Body-Self Unity With a New Hip or Knee: Understanding Total Joint Replacement Within an Embodiment Framework.

Medical research increasingly makes use of embodiment concepts to understand how illness disrupts unity of body and self. However, few have applied embodiment concepts in total joint replacement (TJR), an effective treatment for end-stage arthritis. In considering why a troubling proportion of TJR recipients have continued pain and functional limitation, we ask: what role might be played by the embodied experience of living with an implant? Relevant theoretical models and prior research on embodiment in musculoskeletal health and transplantation are reviewed. Our findings suggest a research agenda with implications for addressing suboptimal outcomes in TJR.

To 'Get by' or 'get help'? A qualitative study of physicians' challenges and dilemmas when patients have limited English proficiency.

OBJECTIVE: Encounters between patients and physicians who do not speak the same language are relatively common in Canada, particularly in urban settings; this trend is increasing worldwide. Language discordance has important effects on health outcomes, including mortality. This study sought to explore physicians' experiences of care provision in situations of language discordance in depth. DESIGN: Qualitative study based on individual interviews. Interview guides elicited physicians' perspectives on how they determined whether communication could proceed unaided. A descriptive qualitative approach was adopted, entailing inductive thematic analysis. PARTICIPANTS: 22 physicians experienced in treating patients in situations of language discordance were recruited from the emergency and internal medicine departments of an urban tertiary-care hospital. SETTING: Large, inner-city teaching hospital in Toronto, Canada, one of the most linguistically diverse cities internationally. RESULTS: Determining when to 'get by' or 'get help' in order to facilitate communication was described as a fluid and variable process. Deciding which strategy to use depended on three inter-related factors: time/time constraints, acuity of situation and ease of use/availability of translation aids. Participants reported at times feeling conflicted about their decisions, portraying some of these clinical encounters as a 'troubling space' in which they experienced one or more dilemmas related to real versus ideal practice, responsibility and informed consent. CONCLUSIONS: In situations of language discordance, a physician's decision to 'get by' (vs 'get help') rests on a judgement of whether communication can be considered 'good enough' to proceed and depends on the circumstances of the specific encounter. The tension set up between what is 'ideal' and what is practically possible can be experienced as a dilemma by physicians. The study's findings have implications for practice and policy not only in Canada but in other multilingual settings, and indicate that physicians require greater support.

A systematic review of surgeon-patient communication: strengths and opportunities for improvement.

OBJECTIVE: Effective communication is critical to patient satisfaction, outcomes of care and malpractice prevention. Surgeons need particularly effective communication skills to discuss complicated procedures and help patients make informed choices. We conducted a systematic review of the literature on surgeon-patient communication. METHODS: Searches were conducted in MEDLINE, PsycINFO, and Sociological Abstract. Two reviewers screened citations and full-text articles. Quality was appraised using the Critical Appraisal Skills Program tool. Studies were categorized into content of communication, patient satisfaction, relationship of communication to malpractice, and duration of visits. RESULTS: 2794 citations and 74 full-text articles, 21 studies and 13 companion reports were included. Surgeons spent the majority of their time educating patients and helping them to make choices. Surgeons were generally thorough in providing details about surgical conditions and treatments. Surgeons often did not explore the emotions or concerns of patients. Potential areas of improvement included discussing some elements of informed decision making, and expressing empathy. CONCLUSION: Surgeons can enhance their communication skills, particularly in areas of relative deficiency. Studies in primary care demonstrate communication programs are effective in teaching these skills. PRACTICE IMPLICATIONS: These can be adapted to surgical training and ultimately lead to improved outcomes and satisfaction with care.

The omni-relevance of surgery: how medical specialization shapes orthopedic surgeons' treatment recommendations.

This article examines treatment recommendations in orthopedic surgery consultations and shows how surgery is treated as "omni-relevant" within this activity, providing a context within which the broad range of treatment recommendations proposed by surgeons is offered. Using conversation analysis to analyse audiotaped encounters between orthopedic surgeons and patients, we highlight how surgeons treat surgery as having a special, privileged status relative to other treatment options by (1) invoking surgery (whether or not it is actually being recommended) and (2) presenting surgery as the "last best resort" (in relation to which other treatment options are calibrated, described and considered). This privileged status surfaces in the design and delivery of recommendations as a clear asymmetry: Recommendations for surgery are proposed early, in relatively simple and unmitigated form. In contrast, recommendations not for surgery tend to be delayed and involve significantly more interactional work in their delivery. Possible implications of these findings, including how surgeons' structuring of recommendations may shape patient expectations (whether for surgery or some alternative), and potentially influence the distribution of orthopedic surgery procedures arising from these consultations, are considered.

