Ronald H. Rozensky, PhD

Continuing Education Information

Stone (1991) recognized that there exists “… a core of knowledge and technique common to all practice of psychology” and “competence acquired elsewhere must be modified and extended if proficiency in medical settings is to be achieved” (p xii). Stone went on to say there is indeed “functional specialization” within medical settings based upon the time it takes an individual psychologist to reach a journeyperson level of competence in some specific area of practice (p xi). Rozensky, Sweet and Tovian (1991) recognized a spectrum of professional titles, or specialties, for the scope of activities undertaken by clinical psychologist in medical settings and in working with medical patient including health psychology, medical psychology, clinical health psychology, neuropsychology, rehabilitation psychology, behavioral medicine, primary care psychology, pediatric psychology, integrative medicine, and clinical psychology. Matarazzo’s (1987) declared that there is only one psychology, no specialties, with many applications.

In practice, psychologists have functioned as practitioners and carried out research in medical settings and with medical patients for many years. For example, primary care has been seen by many as a relatively new endeavor for psychologists “even though psychologists have functioned as de facto primary care providers during a sizable part of our history” (Newman and Rozensky, 1994; p. 3). Similarly, while the American Psychological Association (APA) only changed its bylaws to include health in its mission in 2001 stating that APA’s mission is now “to advance psychology as a science and profession, and as a means of promoting health and human welfare” (Johnson, 2004), the Arden House Conference in 1983 had already acknowledge the growing field of clinical health psychology (Stone, 1983). Clearly, psychologists have been involved in medical care for many, many years even while many practitioners are seeking to expand there practices into this arena today. Belar, Brown, Hersch, Hornyak, Rozensky, Sheridan, Brown, and Reed (2001) offer those practitioners a model of self study that can be used to “assess their readiness to provide services to patients with physical health problems” (p. 136).

This article will present information about the range of medical disorders towards which psychologists can direct their practices, the self study questions that will help with the ethical expansion of practice, and HIPAA and practice issues focused upon the practice of psychology in medical settings and with medical patients.


To illustrate the range of medical problems psychologists study and treat, Rozensky (2006) reviewed some 481 articles published in the Journal of Clinical Psychology in Medical Settings across a thirteen year period. Table I presents, by diagnosis or presenting complaint and key words in the title or abstract of the paper, the twenty three most common topics written about during that period.

Additional topics included obesity in adults and children, Parkinson’s disease, infertility, HIV/AIDS, Hepatitis C, brain tumors & brain injury, and ADHD. Each had several articles that concentrated on them. Highly prevalent disorders, and those not so prevalent, also included such diverse topics as urinary incontinence, spina bifida, sleep apnea, irritable bowel, prostatectomy, postpartum depression, smoking control, aging, menopause, psychological and behavioral health diagnoses, low birth weight, and eating disorders in men, to name just a few of many.

Clearly, most of the major diseases and medical problems of the human condition were covered along with psychologists’ scientific and clinical work with cancer patients, pain, spinal cord injury, chronic illnesses, heart disease, sickle cell disease and asthma that predominated in the journal. The largest general topic of study was that of organ transplantation (31) with heart (9), lung (6), liver (5), and bone marrow (5) transplantation as the primary topics within that category. Rozensky concluded that, when you include the various transplanted organs to the general count of articles, “you see a pattern not too dissimilar from that of the death rates in the United States as published by the Centers for Disease Control” (p. 348) (CDC; Minino, Heron, and Smith, 2006). Further, the top 15 causes of death, according to the CDC included, in rank order, diseases of the heart, malignant neoplasms, cerebrovascular disease, chronic lower respiratory disease, accidents, diabetes mellitus, Alzheimer’s disease, influenza and pneumonia, nephritis, septicemia, suicide, chronic liver disease and cirrhosis, essential hypertension, Parkinson’s disease, and pneumonia. And the National Center for Health Statistics (2005) provides data on chronic health conditions causing limitations of activity and impact on actual quality of life. Those data, across the life span from childhood to older adulthood, presented by the number of individuals per 100,000 of the population with each disorder shows that for children through age 17, problems such as speech disorders, asthma, developmental disorders, emotional and behavioral problems, and ADHD and learning problems predominate as limitations to activity. Mental illness and arthritis predominate in young adults, while arthritis, heart disease, diabetes, lung disease, fractures, and mental illness impose greater limitations on those over age 55. Arthritis, heart or circulatory diseases, hearing and vision problems, diabetes, lung disease, and senility cause the greatest limitations of activity for individuals over 65 years of age.

