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Do Patients Unconsciously Associate Suggestions for More-invasive Treatment with Better Care?

Kortlever, Joost T.P., MD; Ottenhoff, Janna S.E., MD; Tran, Thi T.H., MD; Ring, David, MD, PhD; Vagner, Gregg A., MD; Driscoll, Matt D., MD

Clinical Orthopaedics and Related Research®: March 2019 - Volume 477 - Issue 3 - p 514–522
doi: 10.1097/CORR.0000000000000608

Background It seems common for patients to conceive of care in physical terms, such as medications, injections, and procedures rather than advice and support. Clinicians often encounter patients who seem to prefer more testing or invasive treatments than expertise supports. We wanted to determine whether patients unconsciously associate suggestions for invasive treatments with better care.

Questions/purposes (1) Do patients have (A) an implicit preference and (B) an expressed preference for a physical intervention (such as a pill, an injection, or surgery) over supportive care (such as reassurance and education)? (2) What factors are independently associated with both an implicit and an expressed preference for a physical intervention over supportive care? (3) Is there a relationship between a patient’s implicit preference toward or away from a physical intervention and his/her expressed preference on that subject?

Methods In this study, we approached 129 new patients in a large urban area visiting one of 13 participating surgeons divided among six upper and lower extremity specialist offices. After excluding four patients based on our exclusion criteria, 125 patients (97%) completed a survey of demographics and their expressed preference about receiving either physical treatment or support. Treatment was defined as any surgery, procedure, injection, or medication; support was defined as reassurance, conversation, and education, but no physical treatment. Patients then completed the Implicit Association Test (IAT) to evaluate implicit preferences toward treatment or support. Although other IATs have been validated in numerous studies, the IAT used in this study was specifically made for this study. Scores (D scores) range from -2 to 2, where 0 indicates no implicit preference, positive scores indicate a preference toward receiving a physical treatment is good care, and negative scores indicate a preference toward receiving supportive care is good care. According to the original IAT, break points for a slight (± 0.15 to 0.35), moderate (± 0.35 to 0.65), and strong preference (± 0.65 to 2) were selected conservatively according to psychological conventions for effect size. Patients’ mean age was 50 ± 15 years (range, 18–79 years) and 56 (45%) were men. The patients had a broad spectrum of upper and lower extremity musculoskeletal conditions, ranging from trigger finger to patellofemoral syndrome.

Results We found a slight implicit association of good care with support (D = -0.17 ± 0.62; range, -2 to 1.2) and an expressed preference for physical treatment (mean score = 0.63 ± 2.0; range, -3 to 3). Patients who received both physical and supportive treatment had greater implicit preference for good care, meaning supportive care, than patients receiving physical care alone (β = -0.42; 95% CI, -0.73 to -0.11; p = 0.008; semipartial R2 = 0.04; adjusted R2 full model = 0.13). Gender was independently associated with a greater expressed preference for physical treatment, with men expressing this preference more than women (β = 1.0; 95% CI, 0.31–1.7; p = 0.005; semipartial R2 = 0.06; adjusted R2 full model = 0.08); receiving supportive treatment was independently associated with more expressed preference for support (β = -0.98; 95% CI, -1.7 to -0.23; p = 0.011; semipartial R2 = 0.05). An expressed preference for treatment was not associated with implicit preference (β = 0.01; 95% CI, -0.04 to 0.06; p = 0.721).

Conclusions Although surgeons may sometimes feel pressured toward physical treatments, based on our results and cutoff values, the average patient with upper or lower extremity symptoms has a slight implicit preference for supportive treatment and would likely be receptive.

Level of Evidence Level II, prognostic study.

J. T. P. Kortlever, J. S. E. Ottenhoff, T. T. H. Tran, D. Ring, G. A. Vagner, M. D. Driscoll, Department of Surgery and Perioperative Care, Dell Medical School – The University of Texas at Austin, Austin, TX, USA

D. Ring, Dell Medical School – The University of Texas at Austin, Health Discovery Building HDB 6.706, 1701 Trinity Street, Austin, TX, 78712, USA, E-mail:

One of the authors certifies that he (DR), or a member of his immediate family, has received or may receive payments or benefits, during the study period, in an amount of USD 10,000 to USD 100,000 from Skeletal Dynamics (Miami, FL, USA), in an amount of less than USD 10,000 from Wright Medical for elbow implants (Memphis, TN, USA); and receives a stipend as the deputy editor for Clinical Orthopaedics and Related Research®; has received honoraria for talks from universities and hospitals; and has received payment for expert review, all outside the submitted work.

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.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

Received August 28, 2018

Accepted November 21, 2018

© 2019 Lippincott Williams & Wilkins LWW
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