Of time and troubles: patient involvement and the production of health care disparities.

Patient involvement in care practice has many and diverse proponents. It is endorsed by health care institutions and promoted by community agencies representing people with illness. A vast literature documents the benefits of patient involvement and describes ways to enable it. This article contributes to a critical literature on patient involvement by documenting the work done by women with cancer in relation to care timelines and in responding to troubles with care. We highlight continuities and disjunctures between this work, and discourses of patient involvement as they manifest in documents circulating at an Ontario cancer centre. In making visible the social and material resources that underpin successful involvement, the study shows how initiatives that endorse and promote 'the involved patient' can function to exacerbate health care and social disparities. As well, the study extends analysis of the individualization and privatization of health by showing how contemporary discourses of involvement enlist patients to monitor and sustain not only their own health, but also the health care they receive.

How surgeons design treatment recommendations in orthopaedic surgery.

This paper examines how orthopaedic surgeons skilfully design treatment recommendations to display awareness of what individual patients are anticipating or seeking, and suggests limits to those efforts. It adds leverage to our parallel work by demonstrating that even when surgeons incorporate considerations of recipient design to 'fit' recommendations to patients' displayed orientations, an asymmetry between recommendations for vs. not for surgery remains: recommendations for surgery are generally proposed early, in relatively simple and unmitigated form, and as stand-alone options. In contrast, recommendations not for surgery tend to be significantly more complex: they are likely to be delayed, conveyed indirectly, mitigated and justified, and include other possible treatment options. These findings suggest a tension between surgeons' efforts to design recommendations for specific recipients and an overarching institutional bias favoring surgery. Surgeons' efforts to anticipate and respond to resistance to recommendations demonstrate a similar pattern: the methods used to counter patient resistance, and the sequential placement of those efforts, depends on whether the recommendation is for surgery or another treatment option. This work contributes to an understanding of treatment recommendations generally by showing how patients are co-implicated in their accomplishment: because surgeons incorporate considerations of recipient design in response to information provided explicitly or tacitly by patients, patients influence the rendering of recommendations from the beginning.

An interactional approach to conceptualising small talk in medical interactions.

In medical interactions, it may seem straightforward to identify 'small talk' as casual or social talk superfluous to the institutional work of dealing with patients' medical concerns. Such a broad characterisation is, however, extremely difficult to apply to actual talk, and more specificity is necessary to pursue analyses of how small talk is produced and what it achieves for participants in medical interactions. We offer an approach to delineating a subgenre of small talk called topicalised small talk (TST), derived on the basis of conversation analytically-informed analyses of routine consultations involving orthopaedic surgeons and older patients. TST is a line of talk that is referentially independent from their institutional identities as patients or surgeons, oriented instead to an aspect of the personal biography of one (or both), or to some neutral topic available to interactants in any setting (e.g. weather). Importantly, TST is an achievement of both patient and surgeon in that generation and pursuit of topic is mutually accomplished. In an exploratory but systematic analysis, when this approach was applied to a purposive sample of surgeon-patient interactions, TST was much more prevalent in visits with White than African American patients. Accounts for possible ethnic differences in TST are suggested.

Variability in physician opinions about the indications for knee arthroplasty.

To determine how much of variability in physician opinion about the indications for knee arthroplasty is due to inconsistency in individual physicians' opinions. We surveyed 201 orthopedic surgeons, 141 rheumatologists, and 455 family physicians. Physicians were asked how 34 patient characteristics affected their decision to perform or refer for knee arthroplasty. Surgeons and referring physicians agreed on how 4 and 2 of 34 patient characteristics affected their decision about knee arthroplasty, respectively. Half of the variability in opinion among physicians could be accounted for by inconsistency in their individual responses to the survey 6 weeks apart (mean intraclass correlation coefficient = 0.49). Although surgeons and referring physicians vary in their opinion, half of the variability could be attributed to individual physician inconsistency.

"I like to be an informed person but..." negotiating responsibility for treatment decisions in cancer care.

