Psychological factors, such as greater symptoms of depression, greater health anxiety, or greater catastrophic thinking are consistently associated with more limitations and more intense symptoms in patients with a variety of musculoskeletal illness concerns (1). Orthopedic surgeons have a pivotal role in transitioning the care of musculoskeletal illness from a biomedical to a biopsychosocial model. In an effort to foster this transition and understand potential barriers toward addressing psychosocial factors within orthopedic practices, a recent study aimed to determine surgeons’ attitudes and practice of noticing, screening, and discussing psychological illness with patients, as well as making referrals to address psychosocial issues of patients in need (1). 

Overall, surgeons are likely to notice and discuss psychological factors but less likely to formally screen or refer for psychological treatment (1). A lack of time during patient visits and the stigma associated with psychological factors are important barriers. The stigma associated with mental health is a general problem in medicine. There is an increased understanding that the physical and emotional aspects of illness cannot be separated; that distress, stress, and cognitive error or bias are to be expected and should not be considered shameful; and that psychosocial treatments can significantly alleviate symptoms and improve function. 

Clinicians often encounter patients who seem to prefer more testing or invasive treatments rather than supportive care, such as reassurance and education. A recent study aimed to determine whether patients unconsciously associate suggestions for physical interventions with better care. Although surgeons may sometimes feel pressured toward physical treatments, the results show that the average patient with upper or lower extremity symptoms has a slight implicit preference for supportive treatment and would likely be receptive (2).

Surgeons should be encouraged to practice communication strategies that increase comfort and raise awareness against stigma when discussing emotion and stress associated with orthopedic problems. We should be prepared to offer support. The use of empathic communication can  help normalize the stress, emotions, and cognitive errors associated with musculoskeletal illness. We can address each person as a whole rather than just their disease.

Our research on overcoming stigma, bias, and habit is focusing on several areas:

1. We are identifying potential barriers to and reasons for referrals to psychosocial treatment. 
2. We are addressing the importance of empathy and effective communication strategies in discussing psychosocial factors, making referrals, and maintaining patient satisfaction. 
3. We are investigating which factors are independently associated with both an implicit and an expressed preference for a physical intervention over supportive care.

References

1. Vranceanu AM, Beks RB, Guitton TG, Janssen SJ, Ring D. How do Orthopaedic Surgeons Address Psychological Aspects of Illness? Arch Bone Jt Surg. 2017 Jan;5(1):2-9. PubMed PMID: 28271080; PubMed Central PMCID: PMC5339350.
2. Kortlever JTP, Ottenhoff JSE, Tran TTH, Ring D, Vagner GA, Driscoll MD. Do Patients Unconsciously Associate Suggestions for More-invasive Treatment with Better Care? Clin Orthop Relat Res. 2019 Mar;477(3):514-522. doi: 10.1097/CORR.0000000000000608. PubMed PMID: 30762685.