Abstract
Background
Unhelpful thoughts and feelings of distress regarding symptoms account for a large proportion of variation in a patient’s symptom intensity and magnitude of capability. Clinicians vary in their awareness of this association, their ability to identify unhelpful thoughts or feelings of distress regarding symptoms, and the skills to help address them. These nontechnical skills are important because they can improve treatment outcomes, increase patient agency, and foster self-efficacy without diminishing patient experience.
Questions/purposes
In this survey-based study, we asked: (1) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the total number of identified instances of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters? (2) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the interobserver reliability of a surgeon’s identification of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters?
Methods
Surgeons from an international collaborative consisting of mostly academic surgeons (Science of Variation Group) were invited to participate in a survey-based experiment. Among approximately 200 surgeons who participate in at least one experiment per year, 127 surgeons reviewed portions of transcripts of actual new musculoskeletal specialty encounters with English-speaking patients (who reported pain and paresthesia as primary symptoms) and were asked to identify language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. The included transcripts were selected based on the rated presence of language reflecting unhelpful thinking as assessed by four independent researchers and confirmed by the senior author. We did not study accuracy because there is no reference standard for language reflecting unhelpful thoughts or feelings of distress regarding symptoms. Observers were randomized 1:1 to receive supportive information or not regarding definitions and examples of unhelpful thoughts or feelings of distress regarding symptoms (referred to herein as “priming”) once at the beginning of the survey, and were not aware that this randomization was occurring. By priming, we mean the paragraph was intended to increase awareness of and attunement to these aspects of human illness behavior immediately before participation in the experiment. Most of the participants practiced in the United States (primed: 48% [29 of 60] versus not primed: 46% [31 of 67]) or Europe (33% [20 of 60] versus 36% [24 of 67]) and specialized in hand and wrist surgery (40% [24 of 60] versus 37% [25 of 67]) or fracture surgery (35% [21 of 60] versus 28% [19 of 67]). A multivariable negative binomial regression model was constructed to seek factors associated with the total number of identified instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. To determine the interobserver agreement, Fleiss kappa was calculated with bootstrapped 95% confidence intervals (resamples = 1000) and standard errors.
Results
After controlling for potential confounding factors such as location of practice, years of experience, and subspecialty, we found surgeons who were primed with supportive information and surgeons who had 11 to 20 years of experience (compared with 0 to 5 years) identified slightly more instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms (regression coefficient 0.15 [95% CI 0.020 to 0.28]; p = 0.02 and regression coefficient 0.19 [95% CI 0.017 to 0.37]; p = 0.03). Fracture surgeons identified slightly fewer instances than hand and wrist surgeons did (regression coefficient -0.19 [95% CI -0.35 to -0.017]; p = 0.03). There was limited agreement among surgeons in their ratings of language as indicating unhelpful thoughts or feelings of distress regarding symptoms, and priming surgeons with supportive information had no influence on reliability (kappa primed: 0.25 versus not primed: 0.22; categorically fair agreement).
Conclusion
The observation that surgeons with brief exposure to supportive information about language associated with unhelpful thoughts and feelings of distress regarding symptoms identified slightly more instances of such language demonstrates the potential of training and practice to increase attunement to these important aspects of musculoskeletal health. The finding that supportive information did not improve reliability underlines the complexity, relative subjectivity, and imprecision of these mental health concepts.
Level of Evidence
Level I, therapeutic study.
Introduction
Unhelpful thoughts regarding symptoms (such as worst-case thinking or fear of painful movement) account for a notable proportion of variation in symptom intensity and magnitude of incapability among patients with musculoskeletal illness [8, 17, 24, 30, 31, 34-36]. For instance, patients report more pain and lower capability when pain is misinterpreted as tissue damage [12] or when patients believe painful activities must be avoided (kinesiophobia) [18, 31]. Unhelpful thoughts have an even stronger influence on patient-reported health when there are greater symptoms of distress (such as feelings of worry or despair) [7, 8, 22, 23, 37, 38], underlining the importance of surgeon recognition of unhelpful thoughts and feelings of distress regarding symptoms.
