Every pediatric hospitalist has their stories of patients with somatic symptom related disorders (SSRD). Mine was “Maria,” a 12-year-old admitted to the hospital with abdominal pain. Despite our suspicion that her pain was non-organic, she remained hospitalized for 3 weeks of imaging, testing, and consults. All the while, Maria and her family grew increasingly frustrated with our team’s communication and the lack of a clear diagnosis.
“Characteristics and Resource Utilization of Hospitalized Children with Somatic Symptoms,” by Roelf et al. in this issue of Hospital Pediatrics describes a cohort of 173 children ages 3–18 with SSRD like Maria admitted to a children’s hospital (10.1542/hpeds.2024-007847). Patients had a median of 9 lab studies and 1 imaging study during their hospitalization. A total of 220 physician consults and 360 non-physician consults were performed for the 173 patients included.
Most patients presented with neurologic symptoms. However, it was those with non-neurologic (“somatoform-specific”) SSRD who had a longer duration of stay, more labs, and a higher total admission charge. Altogether, the average charge per patient was $23,942, and the average length of stay was 2 days.
These findings point to a guiding principle for SSRD—high-value care, defined as quality divided by cost. The very high cost for these patients is clear. An important question is whether the extensive workup produces the intended quality, and if not, then why patients receive it.
Diagnostic uncertainty is one driver for this. Some work-up is often warranted. At the same time, physicians often feel confident about the SSRD diagnosis earlier than we express it to our patients. Hospitalists must navigate this tension—pursuing work-up judiciously and in alliance with families while acknowledging the likelihood that the child’s symptoms are somatic. The large differences observed here in the degree of work-up between neurologic and non-neurologic SSRD may reflect our increased discomfort in “walking two paths” for the latter sub-type.
The authors discuss a clinical pathway at their institution to guide clinicians down these paths. Our institution has a similar pathway that highlights several key skills: listening with curiosity, acknowledging symptoms as real and distressing, and naming SSRD. Metaphors (such as pain as a mis-calibrated smoke detector firing without its normal trigger) can help kids and families understand the diagnosis.
Last, hospitalists should convey the harms of the hospital setting and identify and connect families to outpatient resources. Primary care pediatricians, therapists, and school-based providers are well poised to continue necessary anxiety and symptom-reduction strategies, but only if we clearly communicate the diagnosis to them. To that end, our pathway includes templated letters to improve the communication of the diagnosis across patients’ treatment landscape.
SSRD is a challenging diagnosis for hospital physicians and families. Please check out “Characteristics and Resource Utilization of Hospitalized Children with Somatic Symptoms” to gain a deeper understanding of the inpatient care we provide for SSRD and its sub-types as we work toward care that empowers hospitalists, lessens family frustration, and promotes high-value medicine.
