The study aimed to investigate awareness of somatisation disorder among physicians working in emergency departments in western Sweden. The study showed that the level of knowledge regarding somatisation disorder is low, across disciplines. There were generally few differences between the genders, but female physicians were more aware of underlying factors to somatisation disorder than their male colleagues, while type of specialty or years of practice did not affect awareness.

As many as one fifth of the population suffers from some type of somatoform disorder [3] and the probability of meeting this patient group as a physician at an emergency department is high. The low level of awareness about somatisation disorder, its diagnostic criteria, and underlying factors shown in our survey, entail a risk for failure to identify this condition. Such a failure may cause the unwary physician to initiate investigations or diagnostic procedures that may result in iatrogenic complications and considerable financial burden to the society.

A single underlying explanation for somatisation can be difficult to find. The suggested link between violence, especially sexual violence, and somatisation [13, 14] underscores the importance of being aware of the condition so that it can be identified among the women who seek emergency care for symptoms that could be related to somatisation. Several studies have reported associations between somatic symptoms and sexual abuse [18,19,20]. Emergency departments provide a unique opportunity for healthcare professionals to screen patients for intimate partner violence [21], which could increase the possibility of earlier identification and diagnosing of somatisation disorder.

Physicians seem to find somatoform disorders extremely challenging to describe in both clarity and utility [16]. In our study, three of ten responding physicians stated that they had no awareness of somatisation disorder. Nine of ten respondents reported not knowing the diagnostic criteria for the diagnosis. This low level of awareness seemed to be similar across disciplines, suggesting that none of the involved specialties that work in emergency departments are better equipped than others to identify and manage patients that potentially may suffer from somatisation disorder. Despite this, nearly seven of ten physicians claimed they had treated patients they suspected had the diagnosis. As physicians’ awareness and knowledge about somatisation disorder is poorly researched, comparing our findings to other studies was challenging. We found a few studies on physicians’ knowledge about other difficult to diagnose conditions. Our findings are in line with a Canadian survey of physicians’ knowledge of fibromyalgia, in which physician knowledge of fibromyalgia diagnostic criteria was poor and linked to specialist training [22]. Similarly, an Indian study described how family and primary physicians had trouble separating anxiety, depression and somatic presentations amongst their patients [23], pointing to the difficulty in establishing a correct diagnosis and proceed with optimal patient management. In contrast, a Dutch study on family physicians’ recognition of medically unexplained physical symptoms, a condition close to somatisation, showed that the participants believed they could properly identify the condition in their patients [24].

Our expectation was that increased experience would lead to increased awareness, as shown in a study from Saudi Arabia that assessed paediatric physicians’ knowledge of febrile seizures [25]. That study showed that the consultants, with more years of practice, had better knowledge about febrile seizures in comparison to other groups of physicians. However, our study showed no significant differences in awareness related to years of work experience. The previously mentioned Canadian study, which investigated knowledge about fibromyalgia, also found that knowledge was independent of clinical experience [22]. It is difficult to explain why years of experience with these diagnoses do not increase the level of knowledge, which one could expect. Experience in terms of years of practice and its association to knowledge and performance seems rather complex. Although clinical experience can lead to increased clinical knowledge [25], a systematic review from 2005 showed that clinical experience was negatively related to physicians’ quality of care [26]. A possible explanation for this could be that medical advances occur frequently, entailing a risk that the knowledge that physicians possess may become outdated. Therefore, it is possible that greater experience does not lead to increased knowledge in the context of somatisation, which has a history of a lack of diagnostic criteria and an unclear definition of the disorder. However, both the 2013 revised DSM 5 and the new ICD-11 from 2019 have simplified the diagnosis and may possibly improve these weaknesses in the future. In this study, however, we used ICD-10-SE, as ICD-11 has not yet been translated into Swedish.

A previous study has proposed to generally increase physicians’ competence [27]. In addition, we suggest engagement in deliberate practice, with training focused on improving specific tasks, in this case, related to somatisation disorder. This could lead to better knowledge and performance in this field. It is well known that knowledge is essential to make better decisions and judgments [28]. Furthermore, the working environment in emergency departments, with quick decisions and seriously ill patients together with a complex condition such as somatisation, is challenging and may also explain the lack of effect of experience. Under these circumstances, focusing on individual symptoms may be a pragmatic solution and guide the physicians’ investigation, which may be another explanation for not developing increased knowledge about somatisation despite increased years of practice.

