Outlook: Newsletter of the Society of Behavorial Medicine

The Future of Orthopedic Care: Interview with Dr. David Ring, an Orthopedic Surgeon with a Knack for Psychological Care

Ana-Maria Vranceanu, PhD, Pain Special Interest Group (SIG) Chair

David Ring, MD
David Ring, MD

The Pain Special Interest Group is pleased to introduce you to Dr. David Ring. He is the former Chief of Hand and Upper Extremity Service at Massachusetts General Hospital and Professor of Orthopedic Surgery at Harvard Medical School. He left this position 2 years ago to serve as Associate Dean of Comprehensive Care at Dell Medical School in Austin Texas. Dr. Ring is not your typical orthopedic surgeon – he has a strong interest in psychological factors associated with pain, and earned a PhD in Psychology from the University of Amsterdam. His research on psychosocial aspects of musculoskeletal illness encompasses original research publications on topics such as shared decision making, emotional functioning, coping strategies, and physician empathy. I met David in 2006 during my clinical internship in Behavioral Medicine at Massachusetts General Hospital in Boston. David reached out to get help developing a psychosocial program in orthopedics. I did not have much experience with pain or orthopedics at that point, but I was excited for the collaboration. Shortly after starting out, I was hooked.  David and I have continued to learn from each other and collaborate ever since. This interview provides a snippet of a model of a successful collaboration between a medical doctor and a psychologist. Such collaborations are key if we are to be successful with behavioral health integration efforts in both primary and specialty care clinics. The interview provides valuable information about challenges associated with behavioral health integration, as well as strategies to bypass these barriers.

Pain SIG: How did you become interested in psychosocial factors?

Dr. Ring: Medical training can be dehumanizing, but I managed to maintained some curiosity, humility, and compassion. Some people have more symptoms and limitations with a given problem than others. Doctors tend to treat the symptoms.  For instance, many hand surgeons will offer people with disproportionately bothersome intermittent hand numbness and pain a carpal tunnel release even when the disease is so mild it cannot be detected on electrophysiological testing.  But those same hand surgeons won’t offer surgery to people with measurable advanced nerve dysfunction at risk for permanent numbness, or weakness from atrophy if they have no symptoms.  To me that’s like offering antibiotics for sore throat when it’s clearly a virus as long as the patient pushes you hard enough, while withholding penicillin for strep throat if the symptoms are minimal and the patient is very agreeable and deferential. It’s puzzling and unsettling.

When patient reported outcomes became popular in the 1990’s, they gave us a way to quantify and study symptoms and limitations.  I put an advertisement on the Harvard website to recruit medical student researchers; one Dartmouth pre-med psychology major then helped me name and measure some of the constructs I was interested in. That led to your (Dr. Vranceanu) internship and post-doc with me and a slew of additional research.  Within a few years it was clear that symptoms of depression and anxiety, less effective coping strategies like catastrophic thinking and kinesiophobia, and heightened illness concern explained a substantial amount of the variation in symptom intensity and magnitude of limitations for a given nociception or pathophysiology. I’ve also learned about effective treatments like cognitive behavioral therapy and its derivatives.

Pain SIG: The role of psychological factors in the response to nociception is well known now, yet screening and addressing these factors in a standardized and efficient way is lacking. What are some barriers?

Dr. Ring: The interaction between people seeking and people providing care is delicate.  People don’t seek care for a symptom.  People seek care when a symptom becomes a concern.  When it comes to nociception, those concerns are often based on misconceptions.  We humans are wired to prepare for the worst.  What we imagine is often worse than what’s actually going on.  As a result, expert medical advice is often unexpected, counterintuitive, disappointing or unwelcome.  Expert advice may even feel dismissive, belittling, or arrogant.  This creates difficult conversations.  As physicians we tend to develop habits to conduct diagnostic tests of low value and offer treatments to try and avoid these difficult conversations.  

It gets even more difficult when we attempt to offer people opportunities to reduce stress and distress, and improve coping strategies.  The human mind defaults to a false mind-body dichotomy and there is stigma and shame associated with psychological factors.  The message that “there’s a better way to think about this” may sound like “you’re getting it all wrong…your mind is defective” or “it’s all in your head”.

