Surgeons Have an Implicit Preference for Specific Disease Over Nonspecific Illness
Authors: Terzo Madison , Rajagopalan Dayal , Nguoe Marielle , Ring David , Ramtin Sina 
Published: November 2023

Abstract

Background
Many symptoms are not associated with a specific, measurable pathophysiology. Such nonspecific illnesses may carry relative social stigma that biases humans in favor of specific diseases. Such a bias could lead musculoskeletal surgeons to diagnose a specific disease in the absence of a specific, measurable pathology, resulting in potential overdiagnosis and overtreatment.

Questions/purposes
(1) What factors are associated with surgeon implicit preference for specific disease over nonspecific illness? (2) What factors are associated with surgeon explicit preference for specific disease over nonspecific illness? (3) Is there a relationship between surgeon implicit and explicit preferences for specific disease over nonspecific illness?

Methods
One hundred three members of the Science of Variation Group participated in a survey-based experiment that included an Implicit Associations Test (IAT) to assess implicit preferences for specific, measurable musculoskeletal pathophysiology (specific disease) compared with symptoms that are not associated with a specific, measurable pathophysiology (nonspecific illness), and a set of four simple, face valid numerical ratings of explicit preferences. The Science of Variation Group is an international collaborative of mostly United States and European (85% [88 of 103] in this study), mostly academic (83% [85 of 103]), and mostly fracture and upper extremity surgeons (83% [86 of 103]), among whom approximately 200 surgeons complete at least one survey per year. The human themes addressed in this study are likely relatively consistent across these variations. Although concerns have been raised about the validity and utility of the IAT, we believe this was the right tool, given that the timed delays in association that form the basis of the measurement likely represent bias and social stigma regarding nonspecific illness. Both measures were scaled from -150, which represents a preference for nonspecific illness, to 150, which represents a preference for specific disease. The magnitude of associations can be assessed relative to the standard deviation or interquartile range. We used multivariable linear regression to identify surgeon factors associated with surgeon implicit and explicit preference for specific disease or nonspecific illness. We measured the relationship between surgeon implicit and explicit preferences for specific disease or nonspecific illness using Spearman correlation.

Results
Overall, there was a notable implicit bias in favor of specific diseases over nonspecific illness (median [IQR] 70 [54 to 88]; considered notable because the mean value is above zero [neutral] by more than twice the magnitude of the IQR), with a modestly greater association in the hand and wrist subspecialty. We found no clinically important explicit preference between specific disease and nonspecific illness (median 8 [-15 to 37]; p = 0.02). There was no correlation between explicit preference and implicit bias regarding specific disease and nonspecific illness (Spearman correlation coefficient -0.13; p = 0.20).

Conclusion
Given that our study found an implicit bias among musculoskeletal specialists toward specific diseases over nonspecific illness, future research might address the degree to which this bias may account, in part, for patterns of use of low-yield diagnostic testing and the use of diagnostic labels that imply specific pathophysiology when none is detectable.

Clinical Relevance
Patients and clinicians might limit overtesting, overdiagnosis, and overtreatment by anticipating an implicit preference for a specific disease and intentionally anchoring on nonspecific illness until a specific pathophysiology accounting for symptoms is identified, and also by using nonspecific illness descriptions until objective, verifiable pathophysiology is identified.