CORR Insights®: Clinician Facial Expression of Emotion Corresponds with Patient Mindset

Where Are We Now?

The experience of musculoskeletal pain is multidimensional, involving complex interactions among social, psychological, and biomedical factors. The subtle but substantial shift in terminology from “biopsychosocial” to “sociopsychobiomedical” in recent years denotes growing interest in the multidimensional aspects of the musculoskeletal pain experience among the research community [6] .

The study by Versluijs and et al. [11] builds on existing evidence that musculoskeletal clinicians (orthopaedic surgeons, physicians, allied health professionals) widely accept that social and psychological factors play a role along side biomedical factors in the experience of musculoskeletal pain. Unlike previous research, which has relied on clinicians’ self-reporting of explicit beliefs and attitudes around the role of social and psychological factors [3], the current study taps into clinicians’ implicit beliefs and attitudes by studying their behavior as revealed through their facial expressions. In the study by Versluijs et al. [11], clinicians' facial expressions were associated with patient health anxiety, generalized anxiety, and catastrophic thinking, which the authors interpret as evidence that the clinicians implicitly register sociopsychological aspects of the pain experience.

Facial expressions serve a communicative function, conveying understanding, empathy, and goodwill, which patients interpret as clinician warmth. Patient impressions of clinician warmth have been found to be associated with greater trust in the clinician, adherence to treatment protocols, and satisfaction with treatment outcomes [2]. Based on these discoveries, surgeons should be aware of the sociopsychological aspects of their patients' experience, including their own role as social participants in the clinical encounter whose displays of warmth can impact patient outcomes.

Where Do We Need To Go?

But what are the factors that shape perceptions of clinician warmth, and how important is clinician warmth to patients in the context of orthopaedic surgery?

Gender stereotypes appear to play a role in perceptions of clinician warmth. While women surgeons are perceived to display more warmth than men surgeons, this may reflect a greater willingness on the behalf of patients to disclose emotions to women surgeons, rather than men surgeons being less effective communicators [2]. There is also some evidence that clinicians display greater warmth toward patients with whom they identify more closely on characteristics, including gender and ethnic background [9]. While Versluijs and colleagues [11] included a diverse patient sample in their study, it is unclear whether or how clinicians’ facial expressions differed with patients whom they perceived to be more or less like themselves. Addressing unhelpful biases among clinicians is important because in high-stress contexts where time is scarce, clinicians can fall back on implicit biases [9].

Within the medical hierarchy, surgeons are typically rated lower on measures of warmth but higher on measures of competence compared with nonsurgeons [12]. The importance of clinician warmth to patients may depend on the condition for which they are seeking care. Patients have been shown to value warmth highly in interactions involving continuous shared decision-making over a prolonged period of time, such as with oncologists [5], but may value surgeon competence over warmth when undergoing one-off surgical treatment, particularly when the procedure is perceived to be more technically difficult and threatening [1]. It is notable that in their study, Versluijs and colleagues [11] found that clinicians’ facial expressions were not associated with patients’ evaluations of the patient-clinician interaction. From the perspective of patients seeking care for musculoskeletal conditions, the clinician’s primary role is to take action to ease suffering. While encounters with a cold clinician may heighten a patient’s distress, patients are unlikely to feel satisfied by an encounter with a clinician who is warm but perceived to be unable to help ease their suffering.

Registering the social and psychological aspects of a patient’s experience and demonstrating this through facial expressions is one thing; having the skills to act on the modifiable sociopsychological aspects of a patient’s experience is another thing. The consequence of this gap between knowledge and skills is captured nicely in this quote from a musculoskeletal clinician: “Why should I consider a patient’s fear and catastrophic thoughts if I don’t know what to do about it?” [10].

Musculoskeletal clinicians might feel that addressing the sociopsychological dimensions of the patient experience is outside of their professional scope of practice. But this perception is not shared by patients. Caring for the whole person is part of a physician’s role, and patients appropriately expect it of us [4].

How Do We Get There?

The first step to addressing the implicit biases that can influence a clinician’s demonstration of warmth is to draw attention to those biases. Tools such as that applied by Versluijs and colleagues [11] may shed light on clinicians’ implicit biases by assessing how facial expressions change in different contexts, such as when they are experiencing high levels of stress or during encounters with patients whom clinicians perceive to be more or less like themselves.

Clinicians might also reflect on their own biases [8] by asking themselves questions like:

• “How do I respond to my patients' displays of emotion?”

• “How do I respond differently with different patients?”

• “What do I find stressful or frustrating in clinical encounters?”

• “Do I feel equipped to explore sociopsychological aspects of my patients’ pain experiences?”

To understand what surgeon warmth and competence mean to patients in the context of orthopaedic surgery, qualitative research methods may be useful. For example, video recordings of the clinical encounter could be combined with debriefing interviews in which patients have the opportunity to watch the recording and comment on their own perceptions and responses in real time. This could provide rich insights into how patients perceive and respond to surgeon facial expressions and other behavioral displays of goodwill and empathy.

Training programs have been developed to equip musculoskeletal clinicians with the skills and confidence to identify and address modifiable sociopsychological aspects of the patient experience. These programs typically involve a combination of education, expert modeling, and practice with opportunities for feedback and ongoing mentoring [7]. Embedding these programs into surgical training curricula presents an opportunity to train the next generation of surgeons in a sociopsychobiomedical approach to care. As always, exploring patients’ perceptions of interactions with surgeons who have undergone this training will be important.