Social expectations surrounding sickness have undergone a transformation in Western welfare states. Emerging discourses about patients' roles and responsibilities do not however always map neatly onto patients' actions, experiences or desires. This paper emerges from a study in Ontario, Canada. Drawing on in-depth interviews with 5 women diagnosed with breast cancer we explore the activity and effort prompted for patients by the routine professional practice of outlining treatment options and encouraging patients to choose between them. We highlight research participants' complex responses to their responsibility for treatment decisions: their accepting, deflecting and reframing and their active negotiation of responsibility with professionals. The literature on treatment decision making typically characterizes people who resist taking an active role as overwhelmed, misinformed about the nature of treatment decisions, or more generally lacking capacity to participate. In this paper we suggest that patients' expressions of ambivalence about making treatment choices can be understood otherwise: as efforts to recast the identities and positions they and their physicians are assigned in the organization of cancer care. We also begin to map key features of this organization, particularly discourses of patient empowerment, and evidence-based medicine.

'I've heard wonderful things about you': how patients compliment surgeons.

This investigation was motivated by physician reports that patient compliments often raise 'red flags' for them, raising questions about whether compliments are being used in the service of achieving some kind of advantage. Our goal was to understand physician discomfort with patient compliments through analyses of audiotaped surgeon-patient encounters. Using conversation analysis, we demonstrate that both the placement and design of compliments are consequential for how surgeons hear and respond to them. The compliments offered after treatment recommendations are neither designed nor positioned to pursue institutional agendas and are responded to in ways that are largely consistent with compliment responses in everyday interaction, but include modifications that preserve surgeons' expertise. In contrast, some compliments offered before treatment recommendations pursue specific treatments and engender surgeons' resistance. Other compliments offered before treatment recommendations do not overtly pursue institutionally-relevant agendas-for example, compliments offered in the opening phase of the visit. We show how these compliments may but need not foreshadow a patient's upcoming agenda. This work extends our understanding of the interactional functions of compliments, and of the resources patients use to pursue desired outcomes in encounters with healthcare professionals.

Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review.

BACKGROUND: Total joint arthroplasty is a highly efficacious and cost-effective procedure for moderate to severe arthritis in the hip and knee. Although patient characteristics are considered to be important determinants of who receives total joint arthroplasty, no systematic review has addressed how they affect the outcomes of total joint arthroplasty. This study addresses how patient characteristics influence the outcomes of hip and knee arthroplasty in patients with osteoarthritis. METHODS: We searched 4 bibliographic databases (MEDLINE 1980-2001, CINAHL 1982-2001, EMBASE 1980-2001, HealthStar 1998-1999) for studies involving more than 500 patients with osteoarthritis and 1 or more of the following outcomes after total joint arthroplasty: pain, physical function, postoperative complications (short-and long-term) and time to revision. Prognostic patient characteristics of interest included age, sex, race, body weight, socioeconomic status and work status. RESULTS: Sixty-four of 14,276 studies were eligible for inclusion and had extractable data. Younger age (variably defined) and male sex increased the risk of revision 3-fold to 5-fold for hip and knee arthroplasty. The influence of weight on the risk of revision was contradictory. Mortality was greatest in the oldest age group and among men. Function for older patients was worse after hip arthroplasty (particularly in women). Function after knee arthroplasty was worse for obese patients. CONCLUSION: Although further research is required, our findings suggest that, after total joint arthroplasty, younger age and male sex are associated with increased risk of revision, older age and male sex are associated with increased risk of mortality, older age is related to worse function (particularly among women), and age and sex do not influence the outcome of pain. Despite these findings, all subgroups derived benefit from total joint arthroplasty, suggesting that surgeons should not restrict access to these procedures based on patient characteristics. In addition, future research needs to provide standardized measures of outcomes.

"Surgery is certainly one good option": quality and time-efficiency of informed decision-making in surgery.

