Integrating patient values into evidence-based practice: effective communication for shared decision-making

Do patients' preferences and expectations match clinical guidelines? A survey of individuals seeking private primary care for a musculoskeletal disorder

BACKGROUND

Physiotherapists often inconsistently adhere to clinical practice guidelines (CPGs) when managing musculoskeletal disorders (MSKDs), potentially due to discrepancies between patient-valued interventions and guideline recommendations. Since patients' expectations are important predictors of outcome, this disparity between CPGs recommendations and patient preferences could be problematic for the effective care of MSKDs.

OBJECTIVES

To assess patients' expectations and preferences for the interventions used in their MSKD management and to establish correspondence rates between patients' preferences and recommendations from CPGs.

DESIGN

Survey.

METHOD

This cross-sectional descriptive study included a survey on sociodemographics, preferences, and expectations towards interventions for their MSKD, acceptable cost of care, number of treatment sessions required, and their involvement in their MSKD management.

RESULTS

One hundred and fifty participants (94 women and 56 men; mean age: 51 ± 17) responded to the survey. Eighty percent of respondents expected their involvement in their MSKD management to be equal to or superior than that of the physiotherapist. Sixty-nine percent of respondents expected to receive exercises, and 67% expected to receive education. Based on preference ratings, 95% of respondents chose recommended interventions, 57% chose interventions with uncertain levels of recommendation, and 48% chose interventions not recommended by CPGs.

CONCLUSION

Less than 70% of participants expected to receive education and exercises, the two most frequently recommended interventions by CPGs. On the other hand, the majority of respondents indicated that their involvement should be equal to or superior than that of the physiotherapist. This aligns with CPGs, which advocate for active and self-management strategies.

Effectiveness of Training in Evidence-Based Practice on the Development of Communicative Skills in Nursing Students: A Quasi-Experimental Design

BACKGROUND

Communication skills (CSs) and evidence-based practice (EBP) are key foundations for offering personalized and quality nursing care. CS that results in open communication is fundamental for applying EBP.

OBJECTIVES

The objective of the study was to assess the relationship between the acquisition of EBP competencies and learning CS after taking an EBP course in the nursing degree.

METHODS

Pre-test-post-test quasi-experimental study without a control group. The study population comprised fourth-year undergraduate nursing students. Before and after an EBP course, students completed a questionnaire on CS competence (HP-CSS) and EBP competence (EBP-COQ). The EBP course lasts for 15 weeks, with 150 h of work for the student. Out of these 150 h, 60 are conducted in person, while the remaining 90 h are for independent or group work, utilizing the flipped classroom methodology. Bivariate, correlational, pairwise Student's t-test, and linear regression multivariate analyses were performed.

RESULTS

The sample was composed of 153 students. After completing the EBP course, there was a statistically significant improvement in informative communication (p = 0.046) and assertiveness (p = 0.018). However, there were no observed changes in empathy, respect, and the total score of the CS competence. The results from the multivariate analysis showed that the dimensions of attitude towards EBP and EBP knowledge had a positive relation to three of the four dimensions of the CS and overall competence. Regarding the students' variables and characteristics, admission through special programs for athletes and older students (p < 0.001) and being female (p = 0.004) were positively statistically associated with empathy.

CONCLUSIONS

EBP training positively affects the development of CS in nursing students, as shown by significant improvements in the total scores of the CS and the dimensions of informative communication and assertiveness after the intervention. This study demonstrates the initial applicability and usefulness of an EBP training program for the development of CS in nursing students.

Exploring Patient Preferences Related to Shared Decision-Making in Chronic Disease Management

Background and objective Shared decision-making (SDM) in healthcare has transitioned from a paternalistic model to a collaborative approach, particularly significant in chronic disease management. This shift focuses on aligning healthcare decisions with patient preferences and values, thereby enhancing patient engagement and treatment adherence. However, patient preferences regarding involvement in SDM vary widely, influenced by demographic, disease-specific, psychological, cultural, and social factors. This study aimed to explore patient preferences related to SDM in chronic disease management in Saudi Arabia, by assessing attitudes toward SDM, the impact of decision aids, and the role of clinician communication in influencing these preferences. Methods A cross-sectional survey design was employed, involving 409 adult outpatients with chronic diseases attending four public hospitals in Saudi Arabia. Participants were selected using purposive and convenience sampling. The survey, translated into Arabic, collected demographic data and information on preferences and experiences in decision-making, communication, and information sharing. The data were analyzed using SPSS Statistics (IBM Corp., Armonk, NY) to identify patterns and correlations. Results Key findings indicated a strong preference among the participants for involvement in treatment decisions (n=303, 74.2%) and clear communication using layman's terms (n=338, 82.6%). Major barriers to active participation in SDM included lack of time during appointments (n=275, 67.2%), difficulty understanding medical terminology (n=220, 53.9%), and feeling intimidated to ask questions (297, 72.6%). Comfort in SDM was highest in the age group of 41-50 years [mean=4.16, standard deviation (SD)=28.44; F=2.3287, p=0.0739]. Patient satisfaction was significantly higher in the age group of 18-30 years (mean=3.42, SD=1.09; F=3.0503, p=0.0284). Conclusions Our findings highlight the need for incorporating patient preferences into chronic disease management strategies to enhance engagement and satisfaction.

Situational simulation teaching effectively improves dental students' non-operational clinical competency and objective structured clinical examination performance

BACKGROUND

Appropriate communication with dental patients enhances treatment outcomes and patient satisfaction. Implementing simulated patient interviews courses can improve patient-centered care and reduce conflict during clerkship training. Therefore, this study explored the relationship among student participation in a situational simulation course (SSC), academic performance, clerkship performance, and objective structured clinical examination (OSCE) performance.

METHODS

This study was conducted with a sample of fifth-year dental students undergoing clerkship training. After implementing a situational simulation course to investigate the relationship among participation in SSC, academic performance, clerkship performance, and OSCE performance, a path analysis model was developed and tested.

RESULTS

Eighty-seven fifth-year dental students were eligible for the SSC, and most (n = 70, 80.46%) volunteered to participate. The path analysis model revealed that academic performance had a direct effect on OSCE performance (β = 0.281, P = 0.003) and clerkship performance (β = 0.441, P < 0.001). In addition, SSC teaching had a direct effect on OSCE performance (β = 0.356, P < 0.001).

CONCLUSIONS

SSCs can enhance dental students' non-operational clinical competency and OSCE performance effectively. Simulated patient encounters with feedback, incorporated into the dental curricula, have led to improved communication. Based on our findings, we suggest implementing SSC teaching before the OSCE to improve communication and cognitive skills.

Factors influencing shared decision-making in long-term care facilities

BACKGROUND

Shared decision-making, a communicative process to reach decisions based on informed preferences, evidence, and co-created goals, improves care satisfaction and patients' quality of life. However, shared decision-making has not been widely implemented in long-term care facilities, and few studies have examined how to promote the shared decision-making practice. This study aimed to identify the influencing factors of shared decision-making based on the Person-centered Practice Framework in long-term care facilities.