Orthopaedic surgeons vary in their awareness of mental health, ability to identify unhelpful thoughts or feelings of distress regarding symptoms, comfort with making mental health a topic of discussion, and ability to gently reorient misconceptions associated with greater symptom intensity [32]. These nontechnical skills are important because they can improve treatment outcomes, increase patient agency, and foster self-efficacy without diminishing patient experience [7, 36, 37].
One important question is whether exposing surgeons to supportive information about patient language that indicates decreased mental health can improve their ability to detect these symptoms during patient encounters. Some preliminary studies among general practitioners indicated brief education can improve provider detection of psychologic distress [15, 28]. To our knowledge, there is limited evidence regarding the effect of an awareness intervention (priming) on the ability of musculoskeletal specialists to detect language reflecting unhelpful thoughts or feelings of distress regarding symptoms.
The aim of this survey-based study was to measure the degree to which surgeons can identify language and concepts rated as reflecting unhelpful thoughts or feelings of distress about symptoms in transcripts of patient encounters, and whether receiving educational information improves this identification. We asked: (1) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the total number of identified instances of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters? (2) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the interobserver reliability of a surgeon’s identification of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters?
Materials and Methods
Study Design and Setting
We performed a cross-sectional survey-based experiment using deidentified transcripts of patient encounters. Members of the Science of Variation Group were invited to participate via email in April 2021. The Science of Variation Group is an international collective of orthopaedic, plastic, and general surgeons (in Europe, fracture surgery is part of general trauma surgery) that studies variation in care. After the initial invitation, nonresponders were sent three weekly reminders. A survey was created and distributed through an online survey design tool, SurveyMonkey.
Randomization and Intervention
At the start of the survey, surgeons were randomized 1:1 (simple randomization) to receive or not receive supportive information that included definitions and examples of unhelpful thoughts or feelings of distress regarding symptoms (referred to here as “priming”) (Table 1). Participants were not aware of this part of the experiment. Surgeons who were primed with supportive information were reminded of the strong association of unhelpful thinking and feelings of distress with symptom intensity once at the start of the survey and were then potentially more attuned to these aspects of human illness behavior as they considered the patient transcripts. Priming is a phenomenon in which exposure to one stimulus will prepare someone for a subsequent stimulus of a particular situation, without a conscious intention [3]. Participants reviewed 15 fragments of transcripts of audio or video recordings of musculoskeletal specialty visits and were asked to identify examples of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms in 15 transcripts of patient narratives, divided into four to eight sentences each, for a total of 74 rated sentences. The transcripts were collected from new patient encounters in musculoskeletal specialty care and represented English-speaking patients with pain and paresthesia as the most common primary symptoms. The included transcripts were selected based on the rated presence of unhelpful thinking or feelings of distress regarding symptoms as assessed by four independent researchers (MN, SP, RL, DR, the first three of whom are not authors of this study) and one study author (DR) and confirmed by the senior author (DRing). These selected aspects of the transcripts were edited for brevity and readability.
Table 1.
Supportive information provided to one group in the study
| Definitions and examples of unhelpful thoughtsa and feeling of distress regarding symptoms |
| Unhelpful thoughts |
| Definition: the way a particular person understands events, facts, and other people, which is based on his or her own particular set of beliefs and experiences and may not be reasonable or accurateb. |
| Examples of unhelpful thoughts regarding symptoms: |
|
| Distress |
| Definition: feelings of worry or despairb |
| Examples of distress: |
|
Referred to as “cognitive bias” in the original material shown to the participant, but updated here to reflect important evolutions in language. Cognitive biases (automatic thoughts) can be helpful or unhelpful.
If we were to perform this study again today, an “unhelpful thought” would be defined as a misconception that reinforces worst-case thinking or fear of painful movement that makes a person feel more discomfort and less capability. “Feelings of distress” would be defined as an emotion that makes a person feel worse and do less.