BACKGROUND: Informed decision-making has been widely promoted in several medical settings, but little is known about the actual practice in orthopaedic surgery and there are no clear guidelines on how to improve the process in this setting. This study was designed to explore the quality of informed decision-making in orthopaedic practice and to identify excellent time-efficient examples with older patients. METHODS: We recruited orthopaedic surgeons, and patients sixty years of age or older, in a Midwestern metropolitan area for a descriptive study performed through the analysis of audiotaped physician-patient interviews. We used a valid and reliable measure to assess the elements of informed decision-making. These included discussions of the nature of the decision, the patient's role, alternatives, pros and cons, and uncertainties; assessment of the patient's understanding and his or her desire to receive input from others; and exploration of the patient's preferences and the impact on the patient's daily life. The audiotapes were scored with regard to whether there was a complete discussion of each informed-decision-making element (an IDM-18 score of 2) or a partial discussion of each element (an IDM-18 score of 1) as well as with a more pragmatic metric (the IDM-Min score), reflecting whether there was any discussion of the patient's role or preference and of the nature of the decision. The visit duration was studied in relation to the extent of the informed decision-making, and excellent time-efficient examples were sought. RESULTS: There were 141 informed-decision-making discussions about surgery, including knee and hip replacement as well as wrist/hand, shoulder, and arthroscopic surgery. Surgeons frequently discussed the nature of the decision (92% of the time), alternatives (62%), and risks and benefits (59%); they rarely discussed the patient's role (14%) or assessed the patient's understanding (12%). The IDM-18 scores of the 141 discussions averaged 5.9 (range, 0 to 15; 95% confidence interval, 5.4 to 6.5). Fifty-seven percent of the discussions met the IDM-Min criteria. The median duration of the visits was sixteen minutes; the extent of informed decision-making had only a modest relationship with the visit duration. Time-efficient strategies that were identified included use of scenarios to illustrate distinct choices, encouraging patient input, and addressing primary concerns rather than lengthy recitations of pros and cons. CONCLUSIONS: In this study, which we believe is the first to focus on informed decision-making in orthopaedic surgical practice, we found opportunities for improvement but we also found that excellent informed decision-making is feasible and can be accomplished in a time-efficient manner.

Older patients' unexpressed concerns about orthopaedic surgery.

BACKGROUND: As the U.S. population ages, orthopaedic surgeons will increasingly be required to counsel older patients about major surgical procedures. Understanding patient concerns or worries about surgery could help orthopaedic surgeons to assist their patients in making these decisions. The objectives of this study were to explore the nature of patient concerns regarding orthopaedic surgery and to describe how patients raise concerns during visits with orthopaedic surgeons and how orthopaedic surgeons respond. METHODS: As part of a study involving audiotaping of 886 visits between patients and orthopaedic surgeons, fifty-nine patients sixty years of age or older who were considering surgery were recruited to participate in semistructured telephone interviews at five to seven days and one month after the visit. Patients were asked about their perceptions of the visit and how they made their decision about surgery. These interviews were analyzed to identify patients' concerns with the use of qualitative content analysis and then compared with the audiotaped visits to determine whether these concerns were actually raised during the visit and, if so, how well the orthopaedic surgeons responded. Analyses based on patient race (black or white) were also performed. RESULTS: One hundred and sixty-four concerns pertaining to (1) the surgery (anticipated quality of life after the surgery, the care facility, the timing of the operation, and the patient's capacity to meet the demands of the surgery) and (2) the surgeons (their competency, communication, and professional practices) were identified. Patients raised only 53% of their concerns with the orthopaedic surgeons and were selective in what they disclosed; concerns about the timing of the operation and about the care facility were frequently raised, but concerns about their capacity to meet the demands of the surgery and about the orthopaedic surgeons were not. Orthopaedic surgeons responded positively to 66% of the concerns raised by the patients. Only two concerns were raised in response to direct surgeon inquiry. CONCLUSIONS: Patients raised only half their concerns regarding surgery with orthopaedic surgeons. Orthopaedic surgeons are encouraged to fully address how patients' capacity to meet the demands of the surgery, defined by their resources (such as social support, transportation, and finances) and obligations (to family members, employers, and religion), may impinge on their willingness to accept recommended surgery.

"Not everyone who needs one is going to get one'': the influence of medical brokering on patient candidacy for total joint arthroplasty.

BACKGROUND: Many patients in Ontario, despite being appropriate candidates for total joint arthroplasty (TJA), are not offered surgery. To understand this discrepancy, the authors sought to explore the process by which physicians determine patient candidacy for TJA. METHODS: Six focus groups (2 each of orthopedic surgeons, of rheumatologists, and of family physicians) and subsequent in-depth interviews were conducted with 50 practicing clinicians in Ontario. RESULTS: Health care system constraints, including extensive waiting lists, lack of homecare and postoperative support, and, for surgeons, access to operating rooms and resources, are perceived by physicians to routinely influence the ultimate choice of candidates for TJA. Medical brokering, defined as strategies used by physicians in a constrained health system to prioritize patients and to negotiate relationships with other physicians, was an important factor in determining candidacy for TJA. Because individual physicians and surgeons appear to use their own criteria for making these decisions, and because these criteria are modified from time to time in response to specific institutional and system conditions, brokering results in varied decisions about candidacy regardless of patient suitability. CONCLUSIONS: Lack of consensus on the necessary patient characteristics for TJA candidacy does not in and of itself account for the discrepancy between the number of patients who are suitable candidates for TJA and those who receive the procedure. Until the process by which health care system constraints affect and complicate the decision-making process around TJA candidacy is more fully explored, patients may not receive appropriate and timely access to this procedure.

