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December 27, 1995, Vol 274, No. 24 >
ARTICLE | December 27, 1995

Somatization and Medicalization in the Era of Managed Care FREE

Arthur J. Barsky, MD; Jonathan F. Borus, MD
[+] Author Affiliations

Reprint requests to the Division of Psychiatry, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (Dr Barsky).


JAMA. 1995;274(24):1931-1934. doi:10.1001/jama.1995.03530240041038
Text Size: A A A
Published online
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References

Somatization, the reporting of somatic symptoms that have no pathophysiological explanation, appears to be increasing as sociocultural currents reduce the public's tolerance of mild symptoms and benign infirmities and lower the threshold for seeking medical attention for such complaints. These trends coincide with a progressive medicalization of physical distress in which uncomfortable bodily states and isolated symptoms are reclassified as diseases for which medical treatment is sought. Somatization and medicalization are likely to become more problematic in the era of managed care. Under capitation, providers will have greater incentives to reduce utilization, and somatizing patients may feel forced to express their "dis-ease" in more urgent and exaggerated terms in order to gain access to the physician. In addition, prepaid subscribers will suffer little financial disincentive to seek medical attention for relatively minor complaints; therefore, they are likely to increase the demand for physician consultation. This situation suggests an urgent need to improve the management of somatizing patients. Innovative consultative, behavioral, and educational interventions are now available. In addition, medical professionals should greet the process of medicalization with considerable caution and educate the public more about the normative presence of symptoms and bodily distress in healthy people. Additional research is needed into somatization and its relationship to the demand for medical care. In an era of managed care, increased attention should be devoted to understanding and controlling the demand for care, a large portion of which is symptom driven.

(JAMA. 1995;274:1931-1934)

REFERENCES

1 +
Lipowski ZJ.  Somatization: the concept and its clinical application. Am J Psychiatry . 1988;;145:1358-1368.
2 +
Garfield SR, Collen MF, Feldman R, Soghikian K, Richart RH, Duncan JH.  Evaluation of ambulatory medical care system. N Engl J Med . 1976;; 294:426-431.
3 +
Backett EM, Heady JA, Evans JCG.  Studies of a general practice, II: the doctor's job in an urban area. BMJ . 1954;;1:109-115.
4 +
van der Gagg J, van de Ven W.  The demand for primary health care. Med Care . 1978;;26:299-312.
5 +
Pilowsky I, Smith QP, Katsikitis M.  Illness behavior and general practice utilization: a prospective study. J Psychosom Res . 1987;;31:177-183.
6 +
Cummings NA, Vanden Bos GR.  The twenty-year Kaiser-Permanente experience with psychotherapy and medical utilization: implications for national health policy and national health insurance. Health Policy Q . 1981;;1:159-175.
7 +
Follette WT, Cummings WA.  Psychiatric services and medical utilization in a prepaid health plan setting: part II. Med Care . 1968;;6:31-41.
8 +
Hilkevitch A.  Psychiatric disturbance in outpatients of a general medical outpatient clinic. Int J Neuropsychiatry . 1965;;1:371-375.
9 +
Kroenke K, Mangelsdorff AD.  Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med . 1989;;86:262-266.
10 +
Bridges KW, Goldberg DP.  Somatic presentation of DSM-III psychiatric disorders in primary care. J Psychosom Res . 1985;;29:563-569.
11 +
Kroenke K, Arrington ME, Mangelsdorff AD.  The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med . 1990;;150:1685-1690.
12 +
Katon W, Ries RK, Kleinman A.  The prevalence of somatization in primary care. Compr Psychiatry . 1984;;25:208-215.
13 +
Kleinman A, Eisenberg L, Good B.  Culture, illness, and care; clinical lessons from anthropologic and cross-cultural research. Ann Intern Med . 1978;; 88:251-258.
14 +
Gough HG.  Doctors' estimates of the percentage of patients whose problems do not require medical attention. Med Educ . 1977;;11:380-384.
