Surgeon Implicit Association of Women With Supportive Roles in Medicine.

BACKGROUND: In a previous study, we documented patient implicit bias that surgeons are men. As a next step, we tested the implicit bias of surgeons that women in medicine have leading (chair, surgeon) or supporting roles (medical assistant, physician assistant). QUESTIONS/PURPOSE: (1) What is the relationship between the implicit associations and expressed beliefs of surgeons regarding women as leaders in medicine? (2) Are there factors associated with surgeon implicit association and explicit preference regarding the roles of women in medicine? METHODS: A total of 102 musculoskeletal surgeon members of the Science of Variation Group (88 men and 12 women) completed an implicit association test (IAT) of implicit bias regarding sex and lead/support roles in medicine and a questionnaire that addressed respondent demographics and explicit preference regarding women's roles. The IAT consisted of seven rounds with five rounds used for teaching and two rounds for evaluation. RESULTS: On average, there was an implicit association of women with supportive roles (D-score: -48; SD 4.7; P < 0.001). The mean explicit preference was for women in leadership roles (median: 73; interquartile ranges: 23 to 128; P < 0.001). There was a correlation between greater explicit preference for women in a leading role and greater implicit bias toward women in a supporting role (ρ = 0.40; P < 0.001). Women surgeons and shoulder and elbow specialists had less implicit bias that women have supporting roles. CONCLUSION: The observation that musculoskeletal surgeons have an explicit preference for women in leading roles in medicine but an implicit bias that they have supporting roles-more so among men surgeons-documents the gap between expressed opinions and ingrained mental processing that is the legacy of the traditional "roles" of women in medicine and surgery. To resolve this gap, we will need to be intentional about promotion of and emersion in experiences where the leader is a woman. LEVEL OF EVIDENCE: III.

Surgeons Have an Implicit Preference for Specific Disease Over Nonspecific Illness.

BACKGROUND: Many symptoms are not associated with a specific, measurable pathophysiology. Such nonspecific illnesses may carry relative social stigma that biases humans in favor of specific diseases. Such a bias could lead musculoskeletal surgeons to diagnose a specific disease in the absence of a specific, measurable pathology, resulting in potential overdiagnosis and overtreatment. QUESTIONS/PURPOSES: (1) What factors are associated with surgeon implicit preference for specific disease over nonspecific illness? (2) What factors are associated with surgeon explicit preference for specific disease over nonspecific illness? (3) Is there a relationship between surgeon implicit and explicit preferences for specific disease over nonspecific illness? METHODS: One hundred three members of the Science of Variation Group participated in a survey-based experiment that included an Implicit Associations Test (IAT) to assess implicit preferences for specific, measurable musculoskeletal pathophysiology (specific disease) compared with symptoms that are not associated with a specific, measurable pathophysiology (nonspecific illness), and a set of four simple, face valid numerical ratings of explicit preferences. The Science of Variation Group is an international collaborative of mostly United States and European (85% [88 of 103] in this study), mostly academic (83% [85 of 103]), and mostly fracture and upper extremity surgeons (83% [86 of 103]), among whom approximately 200 surgeons complete at least one survey per year. The human themes addressed in this study are likely relatively consistent across these variations. Although concerns have been raised about the validity and utility of the IAT, we believe this was the right tool, given that the timed delays in association that form the basis of the measurement likely represent bias and social stigma regarding nonspecific illness. Both measures were scaled from -150, which represents a preference for nonspecific illness, to 150, which represents a preference for specific disease. The magnitude of associations can be assessed relative to the standard deviation or interquartile range. We used multivariable linear regression to identify surgeon factors associated with surgeon implicit and explicit preference for specific disease or nonspecific illness. We measured the relationship between surgeon implicit and explicit preferences for specific disease or nonspecific illness using Spearman correlation. RESULTS: Overall, there was a notable implicit bias in favor of specific diseases over nonspecific illness (median [IQR] 70 [54 to 88]; considered notable because the mean value is above zero [neutral] by more than twice the magnitude of the IQR), with a modestly greater association in the hand and wrist subspecialty. We found no clinically important explicit preference between specific disease and nonspecific illness (median 8 [-15 to 37]; p = 0.02). There was no correlation between explicit preference and implicit bias regarding specific disease and nonspecific illness (Spearman correlation coefficient -0.13; p = 0.20). CONCLUSION: Given that our study found an implicit bias among musculoskeletal specialists toward specific diseases over nonspecific illness, future research might address the degree to which this bias may account, in part, for patterns of use of low-yield diagnostic testing and the use of diagnostic labels that imply specific pathophysiology when none is detectable. CLINICAL RELEVANCE: Patients and clinicians might limit overtesting, overdiagnosis, and overtreatment by anticipating an implicit preference for a specific disease and intentionally anchoring on nonspecific illness until a specific pathophysiology accounting for symptoms is identified, and also by using nonspecific illness descriptions until objective, verifiable pathophysiology is identified.

