syndrome, tonic-clonic seizures, and previous stroke-like events. Medications include amitriptyline, 25 mg/d; citalopram, 20 mg/d; valproate, 1,200 mg/d; and ropinirole, 0.5 mg/d. Her mother has a history of stroke-like events, but her family history and social history are otherwise unremarkable.

The authors' observations

Conversion disorder requires the exclusion of medical causes that could explain the patient’s neurologic symptoms. It is prudent to rule out the most serious of the potential contributors to Ms. G’s condition—namely, an acute cerebrovascular accident. A CT scan did not find any significant pathology, however. In the ICU, an MRI showed no evidence of acute infarction based on diffusion-weighted imaging. A head and neck MRA demonstrated no hemodynamically significant stenosis of the internal carotid arteries. An EEG revealed generalized, polymorphic slow activity without evidence of seizures or epilepsy. An electrocardiogram showed normal ventricular size with an appropriate ejection fraction.

The ICU staff consulted psychiatry to evaluate a psychiatric cause of Ms. G’s symptoms.

An exhaustive and comprehensive workup was performed; there were no significant findings. Although laboratory tests were performed, it was the physical exam that suggested the diagnosis of conversion disorder. In that sense, the diagnostic tests were more of a supportive adjunct to the findings of the physical examination, which consistently failed to indicate a neurologic insult.

Hoover’s sign is a well-established test of functional weakness, in which the patient extends his (her) hip when the contralateral hip is flexed. However, there are other tests of functional weakness that can be useful when considering a conversion disorder diagnosis, including co-contraction, the so-called arm-drop sign, and the sternocleidomastoid test. Diukova and colleagues reported that 80% of patients with functional weakness demonstrated ipsilateral sternocleidomastoid weakness, compared with 11% with vascular hemiparesis.¹

Ms. G appeared to have suffered an acute ischemic event that caused her neurologic symptoms; her rather extensive psychiatric history was overlooked before the psychiatric service was consulted. When Ms. G was admitted to the ICU, the working differential was postictal seizure state rather than cerebrovascular accident. Ms. G had a poorly defined seizure history, and her history of stroke-like events was murky, at best. She had not been treated previously with tPA, and in all past instances her symptoms resolved spontaneously.

Ms. G’s case illustrates why conversion disorder is difficult to diagnose and why, perhaps, it is even a dangerous diagnostic consideration. Booij and colleagues described two patients with neurologic sequelae thought to be the result of conversion disorder; subsequent imaging demonstrated a posterior stroke.² Over a 6-year period in an emergency department, Glick and coworkers identified six patients with neurologic pathology who were misdiagnosed with conversion disorder.³ In a study of 4,220 patients presenting to a psychiatric emergency service, three patients complained of extremity paralysis or pain, which was attributed to conversion disorder but later attributed to an organic disease.⁴

These studies emphasize the precarious nature of diagnosing conversion disorder. For that reason, an extensive medical workup is necessary prior to considering a diagnosis of conversion disorder. In Ms. G’s case, a reasonably thorough workup failed to reveal any obvious pathology. Only then was conversion disorder included as a diagnostic possibility.

EVALUATION Childhood abuse

When performing a mental status exam, Ms. G has poor eye contact, but is cooperative with our interview. She is disheveled and overweight, and denies suicidal or homicidal ideation. She displays constricted affect.

During the interview, we note a left facial droop, although Ms. G is able to smile fully. As the interview progresses, her facial droop seems to become more apparent as we discuss her past, including a history of childhood physical and sexual abuse. She has a history of depression and has been seeing an outpatient psychiatrist for the past year. Ms. G describes being hospitalized in a psychiatric unit, but she is unable to provide any details about when and where this occurred.

Ms. G admits to occasional auditory and visual hallucinations, mostly relating to the abuse she experienced as a child by her parents. She exhibits no other signs or symptoms of psychosis; the hallucinations she describes are consistent with flashbacks and vivid memories relating to the abuse. Ms. G also recently lost her job and is experiencing numerous financial stressors.

The authors' observations

There are many examples in the literature of patients with conversion disorder (Table 1),⁴ ranging from pseudoseizures, which are relatively common, to intriguing cases, such as cochlear implant failure.⁵

Some studies estimate that the prevalence of conversion disorder symptoms ranges from 16.1% to 21.9% in the general population.⁶ Somatoform disorders, including conversion disorder, often are comorbid with anxiety and depression. In one study, 26% of somatoform disorder patients also had depression or anxiety, or both.⁷ Patients with conversion disorder often report a history of childhood physical or sexual abuse.⁶ In many patients with conversion disorder, there also appears to be a significant association between the disorder and a recent and distant history of psychosocial stressors.⁸

Ms. G had an extensive history of abuse by her parents. Conversion disorder presenting as a stroke with realistic and convincing physical manifestations is an unusual presentation. There are case reports that detail this presentation, particularly in the emergency department setting.⁶

Clinical considerations

The relative uncertainty that accompanies a diagnosis of conversion disorder can be discomforting for clinicians. As demonstrated by Ms. G, as well as other case reports of conversion disorder, it takes time for the patient to find a clinician who will consider a diagnosis of conversion disorder.⁹ Largely, this is because DSM-5 requires that other medical causes be ruled out (Table 2).¹⁰ This often proves to be problematic because feigning, or the lack thereof, is difficult to prove.⁹

