Editor’s Spotlight/Take 5: How Does Traumatic Hand Injury Impact Patients in a Safety-net Healthcare System? A Mixed Methods Study

Jessica Billig MD, MScWe often take our hands for granted. But when we injure part of our hand, what it used to do and what it can’t do now suddenly, and traumatically, becomes inescapable. It no longer earns wages, cares for others, embraces loved ones. The ripple effect extends beyond ourselves. I think of my patient, a framing carpenter who sustained a wrist fracture. While he recovered from his injury, his employer found someone else to fill in. His income plummeted, so his wife and other family members chipped in. As the budget tightened, grocery choices changed and housing became uncertain. The inability to play in his regular music group added to the emotional toll. This reality plays out in our patients’ lives, and it was the reality lived by patients described in this month’s Spotlight article [3]. This study evaluated a group of predominantly working-age men who identify as Hispanic or Latino, many of whom were underinsured and therefore had to rely on a safety-net program provided by their county’s healthcare institution to cover their medical expenses. When assessing impairment, we are used to thinking in terms of loss of a certain function. Our minds are trained to process range of motion loss, diminished grip strength, and elevated disability scores. At the same time, we’ve known that there is limited correlation between impairment and disability, and that psychological factors may impact both [2]. We’ve also known that the inability to work is associated with high financial worry [1]. The study in this month’s Clinical Orthopaedics and Related Research® [3] invites us to delve deeper by looking at the idea of “financial toxicity,” which encompasses a whole cascade of issues that start from the point of injury, affect the patient’s own self, and ripple into the lives of others. To understand this cascading effect, Jessica Billig MD, MSc and her team at the University of Texas Southwestern Medical Center in Dallas, TX, USA, used a mixed-methods approach, pairing survey data with patient interviews to add context and nuance to quantitative data [3]. Her team found that most patients reported disabilities that prevented work, and a quarter of patients reported high levels of financial toxicity in the early postoperative period. Patients shared stories of stretching grocery budgets, cutting vacations, pausing services for a disabled child, and family members working extra shifts to make ends meet. As clinicians, we may lose sight of the indirect costs of the care we provide. But for patients, things like food, rent, and childcare are front of mind when they see us. This disconnect is worth pondering. Our care models don’t factor these things in, despite the heavy burdens they impose on our patients. And these issues, which I’ll discuss in the Take 5 interview with Dr. Billig below, are relevant to you whether or not you’re a hand surgeon, since getting patients back to work and function are squarely within the remit of every orthopaedic surgeon. Dr. Billig’s study [3] also highlights the challenges of safety-net hospitals, which are already stretched thin. Her team’s findings point to the need for practical and creative solutions: social needs screening, financial navigational help, and social prescribing (connecting patients with available resources). We can all learn from her uniquely informed perspective on these solutions. Please join me as I explore these themes with Dr. Jessica Billig, senior author of “How Does Traumatic Hand Injury Impact Patients in a Safety-net Healthcare System? A Mixed Methods Study” [3], in the Take 5 interview that follows. Take 5 Interview with Jessica Billig MD, MSc, senior author of “How Does Traumatic Hand Injury Impact Patients in a Safety-net Healthcare System? A Mixed Methods Study” M. Daniel Wongworawat MD:Your paper [3] introduces the idea of financial toxicity. Most of us understand financial burden and the distress it may cause, but what is it about the burden that makes it toxic? Jessica Billig MD, MSc: Financial burden becomes toxic when it starts to interfere with a patient’s health, recovery, and overall well-being. In this way, financial toxicity goes beyond financial burden alone. The term “financial toxicity” was first introduced in the field of oncology to describe the psychosocial distress and hardship patients with cancer experience that is caused by the cost of medical care, but obviously the problem is not limited to patients with cancer. Numerous studies have demonstrated how high out-of-pocket costs and lost income can be associated with worse quality of life, delays in seeking care, medication nonadherence, and worse mental health outcomes. In some settings, financial toxicity has even been linked to poorer survival [4-6]. In our study [3], we use the term this way because patients described not only medical bills and lost wages, but also the ripple effects of that strain—emotional distress, difficulty meeting basic needs, barriers to follow-up care, and stress on family members. This is especially important in patients cared for in safety-net settings, where they are more likely to be uninsured or underinsured, and likely have very little financial margin to absorb the effects of an injury. In these settings, the financial consequences of trauma can become yet another complication of the injury itself. Dr. Wongworawat:You combined survey data with semistructured interviews. Can you highlight some of the things that you can obtain through quantitative methods (such as percentages and averages) and information that can only be covered by qualitative approaches (such as patient narratives)? Dr. Billig: Mixed methods research aims to provide a deeper and more holistic understanding of a problem by utilizing both quantitative and qualitative methodologies. Quantitative research allows us to describe the scope of a problem in a structured way while qualitative research helps us understand the meaning behind the numbers. For example, a survey question only has so many answers to choose from; adding qualitative interviews provides an opportunity to capture unanticipated