Clinician Interruptions and Patient-Rated Clinician Empathy in Specialty Visits.

INTRODUCTION: Clinicians tend to interrupt patients when they are describing their problem, which may contribute to feeling unheard or misunderstood. Using transcripts of audio and video recordings from musculoskeletal (MSK) specialty visits, we asked what factors are associated with (1) Perceived clinician empathy, including the time a patient spends describing the problem and time to the first interruption, (2) duration of patient symptom description, and (3) duration between the end of greeting and first nonactive listening interruption. METHODS: We analyzed transcripts of 194 adult patients seeking MSK specialty care with a median age (Interquartile range [IQR]) of 47 (33 to 59) years. Participants completed postvisit measures of perceived clinician empathy, symptoms of depression, accommodation of pain, and health anxiety. A nonactive listening interruption was defined as the clinician unilaterally redirecting the topic of conversation. Factors associated with patient-rated clinician empathy, patient problem description duration, and time until the first nonactive listening interruption were sought in bivariate and multivariable analyses. RESULTS: The patient's narrative was interrupted at least one time in 144 visits (74%). The duration of each visit was a median of 12 minutes (IQR 9 to 16 minutes). The median time patients spent describing their symptoms was 139 seconds before the first interruption (IQR 84 to 225 seconds). The median duration between the end of the initial greeting and the first interruption was 60 seconds (IQR 30 to 103 seconds). Clinician interruption was associated with shorter duration of symptom description. Greater perceived clinician empathy was associated with greater accommodation of pain (regression coefficient [95% confidence interval] = 0.015 [0.0005-0.30]; P = 0.04). DISCUSSION: Clinician interruption was associated with shorter symptom presentation, but not with diminished perception of clinician empathy. Although active listening and avoidance of interruption are important communication tactics, other aspects of the patient-clinician relationship may have more effect on patient experience.

When Musculoskeletal Clinicians Respond to Empathetic Opportunities, do Patients Perceive Greater Empathy?

BACKGROUND: Patient use of verbal and nonverbal communication to signal what is most important to them can be considered empathetic opportunities. Orthopaedic surgeons may have mixed feelings toward empathetic opportunities, on one hand wanting the patient to know that they care, and on the other hand fearing offense, prolonged visit duration, or discussions for which they feel ill prepared. Evidence that action about empathetic opportunities does not harm the patient's experience or appreciably prolong the visit could increase the use of these communication tactics with potential for improved experience and outcomes of care. QUESTIONS/PURPOSES: Using transcripts from musculoskeletal specialty care visits in prior studies, we asked: (1) Are there factors, including clinician attentiveness to empathetic opportunities, associated with patient perception of clinician empathy? (2) Are there factors associated with the number of patient-initiated empathetic opportunities? (3) Are there factors associated with clinician acknowledgment of empathetic opportunities? (4) Are there factors associated with the frequency with which clinicians elicited empathetic opportunities? METHODS: This study was a retrospective, secondary analysis of transcripts from prior studies of audio and video recordings of patient visits with musculoskeletal specialists. Three trained observers identified empathetic opportunities in 80% (209 of 261) of transcripts of adult patient musculoskeletal specialty care visits, with any uncertainties or disagreements resolved by discussion and a final decision by the senior author. Patient statements considered consistent with empathetic opportunities included relation of emotion, expression of worries or concerns, description of loss of valued activities or loss of important roles or identities, relation of a troubling psychologic or social event, and elaboration on daily life. Clinician-initiated empathetic opportunities were considered clinician inquiries about these factors. Clinician acknowledgment of empathetic opportunities included encouragement, affirmation or reassurance, or supportive statements. Participants completed post-visit surveys of perceived clinician empathy, symptoms of depression, and health anxiety. Factors associated with perceived clinician empathy, number of empathetic opportunities, clinician responses to these opportunities, and the frequency with which clinicians elicited empathetic opportunities were sought in bivariate and multivariable analyses. RESULTS: After controlling for potentially confounding variables such as working status and pain self-efficacy scores in the multivariable analysis, no factors were associated with patient perception of clinician empathy, including attentiveness to empathetic opportunities. Patient-initiated empathetic opportunities were modestly associated with longer visit duration (correlation coefficient 0.037 [95% confidence interval 0.023 to 0.050]; p < 0.001). Clinician acknowledgment of empathetic opportunities was modestly associated with longer visit duration (correlation coefficient 0.06 [95% CI 0.03 to 0.09]; p < 0.001). Clinician-initiated empathetic opportunities were modestly associated with younger patient age (correlation coefficient -0.025 [95% CI -0.037 to -0.014]; p < 0.001) and strongly associated with one specific interviewing clinician as well as other clinicians (correlation coefficient -1.3 [95% CI -2.2 to -0.42]; p = 0.004 and -0.53 [95% CI -0.95 to -0.12]; p = 0.01). CONCLUSION: Musculoskeletal specialists can respond to empathic opportunities without harming efficiency, throughput, or patient experience. CLINICAL RELEVANCE: Given the evidence that patients prioritize feeling heard and understood, and evidence that a trusting patient-clinician relationship is protective and healthful, the results of this study can motivate specialists to train and practice effective communication tactics.