METHODS

A total of 300 staff (nursing staff, social workers, and personal care workers) in 13 Korean long-term care facilities participated in this study. Data from 280 respondents were finally analyzed, excluding respondents with missing values. Data were collected using structured questionnaires that included items on shared decision-making, personal factors (e.g., knowledge about dementia, person-centered care education, person-centered attitude, communication behavior, and job tenure), and care environment factors (e.g., person-centered climate, staffing level, effective staff relationships, supportive supervisors, and power-sharing). Multilevel linear regression analyses were performed using Mplus Version 8.8.

RESULTS

The mean shared decision-making score was 35.78 (range 8-45). Staff with experience of person-centered care education (β = 0.198, p = 0.034), a higher person-centered attitude score (β = 0.201, p = 0.007), and a higher communication behavior score (β = 0.242, p < 0.001) were more likely to report a higher shared decision-making score. In addition, staff who viewed their care environment as more person-centered were more likely to report a higher shared decision-making score (β = 0.416, p < 0.001).

CONCLUSIONS

This study highlights that personal (e.g., person-centered care education, person-centered attitude, and communication behavior) and care environment (e.g., person-centered climate) factors could influence shared decision-making for long-term care residents. These findings could be foundational evidence for facilitating shared decision-making practice in long-term care settings.

Factors Influencing Surgical Decision Making in Trapeziometacarpal Osteoarthritis

Purpose

With trapeziometacarpal osteoarthritis (TMC OA), the relationship between disease severity and pretreatment dysfunction, patient expectations, and preferred patient treatment and management remains unclear. This study aimed to assess the association between functional status, pretreatment expectations, and demographic and clinical characteristics of TMC OA patients who decide to undergo operative management.

Methods

Patients diagnosed with TMC OA (n = 96) were administered the Thumb Arthritis Expectations Survey and the Brief Michigan Hand Questionnaire (bMHQ) during their initial office visit. Demographic data (sex, age, race, education level, marital status, comorbidities, and hand dominance) and clinical characteristics (prior injury, and therapeutic interventions including splinting, steroid injections, therapy, and anti-inflammatory medication) were collected. Multiple logistic regression was used to assess the association between surgical treatment and expectation scores.

Results

Our logistic regression model found that lower bMHQ scores, high thumb arthritis expectation survey scores, and prior treatments for TMC OA were associated significantly with the surgical treatment of TMC OA. After controlling for all possible covariates, the odds of having surgery was 3.9 times higher among patients with high expectations (above median) compared to patients with low expectations (adjusted odds ratio [AOR], 3.9; 95% confidence interval [CI], 1.3-11.2). Patients with average function, as measured by bMHQ scores, were 74.5% less likely to elect for surgery than those with the lowest bMHQ (AOR, 0.3; 95% CI, 0.1-0.9). Patients treated previously with steroids were 13 times more likely to elect for surgery than those who were never treated for TMC arthritis (AOR,13.1; 95% CI, 2.2-77.0).

Conclusions

Patients with TMC OA who elect to proceed with surgical management have lower bMHQ (greater perceived dysfunction) and higher expectations, and have had prior treatment. Age was not a significant predictor of surgical management of TMC OA.

Type of study/level of evidence

Prognostic IV.

Moderators and Mediators of the Relationship of Shared Decision-Making and Satisfaction

Background:Evidence suggests that health literacy, perceived availability of information and guidance to adapt to challenges (informational support), and symptoms of depression all have the potential to mediate or moderate the relationship between patient-rated involvement in decisions and satisfaction with care. If so these could be useful targets for improving patient experience. Methods: We prospectively enrolled 130 new adult patients visiting an orthopedic surgeon over a 4-month period. All patients were asked to complete measures of satisfaction with care (21-item Medical Interview Satisfaction Scale), perceived involvement in decisions (9-item Shared Decision-Making Questionnaire), symptoms of depression (the Patient-Reported Outcomes Measurement Information Scale [PROMIS] Depression Computerized Adaptive Test [CAT]), perceived availability of information and guidance to adapt to challenges (PROMIS Informational Support CAT), and the Newest Vital Sign test of health literacy. Results: The strong correlation between satisfaction with care (ρ = 0.60, P < .001) and perceived involvement in decisions was neither mediated nor moderated by health literacy, perceived availability of information and guidance, and symptoms of depression. Conclusions: The observation that patient-rated shared decision-making is strongly related to satisfaction with an office visit, independent of health literacy, perceived support, and symptoms of depression, is consistent with evidence that various measures of patient experience tend to correlate and emphasizes the importance of the patient-clinician relationship. Level of Evidence: Level II, prospective study.

Optimizing the implementation of a multisite feasibility trial of a mind-body program in acute orthopedic trauma

The Toolkit for Optimal Recovery (TOR) is a mind-body program for patients with acute orthopedic injuries who are at risk for persistent pain/disability. In preparation for a multisite feasibility trial of TOR at three orthopedic trauma centers, we aim to qualitatively identify barriers and facilitators to study implementation and strategies to mitigate the implementation barriers and leverage facilitators.We conducted 18 live video focus groups among providers and three one-on-one interviews with department chiefs at Level 1 trauma centers in three geographically diverse sites (N = 79 participants). Using a content analysis approach, we detected the site-specific barriers and facilitators of implementation of TOR clinical trial. We organized the data according to 26 constructs of the Consolidated Framework for Implementation Research (CFIR), mapped to three Proctor implementation outcomes relevant to the desired study outcomes (acceptability, appropriateness, and feasibility). Across the three sites, we mapped six of the CFIR constructs to acceptability, eight to appropriateness, and three to feasibility. Prominent perceived barriers across all three sites were related to providers' lack of knowledge/comfort addressing psychosocial factors, and organizational cultures of prioritizing workflow efficiency over patients' psychosocial needs (acceptability), poor fit between TOR clinical trial and the fast-paced clinic structure as well as basic needs of some patients (appropriateness), and limited resources (feasibility). Suggestions to maximize the implementation of the TOR trial included provision of knowledge/tools to improve providers' confidence, streamlining study recruitment procedures, creating a learning collaborative, tailoring the study protocol based on local needs assessments, exercising flexibility in conducting research, dedicating research staff, and identifying/promoting champions and using novel incentive structures with regular check-ins, while keeping study procedures as nonobtrusive and language as de-stigmatizing as possible. These data could serve as a blueprint for implementation of clinical research and innovations in orthopedic and other medical settings.

Guided self-determination in treatment of chronic pain - a randomized, controlled trial

OBJECTIVES

To test whether Guided Self-Determination (GSD) used in chronic pain management could improve the health-related quality of life, patient activation and sense of coherence (SoC) as a measurement of life skills in patients with chronic pain. The method has been shown to be effective in other chronic conditions, but has not been tested in chronic pain.

METHODS

A three-site randomised, controlled trial at three major multidisciplinary pain centres in Denmark. 200 patients were included and randomised. In the intervention period, both groups had regular visits to the pain centre with both doctors and nurses. The intervention group additionally received the GSD intervention with weekly sessions for eight weeks. Data were collected from February 2013 to July 2016 and consisted of three questionnaires answered before and after the 8-week intervention period, and after six months. The primary outcome was self-reported health related quality of life. Secondary outcomes included self-reported activation and SoC.