Reviewing the topics covered by one journal publishing in the area of health psychology for more than a decade, illustrates that psychologists do indeed study and provide clinical services to patients with the major diseases that shorten life or cause limitations to the experience of a quality life.


The APA (2002) Ethical Principles and Code of Conduct states that psychologists should only practice within the boundaries of their competency (p. 4). To assure that this ethical responsibility is met when expanding one’s practice to work with medically ill patients, Belar and colleagues (2001) offer a model for self assessment and continuing education that facilitates that ethical expansion of practice into the domain of clinical health psychology. These authors suggest that, before traditionally trained, mental health focused psychologists (who might have had only an introduction to health psychology during graduate school) seek to work clinically with medically ill patients, they should “develop the necessary expertise to provide quality services across a broader range of health problems” (p. 136). Thus, in preparation for the assessment and treatment of medically ill patients, they suggest that clinicians ask themselves 13 questions to self-assess readiness to deliver these services. This self-assessment should be used by clinicians in a hospital-based practice or those who want to expand their clin ical work and begin seeing patients with a medical diagnosis new to their practice. The self-study questions recommended by Belar et al. (2001, p. 137) are as follows:

Do I have knowledge of the biological bases of health and disease as related to this problem? How is this related to the biological bases of behavior?

Do I have knowledge of the cognitive-affective bases of health and disease as related to this problem? How is this related to the cognitive-affective bases of behavior?

Do I have knowledge of the social bases of health and disease as related to this problem? How is this related to the social bases of behavior?

Do I have knowledge of the developmental and individual bases of health and disease as related to this problem? How is this related to developmental and individual bases of behavior?

Do I have knowledge of the interactions among biological, affective, cognitive, social, and developmental components (e.g., psychophysiological aspects)?

Do I understand the relationships between this problem and the patient and his or her environment (including family, healthcare system, and sociocultural environment)?

Do I have knowledge and skills of the empirically supported clinical assessment methods for this problem and how assessment might be affected by information in areas described by Questions 1–5?

Do I have knowledge of, and skill in implementing, the empirically supported interventions relevant to this problem? Do I have knowledge of how the proposed psychological intervention might impact physiological processes and vice versa?

Do I have knowledge of the roles and functions of other health-care professionals relevant to this patient’s problem? Do I have skills to communicate and collaborate with them?

Do I understand the sociopolitical features of the healthcare delivery system that can impact this problem?
Do I understand the health policy issues relevant to this problem?

Am I aware of the distinctive ethical issues related to practice with this problem?

Am I aware of the distinctive legal issues related to practice with this problem? Am I aware of the special professional issues associated with this practice with this problem?

These questions challenge clinicians to understand the interplay of all aspects of the biopsychosocial dimensions of the disease and to have a working knowledge of the empirically supported assessments and treatments for the management of the disorder and its contributing psychological factors or sequelae. Answers to these questions also readily prepare the clinician to communicate with members of the health care team, including the patient, and to conceptualize problems in a truly integrative manner (Tovian, 2006) in settings from primary to tertiary care.


Practicing psychologists have been inundated in recent years with extensive information about the Health Insurance Portability and Accountability Act (HIPAA) and the management of protected health information. Benefield, Ashkanazi, and Rozensky (2006) have written about the differences between office and hospital practice and how to assure that that hospital-based practice with medical patients is HIPAA compliant.
The HIPAA Privacy Rule of 1996 was proposed as both a remedy to privacy concerns and as groundwork for a national health management registry as well as to address the needs of workers whose health insurance coverage was jeopardized when changing jobs (APA Practice Organization, 2002). HIPAA contains explicit practice standards for maintenance of patients’ privacy and potential punitive actions for violations. This Act has implications for day-to-day office practice but has potentially even greater impact when providing care for patients within the highly visible, highly regulated, organized health care environments such as hospitals and health science centers (Benefield, et al, 2006).