Surgeons Receiving Information About Patient Language Reflecting Unhelpful Thoughts or Distress About Their Symptoms Identify Such Language More Often Than Those Who Do Not Receive This Information.

BACKGROUND: 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? METHODS: 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. RESULTS: 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). CONCLUSION: 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 OF EVIDENCE: Level I, therapeutic study.

MRI findings of acromioclavicular joint osteoarthritis are the norm after age 40.

BACKGROUND: Acromioclavicular joint (AC) arthritis (A) is a common incidental finding on shoulder imaging. An improved knowledge of the age- and sex-specific prevalence (or base rate) of incidental ACA can inform diagnosis and treatment strategies for shoulder pain. HYPOTHESIS: There is no relationship between age or gender and the presence or severity of MRI findings consistent with osteoarthritis of the acromioclavicular joint. METHODS: We rated ACA on 475 MRIs from a database of patients who had MRIs for non-AC indications. The cohort consisted of 51% men, 49% women and had an average age of 55. Bivariate analyses were used for analysis of age and sex-specific prevalence. RESULTS: The prevalence of findings consistent with ACA on MRI for non-AC indications was 83%. The prevalence increased from 75% between ages 40 and 50 to 100% after age 70. Logistic regression demonstrated an association between age and ACA (Odds Ratio 2.89; 95% confidence interval [CI]=2.30 to 3.63; p=0.001). No difference was seen by sex (Chi-Square, 0.16; p=0.67). There was a positive correlation between age and ACA severity (Spearman's rho=0.43; p=0.000010). DISCUSSION: The observation that MRI evidence of ACA is the norm (75%) after age 40 and is universal with human aging (100% after age 70), makes it very difficult to discern ACA as a cause of shoulder symptoms. Given the near universal prevalence of radiological ACA, imaging cannot be used as a reference standard for diagnosis of symptomatic ACA based on symptoms and signs. LEVEL OF EVIDENCE: Not applicable.

Quantitative Patient-Reported Experience Measures Derived From Natural Language Processing Have a Normal Distribution and No Ceiling Effect.

BACKGROUND AND OBJECTIVES: Patient-reported experience measures have the potential to guide improvement in health care delivery. Many patient-reported experience measures are limited by the presence of strong ceiling effects that limit their analytical utility. METHODS: We used natural language processing to develop 2 new methods of evaluating patient experience using text comments and associated ordinal and categorical ratings of willingness to recommend from 1390 patients receiving specialty or nonspecialty care at our offices. One method used multivariable analysis based on linguistic factors to derive a formula to estimate the ordinal likelihood to recommend. The other method used the meaning extraction method of thematic analysis to identify words associated with categorical ratings of likelihood to recommend with which we created an equation to compute an experience score. We measured normality of the 2 score distributions and ceiling effects. RESULTS: Spearman rank-order correlation analysis identified 36 emotional and linguistic constructs associated with ordinal rating of likelihood to recommend, 9 of which were independently associated in multivariable analysis. The calculation derived from this model corresponded with the original ordinal rating with an accuracy within 0.06 units on a 0 to 10 scale. This score and the score developed from thematic analysis both had a relatively normal distribution and limited or no ceiling effect. CONCLUSIONS: Quantitative ratings of patient experience developed using natural language processing of text comments can have relatively normal distributions and no ceiling effect.

