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Clinical Impression Versus Standardized Questionnaire: The Spinal Surgeon's Ability to Assess Psychological Distress
Michael D. Daubs, MD1; Alpesh A. Patel, MD1; Stuart E. Willick, MD1; Richard W. Kendall, DO1; Pamela Hansen, MD1; David J. Petron, MD1; Darrel S. Brodke, MD1
1 Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108. E-mail address for M.D. Daubs: Michael.daubs@hsc.utah.edu
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

A commentary by James D. Kang, MD, is available at www.jbjs.org/commentary and is linked to the online version of this article.
Investigation performed at the Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Dec 15;92(18):2878-2883. doi: 10.2106/JBJS.I.01036
A commentary by James D. Kang, MD, is available here
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Psychological distress can affect spine surgery outcomes. A majority of spinal surgeons do not use standardized questionnaires to assess for psychological distress and instead rely on their clinical impressions. The ability of spinal surgeons to properly assess patients with psychological distress has not been adequately evaluated. Our hypothesis was that the clinical impressions of spinal surgeons were not as accurate as a standardized questionnaire in assessing for psychological distress.


A prospective study was performed with eight physicians, four spinal surgeons and four nonoperative spine specialists, who evaluated 400 patients. All patients completed the Distress and Risk Assessment Method (DRAM) questionnaire for the evaluation of psychological distress. The eight physician subjects, blinded to the results of this questionnaire, performed their routine clinical evaluation and categorized the patients’ psychological distress level. The results of the Distress and Risk Assessment Method questionnaire and the surgeons’ assessments were compared.


In the study population of 400 patients, 64% (254 of 400) were found to have some level of psychological distress. Twenty-two percent (eighty-seven of 400) of the patients were found to have high levels of distress. Overall, the physicians’ rate of sensitivity when assessing patients with high levels of distress was 28.7% (95% confidence interval: 19.5%, 39.4%) with a positive predictive value of 47.2% (95% confidence interval: 33.3%, 61.4%). Nonoperative spine specialists had a significantly higher sensitivity rate when assessing highly distressed patients (41.7% [95% confidence interval: 25.5%, 59.2%]) than surgeons (19.6% [95% confidence interval: 9.8%, 33.1%]) (p = 0.03). The sensitivity rates between experienced (greater than ten years in practice) (14.7% [95% confidence interval: 5.0%, 31.1%]) and less experienced (less than two years in practice) (29.4% [95% confidence interval: 10.3%, 56.0%]) spinal surgeons was not significant (p = 0.27).


A large percentage of patients (64%) presenting for spine evaluation have some level of psychological distress. When compared with a standardized questionnaire designed to screen for psychological distress, spinal surgeons had low sensitivity rates to detect this distress. The routine use of a standardized questionnaire to screen for psychological distress should be considered.

Level of Evidence: 

Diagnostic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Walter J. Finnegan, MD, JD
    Posted on February 11, 2011
    Psychometrics Versus Clinical Spinal Evaluation
    Orthopaedic Surgeon, Meade Orthopedics at Coordinated Health, Allentown, Pennsylvania

    To the Editor:

    As per the recent article by Daubs et al. entitled, "Clinical Impression Versus Standardized Questionnaire: The Spinal Surgeon's Ability to Assess Psychological Distress" (2010;92:2878-83), the authors are to be commended for their fine work and for highlighting the potentially-critical issue of psychological evaluation in the performance of a patient workup for spine surgery.

    Although I am only 66 years young, please permit me the luxury of serving as a quasi-historian for our journal's spine-oriented readers, especially the newer-minted models with a decade or two of clinical experience. I have seen the pendulum swing to and fro over my career, commencing with the enthusiastic response to chymopapain injections after a presentation by Dr. Lyman Smith in Atlantic City 40 years ago.

    Within the next half-decade, I was privileged to both see and hear many great spinal surgeons, especially through the grace of my mentor (Richard Rothman) and membership in the International Society for the Study of the Lumbar Spine. Dr. Alf Nachemsen frequently reminded us that almost any procedure, including placebo interventions, had a roughly 70% success rate, at least in the first year-- perhaps for psychological reasons!?

    While doctors such as Fielding and Farfan – two giants from NYC and Montréal respectively – focused more heavily on technique and conventional pathophysiology, two colleagues from Southern California (Dr. Homer Pheasant and Dr. Leon Wiltse) trained our sights on the growing awareness of linkage between psychological involvement and surgical outcomes. Both of these spine surgeons emphasized the value of psychological testing, especially items such as the MMPI, along with actual clinical psychiatric evaluations--pre-operatively!!

    So beware the return of the frumious bandersnatch, to paraphrase Lewis Carroll: check your patient's motives!

    This is not new; psychometrics has been emphasized before, and the patient's incentive for pursuing our surgical intervention may well be the most critical factor affecting the outcome.

    In my personal experience of more than three decades in spinal surgery (I am aware that personal experience only rates a level "X" on an evidence-based scale), the key determinant on "clinical" evaluation and therefore the most important pre-operative query relates to asking the patient directly: "What is the source of your pain?"

    The patient's perceived source of pain may well be the best barometer for prognosis; if the patient blames his or her continuing distress on the tortious act of another, then one can predictably expect a poor outcome--because any technical intervention (even assuming it is done soundly) is doomed to fail in the face of excessive internalized resentments harbored by the patient. It is simply human nature! Letting go of painful associations,specifically resentments about causation, is more challenging than healing the body.

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