Further complicating the diagnosis is the lack of a diagnostic test. Neurologists can use video EEG or physical exam maneuvers such as the Hoover’s sign to help make a diagnosis of conversion disorder.¹¹ In this sense, the physical exam maneuvers form the basis of making a diagnosis, while imaging and lab work support the diagnosis. Hoover’s sign, for example, has not been well studied in a controlled manner, but is recognized as a test that may aid a conversion disorder diagnosis. Clinicians should not solely rely upon these physical exam maneuvers; interpreting them in the context of the patient’s overall presentation is critical. This demonstrates the importance of using the physical exam as a way to guide the diagnosis in association with other tests.¹²

Despite the lack of pathology, studies demonstrate that patients with conversion disorder may have abnormal brain activity that causes them to perceive motor symptoms as involuntary.¹¹ Therefore, there is a clear need for an increased understanding of psychiatric and neurologic components of diagnosing conversion disorder.⁸

With Ms. G, it was prudent to make a conversion disorder diagnosis to prevent harm to the patient should future stroke-like events occur. Without considering a conversion disorder diagnosis, a patient may continue to receive unnecessary interventions. Basic physical exam maneuvers, such as Hoover’s sign, can be performed quickly in the ED setting before proceeding with other potentially harmful interventions, such as administering tPA.

Treatment. There are few therapies for conversion disorder. This is, in part, because of lack of understanding about the disorder’s neurologic and biologic etiologies. Although there are some studies that support the use of cognitive-behavioral therapy (CBT), there is little evidence advocating the use of a single mechanism to treat conversion disorder.¹³ There is evidence that CBT is an effective treatment for several somatoform disorders, including conversion disorder. Research suggests that patients with somatoform disorder have better outcomes when CBT is added to a traditional follow-up.^14,15

In Ms. G’s case, we provided information about the diagnosis and scheduled visits to continue her outpatient therapy.

Bottom Line

Conversion disorder is difficult to diagnose, and can mimic potentially life- threatening medical conditions. Conduct a thorough medical workup of these patients, even when it is tempting to jump to a diagnosis of conversion disorder. The use of physical exam maneuvers such as Hoover’s sign may help guide the diagnosis when used in conjunction with other testing.

Related Resources

• Conversion disorder. www.nlm.nih.gov/medlineplus/ency/ article/000954.htm.
• Couprie W, Wijdicks EF, Rooijmans HG, et al. Outcome in conver- sion disorder: a follow up study. J Neurol Neurosurg Psychiatry. 1995;58(6):750-752.

Drug Brand Names

Amitriptyline • Elavil       Citalopram • Celexa

Ropinirole • Requip         Valproate • Depakote

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

CASE Sudden weakness

Ms. G, age 59, presents to a local critical access (rural) hospital after an episode of sudden-onset left-sided weakness followed by unconsciousness. She regained consciousness quickly and is awake when she arrives at the hospital. This event was not witnessed, although family members were nearby to call emergency personnel.

EXAMINATION Unremarkable

In the emergency department, Ms. G demonstrates left facial droop, left-sided weakness of her arm and leg, and aphasia. She says she has a severe headache that began after she regained consciousness. She is unable to see out of her left eye.

Ms. G’s NIH Stroke Scale score is 13, indicating a moderate stroke; an emergent head CT does not demonstrate any acute hemorrhagic process. Tissue plasminogen activator (tPA) is administered for a suspected stroke approximately 2 hours after her symptoms began. She is transferred to a larger, tertiary care hospital for further workup and observation.

Upon admission to the ICU, Ms. G’s laboratory values are: sodium, 137 mEq/L; potassium, 5.1 mEq/L; creatinine, 1.26 mg/dL; lipase, 126 U/L; and lactic acid, 9 mg/dL. The glucose level is within normal limits and her urinalysis is unremarkable.

Vital signs are stable and Ms. G is not in acute distress. A physical exam demonstrates 4/5 strength in the left-upper and -lower extremities. Additionally, there are 2+ deep tendon reflexes bilaterally in the biceps, triceps, and brachioradialis. She has left-sided facial droop while in the ICU, and continues to demonstrate some aphasia—although she is alert and oriented to person, time, and place.

The medical history is significant for depression, restless leg syndrome, tonic-clonic seizures, and previous stroke-like events. Medications include amitriptyline, 25 mg/d; citalopram, 20 mg/d; valproate, 1,200 mg/d; and ropinirole, 0.5 mg/d. Her mother has a history of stroke-like events, but her family history and social history are otherwise unremarkable.

The authors' observations

Conversion disorder requires the exclusion of medical causes that could explain the patient’s neurologic symptoms. It is prudent to rule out the most serious of the potential contributors to Ms. G’s condition—namely, an acute cerebrovascular accident. A CT scan did not find any significant pathology, however. In the ICU, an MRI showed no evidence of acute infarction based on diffusion-weighted imaging. A head and neck MRA demonstrated no hemodynamically significant stenosis of the internal carotid arteries. An EEG revealed generalized, polymorphic slow activity without evidence of seizures or epilepsy. An electrocardiogram showed normal ventricular size with an appropriate ejection fraction.

The ICU staff consulted psychiatry to evaluate a psychiatric cause of Ms. G’s symptoms.

An exhaustive and comprehensive workup was performed; there were no significant findings. Although laboratory tests were performed, it was the physical exam that suggested the diagnosis of conversion disorder. In that sense, the diagnostic tests were more of a supportive adjunct to the findings of the physical examination, which consistently failed to indicate a neurologic insult.