15 +
Cartwright A. Patients and Their Doctors: A Study of General Practice . London, England: Routledge & Kegan Paul; 1967;.
16 +
Mechanic D. Politics, Medicine, and Social Science . New York, NY: John Wiley & Sons Inc; 1974;.
17 +
Craig TKJ, Boardman AP, Mills K, Daley-Jones O, Drake H.  The South London Somatization Study, I: longitudinal course and the influence of early life experiences. Br J Psychiatry . 1993;;163:579-588.
18 +
Escobar JI, Golding JM, Hough RL, Karno M, Burnham MA, Wells KB.  Somatization in the community: relationship to disability and use of services. Am J Public Health . 1987;;77:837-840.
19 +
Escobar JI, Burnham A, Karno M, Forsythe A, Golding JM.  Somatization in the community. Arch Gen Psychiatry . 1987;;44:713-718.
20 +
Katon W, Von Korff M, Lin E, et al.  Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry . 1990;; 12:355-362.
21 +
Lipowski ZJ.  Somatization: a borderland between medicine and psychiatry. Can Med Assoc J . 1986;;135:609-613.
22 +
Bass C. Somatization: Physical Symptoms and Psychological Illness . Oxford, England: Blackwell Scientific Publications Inc; 1990;.
23 +
Regier DA, Narrow WE, Rae DS, Manderseheid RW, Locke BZ, Goodwin FK.  The de facto US mental and addictive disorders service system. Arch Gen Psychiatry . 1993;;50:85-94.
24 +
McFarland BH, Freeborn DK, Mullooly JP, et al.  Utilization patterns among long term enrollees in a prepaid group practice health maintenance organization. Med Care . 1985;;23:1211-1233.
25 +
Noyes R, Kathol R, Fisher M, Phillip B, Suelzer M, Holt C.  The validity of DSM-III-R hypochondriasis. Arch Gen Psychiatry . 1993;;50:961-970.
26 +
deGruy F, Columbia L, Dickinson P.  Somatization disorder in a family practice. J Fam Pract . 1987;;25:45-51.
27 +
Swartz M, Blazer D, George L, Landerman R.  Somatization disorder in a community population. Am J Psychiatry . 1986;;143:1403-1408.
28 +
Zoccolillo MS, Cloninger CR.  Excess medical care of women with somatization disorder. South Med J . 1986;;79:532-535.
29 +
Bass C, Murphy M.  Somatization disorder in a British teaching hospital. Br J Clin Pract . 1991;; 45:237-244.
30 +
Barsky AJ, Wyshak G, Latham KS, Klerman GL.  Hypochondriacal patients, their physicians, and their medical care. J Gen Intern Med . 1991;;6:413-419.
31 +
Fink P.  The use of hospitalizations by somatizing patients. Psychol Med . 1992;;22:173-180.
32 +
Smith GR, Monson R, Ray D.  Patients with multiple unexplained symptoms: their characteristics, functional health, and health care utilization. Arch Intern Med . 1986;;146:69-72.
33 +
Fink P.  Surgery and medical treatment in persistent somatizing patients. J Psychosom Res . 1992;; 36:439-447.
34 +
Beaber RJ, Rodney WM.  Underdiagnosis of hypochondriasis in family practice. Psychosomatics . 1984;;25:39-46.
35 +
Lin EH, Katon W, Von Korff M, et al.  Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med . 1991;;6:241-246.
36 +
Benjamin S, Bridges K.  The special needs of chronic somatizers.  In: Benjamin S, House A, Jenkins P, eds. Liaison Psychiatry: Defining Needs and Planning Services . London, England: Gaskell Press; 1994;.
37 +
Hanney DR. The Symptom Iceberg: A Study of Community Health . London, England: Routledge & Kegan Paul; 1979;:31-49.