HIPAA regulations are very similar in spirit to the privacy and confidentiality practice standards and ethical standards that have formed the basis of professional behavior of psychologists (APA, 2002). The integrative perspective engendered by the biopsychosocial model, and the questions detailed above, create for psychologists an understanding of the interrelationship of the individual’s physical and psychological selves and their community and thus enhances psychologists’ understanding of the potentially negative impact of privacy breeches beyond that of a general regard for the well-being of the patient in all aspects of his or her life. While the enactment of the HIPAA regulations has meant little more than complicated administrative changes to the practice of many psychologists, a focus on HIPAA compliance training programs, and the search for HIPAA compliant fax cover sheets, charts, and consent and release of information forms, there are day-to-day record keeping requirements and patient-doctor communication and provider-to-provider communication issues that those working with medical patients and in medical settings must attend to.


The consequences of inadequate maintenance of clinical records are wide ranging and most salient in the organized, hospital environment where HIPAA rule interpretations, medical record committees, chart audits, and interdisciplinary communications occur on a daily basis and have the potential to impact issues of privacy.

The HIPAA regulations clearly define the material that constitutes individually identifiable health information and the ways in which that Protected Health Information (PHI) must be managed (45 CFR § 164.501). Health information considered identifiable, and therefore PHI, includes names of patients and/or their relatives, dates, specific geographic information, telephone and fax numbers, e-mail addresses, web URL’s, IP address numbers, identification numbers (i.e., social security, medical record, health plan, account, certificate/license, vehicle ID, license plate), medical device identifiers and serial numbers, biometric identifiers (such as finger or voice prints), photographs or comparable images, and any other unique identifying numbers, characteristics or codes. This information may relate to the patient’s physical and mental health in the past, present, or future. Also, PHI may be in any form of communication or storage, such as paper, electronic, video, or verbal (Benefield, et al, 2006).

Access to PHI is limited to only those persons directly involved with the patient’s care, those processing paperwork for record keeping or billing, and quality assurance and training staff. PHI must be used exclusively for authorized work-related functions (45 CFR § 164.502). Those with access to PHI are charged with its protection and it is expected that information is limited to what is necessary to complete the approved processes (45 CFR § 164.514 [d]). It is important to note that all healthcare providers practicing within hospital settings actually must document their training and understanding of HIPAA rules. Records are kept by the hospital for each healthcare provider regarding their documented compliance to these rules.

All clinical records must be continually maintained and stored in a manner that complies with the Privacy Rule. These requirements are enforced without regard to the process for which the information is to be used. The length of time inactive records are to be retained is determined by relevant federal and/or state laws and professional standards.

There is an increasingly wide usage of electronic medical records that have practice implications and HIPAA issues for psychologists in medical settings. The psychologist once again must make certain that he or she has the proper training to utilize the local, electronic medical record and access as required by the hospital. Again, local standards of charting, including where psychological information is stored, should be a well understood matter for the psychologist. Electronic materials must be stored with electronic protections such as passwords, closed servers, and encrypted access (Department of Health and Human Services, 2001) and the psychologist is encouraged to understand the local system.


Using and disclosing PHI in a respectful manner can begin to engender patient’s confidence in the health care system’s ability to protect their privacy and an interesting feature of HIPAA is the focus placed on involving the patient in the process of privacy protection (Benefield et al., 2006). The intention behind these policies is to provide patients with greater control over their own health information and within the hospital setting, there maybe specific scrutiny of these practices by audit committees or HIPAA compliance officers.

At the initiation of their treatment, patients are to be provided with a Notice of Disclosure (45 CFR § 164.520), also known as the “Notice of Privacy Practices” (NPP) informing patients what information is designated personally identifiable, how their private health information will be protected, and how disclosures will be made. Those psychologists new to a hospital setting should make certain that they are aware of the hospitals rules and policy as communicated to the patients.

Patients are allowed to request access to their records, may choose to review their records in the practitioner’s office, or they may sign a release to have duplicate copies made for their use (45 CFR § 164.524). Patients now have a formalized right to request amendments of their records should their review reveal information that they do not believe is accurate (45 CFR § 164.525). Thus, the psychologist should be cognizant of these rights and aware of implications vis-à-vis information that enters into the patient’s medical record.

Ross and Lin (2003) suggest that there is a potential for modest benefits to the patient when they review their of case records in the form of improved patient-doctor communication, and enhanced patient adherence, education, and empowerment. However, they add that patients in the general medical population also may have difficulty with psychological material contained in their records and should be afforded the same supports when reading that material.