Hoover’s sign is a well-established test of functional weakness, in which the patient extends his (her) hip when the contralateral hip is flexed. However, there are other tests of functional weakness that can be useful when considering a conversion disorder diagnosis, including co-contraction, the so-called arm-drop sign, and the sternocleidomastoid test. Diukova and colleagues reported that 80% of patients with functional weakness demonstrated ipsilateral sternocleidomastoid weakness, compared with 11% with vascular hemiparesis.¹

Ms. G appeared to have suffered an acute ischemic event that caused her neurologic symptoms; her rather extensive psychiatric history was overlooked before the psychiatric service was consulted. When Ms. G was admitted to the ICU, the working differential was postictal seizure state rather than cerebrovascular accident. Ms. G had a poorly defined seizure history, and her history of stroke-like events was murky, at best. She had not been treated previously with tPA, and in all past instances her symptoms resolved spontaneously.

Ms. G’s case illustrates why conversion disorder is difficult to diagnose and why, perhaps, it is even a dangerous diagnostic consideration. Booij and colleagues described two patients with neurologic sequelae thought to be the result of conversion disorder; subsequent imaging demonstrated a posterior stroke.² Over a 6-year period in an emergency department, Glick and coworkers identified six patients with neurologic pathology who were misdiagnosed with conversion disorder.³ In a study of 4,220 patients presenting to a psychiatric emergency service, three patients complained of extremity paralysis or pain, which was attributed to conversion disorder but later attributed to an organic disease.⁴

These studies emphasize the precarious nature of diagnosing conversion disorder. For that reason, an extensive medical workup is necessary prior to considering a diagnosis of conversion disorder. In Ms. G’s case, a reasonably thorough workup failed to reveal any obvious pathology. Only then was conversion disorder included as a diagnostic possibility.

EVALUATION Childhood abuse

When performing a mental status exam, Ms. G has poor eye contact, but is cooperative with our interview. She is disheveled and overweight, and denies suicidal or homicidal ideation. She displays constricted affect.

During the interview, we note a left facial droop, although Ms. G is able to smile fully. As the interview progresses, her facial droop seems to become more apparent as we discuss her past, including a history of childhood physical and sexual abuse. She has a history of depression and has been seeing an outpatient psychiatrist for the past year. Ms. G describes being hospitalized in a psychiatric unit, but she is unable to provide any details about when and where this occurred.

Ms. G admits to occasional auditory and visual hallucinations, mostly relating to the abuse she experienced as a child by her parents. She exhibits no other signs or symptoms of psychosis; the hallucinations she describes are consistent with flashbacks and vivid memories relating to the abuse. Ms. G also recently lost her job and is experiencing numerous financial stressors.

The authors' observations

There are many examples in the literature of patients with conversion disorder (Table 1),⁴ ranging from pseudoseizures, which are relatively common, to intriguing cases, such as cochlear implant failure.⁵

Some studies estimate that the prevalence of conversion disorder symptoms ranges from 16.1% to 21.9% in the general population.⁶ Somatoform disorders, including conversion disorder, often are comorbid with anxiety and depression. In one study, 26% of somatoform disorder patients also had depression or anxiety, or both.⁷ Patients with conversion disorder often report a history of childhood physical or sexual abuse.⁶ In many patients with conversion disorder, there also appears to be a significant association between the disorder and a recent and distant history of psychosocial stressors.⁸

Ms. G had an extensive history of abuse by her parents. Conversion disorder presenting as a stroke with realistic and convincing physical manifestations is an unusual presentation. There are case reports that detail this presentation, particularly in the emergency department setting.⁶

Clinical considerations

The relative uncertainty that accompanies a diagnosis of conversion disorder can be discomforting for clinicians. As demonstrated by Ms. G, as well as other case reports of conversion disorder, it takes time for the patient to find a clinician who will consider a diagnosis of conversion disorder.⁹ Largely, this is because DSM-5 requires that other medical causes be ruled out (Table 2).¹⁰ This often proves to be problematic because feigning, or the lack thereof, is difficult to prove.⁹

Further complicating the diagnosis is the lack of a diagnostic test. Neurologists can use video EEG or physical exam maneuvers such as the Hoover’s sign to help make a diagnosis of conversion disorder.¹¹ In this sense, the physical exam maneuvers form the basis of making a diagnosis, while imaging and lab work support the diagnosis. Hoover’s sign, for example, has not been well studied in a controlled manner, but is recognized as a test that may aid a conversion disorder diagnosis. Clinicians should not solely rely upon these physical exam maneuvers; interpreting them in the context of the patient’s overall presentation is critical. This demonstrates the importance of using the physical exam as a way to guide the diagnosis in association with other tests.¹²

Despite the lack of pathology, studies demonstrate that patients with conversion disorder may have abnormal brain activity that causes them to perceive motor symptoms as involuntary.¹¹ Therefore, there is a clear need for an increased understanding of psychiatric and neurologic components of diagnosing conversion disorder.⁸

With Ms. G, it was prudent to make a conversion disorder diagnosis to prevent harm to the patient should future stroke-like events occur. Without considering a conversion disorder diagnosis, a patient may continue to receive unnecessary interventions. Basic physical exam maneuvers, such as Hoover’s sign, can be performed quickly in the ED setting before proceeding with other potentially harmful interventions, such as administering tPA.

Treatment. There are few therapies for conversion disorder. This is, in part, because of lack of understanding about the disorder’s neurologic and biologic etiologies. Although there are some studies that support the use of cognitive-behavioral therapy (CBT), there is little evidence advocating the use of a single mechanism to treat conversion disorder.¹³ There is evidence that CBT is an effective treatment for several somatoform disorders, including conversion disorder. Research suggests that patients with somatoform disorder have better outcomes when CBT is added to a traditional follow-up.^14,15

In Ms. G’s case, we provided information about the diagnosis and scheduled visits to continue her outpatient therapy.

Bottom Line

Conversion disorder is difficult to diagnose, and can mimic potentially life- threatening medical conditions. Conduct a thorough medical workup of these patients, even when it is tempting to jump to a diagnosis of conversion disorder. The use of physical exam maneuvers such as Hoover’s sign may help guide the diagnosis when used in conjunction with other testing.