38 +
Dunnell K, Cartwright A. Medicine Takers, Prescribers, and Hoarders . London, England: Routledge & Kegan Paul; 1972;:8-22.
39 +
Wadsworth MEJ, Butterfield WJH, Blaney R. Health and Sickness: The Choice of Treatment . London, England: Tavistock; 1971;.
40 +
White KL, Williams TF, Grenberg BG.  The ecology of medical care. N Engl J Med . 1961;;265: 885-892.
41 +
Egan KJ, Beston R.  Response to symptoms in healthy low utilizers of the health care system. J Psychosom Res . 1987;;31:11-21.
42 +
Verbrugge LM, Ascione FJ.  Exploring the iceberg: common symptoms and how people care for them. Med Care . 1987;;25:539-569.
43 +
Alonzo AA.  Everyday illness behavior: a situational approach to health status deviations. Soc Sci Med . 1979;;13A:397-404.
44 +
Demers RY, Altamore R, Mustin H, Kleinman A, Leonardi D.  An explanation of the dimensions of illness behavior. J Fam Pract . 1980;;11:1085-1092.
45 +
Roghmann KJ, Haggerty RJ.  Daily stress, illness, and the use of health sources in young families. Pediatr Res . 1973;;7:520-526.
46 +
Banks MH, Beresford SAA, Morrell DC, Waller JJ, Watkins CJ.  Factors influencing demand for primary care in women, aged 20-44 years: a preliminary report. Int J Epidemiol . 1975;;4:189-195.
47 +
Barsky AJ. Worried Sick: Our Troubled Quest for Wellness . Boston, Mass: Little Brown & Co Inc; 1988;.
48 +
Shorter E. Bedside Manners . New York, NY: Simon & Schuster Inc Publishers; 1985;.
49 +
Shorter E. From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era . New York, NY: Free Press; 1992;.
50 +
Mishler EG, Amarasingham LR, Osherson SD, et al. Social Contexts of Health, Illness, and Patient Care . New York, NY: Cambridge University Press; 1981;.
51 +
Harris L. Inside America . New York, NY: Vintage Books; 1989;.
52 +
Veroff J, Douvan E, Fulka RA. The Inner American . New York, NY: Basic Books Inc Publishers; 1981;.
53 +
Verbrugge LM.  Longer life but worsening health? trends in health and mortality of middle aged and older persons. Milbank Mem Fund Q . 1984;;62:475-519.
54 +
Barker LR.  Distinctive characteristics of ambulatory medicine.  In: Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory Medicine . Baltimore, Md: Williams & Wilkins; 1982;:1-15.
55 +
Conrad P.  Medicalization and social control. Annu Rev Social . 1992;;18:209-232.
56 +
Relman AS.  The new medical-industrial complex. N Engl J Med . 1980;;303:963-970.
57 +
Stewart DE.  The changing faces of somatization. Psychosomatics . 1990;;31:153-158.
58 +
Braverman P, Schaaf VM, Egerter S, Bennett T, Schechter W.  Insurance-related differences in the risk of ruptured appendix. N Engl J Med . 1994;; 331:444-449.
59 +
O'Grady KF, Manning WG, Newhouse JP, Brook RH.  The impact of cost sharing on emergency department use. N Engl J Med . 1985;;313:384-390.
60 +
Feldman R, Schwartz JS. Paying Physicians: Options for Controlling Cost, Volume, and Intensity of Services . Ann Arbor, Mich: Health Administration Press; 1992;.
61 +
Shapiro MF, Ware JE, Sherbourne CD.  Effects of cost sharing on seeking care for serious and minor symptoms. Ann Intern Med . 1986;;104:246-251.
62 +
Barr JK.  Physicians' views of patients in prepaid group practice: reasons for visits to HMOs. J Health Soc Behav . 1983;;24:244-255.
63 +
Borus JF, Howes MJ, Devins NP, Rosenberg R, Livingston WW.  Primary health providers' recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry . 1988;;10:317-321.
