Surgeon Prioritization of Mental, Social, and Pathophysiological Aspects of Health Among People With Traumatic and Nontraumatic Musculoskeletal Conditions

Background: There is mounting evidence that, among musculoskeletal patients, variation in capability has more notable associations with variations in mental and social health factors than with variation in pathophysiology severity. This study sought factors that could limit the integration of this evidence into more comprehensive care models. Methods: In two scenario-based experiments, surgeon participants in an international collaborative, the Science of Variation Group, reviewed scenarios of (a) nontraumatic (83 participants) and (b) trauma-related (130 participants) pathophysiologies for which tests and treatments were discretionary. The following demographic, mental, and social health elements were varied randomly: sex, age, race/ethnicity, mindsets, social health aspects, and specific pathophysiologies. For each scenario, participants rated their likelihood to offer surgery (continuous) and their sense of presence of an opportunity to address better mental or social health in treatment (yes or no). Factors associated with each rating were sought in multivariable analysis. Results: Greater likelihood to offer discretionary surgery for nontraumatic pathophysiologies was associated with greater pathophysiology severity, trapeziometacarpal arthritis, and greater distress and unhelpful thoughts regarding symptoms. Lateral elbow enthesopathy was associated with a lower likelihood. For trauma-related pathophysiologies, an ankle fracture with slight articular subluxation was associated with greater likelihood to offer surgery, and several other trauma-related pathophysiologies were associated with a lower likelihood. For both nontraumatic and trauma-related pathophysiologies, surgeons noticed unhelpful thinking, distress, and social issues as reasons to consider addressing mental and social health in treatment, relatively independent of pathophysiology. Conclusion: Surgeons seem to recognize opportunities to address mental and social needs but ultimately base their decision to offer discretionary surgery on pathophysiological factors. Clinical relevance: Comprehensive, whole-person care for musculoskeletal illness might be supported by strategies for ensuring that aspects of stress and distress that contribute to greater symptom intensity are not misinterpreted as a reflection of greater pathophysiology severity.