Thus, with medical patients, practitioners are being called upon to chart their patients’ status and progress with clarity and sensitivity. There then is an opportunity to utilize the chart note as a tool in the patient’s actual health care, both within the patient-doctor relationship and within interdisciplinary relationships (Benefield et al., 2006). For the practicing psychologist who attends patients in the medical hospital, the content of the psychological assessment, recommendations, and treatment should be considered in this light.


HIPAA was originally designed to improve fluidity of care. Thus those practicing as a team member in a hospital may communicate freely with others on a patient’s care team once a referral has been received. For psychologists communicating between patients and other health care professionals in medical settings it is important to understanding HIPAA regulations defining the relationship of components of medical facilities with its affiliates and how free communication between these entities, in compliance with the Privacy Rule (45 CFR § 164.504 [a-d]), is needed. Patient releases are not required between team members within the organized healthcare facility but good practice standards include referencing the consultation request by source and date when providing a response. Letting the patients know what psychological information might be put into their medical chart helps involve the patient in their care and assures that they are not surprised to find that a member of the health-care team knows personal information shared with their psychologist who charted that issue in a note.

Thought must be given to include only the material relevant to the patient’s immediate care when communicated psychological information about a patient to the care team. Reports should be written as clearly and as jargon free as possible to insure that all who read the chart understand the material. Sensitive current and historical information gathered and used in formulating the diagnosis that does not immediately impact the patient’s current care should be omitted from the medical record consultation report, but instead should be included in a separate patient file and stored with the mental health practitioners secure files (Benefield, et al, 2006).


HIPAA also allows for communication of PHI with patient’s close friends and family members when necessary for patient care and may be even a greater issue within hospital practice than the private office. A conversation with the patient beginning with “I would like to tell your significant other about thus and such, and concluding with, “Is that ok with you and how would like me to involve them?” addresses the necessary points. Of course, this interaction should be documented in the chart and once again involves the patient.


For referrals and consultation requests to practitioners outside of a specified medical setting or hospital, patient releases are required and patients can request restrictions be placed on how their PHI is used (45 CFR § 164.522) Thus, patient releases must be explicit and the patient’s understanding must be verified. Documentation of a patient’s request to restrict information release should be maintained in the patient’s record, whether granted or not.

When communicating among offices within and outside of a hospital, the identity and authority of the person requesting PHI and the destination of reports or records containing PHI must be verified prior to disclosure (45 CFR § 164.514). Credentials of new referral sources must be verified along with addresses and telephone and fax prior to sending referrals, reports, requests for information, or any other communication containing PHI. This is true for patients seen in an office practice or within the organized health care setting.


Although HIPAA provides for greater ease of consultation among professionals within a defined medical facility and its affiliates, those practitioners outside of an institution who receive consultation requests are presented with new, unique administrative challenges. Independent practice psychologists entering a hospital or other medical setting ‘on consultation’ should be aware that although these are national mandates, individual organized medical settings may have unique regulations, such as training requirements and confidentiality statements. Therefore, psychologists are well advised to contact the institution’s HIPAA compliance administrator for detailed requirements. (For in depth discussion of the HIPAA Security Rule, please see Clearly, those psychologists with hospital privileges who serve as part of the professional staff will have a clear understanding of the policy and procedures as part of their involvement in the professional staff as required by the hospital’s bylaws.


Any licensed psychologist should possess the professional competency and requisite clinical skills needed to practice within an organized healthcare setting (Rozensky, 2006) or with medical patients based up the self study approach described by Belar, et al, (2001). Being successful in organized medical environment, however, is further dependent upon understanding the policies, procedures, ethics, and etiquette of moving from an independent, office-based practice to the complicated milieu of the medical unit, intensive care unit, surgical floor, the emergency department, or inpatient mental health/psychiatric facility and the standards of practice expected therein.

Organized health care settings function under a defined set of rules because they must meet standards of accreditation set forth by external accreditation agencies (Joint Commission for Accreditation of HealthCare Organizations, Committee on Accreditation of Rehabilitation Facilities, and/or state health departments). The independent, office-based practice of psychology requires appropriate licensure and the training and ethically (self) defined competencies to work clinically with specific patient populations. But external standards for hospital practice actually prescribes rules of entry (credentials) and methods for defining scope of practice (privileges) within these organized environments along with a plethora of required clinical, human resource, and facility/environmentally oriented policies, procedures, and regulations (Rozensky, 2006).

