Background: Misperception that an established, gradual-onset disease such as osteoarthritis started when the symptoms were first noticed might lead to testing and treatment choices that are inconsistent with what matters most to a patient. In the present study, the primary null hypothesis was that there are no factors associated with patient-reported symptom duration (in months). The secondary null hypotheses were that there are no factors independently associated with (1) a sudden versus gradual perception of disease onset, (2) an event or injury-related versus age-related perceived cause of disease onset, and (3) the magnitude of physical limitations. Methods: In this cross-sectional study, 121 patients with an atraumatic, established, gradual-onset condition of the upper extremity completed a demographic questionnaire, measures of mental health (symptoms of depression and anxiety, worst-case thinking, and self-efficacy [the ability to adapt and continue with daily activity] when in pain), measurement of the magnitude of upper extremity-specific limitations, and questions about the perceived course and cause of the disease. Results: The median patient-reported symptom duration was 12 months (interquartile range, 3 to 36 months). Twenty-two patients (18%) perceived their disease as new, and 29 patients (24%) believed that the condition was related to ≥1 event (injury) rather than being time and age-related. In multivariable analysis, patients with Medicare insurance were independently associated with longer reported symptom duration (in months). Greater self-efficacy was associated with longer symptom duration in bivariate, but not multivariable, analysis. No factors were independently associated with a sudden versus gradual onset of symptoms. Hispanic ethnicity and federal, county, or no insurance were independently associated with the perception that the problem was caused by an injury or event. Conclusions: Approximately 1 in 5 patients misperceived new symptoms as representing a new disease, often as a type of injury. Misperception of the pathology as new had a limited association with unhealthy thoughts and is likely generally responsive to reorientation. We speculate that gentle, strategic reorientation of misperception can protect patients from choices inconsistent with their values.

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Background Mental health has a notable and perhaps underappreciated relationship with symptom intensity related to musculoskeletal pathophysiology. Tools for increasing awareness of mental health opportunities may help musculoskeletal specialists identify and address psychological distress and unhealthy misconceptions with greater confidence. One such type of technology—software that identifies emotions by analyzing facial expressions—could be developed as a clinician-awareness tool. A first step in this endeavor is to conduct a pilot study to assess the ability to measure patient mental health through specialist facial expressions. Questions/purposes (1) Does quantification of clinician emotion using facial recognition software correlate with patient psychological distress and unhealthy misconceptions? (2) Is there a correlation between clinician facial expressions of emotions and a validated measure of the quality of the patient-clinician relationship? Methods In a cross-sectional pilot study, between April 2019 and July 2019, we made video recordings of the clinician’s face during 34 initial musculoskeletal specialist outpatient evaluations. There were 16 men and 18 women, all fluent and literate in English, with a mean age of 43 ± 15 years. Enrollment was performed according to available personnel, equipment, and room availability. We did not track declines, but there were only a few. Video recordings were analyzed using facial-emotional recognition software, measuring the proportion of time spent by clinicians expressing measured emotions during a consultation. After the visit, patients completed a demographic questionnaire and measures of health anxiety (the Short Health Anxiety Inventory), fear of painful movement (the Tampa Scale for Kinesiophobia), catastrophic or worst-case thinking about pain (the Pain Catastrophizing Scale), symptoms of depression (the Patient Health Questionnaire), and the patient’s perception of the quality of their relationship with the clinician (Patient-Doctor Relationship Questionnaire). Results Clinician facial expressions consistent with happiness were associated with less patient health anxiety (r = -0.59; p < 0.001) and less catastrophic thinking (r = -0.37; p = 0.03). Lower levels of clinician expressions consistent with sadness were associated with less health anxiety (r = 0.36; p = 0.04), fewer symptoms of generalized anxiety (r = 0.36; p = 0.03), and less catastrophic thinking (r = 0.33; p = 0.05). Less time expressing anger was associated with greater health anxiety (r = -0.37; p = 0.03), greater symptoms of anxiety (r = -0.46; p < 0.01), more catastrophic thinking (r = -0.38; p = 0.03), and greater symptoms of depression (r = -0.42; p = 0.01). More time expressing surprise was associated with less health anxiety (r = -0.44; p < 0.01) and symptoms of depression (r = -0.52; p < 0.01). More time expressing fear was associated with less kinesiophobia (r = -0.35; p = 0.04). More time expressing disgust was associated with less catastrophic thinking (r = -0.37; p = 0.03) and less health anxiety (GAD-2; r = -0.42; p = 0.02) and symptoms of depression (r = -0.44; p < 0.01). There was no association between a clinicians’ facial expression of emotions and patient experience with patient-clinician interactions. Conclusion The ability to measure a patient’s mindset on the clinician’s face confirms that clinicians are registering the psychological aspects of illness, whether they are consciously aware of them or not. Future research involving larger cohorts of patients, mapping clinician-patient interactions during consultation, and more sophisticated capture of nonverbal and verbal cues, including a broader range of emotional expressions, may help translate this innovation from the research setting to clinical practice. Clinical Relevance Tools for measuring emotion through facial recognition could be used to train clinicians to become aware of the psychological aspects of health and to coach clinicians on effective communication strategies both for gentle reorientation of common misconceptions as well as for appropriate and timely diagnosis and treatment of psychological distress.

Patient experience measures such as satisfaction are increasingly tracked and incentivized. Satisfaction questionnaires have notable ceiling effects that may limit learning and improvement. This study tested a Guttman-type (iterative) Satisfaction Scale (GSS) after a musculoskeletal specialty care visit in the hope that it might reduce the ceiling effect. We measured floor effects, ceiling effects, skewness, and kurtosis of GSS. We also assessed factors independently associated with GSS and the top 2 possible scores. In this cross-sectional study, 164 patients seeing an orthopedic surgeon completed questionnaires measuring (1) a demographics, (2) symptoms of depression, (3) catastrophic thinking in response to nociception, (4) heightened illness concerns, and (5) satisfaction with the visit (GSS). Bivariate and multivariable analyses sought associations of the explanatory variable with total GSS and top 2 scores of GSS. Accounting for potential confounding using multivariable analysis, lower satisfaction was independently associated with greater symptoms of depression (β: −0.03; 95% CI: −0.05 to −0.00; P = .047). The top 2 scores of the GSS were independently associated with women (compared to men: odds ratio [OR]: 2.12, 99% CI: 1.01-4.45, P = .046) and lower level of education (masters’ degree compared to high school; OR: 0.16, 95% CI: 004-0.61, P = .007). The GSS had no floor effect, a ceiling effect of 38%, a skewness of −0.08, and a kurtosis of 1.3. The 38% ceiling effect of the iterative (Guttman-style) satisfaction measure is lower than ordinal satisfaction scales, but still undesirably high. Alternative approaches for reducing the ceiling effect of patient experience measures are needed.