July #JHSJC Transcript

We’ll be posting all #JHSJC transcripts from here on out (including past conversations!), so be sure to check back in case you miss a discussion! You can read the June #JHSJC here!

July’s #JHSJC was a spirited conversation addressing two articles from Volume 44, Issue 7 of The Journal of Hand Surgery: The Relationship Between Pain-Related Psychological Factors and Postoperative Opioid Use After Ambulatory Hand Surgery and Patient Satisfaction in the Hand Surgery Clinic: An Analysis of Factors That Impact the Press Ganey Survey.  

Feel free to continue the conversation below in the comments!

J Hand Surg Am- ASSH @JHandSurg:
#JHSJC starts now! Let’s get the discussion going!

Brent Graham @BgTalkinman:
Welcome to the July discussion! Tweet #jhsjc to let us know you are here.
Let’s start with the article on #postop #opioid use #jhsjc

The study took place in a tertiary care institution in a metropolitan area. Does that affect the generalizability of the findings? #jhsjc
It’s no surprise that greater catastrophizing was associated with more pain b/c that has been well-established. 

David Ring @DrDavidRing to @BgTalkinman
#JHSJC  There are circumstantial and cultural influences on the variation in pain intensity for a given nociception

Brent Graham @BgTalkinman to @DrDavidRing
How should that be taken into account in managing post-op pain? #jhsjc
Are there any specific issues that affect the generalizability of these findings? #jhsjc

David Ring @DrDavidRing to @BgTalkinman
The influence of thoughts, emotions, and behaviors on the variation in pain intensity for a given nociception is moderated by context #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing
Do you therefore tailor your practices for each pt or do you have any general principles to share? #jhsjc

David Ring @DrDavidRing to @BgTalkinman
Refill rates reflect clinician and practice strategies.  #jhsjc
Standards help depersonalize safe and effective alleviation of pain.  For tips: https://aaos.org/painrelieftoolkit/ … #jhsjc

Brent Graham @BgTalkinman:
The use of non-opioid medications seems to have a clear role in post op pain mgmt. What should the role be of “mindfulness”? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Principle 1: Discuss strategies for alleviation of pain prior to booking surgery.  Put it on your safety checklist.  #jhsjc

Brent Graham @BgTalkinman:
What I mean is whether using such a strategy is feasible in the hand clinic? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Principle 2: Identify factors associated with greater pain intensity with either screeners or attention to verbal and non-verbal q’s #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
That is a useful practical point that I think is probably becoming more pervasive. #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Principle 3: use a practice wide strategy to depersonalize discussions: “I wish I could…but it violates…let’s talk about…” #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
By “screeners” do you mean key questions? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Questionnaires that measure sx’ of depression or anxiety and less effective cognitive coping strategies #jhsjc
The Pain Catastrophizing Scale measures worst case thinking, a less effective cognitive coping strategy known to increase pain #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
I am assuming that you have that info available when you evaluate each new pt. #jhsjc
In your opinion, is that a useful measure if it measures worst case thinking? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Used in this paper and correlated with greater pain intensity and opioid intake for similar levels of nociception #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Is it a practical way to identify pts who might need a different approach? #jhsjc

Brent Graham @BgTalkinman :
Are there others out there with experience to share on the issue of screening to identify these pts? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
We are trying to balance the use of screeners (which can offend) with attentiveness to the interaction  #jhsjc

Look for verbal indicators: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3462883/ #jhsjc
And non-verbal indicators: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260102/ #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
How does the idea of mindfulness figure into managing this kind of pt? #jhsjc
What I mean is that mindfulness was shown to have a small but positive effect. Is that important? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Mindfulness is one strategy to make the story your mind tells as healthy as possible.  
This is pertinent: https://www.wired.com/story/artificial-intelligence-yuval-noah-harari-tristan-harris/ #jhsjc
Measures of mindfulness are not strong correlates of symptom intensity and magnitude of limitations.   #jhsjc
The strategy is to become aware of cognitive errors and replace them with more accurate and healthy thoughts.   #jhsjc
So the small positive effect is notable.  #jhsjc
It’s more about adaptiveness than optimism per se:  “My body needs time to heal.”  #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
I was referring to my own optimism. Sometimes I think that is the best I can do for these people – give them hope. #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
People are getting curious about mental and social health opportunities in people seeking care from hand surgeons.  Love that! #jhsjc
A useful planning question is “What did you take to get comfortable after your last procedure?” #jhsjc
It communicates: 1) This is going to hurt; and 2) I care #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Agreed! It’s a good, important approach. #jhsjc