Participants were asked to mark a checkbox at the end of each sentence they felt contained language reflecting unhelpful thoughts or feelings of distress regarding symptoms. There is no reference standard for language reflecting unhelpful thoughts or feelings of distress, and we did not study accuracy. When we use the term “identified,” we do not imply any accuracy (right or wrong); instead, this term should be interpreted as flagging something as present or not. At the end of the survey, surgeons completed the Jefferson Scale of Empathy [39], a measure of self-rated empathy used to investigate associations between empathy and instances of language identified as reflecting unhelpful thinking or feelings of distress. The Jefferson Scale of Empathy is a 20-item instrument that measures physician rating of their own empathy on a seven-point Likert scale. Raw scores were converted to scores ranging between 0 and 100, with a higher score indicating higher self-rated empathy [39].
Participants
All surgeons from the Science of Variation Group were invited to participate. Among the approximately 200 surgeons who participate in at least one experiment a year, 77% (153 of 200) started the survey, 83% of whom (127 of 153) rated all sentences. Participants receive no financial incentives but are offered group authorship for the current study. There were no differences in surgeon characteristics between surgeons who completed all scenarios and those who did not or between surgeons who were primed and those who were not. All incomplete responses were excluded. Forty-seven percent (60 of 127) of surgeons were randomized to receive supportive information and 53% (67 of 127) were randomized to not receive supportive information. Most participants were men (primed: 85% [51 of 60] versus not primed: 96% [64 of 67]) (Table 2). Most practiced in the United States (primed: 48% [29 of 60] versus not primed: 46% [31 of 67]) or Europe (primed: 33% [20 of 60] versus not primed: 36% [24 of 67]) and specialized in hand and wrist surgery (primed: 40% [24 of 60] versus not primed: 37% [25 of 67]) or fracture surgery (primed: 35% [21 of 60] versus not primed: 28% [19 of 67]). The group labeled fracture surgeons consisted of any type of surgeon who primarily treats fractures, which includes general trauma surgeons practicing in Europe and orthopaedic trauma surgeons practicing in the United States.
Table 2.
Surgeon demographics (n = 127)
| Value | Primed (n = 60) | Not primed (n = 67) |
| Men, % (n) | 85 (51) | 96 (64) |
| Location, % (n) | ||
| United States | 48 (29) | 46 (31) |
| Europe | 33 (20) | 36 (24) |
| Other | 18 (11) | 18 (12) |
| Years of experience, % (n) | ||
| 0 to 5 | 23 (14) | 25 (17) |
| 6 to 10 | 15 (9) | 30 (20) |
| 11 to 20 | 33 (20) | 27 (18) |
| 21 to 30 | 28 (17) | 18 (12) |
| Supervising trainees, % (n) | 82 (49) | 90 (60) |
| Subspecialty, % (n) | ||
| Hand and wrist | 40 (24) | 37 (25) |
| Shoulder and elbow | 12 (7) | 12 (8) |
| Fracture surgery | 35 (21) | 28 (19) |
| Other | 13 (8) | 22 (15) |
| JSE score, median (interquartile range) | 79 (74 to 85) | 78 (71 to 84) |
| Number of identified instances of the findings listed below, median (interquartile range) | ||
| No distress or unhelpful thoughts | 33 (18 to 43) | 36 (28 to 47) |
| Distress | 16 (9 to 23) | 19 (13 to 23) |
| Unhelpful thoughts | 25 (17 to 33) | 15 (8 to 23) |
| Both distress and unhelpful thoughts | 0 (0 to 2) | 0 (0 to 5) |
JSE = Jefferson Scale of Empathy (0 to 100), in which higher scores represent greater empathy.