In our study, women reported knowing more about the underlying factors of the somatisation disorder than their male colleagues. Also, there were gender differences in awareness of somatisation disorder within specific specialties, consistently in favour of the female physicians. In contrast, a study from Wisconsin, USA, reported that female physicians consistently assessed their ability to perform or apply knowledge and skills related to clinical research lower than how men ranked themselves [29]. It is, however, suggested that gender differences in self-perception of abilities and competence are related to gender-specific tasks. In a study by Beyer and Bowden [30], participants were asked to rate specific tasks as either “feminine” or “masculine”, and thereafter perform the tasks and finally rate their confidence of their own performance. In masculine specific tasks, women self-evaluations of their own performance tended to be inaccurately low in relation to their actual performance. This was not seen in feminine specific tasks. It is possible that knowledge about somatisation disorder is more of a “feminine task”. A systematic review, conducted in 2013 [31], reported greater patient engagement by female doctors and some evidence to suggest that female physicians adopt a more partnership-building style and spend an average of 2.2 min longer with patients per consultation than their male colleagues. This communication style may enable disclosure of underlying factors such as intimate partner violence and increase knowledge among female physicians about somatisation in general.

An observational cohort study from Canada [32], identified a similar communication style, patient-centred practice, to increase the efficiency of care by reducing diagnostic tests and referrals. Unnecessary investigations and diagnostic operations that are common in somatisation patients could hence be reduced. Despite the gender differences described above, it can be noted that for most questions, men and women in our study answered relatively similarly regarding awareness and use of the somatisation disorder diagnosis.

This study has several limitations. The questionnaire was developed specifically for the study and was only preliminary validated. However, the pilot test, conducted in a similar cohort of physicians in a different part of Sweden, indicated both content and face validity of the questionnaire. Furthermore, it was not constructed as a psychometric tool, but rather as an indicator of awareness. The responses are self-reported, increasing the level of uncertainty and may also, as all self-report data, reflect a social desirability bias. The results of the self-administered web-based survey are subject to non-response bias, which may result in overestimation of awareness. The inclusion criteria of having served in an emergency department during the past 12 months may entail some variability in the extent of the respondents’ experience. Drawn from only a handful of hospitals in Sweden, caution must be used in generalising the findings to other countries. However, the problem of suboptimal clinical management of patients with somatisation has been identified in other countries [8,9,10], and we believe the knowledge gap we identified in this sample of Swedish physicians is relevant for other countries, especially those with similar healthcare systems.

The main strength of this survey is that it consists of six dichotomous questions, making it easy and rapid to complete, even for very busy physicians. Dichotomous response options force the respondent to choose an alternative – but may also not reveal the nuances that more response options potentially could have provided. The questionnaire reached a large study population with almost 50% response rate. We believe this survey of physicians’ awareness can provide a basis for future research and that it also can be useful to inform a future design of an intervention to increase physicians’ knowledge in this important field. Further research to replicate our findings in other countries is warranted. Future studies are also proposed to take a closer look at how physicians are trained in diagnosing somatisation disorder, and perhaps new clinical guidelines, standards, CME points, etc. are warranted to support diagnosis, investigation, and treatment, both in Sweden and internationally. In addition, the patient’s perspective needs to be highlighted, such as in a study of patients’ experience of consultations with physicians at the emergency departments before being diagnosed with somatisation disorder.

In conclusion, the level of awareness about somatisation disorder is low among physicians working at emergency departments in western Sweden. Three of ten emergency doctors stated that they had no awareness of somatisation disorder. Patients who meet doctors who lack awareness of the disorder are at risk of unnecessary investigations and treatments. The findings suggest a need to increase awareness and knowledge amongst physicians and provide training in diagnosing the condition, to ensure correct decisions and optimal patient management. Correct diagnosis entails substantial benefits in terms of more adequate treatment for the patient and more efficient use of resources in health care and society.