1
|
Broekman M, Brinkman N, Davids F, van den Bekerom M, Ring D, Doornberg J, Ramtin S, Jayakumar P. Surgeon Prioritization of Mental, Social, and Pathophysiological Aspects of Health Among People With Traumatic and Nontraumatic Musculoskeletal Conditions. J Am Acad Orthop Surg 2024; 32:e869-e879. [PMID: 38810227 DOI: 10.5435/jaaos-d-23-00962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 04/15/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND There is mounting evidence that, among musculoskeletal patients, variation in capability has more notable associations with variations in mental and social health factors than with variation in pathophysiology severity. This study sought factors that could limit the integration of this evidence into more comprehensive care models. METHODS In two scenario-based experiments, surgeon participants in an international collaborative, the Science of Variation Group, reviewed scenarios of (a) nontraumatic (83 participants) and (b) trauma-related (130 participants) pathophysiologies for which tests and treatments were discretionary. The following demographic, mental, and social health elements were varied randomly: sex, age, race/ethnicity, mindsets, social health aspects, and specific pathophysiologies. For each scenario, participants rated their likelihood to offer surgery (continuous) and their sense of presence of an opportunity to address better mental or social health in treatment (yes or no). Factors associated with each rating were sought in multivariable analysis. RESULTS Greater likelihood to offer discretionary surgery for nontraumatic pathophysiologies was associated with greater pathophysiology severity, trapeziometacarpal arthritis, and greater distress and unhelpful thoughts regarding symptoms. Lateral elbow enthesopathy was associated with a lower likelihood. For trauma-related pathophysiologies, an ankle fracture with slight articular subluxation was associated with greater likelihood to offer surgery, and several other trauma-related pathophysiologies were associated with a lower likelihood. For both nontraumatic and trauma-related pathophysiologies, surgeons noticed unhelpful thinking, distress, and social issues as reasons to consider addressing mental and social health in treatment, relatively independent of pathophysiology. CONCLUSION Surgeons seem to recognize opportunities to address mental and social needs but ultimately base their decision to offer discretionary surgery on pathophysiological factors. CLINICAL RELEVANCE Comprehensive, whole-person care for musculoskeletal illness might be supported by strategies for ensuring that aspects of stress and distress that contribute to greater symptom intensity are not misinterpreted as a reflection of greater pathophysiology severity.
Collapse
Affiliation(s)
- Melle Broekman
- From the Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX (Broekman, Brinkman, Davids, Ring, Ramtin, and Jayakumar), Faculty of Behavioural and Movement Sciences, Vrije Universiteit van Amsterdam, Amsterdam, the Netherlands (Broekman and van den Bekerom), the Department of Orthopaedic Trauma Surgery, Universitair Medisch Centrum Groningen, Groningen, the Netherlands (Doornberg)
| | | | | | | | | | | | | | | |
Collapse
|
2
|
Davids FA, Ramtin S, Razi A, Ring D, Teunis T, Reichel LM. Variation in Interpretation of Provocative Tests for Carpal Tunnel Syndrome. J Hand Surg Am 2024:S0363-5023(24)00308-3. [PMID: 39140920 DOI: 10.1016/j.jhsa.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 06/22/2024] [Accepted: 07/10/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE We studied variation in interpretation of specific symptoms during clinical tests for carpal tunnel syndrome to estimate the degree to which surgeons consider pain without paresthesia characteristic of median neuropathy. METHODS We invited all upper-extremity surgeon members of the Science of Variation Group to complete a scenario-based experiment. Surgeons read 5-10 clinical vignettes of patients with variation in patient demographics and random variation in symptoms and signs as follows: primary symptoms (nighttime numbness and tingling, constant numbness and loss of sensibility, pain with activity), symptoms elicited by a provocative test (Phalen, Durkan, or Tinel) (tingling, pain), and location of symptoms elicited by the provocative test (index and middle fingers, thumb and index fingers, little and ring fingers, entire hand). RESULTS Patient factors associated with surgeon interpretation of provocative tests as negative included pain rather than paresthesia during the Phalen, Durkan, or Tinel test and location of symptoms in the entire hand rather than the median nerve distribution. CONCLUSIONS Specialists do not consider pain without paresthesia or a noncharacteristic symptom distribution as characteristic of carpal tunnel syndrome. CLINICAL RELEVANCE Awareness that elicitation of pain with Phalen, Durkan, and Tinel tests is regarded by specialists as relatively uncharacteristic of median neuropathy can help limit the potential for both overdiagnosis and overtreatment of median neuropathy as well as underdiagnosis and undertreatment of mental and social health contributions to illness (notable correlates of the intensity and distribution of pain).