Thus, whether the psychologists only occasionally attends their patient in the hospital or makes hospital practice a routine part of their daily clinical work, those seeking to practice in these organized healthcare settings must understand these rules in order to seamlessly follow patients into the hospital and back out into the community.


Robinson and Baker (2006) and Tovian (2006) described issues pertaining to hospital practice based upon being part of a day-to-day consultation service versus those of an independent, outpatient based practitioner who interfaces with their patients in the hospital setting. Some psychologists only see patients on a referral basis with cases sent by the inpatient team or attending physician versus being a member of an integrated team wherein all patients are seen by all members of the team, including the psychologist. Many of the same issues apply to both all these various roles including being aware of the limits and expectations of those roles, formal and informal means of HIPAA complaint communications, and complications of simply scheduling a visit with a patient who is being seen by a multitude of healthcare providers whether the psychologist is a formal team member or seen as a consultant. Further, Tovian (2006) notes that physicians vary in the personal styles as health care providers and the psychologist should be aware of individual differences criteria utilized for referrals.


Brown, Freeman, Brown, Belar, Hersch, Hornyak, Rickel, Rozensky, and Sheridan (2002) note that there is an increasing opportunity for psychologists to collaborate with other health care disciplines and that “… endeavors between psychology and medicine have contributed to improving health outcomes and reducing mortality” (p. 537). Belar et al. (2001) note “there is concern about potential risk to patients should insufficiently trained psychologists prematurely expand their scope of practice …. [and] … there is also risk for damage to [the reputation of] the profession as the perception by other disciplines involved in health care can be markedly influenced by the behavior of individual psychologists” (p. 138).

The psychologist must have documentation of appropriate graduate training or ongoing continuing education when reviewed by the hospital’s credentialing committee. In short, pediatricians do not have privileges in the operating room, surgeons do not see psychotherapy patients in the hospital, psychiatrists do not use the protoscope, and obstetricians do not attend patients on the neurology unit. Likewise, psychologists might be asked about their specific preparation to work with cancer patients, as distinct from seeing their patient in a mental health crisis in the emergency department or attending a patient who is hospitalized on the psychiatric unit. That level of scrutiny is normal operating procedure in hospital settings since hospitals, and their professional staffs, are required to review who does what to whom within their walls. If psychologists wish to practice within these organized health care settings, then these same rules will apply. And frankly, the psycholo gist should be pleased to display for the attending staff the extent of the patients with whom we treat, the range of clinical skills we have, and the scope of practice the profession prepares us to engage in (Rozensky, 2006, p. 261).


Enright (1987) described the hospital practice environment as filled with pitfalls and traps that can make the most well-intentioned psychologist a potential liability to themselves and the profession. “Entering the hospital without knowing the customs, language, protocol, and procedures is like entering the Amazon without a map, provisions, or guide,” and “unfortunately, in both cases the head hunters still roam free and remain quite hungry” (Enright, 1987; p. 11). It is recommended that practicing psychologists learn about, acquaint themselves with, and utilize the formal structure [the map the bylaws] that may exist for psychologists in the particular hospital setting. In other words, with all these words of warning, there is a way to make the system work smoothly for the psychologist and his or her patient[s].

Do not go outside the psychology-based structure and talk to the chairperson of the department of medicine about seeking privileges to see medically ill patients; this will only weaken the political and organizational structure for psychology by dividing efforts (Rozensky, 1991; Rozensky,2004). If no organized structure for psychology exists, then beginning with the senior psychologist on the professional staff is not only respectful of that individual and will help you understand the history and culture of the organization, but can help strengthen the discipline’s numbers in the hospital. Find a guide to help you become a staff member or find the the bylaws (Rozensky, 2006). The American Psychological Association Practice Organization has published information related to cultural, practice, organizational, legal, and bylaw issues in a hospital (1998).

Hospitals also have written policy and procedures that document clinical charting requirements, local application of HIPAA regulations, human resource rules, admission and discharge practices, and emergency and disaster plans, to name a few (Rozensky, 1991). Call the hospital’s professional staff office and ask for a copy of the bylaws; that is a good place to start if you are new to a given hospital setting.


