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01.04.2015 | Clinical Research | Ausgabe 4/2015

Clinical Orthopaedics and Related Research® 4/2015

Patients With Greater Symptom Intensity and More Disability are More Likely to be Surprised by a Hand Surgeon’s Advice

Clinical Orthopaedics and Related Research® > Ausgabe 4/2015
MD Joost A. Strooker, MD Sjoerd P. F. T. Nota, MD Michiel G. J. S. Hageman, MD, PhD David C. Ring
Wichtige Hinweise
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
This study was performed at the Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
A comment to this article is available at http://​dx.​doi.​org/​10.​1007/​s11999-014-4019-6.



A clash between a patient’s assumptions and a doctor’s advice can feel adversarial which might influence satisfaction ratings and compliance with treatment recommendations. A better understanding of sources of patients’ bewilderment might lead to improved strategies for conveying counterintuitive information that improve patient comfort and wellbeing.


This study addressed the following questions: (1) Are magnitude of disability, pain intensity, symptoms of depression, or health anxiety associated with a higher level of surprise when a patient is presented with diagnostic information and/or therapeutic recommendations? (2) Does the surgeon accurately perceive the patient’s bewilderment? (3) Does the surgeon’s perception of patient bewilderment correlate with diagnosis or a patient’s magnitude of disability, pain intensity, symptoms of depression, or health anxiety?

Patients and Methods

In this prospective cohort study, we invited new patients who met prespecified criteria during a 3-month period in one hand-surgery practice to enroll; of 93 patients invited, 84 (90%) agreed to participate. Patients reported demographics and completed the short versions of the DASH questionnaire (QuickDASH), the Patient Health Questionnaire, the Pain Self-Efficacy Questionnaire, and the Short Health Anxiety Inventory; rated their pain intensity; and rated the degree to which the information given by the surgeon was unexpected or surprising on an 11-point ordinal scale. The surgeon also rated his impression of the patient’s surprise on an 11-point ordinal scale.


Only greater symptom intensity and magnitude of disability (QuickDASH) correlated with greater unexpected information when rated by the patient (ß = 0.058; p < 0.001). There was a correlation between patient surprise and the surgeon’s perception of the patient’s surprise (r = 0.58; p < 0.001). Greater surgeon-perceived patient surprise correlated with nonspecific illness (p = 0.007; ß = 3.0).


Patients with greater symptom intensity and magnitude of disability, and perhaps also patients with nonspecific diagnoses, are more likely to be surprised by a hand surgeon’s advice. Future research might address the ability of previsit preparation (using decision aids or other alternative means of education) to ameliorate the discordance between patient assumptions and hand surgeon advice.

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