Related Resources

• Conversion disorder. www.nlm.nih.gov/medlineplus/ency/ article/000954.htm.
• Couprie W, Wijdicks EF, Rooijmans HG, et al. Outcome in conver- sion disorder: a follow up study. J Neurol Neurosurg Psychiatry. 1995;58(6):750-752.

Drug Brand Names

Amitriptyline • Elavil       Citalopram • Celexa

Ropinirole • Requip         Valproate • Depakote

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Psychogenic itch—an excessive impulse to scratch, gouge, or pick at skin in the absence of dermatologic cause—is common among psychiatric inpatients, but can be challenging to assess and manage in outpatients. Patients with psychogenic itch predominantly are female, with average age of onset between 30 and 45 years.¹ Psychiatric disorders associated with psychogenic itch include depression, obsessive-compulsive disorder, anxiety, somatoform disorders, mania, psychosis, and substance abuse.² Body dysmorphic disorder, trichotillomania, kleptomania, and borderline personality disorder may be comorbid in patients with psychogenic itch.³

Characteristics of psychogenic itch

Consider psychogenic itch in patients who have recurring physical symptoms and demand examination despite repeated negative results. Other indicators include psychological factors—loss of a loved one, unemployment, relocation, etc.—that may be associated with onset, severity, elicitation, or maintenance of the itching; impairments in the patient’s social or professional life; and marked preoccupation with itching or the state of her (his) skin. Characteristically, itching can be provoked by emotional triggers, most notably during stages of excitement, and also by mechanical or chemical stimuli.

Skin changes associated with psychogenic itch often are found on areas accessible to the patient’s hand: face, arms, legs, abdomen, thighs, upper back, and shoulders. These changes can be seen in varying stages, from discrete superficial excoriations, erosions, and ulcers to thick, darkened nodules and colorless atrophic scars. Patients often complain of burning. In some cases, a patient uses a tool or instrument to autoaggressively manipulate his (her) skin in response to tingling or stabbing sensations. Artificial lesions or eczemas brought on by self-
manipulation can occur. Stress, life changes, or inhibited rage may be evoking the burning sensation and subsequent complaints.

Interventions to consider

After you have ruled out other causes of pruritus and made a diagnosis of psychogenic itch,  educate your patient about the multifactorial etiology. Explain possible associations between skin disorders and unconscious reaction patterns, and the role of emotional and cognitive stimuli.

Moisturizing the skin can help the dryness associated with repetitive scratching. Consider prescribing an antihistamine, moisturizer, topical steroid, antibiotic, or
occlusive dressing.

Some pharmacological properties of antidepressants that are not related to their antidepressant activity—eg, the histamine-1 blocking effect of tricyclic antidepressants—are beneficial for treating psychogenic itch.⁴ Sedating antihistamines (hydroxyzine) and antidepressants (doxepin) may help break cycles of itching and depression or itching and scratching.⁴ Tricyclic antidepressants also are recommended for treating burning, stabbing, or tingling sensations.

Disclosure

Dr. Jain reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Psychogenic itch—an excessive impulse to scratch, gouge, or pick at skin in the absence of dermatologic cause—is common among psychiatric inpatients, but can be challenging to assess and manage in outpatients. Patients with psychogenic itch predominantly are female, with average age of onset between 30 and 45 years.¹ Psychiatric disorders associated with psychogenic itch include depression, obsessive-compulsive disorder, anxiety, somatoform disorders, mania, psychosis, and substance abuse.² Body dysmorphic disorder, trichotillomania, kleptomania, and borderline personality disorder may be comorbid in patients with psychogenic itch.³

Characteristics of psychogenic itch

Consider psychogenic itch in patients who have recurring physical symptoms and demand examination despite repeated negative results. Other indicators include psychological factors—loss of a loved one, unemployment, relocation, etc.—that may be associated with onset, severity, elicitation, or maintenance of the itching; impairments in the patient’s social or professional life; and marked preoccupation with itching or the state of her (his) skin. Characteristically, itching can be provoked by emotional triggers, most notably during stages of excitement, and also by mechanical or chemical stimuli.

Skin changes associated with psychogenic itch often are found on areas accessible to the patient’s hand: face, arms, legs, abdomen, thighs, upper back, and shoulders. These changes can be seen in varying stages, from discrete superficial excoriations, erosions, and ulcers to thick, darkened nodules and colorless atrophic scars. Patients often complain of burning. In some cases, a patient uses a tool or instrument to autoaggressively manipulate his (her) skin in response to tingling or stabbing sensations. Artificial lesions or eczemas brought on by self-
manipulation can occur. Stress, life changes, or inhibited rage may be evoking the burning sensation and subsequent complaints.

Interventions to consider

After you have ruled out other causes of pruritus and made a diagnosis of psychogenic itch,  educate your patient about the multifactorial etiology. Explain possible associations between skin disorders and unconscious reaction patterns, and the role of emotional and cognitive stimuli.

Moisturizing the skin can help the dryness associated with repetitive scratching. Consider prescribing an antihistamine, moisturizer, topical steroid, antibiotic, or
occlusive dressing.

Some pharmacological properties of antidepressants that are not related to their antidepressant activity—eg, the histamine-1 blocking effect of tricyclic antidepressants—are beneficial for treating psychogenic itch.⁴ Sedating antihistamines (hydroxyzine) and antidepressants (doxepin) may help break cycles of itching and depression or itching and scratching.⁴ Tricyclic antidepressants also are recommended for treating burning, stabbing, or tingling sensations.