RESULTS

We found no clinically relevant difference between the groups for health-related quality of life, patient activation or SoC at either baseline, at three months or at six months. We also analysed data for trends over time using mixed model analysis, and this did not show any significant differences between groups.

CONCLUSIONS

GSD did not improve health-related quality of life, patient activation or SoC when administered to patients with chronic pain treated in a multidisciplinary pain centre. New research is recommended using a combination of self-reported and objective measures and longer follow-up.

Management of Fingertip Injuries: A Survey of Opinions of Surgeons Worldwide

Introduction  Fingertip injuries are common injuries in all ages. There is currently no consensus nor evidence to support the use of any one treatment, with numerous options available for management. The aim is to review the consensus for treatment of fingertip injuries among surgeons worldwide.

Materials and Methods  Nonprobability judgment sampling using purposive method was performed on surgeons ( n = 65) using two digital platforms of the community of practice of hand surgeons. Three illustrative case scenarios were presented to the participants to understand their consensus on treating fingertip injuries, and their choice of treatment for themselves with a similar injury.

Results  This survey demonstrates that there is a wide range of treatment preferences for fingertip injuries for each clinical scenario. In Allen 1 and in crush injuries, most respondents favored healing by secondary intention (66.2 and 92.3%, respectively). In Allen 3 injuries, 72.3% favored surgical intervention. In all clinical scenarios, most surgeons would want their own fingertip injuries treated identically to how they would treat patients with similar fingertip injuries (93.9, 96.9, and 95.4%, respectively). Furthermore, our study demonstrated experience in surgery was not associated with treatment preferences.

Conclusion  Management of fingertip injuries remains controversial, but this study is suggestive that treatment preferences may not be determinant on patient factors, given that all of our respondents are highly functioning individuals who practice microsurgery, but most chose to administer the same treatment to patients as they would to themselves.

Effect of health literacy and shared decision-making on choice of weight-loss plan among overweight or obese participants receiving a prototype artificial intelligence robot intervention facilitating weight-loss management decisions

Implementation of artificial intelligence (AI) in medical decision-making is still in early development. We developed an AI robot intervention prototype with a health literacy-friendly interface that uses interactive voice response (IVR) surveying to assist in decision-making for weight loss. The weight-specific health literacy instrument (WSHLI) and Shared Decision-Making Questionnaire (SDMQ) were used to measure factors influencing weight-loss decisions. Factors associated with participants choosing to lose weight were analyzed using logistic regression, and factors influencing the selection of specific weight-loss plans were examined with one-way analysis of variance. Our study recruited 144 overweight or obese adults (69.4% women, 58.3% with body mass index (BMI) ≥ 24). After interacting with the AI robot, 78% of the study population made the decision to lose weight. SDMQ score was a significant factor positively influencing the decision for weight-loss (odds ratio [OR]: 2.16, 95% confidence interval [CI]: 1.09-4.29, p = 0.027). Individuals who selected self-monitored lifestyle modification (mean ± SD: 11.52 ± 1.95) had significantly higher health literacy than those who selected dietician-assisted plan (9.92 ± 2.30) and physician-guided treatment (9.60 ± 1.52) (both p = 0.001). The study results demonstrated that our prototype AI robot can effectively encourage individuals to make decisions regarding weight management and that both WSHLI and SDMQ scores affect the choice of weight-loss plans.

Are Patient Linguistic Tones Associated with Mental Health and Perceived Clinician Empathy?

BACKGROUND

Musculoskeletal specialists have the expertise to distinguish between (1) symptoms that correspond well with observed pathophysiology and (2) disproportionate or incongruent symptoms that may suggest mental and social health opportunities. There is evidence that patient verbal and nonverbal communication can help with this discernment. This study carried this line of research one step further by addressing whether patient linguistic tones, as assessed with use of Linguistic Inquiry and Word Count (LIWC), are associated with symptoms of depression and health anxiety. We also sought associations between both patient and clinician linguistic tones and patient-perceived clinician empathy.

METHODS

A secondary analysis of transcripts of video and audio recordings of 109 adult patients seeking musculoskeletal specialty care was performed. Patients also completed questionnaires quantifying symptoms of depression (PROMIS [Patient-Reported Outcomes Measurement Information System] Depression computerized adaptive test), self-efficacy when in pain (Pain Self-Efficacy Questionnaire, 2-question version), symptoms of health anxiety (5-item Short Health Anxiety Inventory [SHAI-5]), and perceived clinician empathy (Jefferson Scale of Patient Perceptions of Physician Empathy [JSPPPE]). LIWC was used to detect the relative strength of various emotional tones, cognitive processes, and core drives and needs. Bivariate and multivariable regression analyses sought factors associated with symptoms of depression, symptoms of health anxiety, and patient perception of clinician empathy.

RESULTS

With greater levels of depression, patients express less emotion overall as detected with use of computational linguistic analysis. After accounting for demographic variables, there were no specific linguistic tones associated with health anxiety and symptoms of depression. Stronger negative linguistic tones were associated with lower pain self-efficacy. Greater perceived clinician empathy was associated with more words spoken by the clinician and the patient, greater patient use of adjectives, lower prevalence of patient tones of "analytic," lower clinician tones of "social," and greater tones of "cause."

CONCLUSIONS

Musculoskeletal specialists cannot depend on people experiencing symptoms of psychological distress to verbally express their feelings.

CLINICAL RELEVANCE

Specialists may be more likely to identify important symptoms of psychological distress if they anticipate lower emotional expressiveness and are attentive to specific words, concepts, and mannerisms known to be associated with distress.

Assessment of adult speech disorders: current situation and needs in French-speaking clinical practice

INTRODUCTION

Speech assessment methods used in clinical practice are varied and mainly perceptual and motor. Reliable assessment of speech disorders is essential for the tailoring of the patient's treatment plan.

OBJECTIVE

To describe current clinical practices and identify the shortcomings and needs reported by French-speaking clinicians regarding the assessment of speech disorders in adult patients.

METHODS

Data were collected using an online questionnaire for French-speaking speech and language pathologists (SLPs) in Belgium, France, Switzerland, Luxembourg, and Maghreb. Forty-nine questions were grouped into six domains: participant data, educational and occupational background, experience with speech disorders, patient population, tools and tasks for speech assessment, and possible lacks regarding the current assessment of speech disorders.

RESULTS

Responses from 119 clinicians were included in the analyses. SLPs generally use "à la carte" assessment with a large variety of tasks and speech samples. About one quarter of them do not use existing assessment batteries. Those who do mostly use them partially. Pseudo-words are rarely used and are absent from standardized batteries, in contrast to the major use of words and sentences. Perceptual evaluation largely prevails (mainly overall ratings of speech "intelligibility", "severity," and "comprehensibility" and percent-correct phonemes), whereas the recording equipment for acoustic measures is not standardized and only scarcely described by the SLPs. The most commonly used questionnaire to assess the functional impact of the speech disorder is the Voice Handicap Index; one quarter of the SLPs does not use any questionnaire. Overall, the available tools are considered only moderately satisfactory. The main reported shortcomings are a lack of objectivity and reproducibility of speech measures; exhaustiveness and consideration of specific speech parameters (prosody, speech rate, and nasality); practicality of the assessment tools.