64 +
Goldberg D.  Detection and assessment of emotional disorders in a primary care setting. Int J Ment Health . 1979;;8:30-48.
65 +
Kirmayer LJ, Robbins JM.  Three forms of somatization in primary care: prevalence, co-occurrence, and sociodemographic characteristics. J Nerv Ment Dis . 1991;;179:647-655.
66 +
Strain JJ, Hammer JS, Fulop G.  APM Task Force on Psychosocial Interventions in the General Hospital Inpatient Setting: a review of cost-offset studies. Psychosomatics . 1994;;35:253-262.
67 +
Simon G, Ormel J, Von Korff M, Barlow M.  Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry . 1995;;152:352-357.
68 +
Katon W, Von Korff M, Lin E, et al.  Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA . 1995;;273:1026-1031.
69 +
Smith GR, Rost K, Kashner TM.  A trial of the effect of standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry . 1995;;52:238-243.
70 +
Quill TE, Lipkin M, Greenland P.  The medicalization of normal variants: the case of mitral valve prolapse. J Gen Intern Med . 1988;;3:267-276.
71 +
Illich I. Medical Nemesis . New York, NY: Bantam Books Inc; 1976;.
72 +
DeVries NW, Berg RL, Lipkin M. The Use and Abuse of Medicine . New York, NY: Praeger Publishers; 1982;.
73 +
Macdonald LA, Sackett DL, Haynes RB, Taylor DW.  Labelling in hypertension: a review of the behavioral and psychological consequences. J Chronic Dis . 1984;;37:933-942.
74 +
Sox HC, Margulies I, Sox CM.  Psychologically mediated effects of diagnostic tests. Ann Intern Med . 1981;;95:680-685.
75 +
Kashner TM, Rost K, Smith GR, Lewis S.  The impact of a psychiatric consultation letter on the expenditures and outcomes of care for patients with somatization disorder. Med Care . 1992;;30:811-821.
76 +
Smith GR, Monson RP, Roy DC.  Psychiatric consultation in somatization disorder: a randomized controlled study. N Engl J Med . 1986;;314:1407-1423.
77 +
Barsky AJ.  Hypochondriasis: medical management and psychiatric treatment. Psychosomatics . In press.
78 +
Sharpe M, Peveler R, Mayou R.  The psychological treatment of patients with functional somatic symptoms: a practical guide. J Psychosom Res . 1992;;36:515-529.
79 +
Salkovskis PM.  Somatic problems.  In: Hawton K, Salkovskis PM, Kirk JW, Clark DM, eds. Cognitive-Behavioral Approaches to Adult Psychiatric Disorders: A Practical Guide . Oxford, England: Oxford University Press; 1989;:235-276.
80 +
Hellman CJC, Budd M, Borysenko J, McClelland DC, Benson H.  A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. Behav Med . 1990;;16:165-173.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Lipowski ZJ.  Somatization: the concept and its clinical application. Am J Psychiatry . 1988;;145:1358-1368.
2 +
Garfield SR, Collen MF, Feldman R, Soghikian K, Richart RH, Duncan JH.  Evaluation of ambulatory medical care system. N Engl J Med . 1976;; 294:426-431.
3 +
Backett EM, Heady JA, Evans JCG.  Studies of a general practice, II: the doctor's job in an urban area. BMJ . 1954;;1:109-115.
4 +
van der Gagg J, van de Ven W.  The demand for primary health care. Med Care . 1978;;26:299-312.
5 +
Pilowsky I, Smith QP, Katsikitis M.  Illness behavior and general practice utilization: a prospective study. J Psychosom Res . 1987;;31:177-183.
6 +
Cummings NA, Vanden Bos GR.  The twenty-year Kaiser-Permanente experience with psychotherapy and medical utilization: implications for national health policy and national health insurance. Health Policy Q . 1981;;1:159-175.
