Health providers have an intuition or impression regarding a patient’s adaptation, resiliency and effective coping strategies in the face of injury or illness. These are a product of heuristics (experienced based problem solving or “mental short-cuts”) rather than objective testing. Affective (e.g. depression) and cognitive (e.g. pain catastrophizing and health anxiety) aspects of illness behavior can be quantitatively measured and have been shown to correlate with pain intensity and disability. The relationships between pain and nociception and disability and impairment are mediated by psychological distress, heightened illness concern, and cognitive bias.  

In one study, we studied the degree to which health provider intuition corresponds with quantitative measures of factors that hinder recovery and increase disability. This study is designed to analyze arm-specific disability and quantify psychological factors–specifically depression, anxiety and pain catastrophizing–in patients intuitively classified by a hand surgeon as having relatively effective coping strategies (RECS) or relatively ineffective coping strategies (RICS). It was found that RECS patients had lower pain levels, better DASH scores (a questionnaire that measures perceived arm-specific disability), lower depression, lower anxiety, and lower Pain Catastrophizing scores (1). Depression was the most important predictor of surgeon-judged effective coping strategies. It can be concluded from this study that surgeon heuristics can distinguish relatively effective from relatively ineffective coping strategies.

Nonspecific symptoms are common in all areas of medicine. Patients and caregivers can be frustrated when an illness cannot be reduced to a discrete pathophysiological process that corresponds with the symptoms. Nonspecific diagnoses are not harmful (2). Prospective randomized research is merited to determine if nonspecific, descriptive diagnoses are better for patients than specific diagnoses that imply pathophysiology in the absence of discrete verifiable pathophysiology.

We have the impression that provider uncertainty arises from either nonspecific pathology or disproportionate symptoms and disability, both of which correlate with symptoms of depression, heightened illness concern, and low patient self-efficacy. Our study found that provider confidence was significantly lower for nonspecific diagnoses, but there was no correlation between provider confidence and patient self-efficacy (3).

Our research on surgeon psychology is focusing on several areas:

1. We are determining how surgeons learn and apply heuristics and identifying questionnaires that provide more objective and reliable measures of the things that surgeons are picking up on intuitively. This will allow more general application of these concepts leading surgeons to more readily consider biopsychosocial treatments, such as cognitive behavioral therapy. 

References

1.   Lozano Calderón SA, Ring D. Surgeon Heuristics Regarding Effective Coping Strategies.  Univ Penn Orthop J. 21:98-101, 2011.
2.   Kortlever JT, Janssen SJ, Molleman J, Hageman MG, Ring D. Discrete Pathophysiology is Uncommon in Patients with Nonspecific Arm Pain. Arch Bone Jt Surg. 2016 Jun;4(3):213-9. PubMed PMID: 27517064; PubMed Central PMCID: PMC4969365.
3.   Hageman MG, Bossen JK, King JD, Ring D. Surgeon confidence in an outpatient setting. Hand (N Y). 2013 Dec;8(4):430-3. doi: 10.1007/s11552-013-9533-6. PubMed PMID: 24426961; PubMed Central PMCID: PMC3840763.