CONCLUSION

This study highlights a lack of standardization of the speech assessment in French-speaking adults and the need to offer new reliable tools for an optimized, accurate speech assessment. The automation of these tools would allow for rapid, reproducible, and accurate measures.

Shared Decision-making in Orthopaedic Surgery

Shared decision-making (SDM) is the process by which the physician and the patient collaborate to arrive at the evidence-based treatment that best aligns with the patient's individual goals of care. The implementation of SDM practices is especially important when an invasive surgical procedure is among the treatment options. Ideally, the variation in the patient treatment choice would mirror the variability in patient goals rather than variation in a physician's ability to communicate effectively. Potentially aiding in these communication efforts, decision aids are tools gaining popularity for their ability to help physicians facilitate the SDM process with patients. This article is intended to give the practicing orthopaedic surgeon an understanding of the concept of SDM and how it can improve physician-patient communication. We will explore the key elements of SDM, attendant benefits, indications, and barriers to implementation and propose steps to begin the incorporation of SDM into practice.

Patient Perspectives on Decision Making for Carpal Tunnel Syndrome

PURPOSE

Interventions that improve a patient's understanding of the problem and their options might reduce surgeon-to-surgeon variation, activate healthier patient behaviors and mindset, and optimize stewardship of resources while improving quality of care. Patients with carpal tunnel syndrome (CTS) have more uncertainty about which course of action to take (so-called decision conflict) than hand surgeons. We studied patient preferences regarding shared decision making (SDM) for different parts of the treatment for CTS. We assessed the following hypotheses: (1) Younger age does not correlate with a preference for greater involvement in decisions; (2) Demographic and socioeconomic factors are not independently associated with (A) preferences for decision making (separated into preoperative, operative, postoperative, and the full SDM scale) and (B) the Control Preference Scale; (3) the SDM scale does not correlate with the Control Preference Scale.

METHODS

We prospectively invited 113 new and postoperative patients with CTS to participate in the study. We recorded their demographics and they completed the SDM scale and the Control Preference Scale.

RESULTS

The full SDM scale and all subsets showed a patient preference toward sharing the decisions for treatment with the surgeon with a moderate tendency toward patients wanting more surgeon involvement in decision making. On multivariable analysis, having commercial insurance compared with Medicare was independently associated with a preference for less surgeon involvement (ie, higher SDM scores) in decision making (regression coefficient, 0.60; 95% confidence interval, 0.03-1.2).

CONCLUSIONS

Patients with CTS generally prefer to share decisions with their surgeon with a tendency for more surgeon involvement especially in the operative and postoperative period.

CLINICAL RELEVANCE

Decision aids and preference elicitation tools used to ensure diagnostic and treatment decisions for CTS that are aligned with patient preferences are needed. Future studies might address the routine use of these tools on patient outcomes.

Psychosocial factors affecting variation in patient-reported outcomes after elbow fractures

BACKGROUND

The purpose of this study was to identify factors associated with limitations in function measured by patient-reported outcome measures (PROMs) 6-9 months after elbow fractures in adults from a range of demographic, injury, psychological, and social variables measured within a week and 2-4 weeks after injury.

METHODS

We enrolled 191 adult patients sustaining an isolated elbow fracture and invited them to complete PROMs at their initial visit to the orthopedic outpatient clinic (within a maximum of 1 week after fracture), between 2 and 4 weeks, and between 6 and 9 months after injury; 183 patients completed the final assessment. Bivariate analysis was performed, followed by multivariable regression analysis accounting for multicollinearity. This was evaluated using partial R², correlation matrices, and variable inflation factor assessment.

RESULTS

There was a correlation between multiple variables within a week of injury and 2-4 weeks after injury with PROMs 6-9 months after injury in bivariate analysis. Kinesiophobia measured within a week of injury and self-efficacy measured at 2-4 weeks were the strongest predictors of limitations 6-9 months after injury in multivariable regression. Regression models accounted for substantial variance in all PROMs at both time points.

CONCLUSIONS

Developing effective coping strategies to overcome fears related to movement and reinjury and finding ways of persevering with activity despite pain within a month of injury may enhance recovery after elbow fractures. Heightened fears around movement and suboptimal coping ability are modifiable using evidence-based behavioral treatments.

What Role Does Positive Psychology Play in Understanding Pain Intensity and Disability Among Patients with Hand and Upper Extremity Conditions?

BACKGROUND

A large body of research shows that psychologic distress and ineffective coping strategies substantially contribute to more severe pain and increased physical limitations among patients with orthopaedic disorders. However, little is known about the relationship between positive psychology (constructs that enable individuals to thrive and adapt to challenges) and pain and physical limitations in this population.

QUESTIONS/PURPOSES

(1) Which positive-psychology factors (satisfaction with life, gratitude, coping through humor, resilience, mindfulness, and optimism) are independently associated with fewer upper-extremity physical limitations after controlling for the other clinical and demographic variables? (2) Which positive-psychology factors are independently associated with pain intensity after controlling for relevant clinical and demographic variables?

METHODS

In a cross-sectional study, we recruited patients presenting for a scheduled appointment with an orthopaedic surgeon at a hand and upper-extremity clinic of a major urban academic medical center. Of 125 approached patients, 119 (44% men; mean age, 50 ± 17 years) met screening criteria and agreed to participate. Patients completed a clinical and demographic questionnaire, the Numerical Rating Scale to assess pain intensity, the Patient-reported Outcomes Measurement Information System (PROMIS) Upper Extremity Physical Function computerized adaptive test to assess physical limitations, and six measures assessing positive-psychology constructs: The Satisfaction with Life Scale, the Gratitude Questionnaire, the Coping Humor Scale, the Brief Resilience Scale, the Cognitive and Affective Mindfulness Scale-Revised, and the Life Orientation Test-Revised. We first examined bivariate associations among physical limitations, pain intensity, and all positive-psychology factors as well as demographic and clinical variables. All variables that demonstrated associations with physical limitations or pain intensity at p < 0.05 were included in two-stage multivariable hierarchical regression models.

RESULTS

After controlling for the potentially confounding effects of prior surgical treatment and duration since pain onset (step1; R total = 0.306; F[7,103] = 6.50), the positive-psychology variables together explained an additional 15% (R change = 0.145, F change [5, 103] = 4.297, p = 0.001) of the variance in physical limitations. Among the positive-psychology variables tested, mindfulness was the only one associated with fewer physical limitations (β = 0.228, t = 2.293, p = 0.024, 4% variance explained). No confounding demographic or clinical variables were found for pain intensity in bivariate analyses. All positive-psychology variables together explained 23% of the variance in pain intensity (R = 0.23; F[5,106] = 6.38, p < 0.001). Among the positive-psychology variables, satisfaction with life was the sole factor independently associated with higher intensity (β = -0.237, t = -2.16, p = 0.033, 3% variance explained).

CONCLUSIONS

Positive-psychology variables explained 15% of the variance in physical limitations and for 23% of the variance in pain intensity among patients with heterogenous upper extremity disorders within a hand and upper extremity practice. Of all positive-psychology factors, mindfulness and satisfaction with life were most important for physical limitations and pain intensity, respectively. As positive-psychology factors are more easily modifiable through skills-based interventions than pain and physical limitations, results suggest implementation of such interventions to potentially improve outcomes in this population. Skills-based interventions targeting mindfulness and satisfaction with life may be of particular benefit.

