Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA.
Clin Orthop Relat Res. 2023 May 1;481(5):887-897. doi: 10.1097/CORR.0000000000002496. Epub 2022 Dec 23.
Unhelpful thoughts and feelings of distress regarding symptoms account for a large proportion of variation in a patient's symptom intensity and magnitude of capability. Clinicians vary in their awareness of this association, their ability to identify unhelpful thoughts or feelings of distress regarding symptoms, and the skills to help address them. These nontechnical skills are important because they can improve treatment outcomes, increase patient agency, and foster self-efficacy without diminishing patient experience.
QUESTIONS/PURPOSES: In this survey-based study, we asked: (1) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the total number of identified instances of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters? (2) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the interobserver reliability of a surgeon's identification of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters?
Surgeons from an international collaborative consisting of mostly academic surgeons (Science of Variation Group) were invited to participate in a survey-based experiment. Among approximately 200 surgeons who participate in at least one experiment per year, 127 surgeons reviewed portions of transcripts of actual new musculoskeletal specialty encounters with English-speaking patients (who reported pain and paresthesia as primary symptoms) and were asked to identify language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. The included transcripts were selected based on the rated presence of language reflecting unhelpful thinking as assessed by four independent researchers and confirmed by the senior author. We did not study accuracy because there is no reference standard for language reflecting unhelpful thoughts or feelings of distress regarding symptoms. Observers were randomized 1:1 to receive supportive information or not regarding definitions and examples of unhelpful thoughts or feelings of distress regarding symptoms (referred to herein as "priming") once at the beginning of the survey, and were not aware that this randomization was occurring. By priming, we mean the paragraph was intended to increase awareness of and attunement to these aspects of human illness behavior immediately before participation in the experiment. Most of the participants practiced in the United States (primed: 48% [29 of 60] versus not primed: 46% [31 of 67]) or Europe (33% [20 of 60] versus 36% [24 of 67]) and specialized in hand and wrist surgery (40% [24 of 60] versus 37% [25 of 67]) or fracture surgery (35% [21 of 60] versus 28% [19 of 67]). A multivariable negative binomial regression model was constructed to seek factors associated with the total number of identified instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. To determine the interobserver agreement, Fleiss kappa was calculated with bootstrapped 95% confidence intervals (resamples = 1000) and standard errors.
After controlling for potential confounding factors such as location of practice, years of experience, and subspecialty, we found surgeons who were primed with supportive information and surgeons who had 11 to 20 years of experience (compared with 0 to 5 years) identified slightly more instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms (regression coefficient 0.15 [95% CI 0.020 to 0.28]; p = 0.02 and regression coefficient 0.19 [95% CI 0.017 to 0.37]; p = 0.03). Fracture surgeons identified slightly fewer instances than hand and wrist surgeons did (regression coefficient -0.19 [95% CI -0.35 to -0.017]; p = 0.03). There was limited agreement among surgeons in their ratings of language as indicating unhelpful thoughts or feelings of distress regarding symptoms, and priming surgeons with supportive information had no influence on reliability (kappa primed: 0.25 versus not primed: 0.22; categorically fair agreement).
The observation that surgeons with brief exposure to supportive information about language associated with unhelpful thoughts and feelings of distress regarding symptoms identified slightly more instances of such language demonstrates the potential of training and practice to increase attunement to these important aspects of musculoskeletal health. The finding that supportive information did not improve reliability underlines the complexity, relative subjectivity, and imprecision of these mental health concepts.
Level I, therapeutic study.
患者对症状的无益想法和痛苦感受在很大程度上决定了其症状的强度和能力大小。临床医生对这种关联的认识程度、识别症状相关无益想法或痛苦感受的能力以及解决这些问题的技能各不相同。这些非技术技能很重要，因为它们可以改善治疗效果、提高患者的能动性并增强自我效能感，而不会降低患者的体验。
问题/目的：在这项基于调查的研究中，我们提出了以下问题：（1）是否存在任何因素，包括外科医生对反映症状相关无益想法或痛苦感受的语言信息的暴露，与在患者就诊记录的转录本中识别出的语言实例总数有关，这些语言实例被评定为反映症状相关无益想法或痛苦感受？（2）是否存在任何因素，包括外科医生对反映症状相关无益想法或痛苦感受的语言信息的暴露，与外科医生识别出的被评定为反映症状相关无益想法或痛苦感受的语言实例的观察者间可靠性有关？
由主要由学术外科医生组成的国际合作组织（科学变异组）的外科医生受邀参与基于调查的实验。在每年至少参与一项实验的大约 200 名外科医生中，127 名外科医生回顾了英语为母语的新肌肉骨骼专科患者的实际就诊记录的部分内容（这些患者报告了疼痛和感觉异常作为主要症状），并被要求识别被认为反映症状相关无益想法或痛苦感受的语言。纳入的转录本是根据四位独立研究人员评估的反映无益思维的语言存在情况以及资深作者的确认进行选择的。我们没有研究准确性，因为反映症状相关无益想法或痛苦感受的语言没有参考标准。观察者随机分为 1:1 组，分别接受支持性信息或不接受（在此称为“启动”），在调查开始时只接受一次，并且不知道这种随机分组正在进行。通过启动，我们的意思是在参与实验之前，立即增加对这种人类疾病行为方面的认识和敏感性。大多数参与者在美国（启动：46%[60 名中的 29 名]与不启动：46%[67 名中的 31 名]）或欧洲（33%[60 名中的 20 名]与不启动：36%[67 名中的 24 名]）执业，专门从事手部和腕部手术（40%[60 名中的 24 名]与不启动：37%[67 名中的 25 名]）或骨折手术（35%[60 名中的 21 名]与不启动：28%[67 名中的 19 名]）。构建了多变量负二项回归模型，以寻找与被认为反映症状相关无益想法或痛苦感受的语言实例总数相关的因素。为了确定观察者间的一致性，使用具有 bootstrap 95%置信区间（样本量=1000）和标准误差的 Fleiss kappa 进行计算。
在控制了潜在的混杂因素，如实践地点、经验年限和亚专业后，我们发现接受支持性信息启动的外科医生和具有 11 至 20 年经验的外科医生（与 0 至 5 年相比）识别出更多被认为反映症状相关无益想法或痛苦感受的语言实例（回归系数 0.15[95%CI 0.020 至 0.28]；p=0.02 和回归系数 0.19[95%CI 0.017 至 0.37]；p=0.03）。骨折外科医生识别出的语言实例比手部和腕部外科医生少（回归系数-0.19[95%CI-0.35 至-0.017]；p=0.03）。外科医生在评定语言表示症状相关无益想法或痛苦感受的可靠性方面存在一致性有限，启动外科医生的支持性信息对可靠性没有影响（启动：0.25 与不启动：0.22；适度一致）。
观察到接受简短支持性信息启动的外科医生识别出更多此类语言实例，这表明培训和实践可以增加对肌肉骨骼健康这些重要方面的敏感性。支持性信息并没有提高可靠性这一发现强调了这些心理健康概念的复杂性、相对主观性和不精确性。
一级，治疗性研究。