Disclosure

Dr. Jain reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Psychogenic itch—an excessive impulse to scratch, gouge, or pick at skin in the absence of dermatologic cause—is common among psychiatric inpatients, but can be challenging to assess and manage in outpatients. Patients with psychogenic itch predominantly are female, with average age of onset between 30 and 45 years.¹ Psychiatric disorders associated with psychogenic itch include depression, obsessive-compulsive disorder, anxiety, somatoform disorders, mania, psychosis, and substance abuse.² Body dysmorphic disorder, trichotillomania, kleptomania, and borderline personality disorder may be comorbid in patients with psychogenic itch.³

Characteristics of psychogenic itch

Consider psychogenic itch in patients who have recurring physical symptoms and demand examination despite repeated negative results. Other indicators include psychological factors—loss of a loved one, unemployment, relocation, etc.—that may be associated with onset, severity, elicitation, or maintenance of the itching; impairments in the patient’s social or professional life; and marked preoccupation with itching or the state of her (his) skin. Characteristically, itching can be provoked by emotional triggers, most notably during stages of excitement, and also by mechanical or chemical stimuli.

Skin changes associated with psychogenic itch often are found on areas accessible to the patient’s hand: face, arms, legs, abdomen, thighs, upper back, and shoulders. These changes can be seen in varying stages, from discrete superficial excoriations, erosions, and ulcers to thick, darkened nodules and colorless atrophic scars. Patients often complain of burning. In some cases, a patient uses a tool or instrument to autoaggressively manipulate his (her) skin in response to tingling or stabbing sensations. Artificial lesions or eczemas brought on by self-
manipulation can occur. Stress, life changes, or inhibited rage may be evoking the burning sensation and subsequent complaints.

Interventions to consider

After you have ruled out other causes of pruritus and made a diagnosis of psychogenic itch,  educate your patient about the multifactorial etiology. Explain possible associations between skin disorders and unconscious reaction patterns, and the role of emotional and cognitive stimuli.

Moisturizing the skin can help the dryness associated with repetitive scratching. Consider prescribing an antihistamine, moisturizer, topical steroid, antibiotic, or
occlusive dressing.

Some pharmacological properties of antidepressants that are not related to their antidepressant activity—eg, the histamine-1 blocking effect of tricyclic antidepressants—are beneficial for treating psychogenic itch.⁴ Sedating antihistamines (hydroxyzine) and antidepressants (doxepin) may help break cycles of itching and depression or itching and scratching.⁴ Tricyclic antidepressants also are recommended for treating burning, stabbing, or tingling sensations.

Disclosure

Dr. Jain reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Chimeric antigen receptor-modified T cells represent a new approach to immune therapy in the treatment of hematologic malignancies. The clinical activity of chimeric antigen receptors (CARs) has been published in acute lymphoblastic leukemia (ALL)and chronic lymphocytic leukemia (CLL).¹ The results have been remarkable, although only a very small number of patients have been treated. We are anticipating further clinical trials and further development of this technology for more wide spread treatment opportunities for patients. The CARs that have been the most successful clinically have a similar basic make-up. They are genetically modified T cells. The T cells are collected from the patients through leukapheresis, then they are genetically
modified to express an extracellular recognition domain that is connected in the intracellular signaling domains of the T cells. Various extracellular recognition domains have been engineered, but the target of CD19 has proven most successful in patients with B cell malignancies, and CD19 is widely expressed on CLL and B-cell ALL. The cells are infused back into the patient, sometimes after undergoing chemotherapy to lymphodeplete the patient (which may improve the recovery and persistence of the cells after treatment). The infusion responses have been
dramatic in some patients, with severe cytokine storm described in reports, usually several days after treatment.² This is thought to reflect the very rapid identification of the target protein and response of the T cells to the target. Those patients with acute leukemia who have responded also appear to respond rapidly, with disappearance of blasts from the peripheral blood within a month. The cells have been detectable in some patients for months after treatment.

Please click here to view the PDF.

Chimeric antigen receptor-modified T cells represent a new approach to immune therapy in the treatment of hematologic malignancies. The clinical activity of chimeric antigen receptors (CARs) has been published in acute lymphoblastic leukemia (ALL)and chronic lymphocytic leukemia (CLL).¹ The results have been remarkable, although only a very small number of patients have been treated. We are anticipating further clinical trials and further development of this technology for more wide spread treatment opportunities for patients. The CARs that have been the most successful clinically have a similar basic make-up. They are genetically modified T cells. The T cells are collected from the patients through leukapheresis, then they are genetically
modified to express an extracellular recognition domain that is connected in the intracellular signaling domains of the T cells. Various extracellular recognition domains have been engineered, but the target of CD19 has proven most successful in patients with B cell malignancies, and CD19 is widely expressed on CLL and B-cell ALL. The cells are infused back into the patient, sometimes after undergoing chemotherapy to lymphodeplete the patient (which may improve the recovery and persistence of the cells after treatment). The infusion responses have been
dramatic in some patients, with severe cytokine storm described in reports, usually several days after treatment.² This is thought to reflect the very rapid identification of the target protein and response of the T cells to the target. Those patients with acute leukemia who have responded also appear to respond rapidly, with disappearance of blasts from the peripheral blood within a month. The cells have been detectable in some patients for months after treatment.

Please click here to view the PDF.

