Do Surgeons Experience Moral Dissonance When There Is Misalignment Between Evidence and Action? A Survey and Scenario-based Study
Authors: Okelana Bandele , Razi Amin , Ring David , Ramtin Sina ,   and the Science of Variation Group
Published: August 2024

Background
Moral dissonance is the psychological discomfort associated with a mismatch between our moral values and potentially immoral actions. For instance, to limit moral dissonance, surgeons must develop a rationale that the potential for benefit from performing surgery is meaningfully greater than the inherent harm of surgery. Moral dissonance can also occur when a patient or one’s surgeon peers encourage surgery for a given problem, even when the evidence suggests limited or no benefit over other options. Clinicians may not realize the degree to which moral dissonance can be a source of diminished joy in practice. Uncovering potential sources of moral dissonance can help inform efforts to help clinicians enjoy their work.

Questions/purposes
In a scenario-based experiment performed in an online survey format, we exposed musculoskeletal specialists to various types of patient and practice stressors to measure their association with moral dissonance and asked: (1) What factors are associated with the level of pressure surgeons feel to act contrary to the best evidence? (2) What factors are associated with the likelihood of offering surgery?

Methods
We performed a scenario-based experiment by inviting members of the Science of Variation Group (SOVG; an international collaborative of musculoskeletal surgeons that studies variation in care) to complete an online survey with randomized elements. The use of experimental techniques such as randomization to measure factors associated with specific ratings makes participation rate less important than diversity of opinion within the sample. A total of 114 SOVG musculoskeletal surgeons participated, which represents the typical number of participants from a total of about 200 who tend to participate in at least one experiment per year. Among the 114 participants, 94% (107) were men, 49% (56) practiced in the United States, and 82% (94) supervised trainees. Participants viewed 12 scenarios of upper extremity fractures for which surgery is optional (discretionary) based on consensus and current best evidence. In addition to a representative age, the scenario included randomized patient and practice factors that we posit could be sources of moral distress based on author consensus. Patient factors included potential sources of pressure (such as “The patient is convinced they want a specific treatment and will go to a different surgeon if they don’t get it”) or experiences of collaboration (such as “The patient is collaborative and involved in decisions”). Practice factors included circumstances of financial or reputational pressure (such as “The practice is putting pressure on you to generate more revenue”) and factors of limited pressure (such as “Your income is not tied to revenue”). For each scenario, the participant was asked to rate both of the following statements on a scale from 0 to 100 anchored with “I don’t feel it at all” at 0, “I feel it moderately” at 50, and “I feel it strongly” at 100: (1) pressure to act contrary to best evidence and (2) likelihood of offering surgery. Additional explanatory variables included surgeon factors: gender, years in practice, region, subspecialty, supervision of trainees, and practice setting (academic/nonacademic). We sought factors associated with pressure to act contrary to evidence and likelihood of offering surgery, accounting for potential confounding variables in multilevel mixed-effects linear regression models.

Results
Accounting for potential confounding variables, greater pressure to act contrary to best evidence was moderately associated with greater patient despair (regression coefficient [RC] 6 [95% confidence interval 2 to 9]; p = 0.001) and stronger patient preference (RC 4 [95% CI 0 to 8]; p = 0.03). Lower pressure to act contrary to evidence was moderately associated with surgeon income independent of revenue (RC -6 [95% CI -9 to -4]; p < 0.001) and no financial benefit to operative treatment (RC -6 [95% CI -8 to -3]; p < 0.001). Marketing concerns were the only factor associated with greater likelihood of offering surgery (RC 6 [95% CI 0 to 11]; p = 0.04).

Conclusion
In this scenario-based survey experiment, patient distress and strong preferences and surgeon financial incentives were associated with greater surgeon feelings of moral dissonance when considering discretionary fracture surgery.

Clinical Relevance
To support enjoyment of the practice of musculoskeletal surgery, we recommend that surgeons, surgery practices, and surgery professional associations be intentional in both anticipating and developing strategies to ameliorate potential sources of moral dissonance in daily practice.