AAOS Now

Published 2/1/2009
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Annie Hayashi

Don’t guess—test for your patient’s level of distress

Award-winning study compares physicians’ clinical instincts to patient questionnaire

“Psychological distress has been shown to be a predictor for poor outcomes in spinal surgery,” said Michael D. Daubs, MD, at the recent meeting of the North American Spine Society (NASS).

“Spine surgeons have difficulty accurately assessing our patients’ level of psychological distress, an abnormal psychological state that includes anxiety, depression, and somatic conditions—as well as more subtle indications often seen in at-risk groups and often missed by orthopaedic surgeons,” he said.

Dr. Daubs found that most spinal surgeons rely on their clinical instincts to assess the psychological distress of their patients prior to surgery, rather than using a validated questionnaire such as the Distress Risk Assessment Method (DRAM). When used routinely, the DRAM, he pointed out, is much more effective in identifying patients whose psychological state may be a factor in poor outcomes.

Testing clinical instincts
To evaluate whether clinical instincts were as accurate as patient-reported measures in

identifying psychological distress, Dr. Daubs and his colleagues conducted a prospective, blinded study of 400 new patients (206 female, 194 male; average age: 48 years). The study compared the clinical assessments of 8 physicians (4 spinal surgeons, 4 physiatrists) with DRAM scores.

Each physician was asked to conduct his routine clinical evaluation and assess the patient’s level of psychological distress based on one of the four DRAM categories: normal, at-risk, distressed depressive, and distressed somatic.

“We also compared assessment accuracy between surgeons and physiatrists, and between surgeons with more than 10 years experience and those with less than 2 years experience,” Dr. Daubs reported.

Physicians’ assessments versus the DRAM
According to DRAM scores, 64 percent of the patients had significant psychological stress and 22 percent of that group demonstrated severe distress (
Fig. 1).

“When we examined the results, physicians as a group were correct only 44 percent of the time,” Dr. Daubs stated. “The surgeons accurately assessed patients 40 per­cent of the time and physiatrists scored slightly higher at 49 per­cent but this was not statistically significant.

“We found that physicians were overly optimistic about their patients’ psychological states. Physicians classified people as normal 65 percent of the time; but according to the DRAM scores, only 36 percent of patients were ‘normal’ (Fig. 2).

“Physicians did not identify the patients with the most severe level of distress almost 50 percent of the time,” he said.

The physiatrists’ assessments of the more severely distressed groups were more accurate than the sur­geons, particularly for the de­pressed somatic category.

“Surprisingly, we found no statistical difference between patient assessments performed by more experienced surgeons and those with less experience. It doesn’t seem that experience improves assessment abilities,” Dr. Daubs commented.

Lessons for the future
Because so many patients in this study had some degree of psychological distress, Dr. Daubs believes that physicians should not rely on their own instincts and should routinely use a test such as the DRAM when evaluating patients as spinal surgical candidates.

“Our study demonstrates that spinal specialists’ clinical instincts do not adequately identify psychological distress—particularly severe forms of it—and more than 10 years of surgical experience did not enhance that ability.

“I hope this study helps us see that we are not able to identify distress in patients as well as we think we can,” he continued. “Surgeons need to use the DRAM questionnaire on a routine basis and to consider whether certain patients are indeed surgical candidates. We need to use psychological counseling or other modes of therapy to determine if these help improve surgical outcomes.”

Dr. Daubs sees this study as a beginning and advocates for more studies to examine the role of psychological distress on surgical outcomes.

“More studies are needed to show that these factors definitely affect surgical outcomes. The next study would ideally examine the effect of interventional treatment for patients prior to surgery to determine whether psychological counseling or other modes of therapy might improve surgical outcomes,” Dr. Daubs concluded.

“Clinical instinct versus standardized questionnaire: The spine specialists’ ability to detect psychological distress” was awarded a Best Paper award at the 2008 NASS Meeting. It also received the 2008 Russell Hibbs Award from the Scoliosis Research Society. Co-authors include Alpesh Patel, MD; Stewart Willick, MD; Richard W. Kendall, MD; Pamela Hansen, MD; David Petron, MD and Darrel S. Brodke, MD.

The authors have the following disclosures: Dr. Daubs—Synthes; Dr. Patel—Stryker Spine, DePuy, AO; Dr. Brodke—DePuy, Amedica, Medtronic Sofamor Danek, DFine, Pfizer, Biomet, Zimmer, Stryker, Syndicom. Disclosure information was not available for Drs. Willick, Kendall, Hansen, and Petron.

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org