Discordant Grading of Symptom Severity Common Between Dermatologists, Patients

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The study’s findings bring major lessons for dermatologists to light, the most apparent of which being that many reasons for discordance between clinicians and patients may be modified.

Discordant severity grading (DSG) between patients and clinicians is common among those with psoriasis or eczema, according to recent findings, and DSG is associated with higher symptom expression, greater impairment of life quality, lower resilience, increased negative social comparisons, among other issues.1

These new findings were the result of a study examining the poorly-understood, wide variation of evaluations of disease severity between patients and their clinicians, termed DSG as a means to describe differences in patients' views versus those of their physicians.2

The study’s investigators identified several new factors and associations through prior research which were then used to derive a comprehensive model which could explain DSG. The study on this new model was authored by Ellie Choi, MBBS, from the Department of Medicine’s Division of Dermatology at the National University Hospital in Singapore.

“We hypothesize that this derived model will demonstrate a good fit with clinical data, and the psychobehavioral and cognitive constructs previously identified will be significantly associated with DSG,” Choi and colleagues wrote. “Understanding the drivers of discordance is a necessary first step toward building a patient-centered care model.”

Background and Findings

The investigators used a cross-sectional study which they conducted in Singapore. Patient participants and clinicians were recruited for the trial from 2 outpatient dermatological centers through convenience sampling.

Participants who were aged 18 - 99 with a diagnosis of either psoriasis or eczema and a disease duration of 3 months minimum were included, along with clinicians with 2 months minimum of dermatological experience. Participants were told to complete independent questionnaires following consultations, and data were gathered once from each patient while clinicians could contribute several different times.

Due to limited data and the absence of an existing framework, a qualitative model was developed as a foundation for the study. The validated scales were identified by the investigators through a literature review to assess the identified themes, and ad hoc items were developed as well whenever necessary.

The research team’s participant questionnaire included assessments of life quality, perception of one’s illness, physician empathy, resilience, personality traits, trust in one’s clinician, as well as objective measures of severity of disease. Patient and clinician demographics were also noted by the team.

The investigators’ determined the primary outcome to be the difference in severity grading between patients and clinicians, measured through the use of a numerical rating scale, and categorized as either positive or negative discordance based on a cutoff of 2 points. Intraclass correlation was used by the research team to examine the agreement between clinician and patient-reported severity.

The questionnaire was piloted by the team for readability, completion ease, and feasibility prior to the main cohort’s recruitment. Overall, their study was designed to assess the factors contributing to discordant severity grading and establish a framework for understanding this occurrence.

A total of 1053 participants with diagnoses of psoriasis or eczema were evaluated by the investigators, with 55.0% being male and 76.2% having reported eczema. Among the 44 recruited clinicians, 45.5% were male, and most fell into the age range of 31-40 years.

Each clinician was able to recruit a median of around 5 of their patients. The analysis of patient-clinician pairs demonstrated that 46.3% of the pairs showed discordance in severity grading, with positive discordance being more prevalent (42.4%) than negative discordance (3.8%). The team noted that agreement between patients and doctors on disease severity was shown to be poor.

Additionally, the investigators reported that using structural equation modeling (SEM) demonstrated that positive discordance in severity grading was linked with higher symptom expression and greater impairment in life quality for patients. These associations were shown not to be influenced by patient or clinician demographics.

The team also found that higher quality-of-life impairment was associated with lower resilience and stability, lower self-efficacy, increased negative comparisons socially, increased disease cyclicity, and an even greater expectation of chronicity. The investigators’ model developed based on these findings was found to be a good fit, indicating its effectiveness in explaining the factors contributing to discordant severity grading.

“This paves the way for further interventional work in this area and should be points of focus for the practicing physician,” they wrote. “Further studies can assess longitudinal changes in disease grading over time, the effect of DSG on future health, and treatment response; explore deeper into physician factors; and evaluate different measures and metrics for assessing DSG.”


  1. Long V, Chen Z, Du R, et al. Understanding Discordant Perceptions of Disease Severity Between Physicians and Patients With Eczema and Psoriasis Using Structural Equation Modeling. JAMA Dermatol. Published online July 12, 2023. doi:10.1001/jamadermatol.2023.2008.
  2. Long V, Lau XMN, Ng CX, Phan P, Choi CEE. Discordance in perception of disease severity between patient and physicians. Eur J Intern Med. 2023;109:138-140. doi:10.1016/j.ejim.2022.11.010.