Primary and Secondary Study Outcomes
The primary response variable was the total number of instances a surgeon identified language representing unhelpful thoughts, symptoms of distress, or both unhelpful thinking and symptoms of distress. We did not study accuracy because there is no reference standard for language reflecting unhelpful thoughts or feelings of distress regarding symptoms. The secondary response variable was surgeon rating of language as reflecting unhelpful thinking or feelings of distress in a particular sentence or not (no unhelpful thoughts or symptoms of distress versus unhelpful thoughts, symptoms of distress, or both).
Statistical Analysis
Descriptive statistical analyses were performed for all participants. Continuous data are reported as the mean with standard deviation, and categorical variables are presented as percentages with numerators and denominators. A multivariable negative binomial regression analysis was used to seek factors associated with the total number of rated instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. We also used negative binomial regressions to seek factors associated with the total number of rated instances of language believed to reflect unhelpful thoughts and feelings of distress separately, in which the “both” answers were counted in both models. The interobserver agreement was calculated using Fleiss kappa with bootstrapped 95% confidence intervals (resamples = 1000) and standard errors. Kappa values were compared between all explanatory subgroups, including the provision of supportive information or not, using a two-sample Z-test. The Landis and Koch classification of categorical data was used to interpret kappa values: Values between 0.01 to 0.20 indicate slight agreement; 0.21 to 0.40, fair agreement; 0.41 to 0.60, moderate agreement; 0.61 to 0.80, substantial agreement; and 0.81 to 0.99, almost perfect agreement [21]. All p values below 0.05 were considered statistically significant.
An a priori sample size calculation determined that 102 participants would generate 80% statistical power based on a linear regression model with five predictors, if receiving educational information would explain 10% of the variation in ratings of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms, with alpha set at 0.05.
Results
Association Between Surgeon Factors and Identification of Language Believed to Reflect Unhelpful Thoughts or Feelings of Distress Regarding Symptoms
Accounting for potential confounders such as location of practice, years of experience, subspecialty, and self-rated empathy, we found that a slightly higher number of identified instances of language believed to reflect unhelpful thoughts or feelings of distress was associated with priming surgeons with supportive information (regression coefficient 0.15 [95% CI 0.020 to 0.28]; p = 0.02) and with surgeons who had 11 to 20 years of experience compared with those with 0 to 5 years (regression coefficient 0.19 [95% CI 0.017 to 0.37]; p = 0.03). The subspecialty of fracture surgery was associated with a slightly lower number of identified instances of language believed to reflect feelings of distress or unhelpful thoughts compared with hand and wrist surgeons (regression coefficient -0.19 [95% CI -0.35 to -0.017]; p = 0.03) (Table 3). In separate analyses of language rated as reflecting unhelpful thoughts and language rated as reflecting feelings of distress, we found that priming with supportive information was associated with a moderately higher number of identified instances of language believed to reflect unhelpful thoughts (regression coefficient 0.38 [95% CI 0.18 to 0.58]; p < 0.01) (Supplemental Table 1; http://links.lww.com/CORR/A991), while priming with supportive information was associated with a marginally lower number of identified instances of language believed to reflect feelings of distress (regression coefficient -0.18 [95% CI -0.35 to -0.013]; p = 0.03) (Supplemental Table 2; http://links.lww.com/CORR/A992).
Table 3.