7 +
Follette WT, Cummings WA.  Psychiatric services and medical utilization in a prepaid health plan setting: part II. Med Care . 1968;;6:31-41.
8 +
Hilkevitch A.  Psychiatric disturbance in outpatients of a general medical outpatient clinic. Int J Neuropsychiatry . 1965;;1:371-375.
9 +
Kroenke K, Mangelsdorff AD.  Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med . 1989;;86:262-266.
10 +
Bridges KW, Goldberg DP.  Somatic presentation of DSM-III psychiatric disorders in primary care. J Psychosom Res . 1985;;29:563-569.
11 +
Kroenke K, Arrington ME, Mangelsdorff AD.  The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med . 1990;;150:1685-1690.
12 +
Katon W, Ries RK, Kleinman A.  The prevalence of somatization in primary care. Compr Psychiatry . 1984;;25:208-215.
13 +
Kleinman A, Eisenberg L, Good B.  Culture, illness, and care; clinical lessons from anthropologic and cross-cultural research. Ann Intern Med . 1978;; 88:251-258.
14 +
Gough HG.  Doctors' estimates of the percentage of patients whose problems do not require medical attention. Med Educ . 1977;;11:380-384.
15 +
Cartwright A. Patients and Their Doctors: A Study of General Practice . London, England: Routledge & Kegan Paul; 1967;.
16 +
Mechanic D. Politics, Medicine, and Social Science . New York, NY: John Wiley & Sons Inc; 1974;.
17 +
Craig TKJ, Boardman AP, Mills K, Daley-Jones O, Drake H.  The South London Somatization Study, I: longitudinal course and the influence of early life experiences. Br J Psychiatry . 1993;;163:579-588.
18 +
Escobar JI, Golding JM, Hough RL, Karno M, Burnham MA, Wells KB.  Somatization in the community: relationship to disability and use of services. Am J Public Health . 1987;;77:837-840.
19 +
Escobar JI, Burnham A, Karno M, Forsythe A, Golding JM.  Somatization in the community. Arch Gen Psychiatry . 1987;;44:713-718.
20 +
Katon W, Von Korff M, Lin E, et al.  Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry . 1990;; 12:355-362.
21 +
Lipowski ZJ.  Somatization: a borderland between medicine and psychiatry. Can Med Assoc J . 1986;;135:609-613.
22 +
Bass C. Somatization: Physical Symptoms and Psychological Illness . Oxford, England: Blackwell Scientific Publications Inc; 1990;.
23 +
Regier DA, Narrow WE, Rae DS, Manderseheid RW, Locke BZ, Goodwin FK.  The de facto US mental and addictive disorders service system. Arch Gen Psychiatry . 1993;;50:85-94.
24 +
McFarland BH, Freeborn DK, Mullooly JP, et al.  Utilization patterns among long term enrollees in a prepaid group practice health maintenance organization. Med Care . 1985;;23:1211-1233.
25 +
Noyes R, Kathol R, Fisher M, Phillip B, Suelzer M, Holt C.  The validity of DSM-III-R hypochondriasis. Arch Gen Psychiatry . 1993;;50:961-970.
26 +
deGruy F, Columbia L, Dickinson P.  Somatization disorder in a family practice. J Fam Pract . 1987;;25:45-51.
27 +
Swartz M, Blazer D, George L, Landerman R.  Somatization disorder in a community population. Am J Psychiatry . 1986;;143:1403-1408.
28 +
Zoccolillo MS, Cloninger CR.  Excess medical care of women with somatization disorder. South Med J . 1986;;79:532-535.
29 +
Bass C, Murphy M.  Somatization disorder in a British teaching hospital. Br J Clin Pract . 1991;; 45:237-244.
30 +
Barsky AJ, Wyshak G, Latham KS, Klerman GL.  Hypochondriacal patients, their physicians, and their medical care. J Gen Intern Med . 1991;;6:413-419.
31 +
Fink P.  The use of hospitalizations by somatizing patients. Psychol Med . 1992;;22:173-180.
