Surgeon preferences are associated with utilization of telehealth in fracture care.

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic has the potential to evoke lasting changes in the delivery of care, and the utilization of telehealth. We sought associations between surgeon personal factors and greater use of telehealth to treat fractures relative to in-person care. METHODS: Seventy-five fracture surgeons participated in a survey-based experiment. All surgeons were asked about their preferences regarding remote compared to in-person communication. Participants rated the following items on slider scales: their degree of introversion, the importance of a hands-on/physical exam and surgeon preferences regarding telehealth. We identified factors associated with the use of, and comfort with, telehealth. RESULTS: The use of telehealth during the pandemic was associated with comfort evaluating wounds via telehealth. A greater proportion of remote visits was associated with comfort evaluating wounds and confidence teaching exercises via telehealth. There was consensus that telehealth did not alter utilization rates of radiographs or offer of discretionary surgery. The use of absorbable sutures to limit in-person visits was associated with a preference for working from home and greater comfort with evaluating wounds remotely. The use of 2- and 6-week post-operative telehealth visits and plans to use telehealth after the pandemic (52%) were associated with greater comfort in evaluating wounds through telehealth and greater confidence with video instruction of exercises. CONCLUSIONS: The finding that personal factors are associated with utilization of telehealth helps target strategies for increased use of telehealth and other technologies as the pandemic wanes. Given that telehealth adds convenience for people with ambulatory difficulties or in remote areas, such efforts are warranted. LEVEL OF EVIDENCE: Not applicable.

Surgeon Personal Factors Associated with Care Strategies in Musculoskeletal Telehealth.

Background: Most surgeons used, or are currently using telehealth during the SARS-CoV-2 (COVID-19) pandemic. We studied surgeon personal factors associated with relative use of telehealth during the worldwide height of the pandemic. Questions/Purposes: (1) Are there any personal factors/characteristics associated with use and utilization of telehealth? (2) What are surgeon's perspectives/ opinions with regard to use of telehealth for five common upper extremity conditions in terms of future prospects and viability? Methods: Hand and upper extremity surgeons in the Science of Variation Group (SOVG) were invited to participate in a web-based survey. The first part of the survey focused on surgeon characteristics and work preferences. The second part focused on care strategies during the pandemic and utilization of telehealth. The final part of the survey addressed the care of five common upper extremity conditions during the pandemic. Results: Ninety percent of surgeons used telehealth during the first few months of the pandemic, but only 20% of visits were virtual. A greater percentage of telehealth visits compared to office visits was independently associated with a policy of only seeing people with emergencies in person (RC: 0.64; CI 95%: 0.21 to 1.1; P<0.01). Surgeons found it difficult to reproduce most parts of the physical examination on video, but relatively easy to make a diagnosis, with both ratings associated with less belief that the physical exam is essential. Comfort in offering surgery by video visit was associated with having young children, preference for remote meetings, and less belief that the physical exam is essential. Conclusion: Utilization of, and comfort with, telehealth is related to personal factors and preferences, acceptance of a more limited physical examination in particular. Utilization of early adopters and training to increase comfort with the probabilistic aspects of medicine could facilitate incorporation of telehealth into standard practice.

Symptoms of depression and catastrophic thinking attenuate the relationship of pain intensity and magnitude of incapability with fracture severity.