Factors associated with the total number of rated instances of language believed to reflect unhelpful thoughts and/or feelings of distress regarding symptoms
| Parameter | Regression coefficient (95% confidence interval) | p value |
| Supportive informationa | ||
| Absent (not primed) | Reference value | |
| Present (primed) | 0.15 (0.020 to 0.28) | 0.02 |
| Gender | ||
| Women | Reference value | |
| Men | 0.18 (-0.036 to 0.40) | 0.10 |
| Location | ||
| United States | Reference value | |
| Europe | -0.0073 (-0.17 to 0.15) | 0.93 |
| Other | 0.17 (-0.013 to 0.34) | 0.07 |
| Years of experience | ||
| 0 to 5 | Reference value | |
| 6 to 10 | 0.18 (-0.0076 to 0.36) | 0.06 |
| 11 to 20 | 0.19 (0.017 to 0.37) | 0.03 |
| 21 to 30 | 0.18 (-0.0034 to 0.37) | 0.05 |
| Supervising traineesb | ||
| No | Reference value | |
| Yes | 0.021 (-0.17 to 0.21) | 0.82 |
| Subspecialty | ||
| Hand and wrist | Reference value | |
| Shoulder and elbow | -0.11 (-0.32 to 0.092) | 0.28 |
| Fracture surgery | -0.19 (-0.35 to -0.017) | 0.03 |
| Other | -0.028 (-0.21 to 0.16) | 0.77 |
| JSE score | -0.0015 (-0.0074 to 0.0044) | 0.62 |
Negative binomial regression analysis. The regression coefficients are reported in relation to the chosen reference variable. Effect sizes can be interpreted as slight for regression coefficients of -0.20 to -0.10 and 0.10 to 0.20, and as negligible for -0.10 to 0 and 0 to 0.10.
aProvision of supportive information about definitions and examples of unhelpful thoughts and/or feelings of distress regarding symptoms, as displayed in Table 1.
bSupervision of trainees means the surgeon works with residents or fellows. JSE = Jefferson Scale of Empathy.
Can Observers Reliably Identify Language and Concepts Reflecting Unhelpful Thoughts or Feelings of Distress Regarding Symptoms?
The interobserver agreement of surgeon ratings of instances of language believed to reflect unhelpful thoughts or feelings of distress was fair, and it did not improve when surgeons were primed with supportive information. The kappa value was 0.25 (95% CI 0.20 to 0.31) for surgeons who were primed with supportive information and 0.22 (95% CI 0.17 to 0.26) for surgeons who were not primed (p = 0.30) (Supplemental Table 3; http://links.lww.com/CORR/A993). Surgeons practicing in the United States had considerably higher interobserver agreement (with no overlapping 95% CI) than surgeons practicing outside the United States, regardless of whether they were primed with supportive information (among primed: 0.33 [95% CI 0.26 to 0.39] versus 0.19 [95% CI 0.14 to 0.25]; p < 0.01, and among not primed: 0.28 [95% CI 0.22 to 0.34] versus 0.16 [95% CI 0.12 to 0.20]; p < 0.01).
Discussion
Early identification of unhelpful thoughts or feelings of distress regarding symptoms and appropriate management can improve patient health by alleviating symptoms and increasing capability. This study tested whether there are any factors associated with the total number of identified instances of language rated as reflecting unhelpful thoughts (such as worst-case thinking and fear of painful movement [kinesiophobia]) or feelings of distress regarding symptoms, as well as factors associated with the interobserver reliability of such ratings, including priming with supportive information about unhelpful thinking and symptoms of distress regarding symptoms. Provision of supportive information was associated with a slightly higher number of identified instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms but was not associated with more reliable identification of such language. These findings underline the complexity, relative subjectivity, and imprecision of these concepts, and might reflect a lack of knowledge among clinicians about unhelpful thoughts and symptoms of distress that cannot be addressed with a simple, brief priming tool. The small effect of priming with this tool suggests there may be merit to investigating the ability of more-extensive training to meaningfully improve identification of unhelpful thoughts or feelings of distress regarding symptoms in musculoskeletal specialty care.
