Editorial Comment: The Third Annual I-MESH Symposium

The evidence is consistent and compelling: The traditional orthopaedic focus on the technical and physical overlooks opportunities to help people get and stay well by cultivating healthier stories about their bodies and nurturing secure and supportive environments. The International Consortium for Musculoskeletal Mental and Social Health (I-MESH) was formed in 2020 to provide a forum for people in any discipline who find the evidence associating the importance of mindsets and circumstances with levels of musculoskeletal comfort and capability compelling [11]. I-MESH includes physicians; nurses; physician assistants; physical, occupational, and hand therapists; athletic trainers; psychologists; social workers; communication scholars; ethicists; administrators; and others. We work together to further improve the evidence on these topics, and develop and implement novel interventions and models to improve healthcare delivery for individuals with musculoskeletal illness. Please join us at https://i-mesh.org/.

We hope this year’s third annual I-MESH selected proceedings in CORR® appeals to you. Perhaps you can start by embracing a study in this symposium that measured surgeon unconscious bias in favor of specific pathophysiology over nonspecific symptoms [8]. Bias is part of human intelligence and should inspire curiosity and preparation rather than shame. The human mind’s mental short cuts (heuristics) lead us to what the mind intuits as likely high-yield concepts. These short cuts can be accurate and useful, but they are error-prone. Curiosity, critical thinking, and the scientific method can help us work through these biases to better help our patients. Many human illnesses are characterized by symptoms that are more intense, diffuse, impactful, or longer-lasting than one can account for based on pathophysiology. Evidence increasingly supports a conclusion that these aspects of human illness can, to a notable degree, be accounted for by thoughts, emotions, and circumstances [6, 9]. Perhaps the evidence that our bias is toward specific pathophysiology will draw you in to the evidence that human illness tends to be far more complex.

A sensation becomes a symptom if it becomes a concern [3]. A study of people presenting with symptoms from hip and knee osteoarthritis confirms that unhelpful thoughts (worst-case thinking, fear of painful movement) and feelings of distress regarding sensations—essentially one’s inner narrative about one’s body—are key contributors to levels of discomfort and incapability [4]. We find the evidence that mindsets are closely tied to symptom intensity quite hopeful, because mindset is often easier to change than actual discomfort. This evidence may elucidate the strategies that people with well-accommodated sensations from pathophysiology such as osteoarthritis [5] and rotator cuff tendinopathy [10] identified in population studies are using to limit discomfort and incapability. Perhaps the people not seeking care are those who interpret the sensations from their aging bodies in a relatively healthful manner and thus are able to adjust and live well with these sensations. There are evidence-based strategies for cultivating healthy interpretations that everyone can learn and practice [12].

There are a few areas where biopsychosocial lines of evidence may lead to cognitive dissonance for orthopaedic surgeons. We encourage reflection on the following with the aim of seeing a more comprehensive, evidence-based way forward. Most surgery for musculoskeletal pathophysiology is discretionary. Levels of musculoskeletal comfort and capability have limited correspondence with pathophysiology severity [2, 7]. A large percentage of musculoskeletal pathophysiology represents aspects of human senescence. Treatments, including surgery, have notable nonspecific effects, meaning that the perceived benefits are unrelated to addressing pathophysiology. Treatments may not be as beneficial as they seem and much of the perceived improvement with treatment is often better credited to the patient’s “inner pharmacy” of hormones and neurotransmitters invigorated by a healthier narrative (the placebo effect) [1]. And finally, that surgeons and all clinicians can experience both stress/emotion contagion and moral distress from a sense of inaction. Surgeons may be more helpful to their patients and experience greater enjoyment in their work in proportion to their awareness of these processes, and they may develop an appreciation of the health value of standing with people and guiding them to a healthier regard for their bodies.

David Ring MD, PhD

Ana-Maria Vranceanu PhD