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Background: Evidence is mounting that the biopsychosocial paradigm is more accurate and useful than the biomedical paradigm of care. Habits of thought can hinder the implementation of this knowledge into daily care strategies. To understand and lessen these potential barriers, we asked: 1) What is the relative implicit and explicit attitudes of musculoskeletal surgeons towards the biomedical or biopsychosocial paradigms of medicine? 2) What surgeon factors are associated with these attitudes?, Methods: An online survey-based experiment was distributed to members of the Science of Variation Group (SOVG) with a total of 163 respondents. Implicit bias towards the biomedical or biopsychosocial paradigms was measured using an Implicit Association Test (IAT) designed by our team using open-source software; explicit preferences were measured using ordinal scales., Results: On average, surgeons demonstrated a moderate implicit bias towards the biomedical paradigm (d-score: -0.21; Interquartile range [IQR]: -0.56 to 0.19) and a moderate explicit preference towards the biopsychosocial paradigm (mean: 14; standard deviation: 14). A greater implicit bias towards the biomedical paradigm was associated with male surgeons (d-score: -0.30; IQR: -0.57 to 0.14; P = 0.005). A greater explicit preference towards the biomedical paradigm was independently associated with a European practice location (Regression coefficient: -9.1; 95% CI: -14 to -4.4; P <0.001) and trauma subspecialty (RC: -6.2; 95% CI: -11 to -1.0; P <0.001)., Conclusions: The observation that surgeons have an implicit bias favoring the biomedical paradigm might inform strategies for implementation of care strategies based on evidence favoring the biopsychosocial paradigm., Competing Interests: NO authors have competing interests pertinent to this study., (Copyright: © 2024 Ramtin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

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., (Copyright © 2023. Published by Elsevier Inc.)

Background: Unhelpful thoughts and feelings of worry or despair about symptoms account for a notable amount of the variation in musculoskeletal symptom intensity. Specialists may be best positioned to diagnose these treatable aspects of musculoskeletal illness. Musculoskeletal specialists might be concerned that addressing mental health could offend the patient, and avoidance might delay mental health diagnosis and treatment. Evidence that conversations about mental health are not associated with diminished patient experience might increase specialist confidence in the timely diagnosis and initial motivation to treat unhelpful thoughts and feelings of worry or despair., Questions/purposes: Using transcripts of videotaped and audiotaped specialty care visits in which at least one instance of patient language indicating an unhelpful thought about symptoms or feelings of worry or despair surfaced, we asked: (1) Is clinician discussion of mental health associated with lower patient-rated clinician empathy, accounting for other factors? (2) Are clinician discussions of mental health associated with patient demographics, patient mental health measures, or specific clinicians?, Methods: Using a database of transcripts of 212 patients that were audio or video recorded for prior studies, we identified 144 transcripts in which language reflecting either an unhelpful thought or feelings of distress (worry or despair) about symptoms was detected. These were labeled mental health opportunities. Patients were invited on days when the researcher making video or audio records was available, and people were invited based on the researcher's availability, the patient's cognitive ability, and whether the patient spoke English. Exclusions were not tracked in those original studies, but few patients declined. There were 80 women and 64 men, with a mean age of 45 ± 15 years. Participants completed measures of health anxiety, catastrophic thinking, symptoms of depression, and perceived clinician empathy. Factors associated with perceived clinician empathy and clinician discussion of mental health were sought in bivariate and multivariable analyses., Results: Greater patient-rated clinician empathy was not associated with clinician initiation of a mental health discussion (regression coefficient 0.98 [95% confidence interval 0.89 to 1.1]; p = 0.65). A clinician-initiated mental health discussion was not associated with any factors., Conclusion: The observation that a clinician-initiated mental health discussion was not associated with diminished patient ratings of clinician empathy and was independent from other factors indicates that generally, discussion of mental health does not harm patient-clinician relationship. Musculoskeletal clinicians could be the first to notice disproportionate symptoms or misconceptions and distress about symptoms, and based on the evidence from this study, they can be confident about initiating a discussion about these mental health priorities to avoid delays in diagnosis and treatment. Future studies can address the impact of training clinicians to notice unhelpful thoughts and signs of distress and discuss them with compassion in a specialty care visit; other studies might evaluate the impact of timely diagnosis of opportunities for improvement in mental health on comfort, capability, and optimal stewardship of resources., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Study Aim: There is a gap in evidence that demonstrates an increased risk of hernia formation in laborers. A notable incidence of a second asymptomatic hernia among people making a workers' compensation claim for a hernia would suggest that the pathology is not acute and probably not related to work, or the performance of a single strenuous event., Patients and Methods: We performed a retrospective database study of a consecutive sample of 106 adults who claimed