title: When patients and surgeons disagree about surgical outcome: investigating patient factors and chart note communication.
abstract: OBJECTIVE
  Effective physician-patient communication is a critical component of a clinical practice and in order to achieve optimal patient outcomes. We aimed to investigate indirect effects of physician-patient communication by examining the relationship between a physician-patient mismatch in perceived outcomes and content in the medical record's clinical note. We compared patient records whose perceived subjective assessment of surgery outcomes agreed or disagreed with the surgeon's perception of that outcome (Subjective Disagreement).
  
  
  METHODS
  This study included 172 spine surgery patients at a teaching hospital. Patient-reported outcomes included the Oswestry Disability Index; the Short-Form 36; and a Visual Analogue Scale items for leg and back pain. We content-analyzed the clinical note in the medical record, and used logistic regression to evaluate predictors of Subjective Disagreement (n = 41 disagreed vs. 131 agreed).
  
  
  RESULTS
  Patient and surgeon agreed in 76% of cases and disagreed in 24% of cases. Patients who assessed their outcome worse than their surgeons tended to be less educated and involved in litigation. They also tended to report worsened mental health and leg pain. Content analysis revealed group differences in surgeon communication patterns in the chart notes related to how symptom change was emphasized, how follow-up was described, and a specific word reference. Specifically, disagreement was predicted by using "much" to emphasize the findings and noting long-term prognosis. Agreement was predicted by use of positive emphasis terms, having an "as-needed" follow-up plan, and using "happy" in the chart note.
  
  
  CONCLUSIONS
  The nature of measuring outcomes of surgery is based on patient perception. In surgeon-patient perspective mismatches, patient factors may serve as barriers to improvement. Worsened change on patient-reported mental health may be an independent factor which colors the patient's general perceptions. This aspect of treatment may be missed by the spine surgeon. Chart note communication styles reflect the subjective disagreement. Investigating and/ or treating mental health deterioration may be valuable in resolving this mismatch and for overall outcome.
authors.affiliation: DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA. carolyn.schwartz@deltaquest.org.|Departments of Medicine and Orthopaedic Surgery, Tufts University Medical School, Boston, MA, USA. carolyn.schwartz@deltaquest.org.
authors.forename: Carolyn E
authors.initials: CE
authors.lastname: Schwartz
authors.affiliation: DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA.
authors.forename: Armon
authors.initials: A
authors.lastname: Ayandeh
authors.affiliation: Division of Orthopaedics, Sunnybrook Health Sciences Center and the University of Toronto, 2075 Bayview Avenue, Room MG361, Toronto, ON, Canada.
authors.forename: Joel A
authors.initials: JA
authors.lastname: Finkelstein
mesh_terms: D000328:Adult; D004185:Disability Evaluation; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects* / Q000523:psychology; D017063:Outcome Assessment, Health Care; D010147:Pain Measurement / Q000706:statistics & numerical data; D063868:Patient Outcome Assessment; D017060:Patient Satisfaction; D010817:Physician-Patient Relations; D011183:Postoperative Complications / Q000209:etiology / Q000523:psychology*; D011184:Postoperative Period; D013122:Spinal Diseases / Q000601:surgery*