Editorial Comment: Comprehensive Orthopaedic Care

David Ring MD, PhD

In parallel with the human tendency towards a false mind-body dichotomy, healthcare for mental and physical problems have developed along separate paths. While all forms of illness are stigmatized to greater or lesser degrees, there is little doubt that patients with psychological conditions experience greater stigma. Access to mental health care is constrained, compared to access for somatic illness. In fact, different insurance mechanisms are in place for each, making matters still more complicated for those with psychiatric illnesses. This division reinforces the stigma associated with mental health—that it is a weakness, flaw, failing, or something to be ashamed of. The marked prevalence of illness constructions that are at least as likely to be somatoform disorders as they are to be some as-of-yet elusive pathophysiology (for example, fibromyalgia) reflect, in part, that it is more socially acceptable to report physical than mental symptoms [6].

A survey by the World Health Organization determined that major depression has a greater impact on health than major medical disorders (like angina, arthritis, and diabetes) and incrementally worsens health when comorbid to medical illness [3]. Comorbid major depression often goes undiagnosed and undertreated [4].

The success of collaborative care—the coordination and co-location of mental and physical health clinicians in both outpatient and inpatient medical settings—is inspiring [1]. But to me, this is just the start. Symptoms of depression and anxiety occur on a continuum and, along with less-effective coping strategies such as catastrophic thinking, are the main determinants of symptom intensity for a given pathophysiology [7]. Helping people get and stay healthy has as much to do with helping them reduce stress, and cultivate effective coping strategies, as with treating a disease. If “collaborative care” categorizes people and directs them to mental health treatment, the term “comprehensive care” should be used in reference to a more-complete biopsychosocial approach to health.

In comprehensive care, all clinicians (1) recognize the verbal and nonverbal signs of stress, distress, and less-effective coping strategies; (2) are trained in compassionate, empathetic, and relationship-centered care as a way to gain a patient’s trust, limit low-value tests and treatments, and increase a patient’s motivation in improving their habits, mindset, and coping strategies; (3) understand enough about psychology and communication science to help contribute to improved mental health; and (4) teach mental health clinicians enough about the medicine to accurately identify cognitive errors and other opportunities for improved health.

I admire and thank the researchers who contributed to this symposium on comprehensive care in orthopaedic surgery. Collectively, the work published herein helps us understand that patient-reported outcomes may be insufficient in measuring quality at the point of care. It also notes that patients and loved ones are not always in tune with the psychosocial aspects of illness, and as such, more-effective coping strategies are available. Additionally, these papers help us better understand that illness constructions such as Complex Regional Pain Syndrome [2] and “pillar pain” [5] may hinder the biopsychosocial paradigm by falsely labeling ineffective coping strategies and somatization. Finally, this symposium recognizes that a patient’s expressed preferences may not match his or her values, particularly among people with limited health literacy. Knowing all of this might intensify our efforts for implementing decision aids and incremental care to ensure accurate diagnosis of patient preferences.

I am confident that the major advances in musculoskeletal health in the next 10 years will be realized in care strategies that improve resiliency and self-care. I hope this symposium helps clinicians to help their patients to get healthy and stay that way.