Limitations
First, there is no consensus definition of whether a portion of a transcript reflects unhelpful thoughts or feelings of distress regarding symptoms, and we could not test accuracy. Therefore, we were also unable to assess or account for potential excess rating of unhelpful thoughts or feelings of distress regarding symptoms. We felt that a study about instances of identification and reliability of identification regarding unhelpful thoughts and feelings of distress about symptoms was an important step in this line of inquiry intended to improve the diagnosis and treatment of musculoskeletal illness. In addition, there is little harm in overidentifying potential unhelpful thinking and feelings of distress regarding symptoms [7, 36, 37]. Second, the members of the Science of Variation Group do not represent the typical practicing surgeon (for instance, 86% were supervising trainees), and the absolute numbers and coefficients are unlikely to be reproduced in other populations. Survey-based experiments depend on adequate diversity in the sample. If we achieved adequate diversity in responses in our sample, the relationships identified ought to be reproducible in other samples with sufficient variation in responses. Third, this study could not use incomplete responses because the primary outcome was the sum of rated instances believed to reflect unhelpful thoughts or feelings of distress for the full set of transcripts. Although there were no differences in surgeon characteristics between surgeons who completed all scenarios and those who did not, there may be psychologic differences we could not account for. If surgeons who are less comfortable identifying unhelpful thoughts or feelings of distress regarding symptoms were more likely to end the survey prematurely, this would result in an overestimation of surgeon discernment of language associated with unhelpful thoughts or feelings of distress regarding symptoms. This is another reason to place less attention on the numbers and coefficients and focus instead on the relationships and reliability. Fourth, the results of the assessment of language reflecting distress might be less robust because the transcripts were selected based on language reflecting unhelpful thinking. On the other hand, unhelpful thinking and feelings of distress tend to correlate with each other [1, 33]. Fifth, the wording of the supportive information (priming paragraph) would be worded differently today. We no longer use the term “cognitive bias” because such biases can be useful. A better term is unhelpful thoughts, which also avoids the pejorative tone of “misconceptions.”
Finally, written transcripts cannot capture a patient’s body language or tone, which might play a role in identifying unhelpful thoughts or feelings of distress regarding symptoms in clinical practice [10]. However, the use of scenarios based on transcripts of actual patient visits provides a practical means to begin to study surgeon identification of unhelpful thoughts or feelings of distress regarding symptoms that could be expanded upon in more difficult studies involving observation or video recording of specialty care visits. Prior survey-based studies with written scenarios found plausible correlations that seem to provide useful information [6, 20, 27].
Association Between Surgeon Factors and Identification of Language Believed to Reflect Unhelpful Thoughts or Feelings of Distress Regarding Symptoms
The observation that surgeons identified slightly more instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms if they were primed with supportive information suggests training and practice could increase a surgeon’s attunement to unhelpful thoughts and feelings of distress about symptoms. In the subgroup analysis, this was especially the case for identifying unhelpful thoughts, which moderately improved after priming surgeons with supportive information. The slight decrease in identification of feelings of distress may be spurious, or the priming may have prompted surgeons to classify statements they would have considered signs of distress as reflecting unhelpful thinking, or it may be an artifact of having selected transcripts for language believed to reflect unhelpful thinking. To our knowledge, no prior studies have addressed musculoskeletal specialist detection of unhelpful thoughts or feelings of distress regarding symptoms, but there is relevant evidence from studies that address the detection of symptoms of distress by other types of clinicians specifically (Table 4) [2, 11, 15, 16, 26, 28]. These studies suggest awareness or detection can increase after brief training sessions. A next step might be to test the effectiveness of a more-extensive training program focused on recognizing unhelpful thinking and feelings of distress, understanding the important role of mindsets in musculoskeletal health, emotional self-awareness and confidence-building, and training in effective communication strategies. Some have suggested the use of a checklist during consultation [15].
Table 4.