OBJECTIVE: The relative association of pain intensity and magnitude of incapability with pathophysiology, accounting for psychological factors, is incompletely understood. Using moderation analysis, we assessed the association of pain intensity and magnitude of incapability (dependent variables) with fracture severity (independent variable) and the influence of symptoms of depression and catastrophic thinking (moderators) at early and later stages of recovery. METHODS: A cohort of 731 patients recovering from a shoulder, elbow, or wrist fracture, completed self-reported measures of pain intensity, upper extremity capability, symptoms of depression, and catastrophic thinking between 2 and 4 weeks after injury and again between 6 and 9 months after injury. Fracture severity was rated by clinicians, and we used multivariable regression analysis to examine interaction effects of fracture severity, depression, catastrophic thinking, pain intensity, and magnitude of incapability at early and later stages of recovery. RESULTS: Symptoms of depression and catastrophic thinking attenuate the relationship between pain intensity and fracture severity at earlier and later stages of recovery. Symptoms of depression and catastrophic thinking also attenuate the relationship between the magnitude of incapability and fracture severity, but only at early stages of recovery. CONCLUSION: The relative divergence of pain intensity and magnitude of incapability from the level of fracture severity due to the moderating effects of unhelpful thinking and distress, signals a benefit to anticipating mental health opportunities during recovery after fracture. Fracture management can incorporate measures of unhelpful thinking and symptoms of distress to better address these opportunities and ensure comprehensive optimization of recovery. LEVEL OF EVIDENCE: Level IIc, prognostic.

Which patient and surgeon characteristics are associated with surgeon experience of stress during an office visit?

Objective: To determine clinician and patient factors associated with the surgeon feelings of stress, futility, inadequacy, and frustration during an office visit. Methods: A survey-based experiment presented clinical vignettes with randomized patient factors (such as symptom intensity, the number of prior consultations, and involvement in a legal dispute) and feeling behind schedule in order to determine which are most related to surgeon ratings of stress, futility, inadequacy, and frustration on 11-point Likert scales. Results: Higher surgeon stress levels were independently associated with women patients, multiple prior consultations, a legal dispute, disproportionate symptom intensity, and being an hour behind in the office. The findings were similar for feelings of futility, inadequacy, and frustration. Conclusion: Patient factors potentially indicative of mental and social health opportunities are associated with greater surgeon-rated stress and frustration. Innovation: Trainings for surgeon self-awareness and effective communication can transform stressful or adversarial interactions into an effective part of helping patients get and stay healthy by diagnosing and addressing psychosocial aspects of the illness. Level of evidence: N/a.

Difficult life events affect lower extremity illness.

BACKGROUND: Given the relationship between psychological distress and activity tolerance (capability), a stressful life event might diminish accommodation, increase symptoms, and induce a person to seek specialty care. As a first step to investigate this possibility, this study addressed whether difficult life events are associated with greater activity intolerance and pain intensity. METHODS: A cohort of 127 patients seeking specialty care for lower extremity symptoms completed questionnaires that inquired about difficult life events within the last 12 months as derived from the Holmes Rahe Life Stress Inventory, and recorded pain intensity on an 11-point ordinal scale, activity tolerance [Patient Reported Outcomes Measurement Information System Physical Function Computer Adaptive Test (CAT)], symptoms of anxiety (GAD-2; 2 item version of the Generalized Anxiety Disorder questionnaire), symptoms of depression (PROMIS Depression CAT), self-efficacy when in pain (Pain Self-Efficacy Questionnaire, 2 question version), and demographics. The treating clinician indicated if the disease was established (e.g. arthritis) or relatively new (e.g. sprain/strain). Bivariate and multivariable analyses sought factors associated with activity intolerance and pain intensity. RESULTS: Greater activity intolerance was associated with difficult life events in bivariate analyses (t = 2.13, MD = 3.18, 95% C.I. = 0.22-6.13, p = 0.04) and in multivariable analyses that excluded symptoms of depression. Greater pain intensity was not associated with difficult life events, but was associated with surgeon rating of established disease (ß = 1.20, 95% C.I. = 0.33-2.08, p < 0.01), greater symptoms of anxiety (MD = 3.35, s = 1.72; ρ = 0.30, p < 0.01), and less education (ß = - 1.06, 95% C.I. = - 1.94- - 0.18, p = 0.02) (no college degree). CONCLUSION: When a musculoskeletal specialist identifies less activity tolerance (less capability) than anticipated for a given injury or pathology, they can anticipate a potential difficult life event, and expect alleviation of symptoms and improved capability as the stress is ameliorated with time and support. Specialists can be prepared to direct people to community or professional support if requested.