Collapse
Affiliation(s)
- Floor A Davids
- Department of Orthopedic Surgery, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Sina Ramtin
- Department of Orthopedic Surgery, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Amin Razi
- Department of Orthopedic Surgery, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - David Ring
- Department of Orthopedic Surgery, Dell Medical School, The University of Texas at Austin, Austin, TX.
| | - Teun Teunis
- Department of Plastic Surgery, University Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA
| | - Lee M Reichel
- Department of Orthopedic Surgery, Dell Medical School, The University of Texas at Austin, Austin, TX
| |
Collapse
|
3
|
Alexander J, Rajagopalan D, Ramtin S, Ngoue M, Ring D, Adams J. Surgeon Implicit Association of Women With Supportive Roles in Medicine. J Am Acad Orthop Surg 2024; 32:e26-e32. [PMID: 37678842 DOI: 10.5435/jaaos-d-23-00082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 06/23/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND In a previous study, we documented patient implicit bias that surgeons are men. As a next step, we tested the implicit bias of surgeons that women in medicine have leading (chair, surgeon) or supporting roles (medical assistant, physician assistant). QUESTIONS/PURPOSE (1) What is the relationship between the implicit associations and expressed beliefs of surgeons regarding women as leaders in medicine? (2) Are there factors associated with surgeon implicit association and explicit preference regarding the roles of women in medicine? METHODS A total of 102 musculoskeletal surgeon members of the Science of Variation Group (88 men and 12 women) completed an implicit association test (IAT) of implicit bias regarding sex and lead/support roles in medicine and a questionnaire that addressed respondent demographics and explicit preference regarding women's roles. The IAT consisted of seven rounds with five rounds used for teaching and two rounds for evaluation. RESULTS On average, there was an implicit association of women with supportive roles (D-score: -48; SD 4.7; P < 0.001). The mean explicit preference was for women in leadership roles (median: 73; interquartile ranges: 23 to 128; P < 0.001). There was a correlation between greater explicit preference for women in a leading role and greater implicit bias toward women in a supporting role (ρ = 0.40; P < 0.001). Women surgeons and shoulder and elbow specialists had less implicit bias that women have supporting roles. CONCLUSION The observation that musculoskeletal surgeons have an explicit preference for women in leading roles in medicine but an implicit bias that they have supporting roles-more so among men surgeons-documents the gap between expressed opinions and ingrained mental processing that is the legacy of the traditional "roles" of women in medicine and surgery. To resolve this gap, we will need to be intentional about promotion of and emersion in experiences where the leader is a woman. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Jeremiah Alexander
- From the The University of Texas Dell Medical School, Austin, TX (Alexander, Rajagopalan, Ramtin, Ngoue, and Ring), and the Department of Orthopaedic Surgery, University of Tennessee College of Medicine-Chattanooga, Erlanger Orthopaedic Institute, Chattanooga, TN (Adams)
| | | | | | | | | | | |
Collapse
|
4
|
Boretto JG. CORR Insights®: Diagnosis of Mild-to-moderate Idiopathic Median Neuropathy at the Carpal Tunnel Based on Signs and Symptoms is Discordant From Diagnosis Based on Electrodiagnostic Studies and Ultrasound. Clin Orthop Relat Res 2024; 482:141-142. [PMID: 37610714 PMCID: PMC10723884 DOI: 10.1097/corr.0000000000002822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/20/2023] [Indexed: 08/24/2023]
Affiliation(s)
- Jorge G. Boretto
- Head of the Hand and Upper Extremity Surgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
5
|
