Mental and Social Health Are Inseparable from Physical Health.

Abstract

There is a growing recognition that the relationship between physical, mental, and social health is of relevance in patient care1,2. In orthopaedic surgery, for example, it is established that people who continue to request opioids long after the body has healed tend to have greater misconceptions about their symptoms and greater psychological distress, as most people discontinue opioids as soon as possible3. As another example, individuals with these characteristics stay out of work longer after injury and recover more slowly and less completely compared with those who resume life roles as quickly as possible4. And yet many editors and reviewers, when considering submissions that address the biopsychosocial paradigm of human illness, still say, “Interesting, but not relevant to orthopaedic surgeons.” As surgeons, do we give appropriate attention to the “nontechnical” factors that may contribute to a person’s health status? Is it our job to be concerned with those issues? If we are to provide truly comprehensive orthopaedic care, I believe it is. Conversations on mental and social health and on the interplay of thoughts, emotions, sources of stress, and physiological health need not be “off limits” because of our own discomfort. I see parallels with other cultural transformations taking place. The killing of George Floyd last year was a brutal demonstration of our society’s foundation of White, male privilege that could no longer be ignored. The imbalances seen in the rates of infection, hospitalization, and mortality during the COVID-19 pandemic are indisputable manifestations of the health consequences of racial, ethnic, and socioeconomic inequities5. With these facts firmly out in the open, there is an increasingly loud call to action. Let us not let attitudes of privilege—or stigma—impede us from making other important shifts in our responses to patients. It is time for a transformation away from the biomedical paradigm of human illness (all symptoms are due to pathophysiology) and toward the more accurate and useful biopsychosocial paradigm that recognizes the interconnection of mental, social, and physical health. One manifestation of systemic racism is that mental health crises may be more often interpreted as aggressive criminal action when the person in distress is Black6,7. More broadly, police need training for, and assistance with, the aspects of community engagement related to mental health7. They can learn and practice how to better recognize the ways in which mental health may contribute to an event. They can hone the skills related to de-escalation, emotional self-control, and trust-building. They can develop strategies and systems for promptly involving mental health experts. And although our work may vary greatly from that of police, orthopaedic surgeons can take a similar approach to mental health, emphasizing timely recognition and appropriate intervention. We, as well as our patients, may benefit from an evolution in our habits and from learning new skills for engagement. A key aspect of medical expertise, and our traditional training, is the discernment of symptoms that correspond with verifiable pathophysiology. Now consider, for example, a pain intensity score or patient-reported outcome score that is far greater than one would expect for the known and potential pathology, or symptoms that are diffuse and involve multiple distinct anatomical regions. Symptoms that are vague, diffuse, or disproportionate may be related to social stressors (e.g., job, financial, food, housing, relationship, or role insecurity), psychological distress (i.e., symptoms of anxiety and depression), or unhealthy misconceptions (e.g., worst-case [catastrophic] thinking, fear of painful movement, and intolerance of uncertainty)1. In addition, it is possible that physician expectations for patient pain can be influenced by racial or other biases or misconceptions, such as that Black patients, particularly Black women, have higher pain thresholds8. As such, it is important to take stock of both patient-sided and physician-sided factors that are external to the injury or procedure itself. Nonspecialists may not have the expertise, experience, or confidence to recognize a disconnect between symptoms and pathology. An orthopaedic surgeon may often be the first clinician to notice that a patient has an unhealthy level of worry or despair or is not understanding their symptoms in the healthiest regard. For instance, new symptoms from age-appropriate, gradual-onset changes such as knee arthritis and rotator cuff tendinopathy are often misinterpreted as injury. At the same time, some people may resist adjusting to their aging body because of despair that they will have to alter important roles and activities. Surgeons can also appreciate, for instance, that laborers with limited education often face a crisis as they age and develop arthritis and tendinopathy, finding it more difficult to continue heavy work but seeing few other options. Patients may also experience distress regarding treatment if receiving that treatment would be prohibitively or damagingly costly; this is worth noting especially among communities of color, given that the rate of poverty among Black households is more than double that of White households9. We can recognize that, as orthopaedic surgeons, we are often in the best position to diagnose and begin to address such mental and social health opportunities and concerns. This means a shift in our thinking about what constitutes comprehensive orthopaedic care and what is within the realm of our responsibility. Additionally, we must develop relationships with practitioners outside of our surgical sphere, such as psychologists, social workers, and employment councilors, to whom we can refer patients for further care. People seek care when a symptom becomes a concern. There is often some degree of unsettlement or misconception that has made the symptoms more intense and limiting. It is gratifying to see that members of our community are learning to anticipate these opportunities and are identifying and practicing the communication strategies needed to make thoughts and emotions comfortable topics of conversation. These topics are particularly delicate in a setting in which people are seeking physical diagnoses and treatment from a surgeon, and the surgeon’s reputation, self-esteem, and income are often based on those physical diagnoses and the tests and treatments to which they are linked. People who are experiencing somatic manifestations of stress and distress may not fully appreciate the connection between mental health and physical symptoms. The nontechnical skills of recognizing and addressing mental health opportunities, acting against ego and financial incentives to prioritize them, and making mental and social health comfortable topics of conversation can be as difficult to master as is surgery, but it is worth the effort because both surgeon and patient stand to benefit from a better relationship and more accurate and comprehensive care. Mental health, social health, trust, compassion, and communication effectiveness may not be traditional orthopaedic topics, but for orthopaedic surgeons to do their part for individual and population health, that must change. Increasingly, those of us who benefit and have benefited from the status quo are being asked to take more selfless, reparatory, and equitable actions.