a work-related abdominal hernia between September 2016 and December 2018 and had a Computed Tomography (CT) scan as part of a diagnostic workup. Hernias were classified as incidental if patients had a contralateral inguinal hernia with unilateral groin symptoms, or if patients had a ventral hernia with only groin symptoms or vice versa., Results: Thirty-three percent of patients had an incidental hernia. No patient factors were associated with having an incidental hernia. Higher BMI and having a concurrent incidental hernia were associated with lower odds of surgical treatment under the injury claim., Conclusion: Abdominal symptoms after a work event might lead to a diagnosis of hernia, and there is a notable likelihood that the hernia is incidental and unrelated to work. New symptoms at or near the site of an abdominal hernia may or may not be from the hernia, and very often are more consistent with an abdominal muscle strain. The clinical or imaging finding of an abdominal wall defect or the presence of a hernia may be incidental, unrelated to the physical activity., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Introduction: Measures of mood and effective coping strategies have notable correlations with quality of life and treatment responses. There is evidence that patients with previously diagnosed anxiety disorders have less improvement in patient-reported outcome measures (PROMs) after laparoscopic anti-reflux surgery (LARS) and that objective pathology does not correlate well with symptom severity. We were interested in investigating whether anxiety and hypervigilance, as measured preoperatively with the esophageal hypervigilance anxiety scale (EHAS), is associated with the improvement in GERD-specific PROMs and EHAS scores 6 months after LARS., Methods: We performed a retrospective cohort study of 102 adult patients (31% men, average age 64) who underwent LARS. In the preoperative evaluation, baseline gastroesophageal reflux disease-health-related quality of life (GERD-HRQL), laryngopharyngeal reflux symptom index (LPR-RSI) and EHAS scores were collected in addition to the standard reflux workup, including endoscopy, manometry, barium swallow, and pH study. For all three surveys, a higher score represents worse symptom severity. At 6 months postoperatively, 70 patients completed repeat GERD-HRQL, LPR-RSI, and EHAS surveys. We then analyzed for surgical and patient-related factors associated with improvement in the 6-month postoperative GERD-HRQL and LPR-RSI scores., Results: There was a statistically significant decrease in the GERD-HRQL (25 vs. 2, p &lt; 0.001), LPR-RSI (17 vs. 3, p &lt; 0.001) and EHAS (34 vs. 15, p &lt; 0.001) 6 months after LARS. On multivariable linear regression, a higher baseline EHAS score was independently associated with a greater improvement in GERD-HRQL (β 0.35, p &lt; 0.001) and LPR-RSI (β 0.19, p = 0.03) 6-months after LARS. Additionally, the degree of improvement in EHAS, GERD-HRQL, and LPR-RSI was not influenced by the type of LARS performed or by the severity of disease., Conclusion: These findings are consistent with literature suggesting that measures of psychoemotional health correlate better with symptom intensity than objective pathology. We found that patients with a higher EHAS score have greater symptom severity and lower quality of life at baseline. Novel findings to this study are that patients with a higher preoperative EHAS, a measure of psychoemotional health, actually benefitted more from surgery and not less, which has been the traditional view in the literature. Future studies are warranted to establish directionality and explore the role of preoperative cognitive behavioral therapy with LARS for patients with significant symptoms of hypervigilance and anxiety., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Many clinicians and patients tried telemedicine for the first time during the COVID-19 pandemic. In a prior survey, we found that clinicians who were adaptable and willing to incorporate technology into their clinical practice are more likely to utilize telemedicine. Seeking factors associated with current and future use of telemedicine, and identifying its relative advantages and drawbacks, may help determine the role of telemedicine after the pandemic. Questions/Purposes: We asked (1) which demographic factors and personal preferences are associated with current and planned future use of telemedicine, (2) what factors are associated with telemedicine utilization, and (3) what are clinician-reported advantages and disadvantages of telemedicine? Materials and Methods: Approximately 750 clinicians within a national multispecialty hospital group were invited to complete an online survey assessing telemedicine use and preferences, self-reported technology proficiency, and personal characteristics. A total of 284 clinicians started the survey, and 259 complete responses were analyzed using bivariate analysis and multivariable regression. Results: More frequent current telemedicine use was associated with being a nonsurgeon clinician, not primarily practicing in an inpatient setting, preferring either telemedicine or having no preference for discussing sensitive topics, and greater self-reported technological proficiency. Planned future telemedicine use was associated with greater self-reported troubleshoot ability and less desire for a hands-on physical examination. Clinicians reported that the top benefits of telemedicine are decreased barriers for patients and convenience for clinicians, and disadvantages are technical difficulties for both patients and clinicians. Conclusions: Telemedicine continues to be widely utilized by clinicians, particularly those who are confident in their ability to examine patients over video, and who can troubleshoot issues that arise on the platform. With continued reimbursement, telemedicine is likely to remain a convenient and effective method of caring for patients.