Teunis T, Domico A, Ring D, Fowler J. Diagnosis of Mild-to-moderate Idiopathic Median Neuropathy at the Carpal Tunnel Based on Signs and Symptoms is Discordant From Diagnosis Based on Electrodiagnostic Studies and Ultrasound. Clin Orthop Relat Res 2024; 482:134-140. [PMID: 37404022 PMCID: PMC10723843 DOI: 10.1097/corr.0000000000002751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 05/07/2023] [Accepted: 06/02/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Although idiopathic median neuropathy at the carpal tunnel (IMNCT) is objective and verifiable, distinction of normal and abnormal nerves is imprecise and probabilistic. The associated symptoms and signs (carpal tunnel syndrome [CTS]) vary, particularly for nonsevere (mild and moderate) median neuropathy. Discordance between diagnosis of mild or moderate median neuropathy at the carpal tunnel using symptoms and signs and diagnosis based on objective tests is a measure of the potential for overdiagnosis and overtreatment. QUESTION/PURPOSE What is the difference in the estimated prevalence of mild-to-moderate IMNCT using nonsevere signs and symptoms compared with the estimated prevalence using electrodiagnostic studies (EDS) and ultrasound (US)? METHODS We used data from an existing cross-sectional data registry. To create this registry, between January 2014 and January 2019, we considered all new adult English-speaking people who had an EDS that included the median nerve or people with a diagnosis of CTS who did not have surgery yet. A small and unrecorded number of people declined participation. The cross-sectional area of the median nerve at the distal wrist crease using US in people who already had EDS was measured. People with a diagnosis of CTS underwent both EDS and US. The six signs and symptoms of Carpal Tunnel Syndrome 6 (CTS-6, a validated tool to estimate the probability of IMNCT using ratings of symptoms and signs of CTS) were recorded. This resulted in a registry of 185 participants; we excluded 75 people for obvious, severe IMNCT (defined as nonrecordable nerve conduction velocity, thenar atrophy, or greater than 5 mm 2-point discrimination). Three of the 110 qualifying patients had missing information on ethnicity or race, but we accounted for this in our final analysis. Without a reference standard, as is the case with IMNCT, latent class analysis (LCA) can be used to establish the probability that an individual has specific pathophysiologic findings. LCA is a statistical method that identifies sets of characteristics that tend to group together. This technique has been used, for example, in diagnosing true scaphoid fractures among suspected fractures based on a combination of demographic, injury, examination, and radiologic variables. The prevalence of mild-to-moderate IMNCT was estimated in two LCAs using four signs and symptoms characteristic of mild-to-moderate IMNCT, as well as EDS and US measures of median neuropathy. RESULTS The estimated prevalence of mild-to-moderate IMNCT based on signs and symptoms was 73% (95% CI 62% to 81%), while the estimated prevalence using EDS and US measurements was 51% (95% CI 37% to 65%). CONCLUSION The notable discordance of 22% between the estimated prevalence of mild-to-moderate IMNCT using signs and symptoms and prevalence based on EDS and US criteria, and the overlapping CIs of the probability estimations, indicate considerable uncertainty and a corresponding notable potential for underdiagnosis or overdiagnosis. When signs and symptoms suggest mild-to-moderate median neuropathy and surgery is being considered, patients and clinicians might consider additional testing, such as EDS or US, to increase the probability of actual median neuropathy that can benefit from surgery. We might benefit from a more accurate and reliable diagnostic strategy or tool for mild-to-moderate IMNCT; this might be the focus of a future study. LEVEL OF EVIDENCE Level III, diagnostic study.
