The authors of this interesting study should be congratulated on a well-designed and executed clinical study that raises questions regarding the assessment of emotional well-being in patients with spinal disorders. This study attempted to determine whether spinal surgeons and other nonoperative spine specialists were able to accurately assess psychological distress in patients with spinal problems. The authors asked 400 new patients who presented with spinal disorders to complete the Distress and Risk Assessment Method (DRAM) psychological distress questionnaire and then determined in a blinded fashion how accurate eight physicians were in assessing the patients' level of distress. In general, the physicians were better able to identify patients who had a relatively normal level of stress, but their ability to identify patients who were classified as having a high level of psychological distress was poor. Spinal surgeons seemingly were worse than the nonoperative physicians in their ability to identify patients in distress. The authors advocate that all spinal surgeons and specialists should utilize the DRAM to better identify patients in psychological distress in order to improve the clinical outcomes of those patients.
On the surface, this study would seem to corroborate the commonly held belief that surgeons in general are not very sensitive in dealing with the emotional and psychological aspects of patient care and are just technicians. Although there may be some basis for this notion, I would like to point out some critical issues with this study by Daubs et al. that may lead to alternative interpretations and conclusions.
Main et al.1 popularized the DRAM questionnaire in 1992 to help clinicians objectively identify patients who were in psychological distress. In his original paper, Main studied patients with chronic low-back pain and purposely excluded all patients who required surgery. The original DRAM questionnaire was therefore designed to study patients who have chronic low-back pain but no surgical indications and to evaluate how other psychological stresses can potentially affect the clinical outcomes in these particular patients. They tried to predict which patients with psychological distress would require multidisciplinary psycho-social treatment in addition to physical-modality treatment. They excluded surgical patients in their final predictability analysis, stating that "surgery appeared to reduce the patient's distress in addition to correcting the physical abnormality." They quoted Waddell et al.2, who also found that changes in distress depended on the success or failure of surgery. The DRAM questionnaire was therefore not designed or validated to predict the outcomes of patients who would need surgical care. If the origin of the patient's "psychological distress" is directly and causally related to pain issues that have a clear structural and anatomical basis for the need for surgery, the DRAM questionnaire would be relatively meaningless for the surgeon since he or she would believe that the distress would be resolved by the surgical correction.
The current study by Daubs et al. did not exclude patients who ultimately required surgery. The authors concluded that surgeons were not very adept in identifying patients who were in "psychological distress." What is not known is how many of the 400 patients who were entered into this study actually had anatomical issues that required surgery and how many were patients who had chronic low-back pain that did not require surgery. It would seem logical that most of the patients who had a true anatomical basis for their pain and required surgery were in appreciable distress. In this subgroup, I would venture to state that a well-trained surgeon would be able to easily identify patients whose distress is secondary to the pathologic condition requiring surgery. On the contrary, if a surgeon happens to evaluate a patient with chronic low-back pain (without a clear anatomical basis for surgery, as in the Main study), their level of training may not allow them to accurately identify patients who have psychological distress secondary to other emotional issues. If the 400 patients were mostly comprised of patients who were not in need of surgery, the data could be skewed, thus making the surgeons appear to be less than optimal in identifying patients in emotional distress. It would have been interesting for the authors to have done a subgroup analysis to look into this issue. I would presumptively state that surgeons are very good in identifying patients who are in "distress" due to anatomical pathology requiring surgery. In addition, there is a tendency for surgeons to be empathetic to these patients and to appropriately label them as "distressed" for appropriate reasons and not label or identify them as being "psychologically distressed." The DRAM questionnaire would have arbitrarily labeled these patients as being psychologically distressed, but the surgeon may have labeled them as being relatively normal psychologically.
In conclusion, the authors have certainly made a thought-provoking addition to the literature. They have brought awareness to the spinal surgeons of the world that psychological distress is an important clinical factor when evaluating and treating patients who have spinal disorders. This study, however, does have some methodological limitations that make the conclusions, in my opinion, less than fully valid. Nevertheless, the authors have attempted to address an important and complex issue, which will be a considerable stimulus for further research.