Are Surgeons’ Tendencies to Avoid Discomfort Associated with Attitudes and Beliefs Toward Patient Psychosocial Factors?

Document Type : RESEARCH PAPER


1 Integrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA

2 Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA

3 Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA

4 Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, USA

5 Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA


Background: Orthopedic surgeons are sometimes hesitant to assess and address psychosocial factors.
Surgeon-specific modifiable factors may contribute to surgeon attitudes and beliefs regarding the mental and
social aspects of illness. A better understanding of these factors could help inform interventions to support
surgeons and improve patient outcomes. We aimed to investigate whether orthopedic surgeons’ self-reported
compassion, perceived stress, and experiential avoidance are independently associated with various surgeon
attitudes and beliefs regarding psychosocial aspects of health.
Methods: This is a cross-sectional study of 165 members of the Science of Variation Group (SOVG).
Surgeons completed measures of compassion, stress, experiential avoidance, and demographics. They
answered questions addressing attitudes and beliefs regarding psychosocial aspects of care, which were
condensed to the following 6 dimensions through factor analysis: (1) confidence, (2) perceived resource
availability, (3) blame towards patients, (4) fear of offending patients, (5) professional role resistance, and
(6) fear of negative patient reactions. We performed 6 multivariable hierarchical regression analyses to
determine whether self-reported compassion, perceived stress, and experiential avoidance were associated
with aspects of surgeons’ attitudes and beliefs regarding psychosocial care.
Results: After accounting for the influence of relevant covariates, experiential avoidance explained 2.9-
6.6% of the variance (P-values .002 to .031) in all aspects of surgeon attitudes and beliefs regarding
psychosocial care, except for perceived resource availability. Perceived stress and compassion toward
others were not associated with any outcome variable.
Conclusion: Targeting orthopedic surgeons’ tendency to avoid discomfort (i.e., experiential avoidance) via
supportive/educational programs may decrease barriers and increase their abilities to address psychosocial
factors, resulting in improved patient outcomes.
Level of evidence: III