Background: Accurately distinguishing the severity of pathophysiology from the level of symptom intensity and incapability is a foundation of effective treatment strategies under the biopsychosocial paradigm of illness. With respect to idiopathic median neuropathy at the carpal tunnel (the symptoms and signs of which are referred to as carpal tunnel syndrome), surgeons who are more likely to recommend surgery based on the magnitude of symptoms and incapability rather than the severity of neuropathy may be underappreciating and undertreating mental health opportunities and overtreating mild, and on occasion unmeasurable, disease. A survey-based experiment that randomizes elements of the patient presentation can help determine the relative influence of magnitude of incapability on ratings of pathology severity., Question/purpose: What factors are associated with severity rating of idiopathic median neuropathy at the carpal tunnel on an 11-point ordinal scale?, Methods: One hundred eight hand and wrist members of the Science of Variation Group (among approximately 200 participants who complete at least one survey-experiment a year related to the upper extremity on average) reviewed seven scenarios of fictional median neuropathy with seven randomized variables: age, gender, limitations of daily activity (incapability), Tinel and Phalen test results, duration of numbness episodes, prevention of numbness with nocturnal splint immobilization, constant numbness, and weakness of palmar abduction. Participants had a mean age of 51 ± 10 years, 90% (97 of 108) were men, and 74% (80 of 108) were subspecialized in hand surgery. Surgeons were asked to rate the severity of idiopathic median neuropathy at the carpal tunnel on a on an 11-point ordinal scale. Factors associated with rated severity were sought in multilevel ordered logistic regression models. Fifteen surgeons did not complete all of their assigned randomized scenarios, resulting in a total of 675 ratings., Results: After controlling for potentially confounding variables such as magnitude of incapability, factors associated with severity rating on the 11-point ordinal scale included palmar abduction weakness (odds ratio 11 [95% confidence interval 7.7 to 15]), longer duration of symptom episodes (OR 4.5 [95% CI 3.3 to 6.2]), nocturnal numbness in spite of splint immobilization (OR 3.2 [95% CI 2.3 to 4.3]), constant numbness (OR 2.5 [95% CI 1.9 to 3.4]), positive Tinel and positive Phalen test results (OR 2.2 [95% CI 1.6 to 2.9]), and older age (OR 1.6 [95% CI 1.2 to 2.1])., Conclusion: Our results suggest that surgeons rate the severity of idiopathic median neuropathy at the carpal tunnel based on evidence of worse pathophysiology and are not distracted by greater incapability., Clinical Relevance: Surgeons who consider greater incapability as an indication of more severe pathology seem to be practicing outside the norm and may be underappreciating and undertreating the unhelpful thoughts and feelings of worry or despair that consistently account for a notable amount of the variation in symptom intensity and magnitude of incapability., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

Objective: Patients might exaggerate their symptoms in an attempt to align the clinician's views with their own. A person who sees potential benefit in symptom exaggeration might also experience less trust, more difficulty communicating, and lower satisfaction with their clinician. We asked if there was an association between patient rating of communication effectiveness, patient satisfaction, and patient trust with symptom exaggeration?, Methods: One hundred and thirty-two patients in four orthopaedic offices completed surveys including demographics, Communication-Effectiveness-Questionnaire (CEQ-6), Negative-Pain-Thoughts-Questionnaire (NPTQ-4), a Guttman-style satisfaction question, PROMIS Depression, and Stanford Trust in Physician. Patients were randomly assigned to answer three questions about symptom exaggeration for two scenarios: 1) their own exaggeration during the just-completed visit or 2) the average person's tendency to exaggerate., Results: In multivariable analysis, lower ratings of communication effectiveness were associated with greater symptom exaggeration (p=0.002), while an annual household income>$100,000 (p=0.033) was associated with higher ratings. Higher rating of satisfaction was associated with lower education attained (p=0.004). Greater trust was associated with lower personal exaggeration (p=0.002)., Conclusion: The relationship between greater exaggeration and lower ratings of communication effectiveness and trust suggests that symptom descriptions that seem more intense or diffuse than expected may indicate opportunities for more effective communication and trust., Innovation: Patient experience can be improved by training clinicians to identify symptom exaggeration as a signal that the patient does not feel heard and understood and a cue to return to communication strategies that build trust., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Objectives: Two recent developments favor initial nonoperative treatment of proximal humerus fractures among the older, relatively infirm, less-active patients that represent most patients with such fractures: (1) evidence of minimal benefit of open