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Healio spoke with David Ring, MD, PhD, associate dean for comprehensive care and professor of surgery and psychiatry at the Dell Medical School at The University of Texas at Austin, to discuss the psychological effects of conditions in the hand, considering these effects in treatment and surgical decisions and the importance of establishing trust between hand surgeons and patients.

Healio: What should clinicians know about the psychological effects of conditions or injury in the hand?

Ring: People don’t seek care for a symptom; we all experience symptoms every day. What motivates people to seek care is a symptom plus a concern. For common hand problems such as arthritis, tendinopathy and neuropathy, that concern is usually based on a misinterpretation of symptoms. Such misinterpretations are an expected result of the short cuts the human mind uses to make quick decisions in times of danger. Psychologists refer to these short cuts as cognitive biases. The automatic thinking at the base of cognitive bias is effortless and can be amazingly accurate — think facial recognition. It is also the source of many errors, referred to as cognitive errors. To err is human. Misinterpretations are to be expected. They have greater potential to harm health when they are regarded not as possibilities, but rather as facts. When thoughts become facts, psychologists refer to this as cognitive fusion. It is more likely when people are experiencing distress, such as symptoms of anxiety and depression. 

David Ring

Specialists may be the only clinicians who can discern symptoms that don’t match the pathology, which is the hallmark of misinterpretation of symptoms reinforced by distress. If we don’t identify these mental health opportunities and help nudge people toward the highly effective treatments available — cognitive behavioral therapy can work wonders — then people may miss out. It’s a great responsibility!

Healio: Should physicians consider these effects before making treatment decisions in patients with hand conditions? Why or why not?

Ring: People want to stay within their comfort zone. And, sadly, effective mental health care is not easily accessible and is undervalued. Specialists get in the habit of ordering a test, giving a steroid injection, or offering a surgery just to survive the day, avoid offending patients, limit virulent evaluations and make sure the referrals keep coming. 

It’s time we start to understand that people might feel better temporarily after our interventions, but this can be regression to the mean, the self-limiting course of many symptoms and illnesses, and meaning/context effects like placebo and nocebo effects. If we miss the opportunity to help people learn more better debiasing strategies, flexible thinking, and method to limit distress and stress, it can influence their future health in general, not just the symptom for which they seek our care. 

With symptom intensity and magnitude of limitations is greater than expected for the degree of pathology, we need to step back from our biomedical treatments and think more holistically. Don’t expect to solve the problems yourself. Work on a trusting relationship with the patient as a priority. Forget about the diagnosis and treatment — that can wait. Correspond with the primary care doctor and make sure the entire treatment team understands the mental and social health priorities. When people are ready, they can benefit from your injections or surgeries. 

Healio: How do you talk to your patients about their mental health when discussing next steps?

Ring: Don’t try to talk about mental health with patients until they invite you. Just show compassion. Talk less than the patient. Make sure you understand who they are and why they made the effort to see you; normalize their concerns. Legitimize their reasons for seeking care. Deliver your expertise in brief, bulleted items with pauses in between. You can do this in less than 60 seconds. Notice misconception/misinterpretation. Notice worry and despair. Retreat to empathy and relationship building. Time is on your side. Don’t try to solve it all in one visit — plan care over time. Use phone, portal, email, or in person visits to help people think things through and open up to new ways of interpreting their symptoms. 

Hand specialists may not be able to discuss mental health. They can definitely make strong relationships. And they can definitely choose not to order tests and treatments that have more potential for harm than for benefit.

The issue for specialists is not so much about discussing mental health. People are seeing us in many cases because they are not ready to discuss their thoughts, emotions and stress. They are somatizing those into a physical expression. The issue for specialists is not reinforcing misconceptions or distress, not ordering tests when you’re confused — tests are best for confirming a likely diagnosis — and not giving a treatment that is not proved to be better than simulated treatment. Specialists should work on the self-awareness, and people skills, communication skills in particular to manage these scenarios. And we can contribute to new models of care that are more team and system oriented, so that as soon as misinterpretation of symptoms, stress, and distress are identified, they become the treatment priorities.

We know that misinterpretation of symptoms, distress and stress are the key determinants of symptom intensity and magnitude of incapability or illness. We are at the “last mile” of figuring out how to implement this knowledge. Future research should focus on how we can move away from debatable diagnoses, concepts that reinforce misconceptions, and avoid tests and treatments with more potential for harm than benefit. And most importantly surgeons can spend most of their self-improvement efforts on effective relationship building and communication strategies. With trust, much more is possible.

Q: What should be the focus of future research on psychological outcomes in patients with hand conditions?

Ring: We know that misinterpretation of symptoms, distress and stress are the key determinants of symptom intensity and magnitude of incapability or illness. We are at the “last mile” of figuring out how to implement this knowledge. Future research should focus on how we can move away from debatable diagnoses, concepts that reinforce misconceptions, and avoid tests and treatments with more potential for harm than benefit. And most importantly surgeons can spend most of their self-improvement efforts on effective relationship building and communication strategies. With trust, much more is possible.

Disclosures: Ring reports no relevant financial disclosures.