  1. Helmerhorst GTT, Vranceanu A-M, Vrahas M, Smith M, Ring D. Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma. J Bone Joint Surg Am. 2014; 96(6):495–9.
  2. Trief PM, Grant W, Fredrickson B. A prospective study of psychological predictors of lumbar surgery outcome. Spine (Phila Pa 1976). 2000; 25(20):2616–21.
  3. Vranceanu A-M, Bachoura A, Weening A, Vrahas M, Smith RM, Ring D. Psychological factors predict disability and pain intensity after skeletal trauma. J Bone Joint Surg Am. 2014; 96(3):e20.
  4. Vranceanu A-M, Barsky A, Ring D. Psychosocial aspects of disabling musculoskeletal pain. J Bone Joint Surg Am. 2009; 91(8):2014–8.
  5. Ayers DC, Franklin PD, Ring DC. The role of emotional health in functional outcomes after orthopaedic surgery: extending the biopsychosocial model to orthopaedics: AOA critical issues. J Bone Joint Surg Am. 2013; 95(21):e165.
  6. Zale EL, Ring D, Vranceanu A-M. The Future of Orthopaedic Care: Promoting Psychosocial Resiliency in Orthopaedic Surgical Practices. J Bone Joint Surg Am. 2018; 100(13):e89.
  7. Verbeek J, Sengers M-J, Riemens L, Haafkens J. Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine (Phila Pa 1976). 2004; 29(20):2309–18.
  8. Vranceanu AM, Beks RB, Guitton TG, Janssen SJ, Ring D. How do Orthopaedic Surgeons Address Psychological Aspects of Illness? Arch Bone Jt Surg. 2017; 5(1):2–9.
  9. Wegener ST, Carroll EA, Gary JL, McKinley TO, OʼToole RV, Sietsema DL, et al. Trauma Collaborative Care Intervention: Effect on Surgeon Confidence in Managing Psychosocial Complications after Orthopaedic Trauma. J Orthop Trauma. 2017; 31(8):427–33.
  10. Hayes SC, Strosahl K, Wilson KG, Bissett RT, Pistorello J, Toarmino D, et al. Measuring experiential avoidance: A preliminary test of a working model. Psychol Rec. 2004; 54(4):553–78.
  11. Gilbert P. The Evolution and Social Dynamics of Compassion. Social and Personality Psychology Compass. 2015; 9(6):239–54.
  12. Pegrum J, Pearce O. A stressful job: are surgeons psychopaths? Bulletin. 2015; 97(8):331–4.
  13. Skinta MD, Lezama M, Wells G, Dilley JW. Acceptance and Compassion-Based Group Therapy to Reduce HIV Stigma. Cognitive and Behavioral Practice. 2015; 22(4):481–90.
  14. Balch CM, Freischlag JA, Shanafelt TD. Stress and burnout among surgeons: understanding and managing the syndrome and avoiding the adverse consequences. Arch Surg. 2009; 144(4):371–6.
  15. Williams ES, Rondeau KV, Xiao Q, Francescutti LH. Heavy physician workloads: impact on physician attitudes and outcomes. Health Serv Manage Res. 2007; 20(4):261–9.
  16. Scherr SR, Herbert JD, Forman EM. The role of therapist experiential avoidance in predicting therapist preference for exposure treatment for OCD. Journal of Contextual Behavioral Science. 2015; 4(1):21–9.
  17. Fennell KM, Bamford L, Olver I, Wilson CJ. Good training, systems and funding, not good luck: what hematologists and oncologists believe would make it easier for them to refer their cancer patients to psychosocial care. Transl Behav Med. 2019; 9(1):139–46.
  18. Williams TM, Smith GP. Does training change practice? A survey of clinicians and managers one year after training in trauma-informed care. The Journal of Mental Health Training, Education and Practice. 2017; 12(3):188–98.
  19. Slover JD, Karia RJ, Hauer C, Gelber Z, Band PA, Graham J. Feasibility of integrating standardized patient-reported outcomes in orthopedic care. Am J Manag Care. 2015; 21(8):e494-500.
  20. Maiuro RD, Vitaliano PP, Sugg NK, Thompson DC, Rivara FP, Thompson RS. Development of a health care provider survey for domestic violence: psychometric properties. Am J Prev Med. 2000; 19(4):245–52.
  21. Rehman US, Janssen E, Newhouse S, Heiman J, Holtzworth-Munroe A, Fallis E, et al. Marital satisfaction and communication behaviors during sexual and nonsexual conflict discussions in newlywed couples: a pilot study. J Sex Marital Ther. 2011; 37(2):94–103.
  22. Hwang JY, Plante T, Lackey K. The Development of the Santa Clara Brief Compassion Scale: An Abbreviation of Sprecher and Fehr’s Compassionate Love Scale. Pastoral Psychology. 2008; 56:421–8.
  23. Warttig SL, Forshaw MJ, South J, White AK. New, normative, English-sample data for the Short Form Perceived Stress Scale (PSS-4). J Health Psychol. 2013; 18(12):1617–28.
  24. Gámez W, Chmielewski M, Kotov R, Ruggero C, Suzuki N, Watson D. The brief experiential avoidance questionnaire: development and initial validation. Psychol Assess. 2014; 26(1):35–45.
  25. Levin ME, Krafft J, Pierce B, Potts S. When is experiential avoidance harmful in the moment? Examining global experiential avoidance as a moderator. Journal of Behavior Therapy and Experimental Psychiatry. 2018; 61:158–63.
  26. Dy CJ, Brogan DM, Rolf L, Ray WZ, Wolfe SW, James AS. Variability in surgeon approaches to emotional recovery and expectation setting after adult traumatic brachial plexus injury. Journal of hand surgery global online. 2021; 3(1):30-5.
  27. Cohen J, Cohen P, West SG, Aiken LS. Applied multiple regression/correlation analysis for the behavioral sciences. Routledge; 2013.
  28. Cornell JA, Berger RD. Factors that influence the value of the coefficient of determination in simple linear and nonlinear regression models. Phytopathology. 1987; 77(1):63-70.
  29. Balkin RS, Lenz AS. Contemporary issues in reporting statistical, practical, and clinical significance in counseling research. Journal of Counseling & Development. 2021; 99(2):227-37.
  30. Rubin A, Bellamy J. Practitioner’s guide to using research for evidence-based practice. John Wiley & Sons; 2012.
  31. Neter J, Kutner MH, Nachtsheim CJ, Wasserman W. Applied linear statistical models.
  32. McCaffrey ESN, Chang S, Farrelly G, Rahman A, Cawthorpe D. Mental health literacy in primary care: Canadian Research and Education for the Advancement of Child Health (CanREACH). Evid Based Med. 2017; 22(4):123–31.
  33. Vincent HK, Horodyski M, Vincent KR, Brisbane ST, Sadasivan KK. Psychological distress after orthopedic trauma: prevalence in patients and implications for rehabilitation. PM&R. 2015; 7(9):978-89.
  34. Brown RA, Reed KMP, Bloom EL, Minami H, Strong DR, Lejuez CW, et al. Development and preliminary randomized controlled trial of a distress tolerance treatment for smokers with a history of early lapse. Nicotine Tob Res. 2013; 15(12):2005–15.
  35. Hooper N, Villatte M, Neofotistou E, McHugh L. The effects of mindfulness versus thought suppression on implicit and explicit measures of experiential avoidance. International Journal of Behavioral Consultation and Therapy. 2010; 6(3):233.
  36. Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. The Annals of Family Medicine. 2013; 11(5):412-20.
  37. Ofei-Dodoo S, Cleland-Leighton A, Nilsen K, Cloward JL, Casey E. Impact of a mindfulness-based, workplace group yoga intervention on burnout, self-care, and compassion in health care professionals: a pilot study. Journal of occupational and environmental medicine. 2020; 62(8):581-7.