Do patients' communication behaviors provide insight into their preferences for participation in decision making?

BACKGROUND: The Institute of Medicine report "Crossing the Quality Chasm'' encourages physicians to tailor their approaches to care according to each patient's individual preferences for participation in decision making. How physicians should determine these preferences is unclear. OBJECTIVE: The objective of this study is to assess whether judgments of patient communication behaviors, either globally or individually, can yield insight into patient preferences for participation in decision making. METHODS: Using questionnaire responses to 3 items about the desired level of participation in decision making from a communication study involving 886 audiotaped visits between older patients and surgeons, the authors purposively selected 25 patients who preferred a large role and 25 who preferred a small role in decision making. Two independent raters listened to the audiotapes and coded them for the presence of 7 communication behaviors (question asking, information behavior, initiating, statements of preference, processing, resistance, deference). On the basis of their listening and coding, raters judged patient preferences for participation in decision making. RESULTS: Neither rater accurately judged preferences for participation in decision making beyond chance agreement (kappa statistics: rater 1 = 0.16, rater 2 = 0.20). Inter-rater reliability for the communication behaviors was also generally poor. Area-under-the-curve values for all communication behaviors hovered around 0.50, indicating that none of the behaviors had adequate power to discriminate between patients preferring large versus small roles. CONCLUSION: Patient preferences for participation in decision making cannot be reliably judged during routine visits based on judgments of patient communication behaviors. Engaging patients in a discussion of preferences for decision making may be the best way to determine the role each wants to play in any given decision.

"It's not what you say ...": racial disparities in communication between orthopedic surgeons and patients.

BACKGROUND: Excellent communication between surgeons and patients is critical to helping patients to make informed decisions and is a key component of both high quality of care and patient satisfaction. Understanding racial disparities in communication is essential to provide quality care to all patients. OBJECTIVE: To examine the content and process of informed decision-making (IDM) between orthopedic surgeons and elderly white versus African American patients. To assess the association of race and patient satisfaction with surgeon communication. RESEARCH DESIGN: Analysis of audiotape recordings of office visits between orthopedic surgeons and patients. PARTICIPANTS: Eighty-nine orthopedic surgeons and 886 patients age 60 years or older in Chicago, Illinois. METHODS: Tapes were analyzed by coders for content using 9 elements of IDM and for process using 4 global ratings of the relationship-building component of communication (responsiveness, respect, listening, and sharing). Ratings by race were compared using chi analysis. Patients completed a questionnaire rating satisfaction with surgeon communication and the visit overall. Logistic analysis was used to assess the effect of race on satisfaction. RESULTS: Overall there were practically no significant differences in the content of the 9 IDM elements based on race. However, coder ratings of relationship were higher on 3 of 4 global ratings (responsiveness, respect, and listening) in visits with white patients compared with African American patients (P < 0.01). Patient ratings of communication and overall satisfaction with the visit were significantly higher for white patients. CONCLUSIONS: The content of IDM conversations does not differ by race. Yet differences in the process of relationship building and in patient satisfaction ratings were clearly present. Efforts to enhance cultural communication competence of surgeons should emphasize the skills of building relationships with patients in addition to the content of IDM.

Homeless people's perceptions of welcomeness and unwelcomeness in healthcare encounters.

BACKGROUND: Homeless people face many barriers to obtaining health care, and their attitudes toward seeking health care services may be shaped in part by previous encounters with health care providers. OBJECTIVE: To examine how homeless persons experienced "welcomeness" and "unwelcomeness" in past encounters with health care providers and to characterize their perceptions of these interactions. DESIGN: Qualitative content analysis of 17 in-depth interviews. PARTICIPANTS: Seventeen homeless men and women, aged 29-62 years, residing at 5 shelters in Toronto, Canada. APPROACH: Interpretive content analysis was performed using iterative stages of inductive coding. Interview transcripts were analyzed using Buber's philosophical conceptualization of ways of relating as "I-It" (the way persons relate to objects) and "I-You" (the way persons relate to dynamic beings). RESULTS: Most participants perceived their experiences of unwelcomeness as acts of discrimination. Homelessness and low social class were most commonly cited as the perceived basis for discriminatory treatment. Many participants reported intense emotional responses to unwelcoming experiences, which negatively influenced their desire to seek health care in the future. Participants' descriptions of unwelcoming health care encounters were consistent with "I-It" ways of relating in that they felt dehumanized, not listened to, or disempowered. Welcoming experiences were consistent with "I-You" ways of relating, in that patients felt valued as a person, truly listened to, or empowered. CONCLUSIONS: Homeless people's perceptions of welcomeness and unwelcomeness are an important aspect of their encounters with health care providers. Buber's "I-It" and "I-You" concepts are potentially useful aids to health care providers who wish to understand how welcoming and unwelcoming interactions are fostered.