LEVEL OF EVIDENCE

Level II, prognostic study.

Perceptions and experiences of wrist surgeons on the management of triangular fibrocartilage complex tears: a qualitative study

There is lack of consensus on the management of triangular fibrocartilage injuries. The aim of this study was to investigate wrist surgeons' experiences and perceptions regarding treatment of triangular fibrocartilage complex injuries and to explore the rationale behind clinical decision-making. A purposive sample of consultant wrist surgeons (n = 10) was recruited through 'snow-balling' until data saturation was reached. Semi-structured interviews were conducted, digitally recorded and transcribed verbatim. Two researchers independently analysed data using an iterative/thematic approach. Findings suggest that surgeons rely more on their own training and experience, and patient-related factors such as individual expectations, to inform their decision-making, rather than on published material. Current classification systems are largely considered to be unhelpful. Level of evidence: V.

Complications of Treatment for Dupuytren Disease

Dupuytren contracture is a progressive disease involving collagen within the palmar fascia. When the contracture progresses to meet specific parameters, intervention is considered and includes collagenase injection, percutaneous or open fasciotomy, or palmar fasciectomy. Complications after treatment include contracture recurrence, digital nerve injury or postoperative neurapraxia, flexor tendon injury/rupture, delayed wound healing or skin necrosis, dysvascular digit/arterial injury, hematoma, and infection. Patients with severe or recurrent Dupuytren contracture are more likely to experience complications. Patient education is paramount; one must consider the patient's goals for treatment, functional requirements, time frame for recovery, and tolerance for complications when deciding about treatment.

Patient-centered outcomes: a qualitative exploration of patient experience with electroencephalograms in the Emergency Department

The primary objective of this qualitative project was to understand the experience of patients who had first-time seizures and who did, and did not, have electroencephalograms (EEGs) performed in the Emergency Department (ED) as part of their initial evaluation, so as to refine the diagnostic and therapeutic approach to these patients and transform the standard of care for first-time seizures by focusing on outcomes as defined by patient experiences and expectations. In this paper, we show that, regardless of the diagnostic and therapeutic approach patients are given in the ED, patients and caregivers trust that health care providers will perform the standard of care consistent with the current medical practice for first-time seizures. However, performing EEGs in the ED and initiating appropriate anticonvulsant therapy for those patients who are at high risk for future seizures addresses patient needs by offering patients a sense of security and control over their medical condition and expediting appropriate follow up care, as long as clearly stated written diagnostic, treatment, and referral instructions are provided upon discharge.

Patients Older Than 40 Years With Unilateral Occupational Claims for New Shoulder and Knee Symptoms Have Bilateral MRI Changes

BACKGROUND

Minor events that occur in the workplace sometimes are evaluated with MRI, which may reveal age-related changes in the symptomatic body part. These age-related changes are often ascribed to the event. However, evidence of similar or worse pathophysiology in the contralateral joint would suggest that the symptoms might be new, but the pathophysiology is not.

QUESTIONS/PURPOSES

Using a convenience sample of occupational injury claimants with bilateral MRI to evaluate unilateral knee or shoulder symptoms ascribed to a single event at work, we sought to determine whether MRI findings of the shoulder and knee are more often congruent or incongruent with new unilateral symptoms.

METHODS

Two hundred ninety-four occupational injury claimants employed at companies throughout Texas that do not subscribe to workers' compensation insurance, who were older than 40 years, and with unilateral shoulder or knee symptoms, were studied. Starting in 2012, all patients seen by OccMD Group PA who present with unilateral symptoms ascribed to work undergo bilateral MRI, based on several previous occasions where bilateral MRI proved to be a compelling demonstration that perceived injuries are more likely age-related, previously well-adapted pathophysiology. MRI findings (anything described as abnormal by the radiologist; eg, defect size or signal change) was considered congruent if the abnormality of one or more structures on the symptomatic side was greater than that of the corresponding structures in the asymptomatic joint. Bivariate analysis was used to compare the frequency of MRI findings congruent and incongruent with symptoms. Logistic regression was used to evaluate factors associated with MRI findings of the shoulder or knee.

RESULTS

Less than half of the patients with shoulder (90 of 189; 48%; p = 0.36) or knee (45 of 105; 43%; p = 0.038) symptoms had worse pathologic features on the symptomatic side. Older age was associated with disorders in the infraspinatus tendon (59 ± 8 versus 56 ± 8 years; p = 0.012), glenoid labrum (60 ± 9 versus 57 ± 8 years; p = 0.025), and biceps tendon (60 ± 8 versus 57 ± 8 years; p = 0.0038). Eighty-seven percent of patients (91 of 105) had structural changes in the medial meniscus described by the radiologist.

CONCLUSIONS

Occupational injury claimants 40 years of age and older with unilateral knee and shoulder symptoms ascribed to a work event tend to have bilateral age-related MRI changes. Age-related disorders should be distinguished from acute injury.

LEVEL OF EVIDENCE

Level IV, diagnostic study.

Current concepts of shared decision making in orthopedic surgery

PURPOSE OF REVIEW

The Shared Decision Making (SDM) model, a collaborative decision making process between the physician and patient to make an informed clinical decision that enhances the chance of treatment success as defined by each patient's preferences and values, has become a new and promising tool in the healthcare process; however, minimal data exists on its application in the orthopedic surgical specialty. Increasing evidence has demonstrated that this once novel idea can be implemented successfully in the orthopedic setting to improve patient outcomes.

RECENT FINDINGS

SDM can be applied without significant increases in the office length. Patients report that a physician that takes the time to listen to them is among the most important factors in their care. When time was focused on the SDM process, there was a direct correlation between the time spent with a patient and patient satisfaction. Patients exposed to a decision aid prior to surgery gained a greater knowledge from baseline to make a higher quality decision that was consistent with their values. Involving family members preoperatively can help all patients adhere to postoperative regimens. Exposing patients to a decision aid can reduce expensive elective surgeries, in favor of non-operative management. Incorporating patient goals into the decision-making process has increased satisfaction, compliance, and outcomes. SDM is a two-way exchange of information that attempts to correct the inequality of power between the patient and physician. Decision-aids are helpful tools that facilitate the decision-making process. Treatment decisions are consistent with patient preferences and values when there may be no "best" therapy. A good patient-physician relationship is essential during the process to reduce decisional conflict and increase overall patient outcomes.

Understanding North American yoga therapists' attitudes, skills and use of evidence-based practice: A cross-national survey

INTRODUCTION

Little is known about the adoption of evidence-based practice (EBP) by yoga therapists (YTs).

OBJECTIVE

To determine the attitudes, skills, training, use, barriers and facilitators to the use of EBP amongst North American YTs DESIGN: Cross-sectional, descriptive survey METHODS: Self-identified YTs practicing in North America were invited to participate in an online survey. YT attitudes, skills, training, utilisation, barriers to use, and facilitators of EBP use were measured using the 84-item Evidence-Based practice Attitude and utilization SurvEy (EBASE).