32 +
Smith GR, Monson R, Ray D.  Patients with multiple unexplained symptoms: their characteristics, functional health, and health care utilization. Arch Intern Med . 1986;;146:69-72.
33 +
Fink P.  Surgery and medical treatment in persistent somatizing patients. J Psychosom Res . 1992;; 36:439-447.
34 +
Beaber RJ, Rodney WM.  Underdiagnosis of hypochondriasis in family practice. Psychosomatics . 1984;;25:39-46.
35 +
Lin EH, Katon W, Von Korff M, et al.  Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med . 1991;;6:241-246.
36 +
Benjamin S, Bridges K.  The special needs of chronic somatizers.  In: Benjamin S, House A, Jenkins P, eds. Liaison Psychiatry: Defining Needs and Planning Services . London, England: Gaskell Press; 1994;.
37 +
Hanney DR. The Symptom Iceberg: A Study of Community Health . London, England: Routledge & Kegan Paul; 1979;:31-49.
38 +
Dunnell K, Cartwright A. Medicine Takers, Prescribers, and Hoarders . London, England: Routledge & Kegan Paul; 1972;:8-22.
39 +
Wadsworth MEJ, Butterfield WJH, Blaney R. Health and Sickness: The Choice of Treatment . London, England: Tavistock; 1971;.
40 +
White KL, Williams TF, Grenberg BG.  The ecology of medical care. N Engl J Med . 1961;;265: 885-892.
41 +
Egan KJ, Beston R.  Response to symptoms in healthy low utilizers of the health care system. J Psychosom Res . 1987;;31:11-21.
42 +
Verbrugge LM, Ascione FJ.  Exploring the iceberg: common symptoms and how people care for them. Med Care . 1987;;25:539-569.
43 +
Alonzo AA.  Everyday illness behavior: a situational approach to health status deviations. Soc Sci Med . 1979;;13A:397-404.
44 +
Demers RY, Altamore R, Mustin H, Kleinman A, Leonardi D.  An explanation of the dimensions of illness behavior. J Fam Pract . 1980;;11:1085-1092.
45 +
Roghmann KJ, Haggerty RJ.  Daily stress, illness, and the use of health sources in young families. Pediatr Res . 1973;;7:520-526.
46 +
Banks MH, Beresford SAA, Morrell DC, Waller JJ, Watkins CJ.  Factors influencing demand for primary care in women, aged 20-44 years: a preliminary report. Int J Epidemiol . 1975;;4:189-195.
47 +
Barsky AJ. Worried Sick: Our Troubled Quest for Wellness . Boston, Mass: Little Brown & Co Inc; 1988;.
48 +
Shorter E. Bedside Manners . New York, NY: Simon & Schuster Inc Publishers; 1985;.
49 +
Shorter E. From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era . New York, NY: Free Press; 1992;.
50 +
Mishler EG, Amarasingham LR, Osherson SD, et al. Social Contexts of Health, Illness, and Patient Care . New York, NY: Cambridge University Press; 1981;.
51 +
Harris L. Inside America . New York, NY: Vintage Books; 1989;.
52 +
Veroff J, Douvan E, Fulka RA. The Inner American . New York, NY: Basic Books Inc Publishers; 1981;.
53 +
Verbrugge LM.  Longer life but worsening health? trends in health and mortality of middle aged and older persons. Milbank Mem Fund Q . 1984;;62:475-519.
54 +
Barker LR.  Distinctive characteristics of ambulatory medicine.  In: Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory Medicine . Baltimore, Md: Williams & Wilkins; 1982;:1-15.
55 +
Conrad P.  Medicalization and social control. Annu Rev Social . 1992;;18:209-232.
56 +
Relman AS.  The new medical-industrial complex. N Engl J Med . 1980;;303:963-970.
57 +
Stewart DE.  The changing faces of somatization. Psychosomatics . 1990;;31:153-158.