Chimeric antigen receptor-modified T cells represent a new approach to immune therapy in the treatment of hematologic malignancies. The clinical activity of chimeric antigen receptors (CARs) has been published in acute lymphoblastic leukemia (ALL)and chronic lymphocytic leukemia (CLL).¹ The results have been remarkable, although only a very small number of patients have been treated. We are anticipating further clinical trials and further development of this technology for more wide spread treatment opportunities for patients. The CARs that have been the most successful clinically have a similar basic make-up. They are genetically modified T cells. The T cells are collected from the patients through leukapheresis, then they are genetically
modified to express an extracellular recognition domain that is connected in the intracellular signaling domains of the T cells. Various extracellular recognition domains have been engineered, but the target of CD19 has proven most successful in patients with B cell malignancies, and CD19 is widely expressed on CLL and B-cell ALL. The cells are infused back into the patient, sometimes after undergoing chemotherapy to lymphodeplete the patient (which may improve the recovery and persistence of the cells after treatment). The infusion responses have been
dramatic in some patients, with severe cytokine storm described in reports, usually several days after treatment.² This is thought to reflect the very rapid identification of the target protein and response of the T cells to the target. Those patients with acute leukemia who have responded also appear to respond rapidly, with disappearance of blasts from the peripheral blood within a month. The cells have been detectable in some patients for months after treatment.

Please click here to view the PDF.

A new report that shows double-digit gains in hospitals’ electronic health information exchanges with other providers is a boon to healthcare, says one of SHM’s leading health information technology experts.

Published last month at HealthAffairs.org, “Hospital Electronic Health Information Exchange Grew Substantially in 2008-2012,” found that nearly 6 in 10 hospitals actively exchanged electronic health information with providers and hospitals outside of their own organization in 2012, a 41% jump since 2008.

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, says in an email to The Hospitalist that the growth is a good thing.

“Obviously, flow of information is never a bad thing for hospital medicine,” writes Dr. Rogers, chair of SHM’s Information Technology Executive Committee. “I think we have made more progress getting information back out to providers in the community, [and] helping with a safer transition (though we still have a long way to go), but we still lack significantly [in] getting info from providers or other hospitals on admission.”

The report notes that while more information has flowed among hospitals and providers, exchanges of clinical-care summaries and medication lists remain limited. The authors suggest that “new and ongoing policy initiatives and payment reforms may accelerate” the process.

Dr. Rogers adds that making systems more user-friendly may also encourage meaningful participation. “We have a health information exchange here in New Mexico that includes most hospitals”; however, he writes, “it is cumbersome and not routinely used, but definitely a step in the right direction.”

Visit our website for more information on health information technology.

A new report that shows double-digit gains in hospitals’ electronic health information exchanges with other providers is a boon to healthcare, says one of SHM’s leading health information technology experts.

Published last month at HealthAffairs.org, “Hospital Electronic Health Information Exchange Grew Substantially in 2008-2012,” found that nearly 6 in 10 hospitals actively exchanged electronic health information with providers and hospitals outside of their own organization in 2012, a 41% jump since 2008.

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, says in an email to The Hospitalist that the growth is a good thing.

“Obviously, flow of information is never a bad thing for hospital medicine,” writes Dr. Rogers, chair of SHM’s Information Technology Executive Committee. “I think we have made more progress getting information back out to providers in the community, [and] helping with a safer transition (though we still have a long way to go), but we still lack significantly [in] getting info from providers or other hospitals on admission.”

The report notes that while more information has flowed among hospitals and providers, exchanges of clinical-care summaries and medication lists remain limited. The authors suggest that “new and ongoing policy initiatives and payment reforms may accelerate” the process.

Dr. Rogers adds that making systems more user-friendly may also encourage meaningful participation. “We have a health information exchange here in New Mexico that includes most hospitals”; however, he writes, “it is cumbersome and not routinely used, but definitely a step in the right direction.”

Visit our website for more information on health information technology.

A new report that shows double-digit gains in hospitals’ electronic health information exchanges with other providers is a boon to healthcare, says one of SHM’s leading health information technology experts.

Published last month at HealthAffairs.org, “Hospital Electronic Health Information Exchange Grew Substantially in 2008-2012,” found that nearly 6 in 10 hospitals actively exchanged electronic health information with providers and hospitals outside of their own organization in 2012, a 41% jump since 2008.

Kendall Rogers, MD, FACP, SFHM, chief of the division of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque, says in an email to The Hospitalist that the growth is a good thing.

“Obviously, flow of information is never a bad thing for hospital medicine,” writes Dr. Rogers, chair of SHM’s Information Technology Executive Committee. “I think we have made more progress getting information back out to providers in the community, [and] helping with a safer transition (though we still have a long way to go), but we still lack significantly [in] getting info from providers or other hospitals on admission.”

The report notes that while more information has flowed among hospitals and providers, exchanges of clinical-care summaries and medication lists remain limited. The authors suggest that “new and ongoing policy initiatives and payment reforms may accelerate” the process.

Dr. Rogers adds that making systems more user-friendly may also encourage meaningful participation. “We have a health information exchange here in New Mexico that includes most hospitals”; however, he writes, “it is cumbersome and not routinely used, but definitely a step in the right direction.”

Visit our website for more information on health information technology.

When it comes to controlling healthcare costs, only 36% of physicians agree that practicing physicians have a “major responsibility” to participate in cost containment, according to a recently published Journal of the American Medical Association study, "Views of U.S. Physicians About Controlling Health Care Costs.”

More than half of the 2,556 physicians who responded to a survey said trial lawyers, health insurance companies, hospitals and health systems, pharmaceutical and device manufacturers, and patients have a major responsibility for controlling healthcare costs.

In an accompanying editorial, Ezekiel Emanuel, MD, PhD, and Andrew Steinmetz, BA, of the department of medical ethics and health policy at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, labeled the responses as “somewhat discouraging” and “a denial of responsibility” by physicians about their role in bringing costs under control.