RESULTS

367 members responded (∼20% of eligible participants). Attitudes towards EBP were generally positive with 88% agreeing that professional literature and research findings were useful for the practice of yoga therapy. Most (80%) were interested in improving their skills and the majority agreed that EBP improves the quality of care (68%), assists in making decisions (74%) and takes into account the YTs clinical experience when making clinical decisions (59%). Moderate to moderately-high levels of perceived skill in EBP were reported mostly utilizing online search engines (51%). Lack of clinical evidence was the only notable barrier to uptake reported by YTs (48%). Facilitators to EBP included access to online EBP education materials (70.6%), ability to download full-text journal articles and access to free online databases in the workplace (67.3%).

CONCLUSION

North American YTs report positive attitudes, moderate to moderately-high levels of perceived skill and moderate uptake of EBP. This aligns them with other complementary and integrative health practitioners. Initiatives to support the adoption of EBP are proposed as a means of improving best practice in yoga therapy.

Patient Satisfaction in an Outpatient Hand Surgery Office: A Comparison of English- and Spanish-Speaking Patients

BACKGROUND

As health care in the United States transitions from a fee-for-service to an outcomes-based environment, patient satisfaction is increasingly incentivized and publicly reported. Despite the continued growth of the Latino population and concomitant rise in the demand for health care, relatively little is known regarding patient satisfaction in Spanish speakers. We sought to compare patient satisfaction with hand surgery office visits between Spanish- and English-speaking patients.

METHODS

Directly after the office visit, 150 patients (75 English speakers and 75 Spanish speakers) completed a sociodemographic survey, an 11-point ordinal rating of pain intensity, and a survey of satisfaction with the encounter using items derived from the CG-CAHPS (Clinician and Group-Consumer Assessment of Healthcare Providers and Systems) survey. Multivariable regression modeling was used to identify factors associated with patient dissatisfaction.

RESULTS

Overall, 79% of Spanish-speaking patients were satisfied with the physician as compared with 91% of English speakers (P = .041). Compared with English-speaking patients, Spanish speakers were less likely to be satisfied with provider listening carefully (91% vs 100%, P = .007) and spending enough time with them (56% vs 93%, P < .001), as well as with waiting times (81% vs 96%, P = .005). There was no difference with regard to provider showing respect, clarity of communication, and explanation of what was done. Younger age and Spanish language were independent predictors of patient dissatisfaction.

CONCLUSIONS

Spanish-speaking patients are less satisfied with the care provided in a hand surgery office. In light of the growing diversity of the US population and the fact that patient satisfaction is increasingly tied to reimbursement, additional research might identify potential areas of improvement from both the surgeon (eg, communication strategies, cultural competence) and patient (eg health literacy, expectations) perspectives.

Patient preferences for emergency or planned hip fracture surgery: a cross-sectional study

BACKGROUND

The ideal timing of surgical management for hip fractures remains controversial. Currently, individual surgeon preference and departmental resources guide decision making regarding the use of emergency or planned operating lists for hip fracture surgery. We evaluated patient preference for emergency or planned surgery.

METHODS

102 patients awaiting surgery for a hip fracture at a tertiary hospital were surveyed in this cross-sectional study. After being informed of the benefits and risks associated with an emergency or planned operation, the patients were asked to indicate a hypothetical preference for surgical operating time. They were then asked to give an importance value for six factors that may influence decision making including consultant supervision, operative timeliness, surgical cancellation, after hours operation, length of hospital stay and repeated fasting. For each factor, absolute importance was rated from 0 to 10, and factors were independently ranked for relative importance from 1 to 6. An open ended question was used to include any other factors they thought relevant to their hypothetical decision making.

RESULTS

Of the 102 patients surveyed, 95 patients (93 %) indicated that they preferred planned over emergency surgery. The most important influencing factor was the presence of specialist supervision (mean rating 9.4, mean rank 1.3) followed by avoidance of operative cancellation (mean rating 8.8, mean rank 2.3) and avoidance of after hours operations (mean rating 8.1, mean rank 3.2). A lower importance was attached to operative timeliness and avoiding prolonged fasting, with reduction in length of hospital stay being the least important variable. There was a direct correlation between absolute ratings and relative rankings independently assigned by patients to each factor.

CONCLUSIONS

Patients with hip fractures prefer planned rather than emergency surgery, the presence of specialist supervision being the most important factor influencing their preference.

A Randomized Controlled Trial of Two Distinct Shared Decision-Making Aids for Hip and Knee Osteoarthritis in an Ethnically Diverse Patient Population

OBJECTIVES

To evaluate the use of decision aids for hip and knee osteoarthritis (OA) regarding the potential risks and benefits of different treatment options.

METHODS

A prospective, randomized controlled trial was conducted of 147 patients with advanced hip or knee OA to compare the effect of two decision aids (booklet-only vs. booklet with DVD).

RESULTS

Both decision aid programs were well received and demonstrated improvements in patient knowledge and willingness to participate in treatment decisions. The decision aids, however, had a marginal effect on patient willingness to participate in OA management, with an increase of 0.11 and 0.6 on a scale of 2 (P = 0.58) between groups.

CONCLUSIONS

The decision aids were accepted for most patients and effective in improving patient knowledge and willingness to participate in the decision process. Nevertheless, the addition of a more expensive DVD to the booklet program did not improve patient acceptance or knowledge.

Do Surgeons Treat Their Patients Like They Would Treat Themselves?

BACKGROUND

There is substantial unexplained geographical and surgeon-to-surgeon variation in rates of surgery. One would expect surgeons to treat patients and themselves similarly based on best evidence and accounting for patient preferences.

QUESTIONS/PURPOSES

(1) Are surgeons more likely to recommend surgery when choosing for a patient than for themselves? (2) Are surgeons less confident in deciding for patients than for themselves?

METHODS

Two hundred fifty-four (32%) of 790 Science of Variation Group (SOVG) members reviewed 21 fictional upper extremity cases (eg, distal radius fracture, De Quervain tendinopathy) for which surgery is optional answering two questions: (1) What treatment would you choose/recommend: operative or nonoperative? (2) On a scale from 0 to 10, how confident are you about this decision? Confidence is the degree that one believes that his or her decision is the right one (ie, most appropriate). Participants were orthopaedic, trauma, and plastic surgeons, all with an interest in treating upper extremity conditions. Half of the participants were randomized to choose for themselves if they had this injury or illness. The other half was randomized to make treatment recommendations for a patient of their age and gender. For the choice of operative or nonoperative, the overall recommendation for treatment was expressed as a surgery score per surgeon by dividing the number of cases they would operate on by the total number of cases (n = 21), where 100% is when every surgeon recommended surgery for every case. For confidence, we calculated the mean confidence for all 21 cases per surgeon; overall score ranges from 0 to 10 with a higher score indicating more confidence in the decision for treatment.

RESULTS

Surgeons were more likely to recommend surgery for a patient (44.2% ± 14.0%) than they were to choose surgery for themselves (38.5% ± 15.4%) with a mean difference of 6% (95% confidence interval [CI], 2.1%-9.4%; p = 0.002). Surgeons were more confident in deciding for themselves than they were for a patient of similar age and gender (self: 7.9 ± 1.0, patient: 7.5 ± 1.2, mean difference: 0.35 [CI, 0.075-0.62], p = 0.012).