Collapse
Affiliation(s)
- Teun Teunis
- Department of Plastic Surgery, University Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Adam Domico
- First Settlement Orthopaedics, Marietta, OH, USA
| | - David Ring
- Dell Medical School, the University of Texas at Austin, Austin, TX, USA
| | - John Fowler
- Department of Orthopaedic Surgery, University Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
6
|
Tinwala H, Brinkman N, Ramtin S, Ring D, Crijns T, Reichel L. Factors Associated With Comfort Using Telemedicine for Upper Limb Specialty Care. J Hand Surg Am 2023; 48:647-654. [PMID: 37407147 DOI: 10.1016/j.jhsa.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/03/2023] [Accepted: 04/14/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE There is a growing interest in diagnosis and treatment through telemedicine because of its convenience, accessibility, and lower costs. There are clinician and patient barriers to wider adoption of telemedicine. To support the effective and equitable use of telemedicine, we investigated the patient, illness, and surgeon factors associated with the specialist level of comfort in providing upper limb care via telemedicine. METHODS Seventy-five upper-extremity musculoskeletal specialists completed an online survey-based experiment in which they viewed 12 patient scenarios with randomized patient age, gender, diagnosis, pain intensity, and patient preference for surgical treatment (yes or no) and rated their comfort with telemedicine from 0, no comfort, to 10, complete comfort. The participants were able to provide a rationale for their stance in open text boxes. We recorded the following specialist factors: gender, location of practice, years in practice, subspecialty, the supervision of trainees, and surgeon-rated importance of a physical examination. RESULTS In a multivariable analysis, greater surgeon comfort using telemedicine was associated with nontrauma conditions, four specific diagnoses, and patients who did not have severe pain. Lower surgeon comfort with telemedicine was associated with the higher clinician-rated importance of a hands-on physical examination and supervising trainees. Text-based reasons provided for relative comfort with telemedicine included nonsurgical treatment and facility of diagnosis based on interviews alone. Text-based reasons for relative discomfort with telemedicine included a perceived need for a hands-on physical examination and a preference for an in-person conversation for specific discussions, including scheduling surgery. CONCLUSIONS Greater specialist enthusiasm for telemedicine is associated with personal preferences regarding the upper-extremity condition, patients with less severe pain, and a willingness to forego a hands-on examination. CLINICAL RELEVANCE Utilization of telemedicine for upper-extremity specialty care may be facilitated by diagnosis-specific care strategies and strategies for video examination, with a focus on tactics that are effective for people with more intense symptoms.
Collapse
Affiliation(s)
- Hasan Tinwala
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Niels Brinkman
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Sina Ramtin
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX.
| | - Tom Crijns
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Lee Reichel
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX
| |
Collapse
|
7
|
Ramtin S, Ring D, Vallier H, Wolinsky PR, Miller AN. Factors associated with surgeon recognition of mental health care opportunities and inclination to attend to mental health. J Psychosom Res 2023; 170:111368. [PMID: 37245450 DOI: 10.1016/j.jpsychores.2023.111368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 05/07/2023] [Accepted: 05/09/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE A notable percentage of people that die by suicide have had a medical visit within a few months of their death. In a survey-based experiment, we evaluated: 1) whether there are any surgeon, setting, or patient factors associated with surgeon rating of mental health care opportunities, and 2) if there are any surgeon, setting, or patient factors associated with likelihood of mental health referrals. METHODS One hundred and twenty-four upper extremity surgeons of the Science of Variation Group viewed five scenarios of a person with one orthopedic condition. The following aspects of the scenarios were independently randomized: Social worker or psychologist available, office workload, socioeconomic status, gender, age, mental health factors, mental health clues, and diagnosis. RESULTS Accounting for potential confounders, surgeon likelihood of discussing mental health was associated with cancer, disadvantaged socioeconomic status, mental health factors other than being shy, prior suicide attempt, history of physical or emotional abuse, isolation, and when the office is not busy. Factors independently associated with higher likelihood of referring a patient for mental health care included cancer, disadvantaged socioeconomic status, mental health cues, mental health risk factors, and a social worker or psychologist available in the office. CONCLUSION Using random elements in fictitious scenarios we documented that specialist surgeons are aware of and attuned to mental health care opportunities, are motivated to discuss notable cues, and will make mental health referrals, in part influenced by convenience.
Collapse
Affiliation(s)
- Sina Ramtin
- Dell Medical School at University of Texas at Austin, TX, United States of America
| | - David Ring
- Dell Medical School at University of Texas at Austin, TX, United States of America.
| | - Heather Vallier
- Case Western Reserve University, The MetroHealth System, Cleveland, OH, United States of America
| | - Philip R Wolinsky
- Dartmouth Geisel School of Medicine, Hanover, NH, United States of America
| | - Anna N Miller
- Washington University in St. Louis Department of Orthopaedic Surgery, St. Louis, MO, United States of America
| |
Collapse
|
8
|
Shah KN. CORR Insights®: Surgeon Ratings of the Severity of Idiopathic Median Neuropathy at the Carpal Tunnel Are Not Influenced by Magnitude of Incapability. Clin Orthop Relat Res 2022; 480:1150-1151. [PMID: 35238802 PMCID: PMC9263478 DOI: 10.1097/corr.0000000000002162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/09/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Kalpit N Shah
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, CA, USA
| |
Collapse
|