Unstable embodiments: a phenomenological interpretation of patient satisfaction with treatment outcome.

Many patients experience aspects of treatment and care as dehumanizing because the body is considered separate from the self and its life context. An attempt to transcend viewing persons in dualistic terms is posed by phenomenologists who focus not on "the body" as such but on what it means to be "embodied." In this paper, we review the relevance of the phenomenology of the body for health care and report the results of comparing Sally Gadow's phenomenological insights about body-self unity with a qualitative analysis of patients' accounts of satisfaction with the outcome of hand surgery. We illustrate the ways in which our findings were and were not congruent with Gadow's conceptualization of embodiment and highlight aspects that are ambiguous. We conclude that the body-self dialectical relationship should be recast as a body-self-society trialectic and discuss the implications of this new conceptualization for clinical practices.

Are physicians ready for patients with Internet-based health information?

BACKGROUND: An increasing number of patients bring Internet-based health information to medical consultations. However, little is known about how physicians experience, manage, and view these patients. OBJECTIVE: This study aimed to advance the understanding of the effects of incorporating Internet-based health information into routine medical consultations from physicians' perspectives, using a qualitative approach. METHODS: Six focus groups were conducted with 48 family physicians practising in Toronto. The data were analyzed using qualitative methods of content analysis and constant comparison, derived from grounded theory approach. RESULTS: Three overarching themes were identified: (1) perceived reactions of patients, (2) physician burden, and (3) physician interpretation and contextualization of information. Physicians in our study generally perceived Internet-based health information as problematic when introduced by patients during medical consultations. They believed that Internet information often generated patient misinformation, leading to confusion, distress, or an inclination towards detrimental self-diagnosis and/or self-treatment. Physicians felt these influences added a new interpretive role to their clinical responsibilities. Although most of the physicians felt obliged to carry out this new responsibility, the additional role was often unwelcome. Despite identifying various reactions of patients to Internet-based health information, physicians in our study were unprepared to handle these patients. CONCLUSION: Effective initiatives at the level of the health care system are needed. The potential of Internet-based health information to lead to better physician-patient communication and patient outcomes could be facilitated by promoting physician acknowledgment of increasing use of the Internet among patients and by developing patient management guidelines and incentives for physicians.

Understanding the meaning of satisfaction with treatment outcome.

OBJECTIVE: Although satisfying patients is an important goal in health care, what is meant by satisfaction in relation to treatment outcome is not clear. The objective of this study was to explore patients' perspectives on the meaning of satisfaction with treatment outcome. DESIGN: We conducted a qualitative exploratory study. SETTING: This study was conducted at an adult tertiary care hospital. PATIENTS: Individuals who had undergone elective hand surgery were included in this study. INTERVENTION: In-depth, open-ended interviews in which 31 participants described their experience of a hand condition, how they evaluated the outcome of surgical interventions, and what it meant to be satisfied or dissatisfied with these outcomes were examined. ANALYSIS: : Interview transcripts were analyzed using Gadow's conceptualization of embodiment states: "object body" (disunity between the affected hand and the self) or "cultivated immediacy" (harmony between the hand and the self). RESULTS: Eight of 9 dissatisfied individuals were categorized as "object body" and 15 of 19 satisfied individuals were in, or in transition to, "cultivated immediacy". These states fluctuated and were also dependent on context (eg, social setting) and time since surgery. CONCLUSION: In relation to the outcome of hand surgery, satisfaction was experienced as a relative lack of tension between the patient's sense of self and the affected hand (ie, satisfaction was having a hand that could be lived with unself-consciously). Emotional and social effects of interventions and the influence of context should be considered in future measures of satisfaction with treatment outcome. Finally, interventions directed toward facilitating patients' experience of body-self unity could promote satisfaction with treatment outcome.