CONCLUSIONS

Surgeons are slightly more likely to recommend surgery for a patient than they are to choose surgery for themselves and they choose for themselves with a little more confidence. Different perspectives, preferences, circumstantial information, and cognitive biases might explain the observed differences. This emphasizes the importance of (1) understanding patients' preferences and their considerations for treatment; (2) being aware that surgeons and patients might weigh various factors differently; (3) giving patients more autonomy by letting them balance risks and benefits themselves (ie, shared decision-making); and (4) assessing how dispassionate evidence-based decision aids help inform the patient and influences their decisional conflict.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Physician Empathy as a Driver of Hand Surgery Patient Satisfaction

PURPOSE

To examine the relationship between patient-rated physician empathy and patient satisfaction after a single new hand surgery office visit.

METHODS

Directly after the office visit, 112 consecutive new patients rated their overall satisfaction with the provider and completed the Consultation and Relational Empathy Measure, the Newest Vital Sign health literacy test, a sociodemographic survey, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Pain Interference, Upper-Extremity Function, and Depression. We also measured the waiting time in the office to see the physician, the duration of the visit, and the time from booking until appointment. Multivariable logistic and linear regression models were used to identify factors independently associated with patient satisfaction.

RESULTS

Patient-rated physician empathy correlated strongly with the degree of overall satisfaction with the provider. After controlling for confounding effects, greater empathy was independently associated with patient satisfaction, and it alone accounted for 65% of the variation in satisfaction scores. Older patient age was also associated with satisfaction. There were no differences between satisfied and dissatisfied patients with regard to waiting time in the office, duration of the appointment, time from booking until appointment, and health literacy.

CONCLUSIONS

Physician empathy was the strongest driver of patient satisfaction in the hand surgery office setting. As patient satisfaction plays a growing role in reimbursement, targeted educational programs to enhance empathic communication skills in hand surgeons merit consideration.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Health literacy in hand surgery patients: a cross-sectional survey

PURPOSE

To determine the prevalence of and factors associated with limited health literacy among outpatients presenting to an urban academic hospital-based hand surgeon.

METHODS

A cohort of 200 English- and Spanish-speaking patients completed the Newest Vital Sign (NVS) health literacy assessment tool, a sociodemographic survey, and 2 Patient-Reported Outcomes Measurement Information System-based computerized adaptive testing questionnaires: Patient-Reported Outcomes Measurement Information System Pain Interference and Upper-Extremity Function. The NVS scores were divided into limited (0-3) and adequate (4-6) health literacy. Multivariable regression modeling was used to identify independent predictors of limited health literacy.

RESULTS

A total of 86 patients (43%) had limited health literacy (English-speaking: 33%; Spanish-speaking: 100%). Factors associated with limited health literacy were advanced age, lower income, and being publicly insured or uninsured. Increasing years of education was a protective factor. Primary language was not included in the logistic regression model because all Spanish-speaking patients had limited health literacy. When evaluating health literacy on a continuum, primary language was the factor that most influenced the NVS scores, accounting for 14% of the variability.

CONCLUSIONS

Limited health literacy was commonplace among patients seeing a hand surgeon, more so in elderly and disadvantaged individuals. We hope our study raises awareness of this issue among hand surgeons and encourages providers to simplify messages and improve communication strategies.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Treatment expectations among adolescents with chronic musculoskeletal pain and their parents before an initial pain clinic evaluation

OBJECTIVES

To understand expectations regarding treatment recommendations among treatment-seeking adolescents with chronic musculoskeletal pain and their parents.

METHODS

A total of 102 adolescent-parent dyads were recruited at the time of initial contact with a multidisciplinary pain management clinic. Each participant completed reports of adolescent pain intensity and disability, biopsychosocial perspective of pain, and treatment expectations related to recommendations and feedback for a vignette description of an adolescent presenting at an initial multidisciplinary pain clinic evaluation.

RESULTS

Descriptive findings for individual treatment expectations and adolescent-parent dyad agreement statistics were examined. Slight to fair levels of agreement occurred for 50% of the expectations assessed. The strongest shared expectations were for recommendations to return to school, pursue psychological counseling, and pursue PT/OT treatment. Stronger agreement occurred for items reflecting alternative, emotional, behavioral, and activity recommendations with weaker agreement for medical interventions (eg, medication and surgery). Correlations emerged between individual expectations and adolescent pain intensity, disability, with the greatest number of significant relationships found for adolescent and parent expectations and biopsychosocial perspectives of pain.

DISCUSSION

Our results document that adolescents and parents show modest levels of agreement on expectations for treatment at the time of an initial pain clinic evaluation. This may relate to expectations being internal perspectives not clearly expressed within families; thus, the initial treatment consultation may provide an important opportunity to create and align appropriate expectations. Implications of our findings are considered with respect to education, treatment, and future research to understand factors that contribute to treatment adherence and outcomes.

Patient preference and satisfaction with their involvement in the selection of an anesthetic method for surgery

This prospective study aimed to evaluate the satisfaction of patients who participated in the decision-making process for selecting an anesthesia method for surgery; the patients' preferred role (active, collaborative or passive) in the decision-making; and the patients' preferred choice of anesthetic method. The study included 257 patients scheduled for simple elective surgeries involving the upper or lower extremities. During the preanesthetic visit, patients were informed regarding two methods of anesthesia for their surgeries, and participated in selecting one option. Of the 257 patients, 69.6% preferred a collaborative role, 18.3% and 12.1% preferred an active and a passive role, respectively. Among patients requiring surgery on an upper extremity and on a lower extremity, 64.3% and 51.3% expressed a preference for general anesthesia over regional anesthesia, respectively. After surgery, the majority of our patients were satisfied (93.4%) and felt respected (97.7%). Furthermore, the patients expressed a change in preference for assuming an active role (49.4%) and a collaborative role (43.6%) in the decision-making process for their future anesthesia needs. This study may help to promote patient centered care in a department of anesthesiology.

Does rewording MRI reports improve patient understanding and emotional response to a clinical report?

BACKGROUND

Diagnostic MRI reports can be distressing for patients with limited health literacy. Humans tend to prepare for the worst particularly when we are in pain, and words like "tear" can make us feel damaged and in need of repair. Research on words used in provider-patient interactions have shown an affect on response to treatment and coping strategies, but the literature on this remains relatively sparse.

QUESTIONS/PURPOSES

The aim of this observational cross-sectional study is to determine whether rewording of MRI reports in understandable, more dispassionate language will result in better patient ratings of emotional response, satisfaction, usefulness, and understanding. Furthermore, we wanted to find out which type of report patients would choose to receive.

METHODS

One hundred patients visiting an orthopaedic hand and upper extremity outpatient office for reasons unrelated to the presented MRI report were enrolled. Four MRI reports, concerning upper extremity conditions, were reworded to an eighth-grade reading level and with the use of neutral descriptive words and the most optimistic interpretations based on current best evidence. After reading each report, emotional response was measured using the Self Assessment Manikin (SAM). Subjects also completed questions about satisfaction, usefulness, and understanding of the report.