When providing care for your medically hospitalized patient, you want to officially document in the chart at the nurses’ station that you were there seeing your patient and thus make certain that your treatment and recommendations are considered as an ongoing part of the patient’s hospital care. Coming to see your patient without being there as an official member of the professional staff and thus providing documented care might not be helpful to patient given the inter disciplinary team structure and certainly does nothing to help the profession of psychology expand its official presence and recognition in the hospital setting (Rozensky, 2006).

Healthcare providers do not just walk into an organized healthcare facility and see their patients. Hospitals can lawfully grant or decline professional staff membership and privileges for any health-care provider, including psychologists, “on any basis which is rationally related to his or her competence” (Stromberg et al., 1988, p. 329). Further, Resnick, Enright, and Thompson (1991) note that the APA policy regarding [hospital] privileges recognizes “ … that privileges be granted and assigned on the basis of each individual psychologist’s documented training and\or experience, demonstrated abilities, and current competence” (p.1). Also important is an understanding of the scope of practice allowed for psychologists within the given medical setting. JCAHO (2000) states that “the exercise of clinical privileges within any department is subject to the rules and regulations of that department and the authority of the department’s director” (p. 271). Further, the JCAHO states that one practices in the hospital setting within the scope of their own competences as “… indicated by the score of their delineated privileges” (p. 271). Herein, the organized healthcare setting can be experienced very differently than the freedom explicit in an independent office practice. Simply put, while you are free to practice as you are trained and competent, that is, to do what you see fit as quality patient care, there is a peer group and director of psychology who has the responsibility to oversee your work within the walls of the hospital setting. This will include chart reviews, audit committees, and quality improvement activities as mandated by external review agencies and explicated in the bylaws or policies and procedure documents. This local standard of practice should not hamper your work, actually it should be engaging to have a peer group with whom to consult and work, but that group might have local standards of care or practices that might differ from yours (Rozensky, 2006).


Psychology has embraced its role as a healthcare profession with the formal inclusion of health in the APA Bylaws. This policy statement simply reflected the longstanding scientific and clinical roles psychologists have had in organized healthcare settings and with medical patients for many decades. Current interest in expanding traditional office-based, mental health-oriented practices to include work within hospitals and with medical patients has challenged the field to explicate methods to assure competent practice with a wide range of medically ill patients and their families and help direct psychologists to seek successful practice opportunities in hospitals, nursing homes, hospices, and medical centers. The practicing psychologist is urged to seek the opportunity to expand practice by carrying out the self assessment recommended by Belar et al. (2001) to work with medical patients and to understand the complications and opportunities for an expanded role in hospital settings (Rozensky, 2006).

Thoreau wrote that “disease … in some form, and to some degree or other, it is one of the permanent conditions of life.” This rather sobering statement does set the stage for psychologists to expand their practices given the rather wide range of people and opportunities it suggests will continue to exist. Bringing quality psychological services to patients seems a natural thing for psychologists to do.


Ronald H. Rozensky received his PhD in clinical psychology from the University of Pittsburgh. After practicing more than twenty years in Illinois, he served as professor and chairperson of the Department of Clinical and Health Psychology at the University of Florida where he is currently Professor and Associate Dean for International Programs. He is Board Certified in Clinical and Clinical Health Psychology (ABPP). Dr. Rozensky founded and edited the Journal of Clinical Psychology in Medical Settings. He published five books, numerous chapters and peer reviewed journal articles on health psychology and professional issues. An APA Fellow, he currently serves on APA's Board of Directors and previously chaired APA's Board of Educational Affairs and Board of Professional Affairs. Dr. Rozensky has been credentialed by the National Register since 1976.

Table I

Articles in The Journal of Clinical Psychology In Medical Settings 1994-2006
Most Common "Key Words" by Diagnosis or Presenting Problem
(from Rozensky, 2006, p. 347)

Transplant Psychology 31
Cancer 27
Pain 12
Spinal Cord Injury 12
Chronic Illness 10
Heart Disease 10
Sickle Cell 9
Asthma 7
Cystic Fibrosis 6
Brain Injury 5
Multiple Sclerosis 5
Panic Disorder/Noncardiac Chest Pain 5
Hepatitis C 4
Infertility 4
Obesity 4
Parkinson's Disease 4
Arthritis 3
Brain Tumor 3
Chronic Fatigue 3
Fibromyalgia 2


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