Christopher Moriates, MD, a hospitalist at the University of California at San Francisco (UCSF) who developed a cost-awareness curriculum for physicians and serves as co-chair of UCSF’s High Value Care Committee, calls the survey a snapshot of changing attitudes in medicine because it does not include medical students or residents who, he says, are more engaged in fighting wasteful spending.

“Younger physicians are growing up in a medical world that has stressed systems-thinking and teamwork,” Dr. Moriates says. “They are ready to take that major responsibility for our healthcare system. We just need to make sure that we are teaching them how.”

Visit our website for more information on controlling healthcare costs.

When it comes to controlling healthcare costs, only 36% of physicians agree that practicing physicians have a “major responsibility” to participate in cost containment, according to a recently published Journal of the American Medical Association study, "Views of U.S. Physicians About Controlling Health Care Costs.”

More than half of the 2,556 physicians who responded to a survey said trial lawyers, health insurance companies, hospitals and health systems, pharmaceutical and device manufacturers, and patients have a major responsibility for controlling healthcare costs.

In an accompanying editorial, Ezekiel Emanuel, MD, PhD, and Andrew Steinmetz, BA, of the department of medical ethics and health policy at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, labeled the responses as “somewhat discouraging” and “a denial of responsibility” by physicians about their role in bringing costs under control.

Christopher Moriates, MD, a hospitalist at the University of California at San Francisco (UCSF) who developed a cost-awareness curriculum for physicians and serves as co-chair of UCSF’s High Value Care Committee, calls the survey a snapshot of changing attitudes in medicine because it does not include medical students or residents who, he says, are more engaged in fighting wasteful spending.

“Younger physicians are growing up in a medical world that has stressed systems-thinking and teamwork,” Dr. Moriates says. “They are ready to take that major responsibility for our healthcare system. We just need to make sure that we are teaching them how.”

Visit our website for more information on controlling healthcare costs.

When it comes to controlling healthcare costs, only 36% of physicians agree that practicing physicians have a “major responsibility” to participate in cost containment, according to a recently published Journal of the American Medical Association study, "Views of U.S. Physicians About Controlling Health Care Costs.”

More than half of the 2,556 physicians who responded to a survey said trial lawyers, health insurance companies, hospitals and health systems, pharmaceutical and device manufacturers, and patients have a major responsibility for controlling healthcare costs.

In an accompanying editorial, Ezekiel Emanuel, MD, PhD, and Andrew Steinmetz, BA, of the department of medical ethics and health policy at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, labeled the responses as “somewhat discouraging” and “a denial of responsibility” by physicians about their role in bringing costs under control.

Christopher Moriates, MD, a hospitalist at the University of California at San Francisco (UCSF) who developed a cost-awareness curriculum for physicians and serves as co-chair of UCSF’s High Value Care Committee, calls the survey a snapshot of changing attitudes in medicine because it does not include medical students or residents who, he says, are more engaged in fighting wasteful spending.

“Younger physicians are growing up in a medical world that has stressed systems-thinking and teamwork,” Dr. Moriates says. “They are ready to take that major responsibility for our healthcare system. We just need to make sure that we are teaching them how.”

Visit our website for more information on controlling healthcare costs.

We as hospitalists have been missing a huge piece of the puzzle when it comes to readmissions. With such a huge push to reduce the readmission rate at our hospitals and avoid the resultant penalties, have we been too internally focused?

In a recent article in, titled, "A primary care physician’s ideal transitions of care – where’s the evidence?" Dr. Ning Tang gives a PCP’s perspective on how outpatient providers can greatly facilitate our common goal of optimizing patients’ transition from hospital to home (J. Hosp. Med. 2013;8:472-7). After all, most of our patients do have a PCP, who has known them for a long time and who will have much more insight into their values and support systems, their idiosyncrasies, what they will and won’t follow through on, and even their pet peeves. When we who may interact with them for only a couple of hours try to use a cookie-cutter approach to care, it simply may not be received well, if at all.

Dr. Tang suggests that PCP communication begins at the point of admission. While some ERs and admissions offices have automated systems in place to contact PCPs when their patients are admitted, for most of us, this communication comes by way of a phone call or as an electronic or faxed copy of the admission note. While I do not think anyone would argue that early involvement by the PCP has a tremendous potential to improve both the patient’s transition from home into the hospital and vice versa, in real life doctors are frequently too busy and stressed to meet this basic expectation. Hopefully that will change in the future.

Some PCPs have no desire to talk with a hospitalist each time a patient is admitted because it takes them away from seeing patients in their office. Yet others would welcome the opportunity for early involvement. It is an individual preference, one we should strive to understand in order to optimize our patients’ experience – and the experience of the physician who has entrusted patients to us.

Medication reconciliation is but the tip of the iceberg of issues the PCP could assist with, and the realization that their patient may not actually be taking all the medications they prescribed (or taking medications they didn’t) can help improve the level of care patients receive once discharged.

In the midst of brutal day, we have all had medication nightmares that make us cringe, as we slowly count to three while practicing deep-breathing exercises. You know, the patient who pulls out a crumpled list of medications. Some have been crossed out and others are too illegible to read. Then, the spouse pulls out another "updated" list, and the physician and pharmacist each have their own list, and no two lists are exactly alike.

But these nightmares could soon end. I was surprised to find out that in January of this year, the Centers for Medicare and Medicaid Services introduced new codes to reimburse primary care providers for care coordination after hospital discharge. These codes, 99495 and 99496 reimburse a substantial fee, carrying weights of 3.96 and 5.81 RVUs (relative value units), respectively, a lot more than we typically make for even an extended history and physical.