Unhelpful Thoughts and Distress Regarding Symptoms Limit Accommodation of Musculoskeletal Pain.

BACKGROUND: Among people with musculoskeletal disorders, much of the variation in magnitude of incapability and pain intensity is accounted for by mental and social health opportunities rather than severity of pathology. Current questionnaires seem to combine distinct aspects of mental health such as unhelpful thoughts and distress regarding symptoms, and they can be long and burdensome. To identify personalized health strategies, it would be helpful to measure unhelpful thoughts and distress regarding symptoms at the point of care with just a few questions in a way that feels relevant to a person's health. QUESTIONS/PURPOSES: (1) Do questions that address unhelpful thoughts and distress regarding symptoms independently account for variation in accommodation of pain? (2) Which questions best measure unhelpful thoughts and distress regarding symptoms? METHODS: This is a cross-sectional questionnaire study of people seeking care regarding upper and lower extremity conditions from one of eight specialist clinicians (one upper extremity, one arthroplasty, and one sports surgeon and their three nurse practitioners and two physician assistants) in one urban office. Between June 2020 and September 2020, 171 new and returning patients were approached and agreed to participate, and 89% (153) of patients completed all questionnaires. The most common reason for noncompletion was the use of a pandemic strategy allowing people to use their phone to finish the questionnaire, with more people leaving before completion. Women and divorced, separated, or widowed people were more likely to not complete the survey, and we specifically account for sex and marital status as potential confounders in our multivariable analysis. Forty-eight percent (73 of 153) of participants were women, with a mean age 48 ± 16 years. Participants completed demographics and the validated questionnaires: Pain Catastrophizing Scale, Negative Pain Thoughts Questionnaire, Tampa Scale of Kinesiophobia, Intolerance of Uncertainty Scale, and Pain Self-Efficacy Questionnaire (a measure of accommodation to pain). In an exploratory factor analysis, we found that questions group together on four topics: (1) distress about symptoms (unhelpful feelings of worry and despair), (2) unhelpful thoughts about symptoms (such as worst-case thinking and pain indicating harm), (3) being able to plan, and (4) discomfort with uncertainty. We used a multivariable analysis, accounting for potential confounding demographics, to determine whether the identified question groupings account for variation in accommodation of pain-and thus are clinically relevant. Then, we used a confirmatory factor analysis to determine which questions best represent clinically relevant groupings of questions. RESULTS: After accounting for sex, marital status, work, and income, we found that distress and unhelpful thoughts about symptoms were independently associated with accommodation of pain, and together, they explained 60% of its variation (compared with 52% for distress alone and 40% for unhelpful thoughts alone). Variation in symptoms of distress was best measured by the question "I feel I can't stand it anymore" (76%). Variation in unhelpful thoughts was best addressed by the question "I wouldn't have this much pain if there wasn't something potentially dangerous going on in my body" (64%). CONCLUSION: We found that distress (unhelpful feelings) and unhelpful thoughts about symptoms are separate factors with important and comparable associations with accommodation to pain. It also appears that these two factors can be measured with just a few questions. Being attentive to the language people use and the language of influential questions might improve clinician identification of mental health opportunities in the form of distress and unhelpful thoughts about symptoms, which in turn might contribute to better accommodation and alleviation of symptoms. LEVEL OF EVIDENCE: Level II, prognostic study.

Do Unhelpful Thoughts or Confidence in Problem Solving Have Stronger Associations with Musculoskeletal Illness?