Summary of relevant evidence regarding identification of symptoms of distress
| Study | Setting | Key findings |
| Howe [15] | 19 general practitioners | After a brief educational training, general practitioners detected 8% more instances of distress (from 44% to 52%) among a patient population in which 40% scored above a threshold of General Health Questionnaire (reference standard). General practitioners with the worst baseline tendency to make psychologic diagnoses improved the most after training. |
| Pfaff et al. [28] | 23 general practitioners | After a brief educational training session, general practitioners identified more patients with symptoms of distress who scored above a certain cutoff on the General Health Questionnaire-12 and Center for Epidemiologic Studies–Depression scale, with proportions of 48% and 40%, respectively. The identification of patients with suicidal ideation scoring above a certain cutoff on Depressive Symptom Inventory–Suicidality Subscale increased by 130%, with a substantial reduction of false negatives and minimal increase of false positives. |
| Fukui et al. [11] | Eight nurses at a cancer screening center | In a randomized controlled trial, distress ratings of nurses had a stronger association with patient-reported distress when a communication skills training was completed (0.57 versus 0.12 at 1 week after cancer diagnosis, 0.46 versus 0.05 at 1 month, and 0.62 versus 0.20 at 3 months). The training consisted of two sessions at the beginning and end of a 3-month period and used a brief, highly structured and systematic six-step model developed by Baile et al. [2]. |
| Jacobs et al. [16] | 26 physical therapists (musculoskeletal department) | Brief psychologically informed physiotherapy training was associated with a considerably higher score for biopsychosocial aspects and lower score for biomedical aspects of the Pain Attitudes and Beliefs Scale for Physiotherapists questionnaire regarding the treatment of patients with chronic pain. |
| Merckaert et al. [26] | 58 physicians treating cancer patients | In a randomized controlled trial, 19 hours of training with lectures focused on communication and management (2 hours) and role-playing sessions (17 hours) did not alter physician detection of symptoms of distress among patients treated for cancer, but did improve elicitation and clarification of psychologic concerns. |
Can Observers Reliably Identify Language and Concepts Reflecting Unhelpful Thoughts or Feelings of Distress Regarding Symptoms?
The interobserver reliability of identified language believed to reflect unhelpful thoughts or feelings of distress about symptoms was limited and unrelated to receiving supportive information. This might reflect the relative subjectivity and imprecision of these concepts, or it might reflect a lack of training and awareness of language believed to reflect unhelpful thoughts and symptoms of distress regarding symptoms. Although there is a limited amount of evidence about the identification of unhelpful thoughts and symptoms of distress in specialty care, studies in other disciplines found limited reliability among clinicians [19, 29]. For example, a study with 43 patients with psoriasis compared patient perceptions of symptoms of distress measured with the Hospital Anxiety and Depression Scale with the perception of dermatologists regarding the probability a patient would experience a threshold level of symptoms of distress (anxiety and depression) [29]. Dermatologist determinations were 50% and 60% sensitive and 26% and 21% specific for a threshold level of symptoms of anxiety or depression, respectively. As in our study, the interobserver agreement (kappa value of 0.26; categorically fair) in the clinician’s designations was limited. Another study compared recognition of a threshold level of psychologic distress among patients with musculoskeletal illness seeing a general practitioner and again found fair interobserver agreement (kappa values ranging from 0.22 to 0.30) [19]. These findings underline the relative subjectivity and imprecision of these concepts as well as the potential influence of unfamiliarity and lack of training. The work of the Science of Variation Group and others has identified limited reliability (notable disagreement) as a common feature in musculoskeletal medicine, and one that is difficult to improve upon [4, 5, 9, 13, 14, 25]. Training programs as discussed might help, but a key factor may simply be an awareness of limited reliability in our daily work. If we are attuned to the mindset aspects of musculoskeletal health, we might disagree on where these are noted in the visit, while still arriving at a useful diagnosis and helpful management strategy.
Conclusion
In this survey-based study, surgeons identified more instances of language reflecting unhelpful thoughts if they received a brief training and awareness paragraph, demonstrating the potential for training and practice to improve a surgeon’s ability to identify unhelpful thoughts and symptoms of distress. On the other hand, identification of unhelpful thoughts or feelings of distress regarding symptoms had only slight interobserver reliability unrelated to priming with supportive information before the survey. A continuation of this line of research might address whether more-extensive clinician training focusing on increasing knowledge, self-awareness, skills, and confidence can result in more-reliable surgeon identification of unhelpful thoughts or feelings of distress regarding symptoms among people seeking musculoskeletal specialty care. It is no surprise that a brief one-page supportive document had only a slight association with more ratings of language reflecting unhelpful thinking and no influence on reliability. What is notable, and hopeful, is that such a small intervention had any measurable influence at all.
