CORR Insights®: Did the Physical and Mental Health of Orthopaedic Patients Change After the Onset of the COVID-19 Pandemic?

Where Are We Now?

The psychosocial and socioeconomic effects of COVID-19 in the United States have been far-reaching and well documented. Increased prevalence of anxiety, depression, and emotional distress has been reported in the general United States population throughout the pandemic [9]. In a thoughtful study on this topic in this month’s Clinical Orthopaedics and Related Research®, Hollenberg et al. [4] investigated whether these pandemic-related stressors might be associated with changes in clinical outcome scores among orthopaedic patients. In their analysis, they interestingly found no differences in physical and mental health metrics among patients presenting to a variety of orthopaedic providers before and during the COVID-19 pandemic.

Perhaps most notably, they found that even among patients from areas of higher social deprivation, these physical and mental health metrics did not change during the pandemic. These data surprised me, and contrast with findings from several studies (reported in a systematic review [6]) that documented worse overall health outcomes among patients from underresourced communities, especially Black and Hispanic individuals.

Where Do We Need to Go?

As we continue to grapple with the effects of the pandemic on the interesection of mental health, general well-being, and orthopaedic care, it is important to understand whether the findings in this analysis are generalizable to a larger subset of orthopaedic patients nationwide. Although the data presented by Hollenberg et al. [4] at first seem counterintutive, they may in fact be a subtle commentary on the types of patients who have access to elective orthopaedic care at large tertiary academic centers; more explicitly, White patients from higher socioeconomic backgrounds—who are less affected by COVID-19—might have increased access to elective orthopaedic care at these centers. Additional studies could be helpful to assess similar physical and mental health metrics in smaller community hospitals, or larger urban centers that serve a higher percentage of racially diverse patients who may have been disproportionately affected by the pandemic [1].

The value of Hollenberg et al.’s study [4], however, extends beyond just capturing the effects of the COIVD-19 pandemic on patients with musculoskeletal conditions. It also serves as an invaluable reminder that orthopaedic outcomes are inextricably tied to a complex array of psychosocial stressors and mental health conditions that may be influenced by national events, socioeconomic downturns, and even smaller-scale community social conflict. As the authors of this study [4] aptly acknowledge, these stressors can affect certain racial, ethnic, or socioeconomic groups more than others. Take, for example, the national impact of the murder of George Floyd in 2020 on Black Americans [2, 3], or the ongoing water crisis in Flint, Michigan, on individuals from the local community [7]. To this point, even though the day-to-day effects of the pandemic are slowly diminishing, there will always be new waves of national and local psychosocial stressors that our patients, and we as clinicians, will invariably respond to. The challenge comes in not only recognizing and acknowledging their existence but in also finding sensitive and clinically relevant metrics that capture their potential short-term and long-term effects on our patients.

How Do We Get There?

The study by Hollenberg et al. [4] did not demonstrate a difference in average Patient-Reported Outcome Measurement Information System scores between before and after the pandemic, but we as clinicians have likely treated individual patients whom we know have been profoundly affected by COVID-19. Although our current clinical surveys may not capture the full extent of the changes in their psychosocial health, we should still be sensitive and responsive to the emotional clues their clinical stories provide [5]. This can undoutably be difficult. These clinical windows of opportunity often are obstructed by surgeons’ demanding schedules and administrative burdens that we as providers are far too familiar with. Even as a resident, I find myself minimizing empathetic communication with patients as I try to balance the pressures of a late-night call and seeing a long consult list in a timely manner. I can only imagine what it will be like as an attending with a demanding clinical practice. One strategy reccomended to me by a mentor that has helped me provide more humanized orthopaedic care is to find an interesting (medically unrelated) fact about every patient with trauma I take care of; very often, for my pediatric patients, its their favorite TV show or sport, and for my adult patients, its their favorite food, hobby, or musician. Most call shifts I fall short of this lofty goal, but it has been a useful trick I use to try to connect with my patients with trauma, who can otherwise quickly become indistinct from their chief orthopaedic injuries.

There likely will never be a way to capture all the nuances and complex social stressors that affect the diverse patient populations that orthopaedic surgeons care for, even with improved clinical surveys and sophisticated statistical modeling. But this is beside the point. We as providers should start by simply appreciating that a variety of psychosocial stressors affect not only our individual patients on a national scale, but just as importantly, a smaller microcommunity scale. Although familiarizing yourself with all of these complex stressors overnight is nearly impossible, being attentive to the local news and continuing to lend an inquisitive ear when patients divulge difficult social circumstances allows us to slowly familiarize ourselves with a growing repository of diverse social contexts to better care for our patients [8].

Our acknowledgment of these stressors is a critical step in providing holistic and culturally competent care, especially for individuals from communities who may be disproportionately affected by national stressors, socioeconomic deprivation, neighborhood violence, or systemic racism. It is of course not incumbent on any orthopaedic provider to fully understand or address all these complex stressors, but instead, all of us need to be willing to respond clinically to the psychosocial forces that shape our patients’ lives, to the best of our abilities. This can be as simple as providing an emotionally empathetic statement to a patient or even asking a question to better understand a patient’s social context or support systems. This in turn will not only increase the trust many of our patients have in us as surgeons but also allow us to direct patients to the appropriate clinical and mental health resources that they otherwise may not have been referred to.