reduction, internal fixation over nonoperative treatment, and (2) evidence of the effectiveness of the reverse total shoulder arthroplasty. As one step in determining the feasibility of a strategy of initial nonoperative treatment of proximal humerus fracture among older, relatively infirm, less-active people, we performed a survey-based experiment to measure factors associated with surgeon recommendation for initial nonoperative treatment., Methods: Members of the Science of Variation Group viewed 8 hypothetical patients with radiographs of complex proximal humeral fractures and 7 randomized patient variables. For each scenario, surgeons were asked whether they would recommend (1) initial nonoperative treatment with bailout reverse arthroplasty or (2) immediate reverse arthroplasty., Results: The mean percentage of recommendations for initial nonoperative treatment was 63%, with wide variation by surgeon (range 0%-100%). In multilevel mixed-effects logistic regression, recommendation for initial nonoperative treatment was associated with specific radiographs, older age, having a comorbidity, being homebound, surgical subspecialists, and more than 20 years in practice., Conclusions: These findings suggest that surgeons may consider initial nonoperative treatment with potential for future conversion to reverse arthroplasty an acceptable treatment option, particularly for older, less-active, more infirm individuals, and relatively less displaced fractures with little comminution., Competing Interests: One of the authors (D.R.) received royalties from Wright Medical (Memphis, TN) for elbow plates in the amount of less than USD 10,000 per year and from Skeletal Dynamics for an internal joint stabilizer elbow in the amount of between 10,000 and 100,000 USD per year. One of the authors certifies that he (D.R.) is a Deputy Editor for Hand and Wrist, Journal of Orthopaedic Trauma, and Clinical Orthopaedics and Related Research and has received or may receive payments or benefits in the amount of USD 5000 per year. One of the authors certifies that he (D.R.) received honoraria from meetings of the AO North America (Wayne, PA), AO International (Davos, Switzerland), and various hospitals and universities. The remaining authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: One of the authors (DR) received royalties from Skeletal Dynamics for an internal joint stabilizer elbow in the amount of between 10,000 and 100,000 USD per year. One of the authors certifies that he (DR) is a Deputy Editor for Hand and Wrist, Journal of Orthopaedic Trauma, and Clinical Orthopaedics and Related Research® and has received or may receive payments or benefits in the amount of USD 5000 per year. One of the authors certifies that he (DR) received honoraria from meetings of the AO North America (Wayne, PA, USA), AO International (Davos, Switzerland), and various hospitals and universities., (© 2022 The Authors.)

Introduction: Shoulder abnormalities on imaging are increasingly common with advancing age.We tested the difference in the accuracy of diagnosing the injured shoulder between surgeons who reviewed MRI reports and who did and did not receive information about the patients., Methods: Thirty people aged 40 or older that experienced new shoulder symptoms after an event at work had MRI of both shoulders. Members of the Science of Variation Group (SOVG) were invited to review the radiologist's reports and diagnose the symptomatic side. Ninety-seven surgeons participated., Results: Surgeon observers provided with patient information were not more accurate in diagnosing the symptomatic shoulder (Odds Ratio: 0.90; 95% CI: 0.75 to 1.1; P  = 0.29). There was slight agreement between surgeons (kappa = 0.10). The sensitivity and specificity for diagnosing the symptomatic side were 51% (CI: 48%-54%) and 67% (CI: 64%-70%) respectively. A binomial test showed that surgeons indicated the injured shoulder slightly more frequently than expected by random chance (59%; P  < 0.001)., Conclusions: Surgeons were only slightly better at indicating the symptomatic side than random chance. Shoulder pain in people aged 40 or older should probably be considered age-related unless there is good objective evidence of acute traumatic pathology., Level of Evidence: Level II, diagnostic study., Competing Interests: No benefits in any form have been received or will be received related directly or indirectly 3 to the subject of this article. EB, TC, MN, ME, SJ certify that they have no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. One of the authors (DR) received royalties from Wright Medical (Memphis, TN, USA) for elbow plates in the amount of less than USD 10,000 per year and from Skeletal Dynamics for an internal joint stabilizer elbow in the amount of between 10,000 and 100,000 USD per year. One of the authors certifies that he (DR) is a Deputy Editor for Hand and Wrist, Journal of Orthopaedic Trauma, and Clinical Orthopaedics and Related Research® and has received or may receive payments or benefits in the amount of USD 5000 per year. One of the authors certifies that he (DR) received honoraria from meetings of the AO North America (Wayne, PA, USA), AO International (Davos, Switzerland), and various hospitals and universities., (© 2020 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.)