aspects of each question that can be used to further interpret the quantitative data. Therefore, mixed methods provide a stronger inference than either approach would on its own. Our paper [3] provided a more holistic picture of financial toxicity through aggregate survey data and in-depth, patient-informed descriptions of what some of that survey data means. For example, the financial toxicity survey we used identifies patients who have and do not have financial toxicity, but there is a large spectrum of financial toxicity. From our interviews, we saw some people who had to adjust some of their spending, such as less recreational activities, while others were late on rent or had to pick up side jobs. The spectrum of financial toxicity simply could not be elucidated from quantitative methods alone. That is the strength of mixed methods: The quantitative data show us the scale and distribution of the problem, while the qualitative interviews provide the context, nuance, and patient voice needed to fully understand it. Together, they give a much more complete picture than either approach could alone. Dr. Wongworawat:You found that most patients with hand trauma had to cope with disabilities that limited their ability to work [3]. On one hand, this sounds unsurprising. What struck you as unexpected? Dr. Billig: What stood out to me was that the injury was not just a short-term physical event; for many patients, it reshaped multiple parts of their lives. The financial impact of being unable to work was only one part of a much larger cascade of consequences that involved emotional strain, disruptions in daily life, and effects on family members that extended well beyond the initial injury period. What was striking was how broad and persistent these consequences seemed to be. Another important finding was how much of the hardship came from the interaction between the injury and gaps in the healthcare and social support systems. Patients were not recovering from injury in isolation but also had to navigate gaps in assistance, barriers in access to care, and insufficient recovery support systems. These data point to the broader systems-level challenges that patients face during and after the injury period. Dr. Wongworawat:You uncovered wider effects of traumatic hand injury that extend beyond the person, emotionally and financially; but in medicine, we generally only treat the patient. What systems solutions do you see that can be set in place to address the impact on others (without taking up too much more clinic time, of course)? Dr. Billig: This is hard question to answer. I think one important lesson from this work [3] is that traumatic hand injury often affects more than the individual patient. It affects the whole household and family unit. Family members may take on caregiving responsibilities, help with transportation or childcare, absorb lost income, and share in the emotional strain of recovery. If that is the reality, then our care models need to reflect it. A practical first step would be to build routine screenings for social and financial needs into trauma follow-up care. If we identify early on that an injury is likely to affect employment, transportation, childcare, or caregiver stability, we may have an opportunity to connect patients and families with support before those problems worsen. Many hospitals and health systems already use social-needs screening tools that capture issues like financial strain, employment disruption, transportation barriers, and family support. In a hand surgery practice, those existing tools could likely be paired with a few focused questions about missed work, concern about paying for care, and difficulty accessing therapy. That would give us a practical way to identify high-risk patients using already established workflows in hospitals and healthcare systems while we work on building a financial toxicity screening tool validated specifically for hand trauma. Another important step is improving access to services that can help address those ripple effects, including social work, benefits counseling, financial navigation, return-to-work support, and mental health resources. More broadly, we may need to expand how we define a successful outcome after hand trauma. Recovery should not be measured only by range of motion or functional status, but also by whether patients are able to return to work, whether family caregiving demands become overwhelming, and whether the injury creates ongoing financial or emotional instability. If we start measuring those outcomes, we will be in a much better position to design interventions that address them. Dr. Wongworawat:Some of the financial and emotional impacts extend far beyond the time period of injury and recovery. Are there clues that the effects might last longer? Dr. Billig: I definitely believe that these effects last longer than the injury period. In fact, I think our research demonstrates that the effects last well beyond the postoperative period. First, in our study [3], the impact of hand trauma was not limited to the injury itself or to short-term lost wages. Patients described broader disruptions involving emotional well-being, family responsibilities, daily functioning, and difficulty navigating needed support. When the consequences spread across multiple parts of a person’s life, this suggests the effects are less likely to resolve simply when the bone heals or therapy ends. Second, the way financial strain and emotional strain seem to reinforce one another point to longer term sequelae. Financial hardship can worsen stress, and stress can make it harder to return to work, stay engaged in care, or move forward in recovery. That kind of cycle may help explain why the consequences can persist longer than what we typically capture during the standard postoperative period. Third, our study fits in with the broader evidence on traumatic hand injury, which suggests that psychological effects can persist beyond the acute period and may remain clinically important over time. This broader context reinforces the idea that the financial and emotional consequences we identified may not be brief or self-limited for many patients, and may extend beyond the typical post injury period.