Quality and Accuracy of Cervical Radiculopathy-specific Information on the Internet: A Cross-sectional Analysis.

STUDY DESIGN: Cross-sectional analysis. OBJECTIVE: This study aimed to evaluate the quality and accuracy of the content surrounding cervical radiculopathy available on the internet. SUMMARY OF BACKGROUND DATA: Those experiencing cervical radiculopathy and their families are increasingly browsing the worldwide web for medical information. As the information offered is likely to influence their health care choices, spine care providers must understand the quality and accuracy of that information. METHODS: Independent searches were conducted on the three most commonly accessed search engines (Google, Yahoo, and Bing) using the keyword "cervical radiculopathy." The searches were performed on June 28th, 2019. The top 50 sites from each search engines were reviewed. The websites were evaluated using quality, accuracy and usability markers. RESULTS: Seventy-seven unique websites were analyzed; 54.5% were physician or medical group professional sites, 20.8% as non-physician, 10.4% as unidentified, 7.8% as academics, and 6.5% were commercial. Accuracy ranged from <25% to >75% were recorded with a mean accuracy of 3.5 signifying 50% to 75% agreement. Overall, website categories had a significant effect on Journal of American Medical Association (JAMA) score, content quality, accuracy, total summary scores, distraction index, reading ease, and grade level (P  < 0.05). Academic sites had the highest mean quality content, accuracy and total summary scores. Four of the top five websites with the highest total summary scores were physician driven. On average, Health on the Net code (HONcode) certified websites had lower grade level readability with greater reading ease and higher DISCERN and JAMA scores than uncertified sites (P < 0.05). CONCLUSION: Despite the wide number of sources available, the quality, accuracy, pertinence, and intelligibility of the information remains highly variable. Clinicians treating patients with cervical radiculopathy should direct them to verifiable sites with regulated information and, where possible, contribute high- quality information to those sites.Level of Evidence: 4.

Profile of Data Sharing in the Clinical Neurosciences.

IMPORTANCE:  In today's climate of high healthcare costs and limited research resources, much attention has been given to inefficiency in research. Open access to research data has been proposed as a way to pool resources and make the most of research funding while also promoting transparency and scientific rigor.  Objective: The clinical neurosciences stand to benefit greatly from the potential opportunities afforded by open data, and we sought to evaluate the current state of publicly available research findings and data sharing policies within the clinical neurosciences.  Design: The Clarivate Analytics Web of Science journal citation reports for 2017 were used to sort journals in the category 'Clinical Neurosciences' by impact factor. The top 50 journals were selected and reviewed, but data was only collected from journals focused on original research (42/50). For each journal we reviewed the 10 most recent original research articles for 2016, 2017, and 2018 as designated by Scopus.  Results: A data sharing policy existed for 60% (25/42) of the journals reviewed. Of the articles studied 41% (517/1255) contained source data, and the amount of articles with available source data increased from 2016 to 2018. Of all the articles reviewed, 49.4% (620/1255) were open access. Overall, 6.9% (87/1255) of articles had their source data accessible outside of the manuscript (e.g. registries, databases, etc.) and 8.9% (112/1255) addressed the availability of their source data within the publication itself. The availability of source data outside the manuscript and in-article discussion of source data availability both increased from 2016 to 2018. Only 3.9% (49/1255) of articles reviewed reported negative results for their primary outcome, and 7.6% (95/1255) of the articles could not be defined as primarily reporting positive or negative findings (characterization studies, census reporting, etc.). The distribution of negative versus positive results reported showed no significant trend over the years studied.  Conclusion and Relevance: Our results demonstrate an opportunity for increased data sharing in neuroscience original research. These findings also suggest a trend towards increased adoption of open data sharing policies among journals and increased availability of unprocessed data in publications. This can increase the quality and speed at which new research is developed in the clinical neurosciences.