Group Authorship
Members of the Science of Variation Group include: Julie E. Adams, Lars Adolfsson, Ngozi M. Akabudike, Thomas Apard, Hannu T. Aro, Duffield Ashmead IV, H. Utkan Aydin, George C. Babis, B. Todd Bafus, Efstathios G. Ballas, Taizoon Baxamusa, Grant J. Bayne, Jan Biert, Julius A. Bishop, Frank W. Bloemers, Ole Brink, Henry Broekhuyse, Jacob W. Brubacher, Richard Buckley, Ken Butters, Juan C. Cagnone, Maurizio Calcagni, Chris E. Casstevens, Brett D. Crist, Ramon de Bedout, Kyle Dickson, Julio Domenech, C. Liam Dwyer, Nelson Elias, John E. Erickson, John P. Evans, Carlos Henrique Fernandes, Frede Frihagen, Christos Garnavos, R. Glenn Gaston, Richard S. Gilbert, Vincenzo Giordano, Amparo Gomez Gelvez, Amanda I. Gonzalez, Taco Gosens, Michael W. Grafe, Jose Eduardo Grandi Ribeiro Filho, Jeffrey A. Greenberg. T. G. Guitton, Warren C. Hammert, Ian Harris, Tomo Havliček, Bernard F. Hearon, Steve L. Henry, Nathan A. Hoekzema, Peter E. Hoepfner, Eric P. Hofmeister, Peter Jebson, Richard Jenkinson, Scott G. Kaar, Koroush Kabir, F. Thomas D. Kaplan, Matej Kastelec, Stephen A. Kennedy, Cyrus Klostermann, George Kontakis, G. A. Kraag, Anze Kristan, Lewis B. Lane, Nikolaos G. Lasanianos, Aaron Lawson McLean, Kendrick E. Lee, Nina Lightdale-Miric, Naquira Escobar Luis Felipe, Hal McCutchan, Toni M. McLaurin, Ladislav Mica, Constanza L. Moreno-Serrano, Jesus Moreta, Steven J. Morgan, James F. Nappi, Vasileios S. Nikolaou, Betsy M. Nolan, Michael Jason Palmer, Juan M. Patiño, David P. Patterson, Rodrigo Pesantez, Marinis Pirpiris, L. M. S. J. Poelhekke, Dan Polatsch, Andrew John Powell, Ante Prkic, Michael Quell, Ashish S. Ranade, Martin Richardson, Craig Rodner, Edward K. Rodriguez, Juan Miguel Rodrígues Roiz, Sergio Rowinski, Jorge Rubio, David Ruch, Michell Ruiz-Suarez, Julie Balch Samora, Ellen Satteson, Peter Schandelmaier, Tim Schepers. Andrew Schmidt, Evan D. Schumer, Adam B. Shafritz, Todd Siff, Andy B. Spoor, Emilia Stojkovska Pemovska, Philipp Streubel, Fabio Suarez, Ben Sutker, Marc Swiontkowski, Lisa A. Taitsman, Andrew L. Terrono, Eric T. Tolo, Minos Tyllianakis, Christiaan J. A. van Bergen, Huub van der Heide, Anne J. H. Vochteloo, Erik T. Walbeehm, Ralf P. Walbeehm, Daniel C. Wascher, Yoram Weil, Carl Weiss, Lawrence Weiss, Ezequiel E. Zaidenberg, Charalampos Zalavras, and David W. Zeltser.
Acknowledgments
We thank Marielle Ngoue MD, Stephen Pierson BS, Dayal Rajagopalan MD, and Ryan Liam BS for organizing and rating the transcripts used in this study.
Footnotes
aMembers of the Science of Variation Group can be found in an Appendix at the end of this article.
Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
This study was deemed exempt from ethical review board approval by the University of Texas at Austin, Austin, TX, USA (number 2020-05-0040).
This work was performed at the University of Texas at Austin, Austin, Texas, USA.
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