A qualitative study with orthopedic surgeons on pain catastrophizing and surgical outcomes: shifting from a medical towards a biopsychosocial model of surgery.

Background: Pain catastrophizing and psychological distress moderate surgical outcomes and psychological interventions are recommended to optimise post-operative results. Orthopaedic surgeons value the role of psychological factors however, despite evidence arising to the modifiable risk factors that impact on patients’ outcomes, they often refrain from making referrals for treatment and orthopaedic surgery is framed within a biomedical model. Barriers towards the management of psychosocial factors include having a lack of time, stigma, feeling uncomfortable, professional confidence, fear of offending patients and of negative patient reactions. Willingness to discuss psychosocial issues with patients is due to the lack of resources available for patients. Patients should be supported both physically and emotionally during the perioperative period and surgeons need to be aware of the emotional health of the patient and how this influences their physical recovery after surgery. There is little evidence to understand orthopaedic surgeons’ experiences of providing care, their thoughts on the best ways to manage and support patients who present with psychosocial factors and who may be at risk of suboptimal recovery. By understanding orthopaedic practitioners’ views on providing care, this may offer an opportunity to implement changes within the surgical care pathway and provide overall better-quality care.

Aims: It was therefore invaluable to understand surgeons’ views on how best to support patients who may be at risk of suboptimal recovery and the development of persistent pain, and their attitudes towards the use of interventions in practice.

Method: Eleven surgeons and three registrar orthopaedic practitioners took part in semi-structured interviews within a secondary care hospital setting. The surgical decision-making process, views of catastrophizing and psychological distress and the use of psychological interventions in surgical practice were explored.

Results: Thematic analysis identified five themes: pain expressions and pain behaviours affect the surgeons decision-making process; when pathologies and symptoms do not match; psychological factors pertaining to unsatisfactory outcomes; a service gap in surgical care and the acceptability of using a screening tool in surgical practice to identify patients at risk of suboptimal recovery.

Conclusion: Orthopaedic practitioners face challenges in identifying who is likely to reach optimal versus sub-optimal outcome. Surgeons are becoming increasingly aware that the etiology of pain is multifactorial, and a variety of factors may explain the unpredictability of post-operative outcomes. The surgeons support the use of psychological interventions to optimise post-operative results or stop unnecessary treatments and they accept the use of a screening tool in surgical practice. A screening tool may provide great utility for identifying at risk patients, to allow for modification of surgical patients care plans to reduce the likelihood of developing persistent post-operative pain. To aid this process, input is needed from allied health professionals.