BACKGROUND: Measures of unhelpful thoughts and distress correlate with the intensity of pain and the magnitude of incapability among people seeking musculoskeletal specialty care. In this evolving knowledge area, we want to be sure we have not neglected other important mental health factors. This study addressed how measures of confidence in problem solving as well as past and current ability to achieve goals account for variation in symptoms and capability independent of unhelpful thoughts and distress. QUESTIONS/PURPOSES: (1) Are measures of confidence in problem solving ability and past and current ability to achieve goals regarding future outcomes associated with variation in capability, independent of measures of symptoms of depression and anxiety (distress) and measures of unhelpful thoughts (worst-case thinking, negative pain thoughts)? (2) Are these measures independently associated with variation in pain intensity? (3) Are these measures associated with measures of symptoms of depression, symptoms of anxiety, and unhelpful thoughts? METHODS: Over a 7-month period during the pandemic, we enrolled sporadically from the offices of four surgeons treating patients who sought care for various upper and lower extremity conditions. We invited approximately 200 adult new and returning patients to participate (the number of invitations was not formally tracked) and 187 accepted. Thirty-one were excluded due to markedly incomplete entries (related to a problematic attempt to use the patient's cell phone to complete questionnaires as a pandemic work around), leaving 156 for analysis. Patients completed an 11-point ordinal rating of pain intensity, two measures of unhelpful thoughts (the Pain Catastrophizing Scale and the Negative Pain Thoughts Questionnaire), the Adult Hope Scale to measure past and current ability to achieve goals, the Personal Optimism and Self-Efficacy Optimism Scale to measure confidence in problem solving ability, the Patient-reported Outcomes Measurement Information System (PROMIS) computer adaptive test to measure symptoms of anxiety, the PROMIS computer adaptive test to measure symptoms of depression, and the PROMIS physical function computer adaptive test to assess the magnitude of capability. All questionnaires were validated in previous studies. We used bivariate analyses to identify factors associated with magnitude of capability, pain intensity, confidence in problem solving ability, and past and current ability to achieve goals. All factors with a p value of less than 0.1 were included in multivariable analyses to seek associations between these measures accounting for confounders. We reported partial η2 as a measure of effect size for all multivariable regression models. The following rules of thumb are used to interpret values for partial η2: a value of 0.01 = small, 0.06 = medium, and values of 0.14 and higher show large effect size. RESULTS: Greater capability was modestly associated with fewer negative pain thoughts (ß = -0.63 [95% CI -1.0 to -0.22]; standard error = 0.20; partial η2 = 0.06; p = 0.003) and no self-reported comorbidities (ß = 2.6 [95% CI 0.02 to 5.3]; standard error = 1.3; partial η2 = 0.03; p = 0.048) after controlling for education, symptoms of depression and anxiety, worst-case thinking, as well as past and current ability to achieve goals. In a similar multivariable model, greater pain intensity was modestly associated with greater worst-case thinking (ß = 0.33 [95% CI 0.20 to 0.45]; standard error = 0.06; partial η2 = 0.16; p < 0.001) and established patients (ß = -1.1 [95% CI -1.8 to -0.31]; standard error = 0.38; partial η2 = 0.05; p = 0.006). In another similar multivariable model, having more confidence in problem solving ability had a limited association with higher ratings of past and current ability to achieve goals (ß = 0.15 [95% CI 0.09 to 0.21]; standard error = 0.03; partial η2 = 0.13; p < 0.001). In a final multivariable model, lower past and current ability to achieve goals was independently associated with having greater symptoms of depression (ß = -0.45 [95% CI -0.67 to -0.23]; standard error = 0.11; partial η2 = 0.1; p < 0.001) and more negative pain thoughts (ß = -0.49 [95% CI -0.89 to -0.09]; standard error = 0.20; partial η2 = 0.04; p = 0.02). CONCLUSION: The observation that unhelpful thoughts about symptoms are more strongly associated with symptom intensity than past and current ability to achieve goals and confidence in problem solving ability add to the evidence that attentiveness to unhelpful thinking is an important aspect of musculoskeletal health. Musculoskeletal specialists can prioritize communication strategies such as relationship building and motivational interviewing that develop trust and facilitate reorientation of common unhelpful thoughts. LEVEL OF EVIDENCE: Level II, prognostic study.

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.