So, I have to agree with Dr. Tang. We, PCPs and hospitalists alike, are missing a huge potential to optimize care transitions, decrease our readmission rate, and lower medical costs. Dialogue needs to take place between hospitalist and the PCPs they serve to bridge some of these gaps.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

We as hospitalists have been missing a huge piece of the puzzle when it comes to readmissions. With such a huge push to reduce the readmission rate at our hospitals and avoid the resultant penalties, have we been too internally focused?

In a recent article in, titled, "A primary care physician’s ideal transitions of care – where’s the evidence?" Dr. Ning Tang gives a PCP’s perspective on how outpatient providers can greatly facilitate our common goal of optimizing patients’ transition from hospital to home (J. Hosp. Med. 2013;8:472-7). After all, most of our patients do have a PCP, who has known them for a long time and who will have much more insight into their values and support systems, their idiosyncrasies, what they will and won’t follow through on, and even their pet peeves. When we who may interact with them for only a couple of hours try to use a cookie-cutter approach to care, it simply may not be received well, if at all.

Dr. Tang suggests that PCP communication begins at the point of admission. While some ERs and admissions offices have automated systems in place to contact PCPs when their patients are admitted, for most of us, this communication comes by way of a phone call or as an electronic or faxed copy of the admission note. While I do not think anyone would argue that early involvement by the PCP has a tremendous potential to improve both the patient’s transition from home into the hospital and vice versa, in real life doctors are frequently too busy and stressed to meet this basic expectation. Hopefully that will change in the future.

Some PCPs have no desire to talk with a hospitalist each time a patient is admitted because it takes them away from seeing patients in their office. Yet others would welcome the opportunity for early involvement. It is an individual preference, one we should strive to understand in order to optimize our patients’ experience – and the experience of the physician who has entrusted patients to us.

Medication reconciliation is but the tip of the iceberg of issues the PCP could assist with, and the realization that their patient may not actually be taking all the medications they prescribed (or taking medications they didn’t) can help improve the level of care patients receive once discharged.

In the midst of brutal day, we have all had medication nightmares that make us cringe, as we slowly count to three while practicing deep-breathing exercises. You know, the patient who pulls out a crumpled list of medications. Some have been crossed out and others are too illegible to read. Then, the spouse pulls out another "updated" list, and the physician and pharmacist each have their own list, and no two lists are exactly alike.

But these nightmares could soon end. I was surprised to find out that in January of this year, the Centers for Medicare and Medicaid Services introduced new codes to reimburse primary care providers for care coordination after hospital discharge. These codes, 99495 and 99496 reimburse a substantial fee, carrying weights of 3.96 and 5.81 RVUs (relative value units), respectively, a lot more than we typically make for even an extended history and physical.

So, I have to agree with Dr. Tang. We, PCPs and hospitalists alike, are missing a huge potential to optimize care transitions, decrease our readmission rate, and lower medical costs. Dialogue needs to take place between hospitalist and the PCPs they serve to bridge some of these gaps.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

We as hospitalists have been missing a huge piece of the puzzle when it comes to readmissions. With such a huge push to reduce the readmission rate at our hospitals and avoid the resultant penalties, have we been too internally focused?

In a recent article in, titled, "A primary care physician’s ideal transitions of care – where’s the evidence?" Dr. Ning Tang gives a PCP’s perspective on how outpatient providers can greatly facilitate our common goal of optimizing patients’ transition from hospital to home (J. Hosp. Med. 2013;8:472-7). After all, most of our patients do have a PCP, who has known them for a long time and who will have much more insight into their values and support systems, their idiosyncrasies, what they will and won’t follow through on, and even their pet peeves. When we who may interact with them for only a couple of hours try to use a cookie-cutter approach to care, it simply may not be received well, if at all.

Dr. Tang suggests that PCP communication begins at the point of admission. While some ERs and admissions offices have automated systems in place to contact PCPs when their patients are admitted, for most of us, this communication comes by way of a phone call or as an electronic or faxed copy of the admission note. While I do not think anyone would argue that early involvement by the PCP has a tremendous potential to improve both the patient’s transition from home into the hospital and vice versa, in real life doctors are frequently too busy and stressed to meet this basic expectation. Hopefully that will change in the future.

Some PCPs have no desire to talk with a hospitalist each time a patient is admitted because it takes them away from seeing patients in their office. Yet others would welcome the opportunity for early involvement. It is an individual preference, one we should strive to understand in order to optimize our patients’ experience – and the experience of the physician who has entrusted patients to us.

Medication reconciliation is but the tip of the iceberg of issues the PCP could assist with, and the realization that their patient may not actually be taking all the medications they prescribed (or taking medications they didn’t) can help improve the level of care patients receive once discharged.

In the midst of brutal day, we have all had medication nightmares that make us cringe, as we slowly count to three while practicing deep-breathing exercises. You know, the patient who pulls out a crumpled list of medications. Some have been crossed out and others are too illegible to read. Then, the spouse pulls out another "updated" list, and the physician and pharmacist each have their own list, and no two lists are exactly alike.

But these nightmares could soon end. I was surprised to find out that in January of this year, the Centers for Medicare and Medicaid Services introduced new codes to reimburse primary care providers for care coordination after hospital discharge. These codes, 99495 and 99496 reimburse a substantial fee, carrying weights of 3.96 and 5.81 RVUs (relative value units), respectively, a lot more than we typically make for even an extended history and physical.

So, I have to agree with Dr. Tang. We, PCPs and hospitalists alike, are missing a huge potential to optimize care transitions, decrease our readmission rate, and lower medical costs. Dialogue needs to take place between hospitalist and the PCPs they serve to bridge some of these gaps.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.