Doctors—surgeons in particular—may have developed relative “stress immunity” and other personality traits that make it possible to perform such a high-stress profession, yet at the cost perhaps of lower empathy.  This might contribute to challenges with communication skill for many surgeons and other physicians.  Physician training focuses largely on the technical aspects of medicine, while non-technical skills such as effective communication strategies aren’t typically as well practiced.  So we are asking less effective communicators to have high-stakes, difficult conversations.  It’s not surprising that surgeons often choose to avoid discussing psychosocial issues.   

To improve, we’ll need a culture change where people see mind training and cognitive exercises are just as helpful and important as body training and exercise, healthy diet, and other healthy habits. We’re starting to see this in the military where resiliency training is increasingly common, and in sports where many accomplished athletes have mindset coaches (i.e., sports psychologists). We need to also change the way we train doctors.  Effective communication should be just as important if not more important than adequate knowledge and technical skills.  Psychologists trained in behavioral medicine are key in helping doctors learn how to discuss psychosocial factors with patients and how to use simply cognitive behavioral therapy skills during their visits with patients. You (Dr. Vranceanu) and I used to see patients together at the beginning of our collaboration, and that has helped us learn from each other so that eventually we became able to see patients independently and stay on the same page.

Pain SIG: You and I worked together for many years, yet this collaboration is pretty unique. We are Co-PIs on a grant testing a 4 session live video skills intervention for patients with acute fractures who have difficulties coping and are at risk for chronic pain and disability, “The Toolkit for Optimal Recovery”.  Although patients who undergo this program do really well and like it, it is challenging to convince surgeons to refer patients. What do you think we can do better to facilitate their buy in?

Dr. Ring: I think surgeons increasingly understand the importance of psychosocial factors.  That’s a development we can be proud of.  I think the next step is helping surgeons and their teams develop effective communication strategies.  You and I did a survey of orthopedic surgeons and found that surgeons do notice psychosocial factors, but are uncomfortable discussing them with patients. In addition, we know that patients are not generally happy when their surgeon tells them to see a psychologist. But starting the conversation by asking patients who their social/instrumental support is might increase their acceptance of an offer of more support.  When a patient requests more support, then a referral can be made and may be better received by patients.

Historically, surgeons made referrals to Psychiatry Departments, but this has been problematic not only because of stigma associated with mental health, but also because of the long wait, often months, to see a psychologist. There are also few psychologists with specialized training who can work well with orthopedic patients. You, Dr. Vranceanu, trained and saw patients with me, and learned the specific culture of both the orthopedic practice and orthopedic patients. When I was at Massachusetts General Hospital, I was blessed to have you available when people requested support.  Most surgeons don’t have this type of colleague ready at hand. 

I think surgeons are now receptive to the approach of “comprehensive care”. This means that surgeons can learn to effectively communicate about psychosocial factors with patients during the medical appointments, and introduce cognitive behavioral skills. In our work with the “Toolkit for Optimal Recovery”, we found that approximately 50% of patients do pretty well on their own, and we know this has little to do with the severity of the injury. They may have some misconceptions about pain, and some pain-related anxiety, and they can respond very well to an empathic, encouraging surgeon who can put them at ease. The other 50% have more difficulties - in the form of anxiety about pain and catastrophic thinking about pain. These patients can still benefit from working with a reassuring surgeon, but a friendly program like the “Toolkit for Optimal Recovery”, which is delivered early in the recovery process through telehealth (so very convenient), can make a big difference in helping patients develop a resilient mindset that is not contingent on being pain free, but on engaging in activities and getting back to living a full life. The surgeon’s role in this process is key to reinforce the work of the psychologist. As you and I have learned, speaking the same language and having a similar understanding of both the medical and psychosocial factors in pivotal in order to help our patients. The words we use when discussing psychosocial aspects of illness are also very important, and the Toolkit is successful with patients because it is framed as coaching rather than a therapy program; it normalizes the pain experience while instilling hope, teaching and reinforcing skills, and keeping patients accountable to developing engrained adaptive habits.