Editorial Comment: Symposium: Psychosocial Aspects of Musculoskeletal Illness

The aspects of illness unrelated to pathophysiology have long been the “elephant in the room” [1]. Orthopaedic surgeons are accustomed to patients asking to be “fixed” as if they were a broken machine. Our incentives are to attempt to identify pathophysiology that can be addressed with surgery, injection, or immobilization. Surgeons tend to be technically oriented, so we find this role comfortable.

David Ring MD, PhD

David C. Ayers MD

But the musculoskeletal system is a common somatic focus for stress and distress, and there is substantial variation in symptom intensity. The magnitude of disability for a given pathophysiology is explained largely by the effectiveness of one’s coping strategies. These are delicate issues. It is more acceptable to say “my body hurts” than “I am depressed.” Getting a patient to open up requires a trusting relationship and a safe environment—not the typical strong suit of an orthopaedic surgeon.

The American Academy of Orthopaedic Surgeons (AAOS) polled orthopaedic patients in the 1990s and found that they appreciated our technical skills, but thought our “bedside manner” could be better. The AAOS summarized this as “high tech, low touch” and organized the Communication Skills Mentoring program to help coach surgeons on more effective communication strategies. A recent study of outpatient satisfaction scores [3] shows that orthopaedic surgeons remain at the bottom of the list.

The pathway is clear when following the advice of Drs. George Engel and John Romano [2]. Their biopsychosocial model of illness is utilized to evaluate a patient with a musculoskeletal symptom [1]. Musculoskeletal illness is biological (arthritis, fracture), psychological (stress, distress), and sociological (family, work, disputes). Patients benefit when we recognize and address all aspects of their illness. When surgeons direct treatment towards a patient’s somatic focus without addressing the underlying stress, distress, and ineffective coping strategies, the result is not something to take pride in, and often fails to relieve the patient’s symptoms. One version of this is the so-called “failed back,” but we can attest to the “failed hands” and “failed knees” as well: Patients who received technically adequate—or even exceptional—surgical procedures, yet who remain (or became) symptomatic and disabled.

To do better, we will need better methods for assessing, discussing, and treating the psychosocial aspects of illness. This symposium brings together research addressing the psychosocial aspects of illness in many areas of orthopaedic surgery. As you will see, we are learning to measure these nontechnical aspects of musculoskeletal care and building towards a better way to address all facets of our patients’ illnesses.