Brent Graham @BgTalkinman:
Let’s move on to the study on pt satisfaction #jhsjc
Authors know I have some strong views on the measurement of this important but complex construct: https://www.jhandsurg.org/article/S0363-5023(16)30421-X/fulltext #jhsjc

The key distinction is satisfaction with outcome or satisfaction with process of care. #jhsjc
Clearly the #PressGaney tool measures the latter – care process #jhsjc

Let’s talk about a few methodology points: the standard for satisfaction was 33rd percentile #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Although CG-CAPHS (in Press Ganey) asks about “explain”, “respect”, “recommend”  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4385380/ #jhsjc
Satisfaction, empathy, and communication effectiveness questionnaires all have massive ceiling effects #jhsjc
We miss out on information that could help us learn and improve #jhsjc
We are working with psyshometricians to develop a satisfaction measure with a normal distribution #jhsjc
Then we will see what factors correlate with satisfaction #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
That seems to be the rationale for choosing the 33rd percentile. It is essentially a binary measure. #jhsjc
What kind of satisfaction? Process or outcome? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Another thing we have learned is communication, perceived empathy, and more extensive satisfaction measures are similar  #jhsjc
They all ask about trust and the relationship.  The key is an effective relationship that motivates healthy behaviors.  #jhsjc
Satisfaction with the visit.  #jhsjc
It has to be dichotomized with current measures, but that is obviously not ideal.  #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Really key – but most of our submissions talk about satisfaction with a result. None of these instruments do that. #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Satisfaction with a result is not helpful.  Also has a ceiling effect. #jhsjc
And no accounting for placebo effect, regression to the mean, and self-limiting course #jhsjc
The most interesting finding for me was the association with an intervention.   #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
I agree and in some ways that seems a little dangerous! #jhsjc

David Ring @DrDavidRing:
People often come to a hand surgeon in some degree of despair.  And with some degree of “you’re my only hope” #jhsjc
And “I can’t be myself unless we fix this” #jhsjc
And we can satisfy that stated preference.  We can also delve in and make sure it’s not based on misconceptions #jhsjc
Initial stated preference may be based on the same cognitive errors that are associated with greater pain intensity #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
agreed but shouldn’t we also be relying on indications and evidence? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
I find that indications and evidence are the “easy part”.  I think we only stray from those in desperation. #jhsjc
It’s our responsibility–as the experts–to gently correct those misconceptions.  The risk is misdiagnosis of preference #jhsjc
Most debate in hand surgery is in the areas of disproportionate symptoms and limitations–the despair area #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Right! So if desperation leads to interventions that are associated with satisfaction, it feels like a slippery slope! #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
We can help patients identify what matters most (values), get past misconceptions, and choose base on their values #jhsjc
As an example of how important this is: the charlatan has always been ready to take advantage of despair #jhsjc
I don’t know a single hand surgeon that wants to be identified as even 1% charlatan #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
That has been an approach in measuring hip arthroplasty results – personal goals. That could be very useful in hand sx. #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Although not if the personal goals are based on misconceptions.  That’s the key #jhsjc
There is a boldness that seems to be a key part of good care.  Maybe we need to be willing to risk dissatisfaction.  We can simultaneously do everything we can to build strong relationships in which we can effectively guide people without losing trust. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Agreed! I’m sure that general categories of goals – not misconceptions – can be identified and operationalized #jhsjc

Brent Graham @BgTalkinman:
Thanks to @DrDavidRing for his great insights on these important topics! Back next month. #jhsjc