RESULTS

According to the results of the SAM questionnaire, the reworded MRI reports resulted in significantly higher pleasure and dominance scores and lower arousal scores. The mean satisfaction, usefulness, and understanding scores of the reworded report were significantly higher compared with the original reports. Seventy percent of the patients preferred the reworded reports over the original reports.

CONCLUSIONS

Emotional response, satisfaction, usefulness, and understanding were all superior in MRI reports reworded for lower reading level and optimal emotional content and optimism. Given that patients increasingly have access to their medical records and diagnostic reports, attention to health literacy and psychologic aspects of the report may help optimize health and patient satisfaction.

Shared decision making in complementary and alternative medicine therapies

OBJECTIVE

This paper provides a structured approach for pediatricians responding to requests from patients and their families about the complementary medicine treatment options.

METHODS

Using a case-based narrative review approach, the authors outline practical strategies for addressing conflict, uncertainty, and challenges in explaining alternative health paradigms in routine pediatric care. Reflections are drawn from the clinical experience of the authors, the literature, and recent high-profile cases in the United States.

RESULTS

The discussion of common case-based scenarios illustrates a general guide for approaching conversations about complementary medicine in the care of the pediatric patient that is responsive to evidence and informed by patient and family values.

CONCLUSIONS

The principles of shared decision making can guide constructive conversations in this area in an effort to facilitate improved satisfaction for patient, family, and provider.

PRACTICE IMPLICATIONS

Discussions of complementary and alternative medicine in pediatrics pose a specific challenge with regard to patient and/or family preferences and the duty of the provider to advocate for the safety of the child. The proposed structured approach is useful in navigating these important conversations.

The emotive impact of medical language

BACKGROUND

Words can shape or reinforce a patient's coping strategies. We measured the emotional content of hand surgery words and some synonyms or alternatives in five categories (19 words total).

METHODS

Healthy adult companions of 100 patients presenting to an orthopedic hand surgical practice were asked to score five hand surgery words and some synonyms and alternatives (19 total words) on three dimensions: affective/emotional (ranging from pleasant to unpleasant), arousal (ranging from calm to aroused), and dominance/control (ranging from dominated to feeling in control) using a validated methodology. Ratings were done using the self-assessment manikin-a validated graphic affective rating system.

RESULTS

The emotional reaction to "discomfort" and "ache" was more positive than "pain." The words "tear" and "defect" were more positive than "rupture." The words "tight" and "stiff" were more positive than "locked" and "frozen." The word "faded" was more positive than "degenerated," "diminished," and "wasted". The words "overused" and "worn" were more positive than "cracked," "inflamed," and "broken."

CONCLUSIONS

Some common hand surgery words have a relatively negative emotional content. Given that psychological distress is an important predictor of pain intensity and disability, additional research is merited to develop optimally positive language for describing musculoskeletal pathology.

The influence of evidence-based medicine training on decision-making in relation to over-the-counter medicines: a qualitative study

Objectives

To explore the role of evidence of effectiveness when making decisions about over-the-counter (OTC) medication and to ascertain whether evidence-based medicine training raised awareness in decision-making. Additionally, this work aimed to complement the findings of a previous study because all participants in this current study had received training in evidence-based medicine (unlike the previous participants).

Methods

Following ethical approval and an e-mailed invitation, face-to-face, semi-structured interviews were conducted with newly registered pharmacists (who had received training in evidence-based medicine as part of their MPharm degree) to discuss the role of evidence of effectiveness with OTC medicines. Interviews were recorded and transcribed verbatim. Following transcription, all data were entered into the NVivo software package (version 8). Data were coded and analysed using a constant comparison approach.

Key findings

Twenty-five pharmacists (7 males and 18 females; registered for less than 4 months) were recruited and all participated in the study. Their primary focus with OTC medicines was safety; sales of products (including those that lack evidence of effectiveness) were justified provided they did no harm. Meeting patient expectation was also an important consideration and often superseded evidence. Despite knowledge of the concept, and an awareness of ethical requirements, an evidence-based approach was not routinely implemented by these pharmacists. Pharmacists did not routinely utilize evidence-based resources when making decisions about OTC medicines and some felt uncomfortable discussing the evidence-base for OTC products with patients.

Conclusions

The evidence-based medicine training that these pharmacists received appeared to have limited influence on OTC decision-making. More work could be conducted to ensure that an evidence-based approach is routinely implemented in practice.

Shared decision-making in orthopaedic surgery

BACKGROUND

The process of clinical decision-making and the patient-physician relationship continue to evolve. Increasing patient involvement in clinical decision-making is embodied in the concept of "shared decision-making" (SDM), in which the patient and physician share responsibility in the clinical decision-making process. Various patients' decision aid tools have been developed to enhance this process.

QUESTIONS/PURPOSES

We therefore (1) describe decision-making models; (2) discuss the different types of patients' decision aids available to practice SDM; and (3) describe the practice and early impact of SDM on clinical orthopaedic surgery.

METHODS

We performed a search of the literature using PubMed/MEDLINE and Cochrane Library. We identified studies related to shared decision-making and the use of patients' decision aids in orthopaedics. The search resulted in 113 titles, of which 21 were included with seven studies on patients' decision aid use specifically in orthopaedics.

RESULTS

Although limited studies suggest the use of patients' decision aids may enhance decision-making, conclusions about the use of these aids in orthopaedic clinical practice cannot be made and further research examining the best type, timing, and content of patients' decision aids that will lead to maximum patient involvement and knowledge gains with minimal clinical workflow interruption are needed.

CONCLUSION

In clinical practice today, patients are increasingly involved in clinical decision-making. Further research on SDM in orthopaedic surgery examining the feasibility and impact on practice, on patients' willingness and ability to actively participate in shared decision-making, and the timing and type of patients' decision aids appropriate for use is still needed.

Narratives in hand therapy

This article reviews literature on Narrative Medicine and applies this knowledge to hand therapy using brief case examples in which the narrative message of each example is illustrated. The value of narratives in hand therapy is thereby described.

LEVEL OF EVIDENCE

5.

Biopsychosocial approach to orthotic intervention

Orthotic intervention should be individualized and patient or client centered. The best outcomes occur when orthotic interventions are designed with patient involvement and holistic consideration of the individual's unique personal attributes, context, and environment. The authors discuss Shelley's story, which illustrates an approach to orthotic intervention that is based on Engel's biopsychosocial model and the International Classification of Functioning, Disability and Health. Fifteen guiding principles for the biopsychosocial orthotic approach are presented. Orthoses that are thoughtfully designed with patient input, carefully constructed and monitored, and modified as needed, can make a difference in a person's life by relieving pain, providing joint stabilization, protecting vulnerable tissues and enabling valued activity and participation. This, in turn, promotes physical and emotional well-being.

The emotive impact of orthopedic words

Research has shown that effective communication skills are paramount for delivering efficient and quality health care. More recently, research has started to show that in addition to how the medical information is delivered, the words used by health care providers are important factors in how patients cope with illness and their reports of pain intensity and disability. In this article, we discuss the emotional impact of words used by hand specialists, the impact of the nomenclature chosen to describe orthopedic diagnosis and procedures, and provide recommendations consistent with evidence-based practice.