58 +
Braverman P, Schaaf VM, Egerter S, Bennett T, Schechter W.  Insurance-related differences in the risk of ruptured appendix. N Engl J Med . 1994;; 331:444-449.
59 +
O'Grady KF, Manning WG, Newhouse JP, Brook RH.  The impact of cost sharing on emergency department use. N Engl J Med . 1985;;313:384-390.
60 +
Feldman R, Schwartz JS. Paying Physicians: Options for Controlling Cost, Volume, and Intensity of Services . Ann Arbor, Mich: Health Administration Press; 1992;.
61 +
Shapiro MF, Ware JE, Sherbourne CD.  Effects of cost sharing on seeking care for serious and minor symptoms. Ann Intern Med . 1986;;104:246-251.
62 +
Barr JK.  Physicians' views of patients in prepaid group practice: reasons for visits to HMOs. J Health Soc Behav . 1983;;24:244-255.
63 +
Borus JF, Howes MJ, Devins NP, Rosenberg R, Livingston WW.  Primary health providers' recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry . 1988;;10:317-321.
64 +
Goldberg D.  Detection and assessment of emotional disorders in a primary care setting. Int J Ment Health . 1979;;8:30-48.
65 +
Kirmayer LJ, Robbins JM.  Three forms of somatization in primary care: prevalence, co-occurrence, and sociodemographic characteristics. J Nerv Ment Dis . 1991;;179:647-655.
66 +
Strain JJ, Hammer JS, Fulop G.  APM Task Force on Psychosocial Interventions in the General Hospital Inpatient Setting: a review of cost-offset studies. Psychosomatics . 1994;;35:253-262.
67 +
Simon G, Ormel J, Von Korff M, Barlow M.  Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry . 1995;;152:352-357.
68 +
Katon W, Von Korff M, Lin E, et al.  Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA . 1995;;273:1026-1031.
69 +
Smith GR, Rost K, Kashner TM.  A trial of the effect of standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry . 1995;;52:238-243.
70 +
Quill TE, Lipkin M, Greenland P.  The medicalization of normal variants: the case of mitral valve prolapse. J Gen Intern Med . 1988;;3:267-276.
71 +
Illich I. Medical Nemesis . New York, NY: Bantam Books Inc; 1976;.
72 +
DeVries NW, Berg RL, Lipkin M. The Use and Abuse of Medicine . New York, NY: Praeger Publishers; 1982;.
73 +
Macdonald LA, Sackett DL, Haynes RB, Taylor DW.  Labelling in hypertension: a review of the behavioral and psychological consequences. J Chronic Dis . 1984;;37:933-942.
74 +
Sox HC, Margulies I, Sox CM.  Psychologically mediated effects of diagnostic tests. Ann Intern Med . 1981;;95:680-685.
75 +
Kashner TM, Rost K, Smith GR, Lewis S.  The impact of a psychiatric consultation letter on the expenditures and outcomes of care for patients with somatization disorder. Med Care . 1992;;30:811-821.
76 +
Smith GR, Monson RP, Roy DC.  Psychiatric consultation in somatization disorder: a randomized controlled study. N Engl J Med . 1986;;314:1407-1423.
77 +
Barsky AJ.  Hypochondriasis: medical management and psychiatric treatment. Psychosomatics . In press.
78 +
Sharpe M, Peveler R, Mayou R.  The psychological treatment of patients with functional somatic symptoms: a practical guide. J Psychosom Res . 1992;;36:515-529.
79 +
Salkovskis PM.  Somatic problems.  In: Hawton K, Salkovskis PM, Kirk JW, Clark DM, eds. Cognitive-Behavioral Approaches to Adult Psychiatric Disorders: A Practical Guide . Oxford, England: Oxford University Press; 1989;:235-276.
80 +
Hellman CJC, Budd M, Borysenko J, McClelland DC, Benson H.  A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. Behav Med . 1990;;16:165-173.

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To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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