The presence of person-centered language in orthopedic-related amputation research: a cross-sectional analysis

Methods

Journal selection and article inclusion

Our study is a cross-sectional analysis design that we conducted utilizing a systematic search on PubMed on February 14, 2022. Our study did not require IRB approval due to the secondary nature of the research. We utilized a similar search string to Headley et al. [26] to isolate amputation studies. To focus on orthopedic-related amputation papers, we localized our search to the top 20 orthopedic journals on the Google h5-index [29]. Our search string also included the top two indexed foot and ankle/hand orthopedic journals. The search string is found in Figure 1 and includes studies published over the past 10 years. After searching for the items, we randomized our sample utilizing the “RAND” function on Google Sheets and included the first 300 articles that fit our inclusion criteria. We chose 300 articles to provide adequate power to our study; this was decided based on previously published literature looking at PCL [22, 30]. The article must be (1) about or related to amputation procedures, associated complications, or individuals with amputations; (2) published between 2012 and February 2022; and (3) written in English. The study types must also be primary or secondary in nature; commentaries and editorials were excluded from our sample. Our date range was decided based on having a sample that contained an even 10 years of data.

Figure 1:

Search string.

Results

Our search yielded 687 returns. After randomization of the sample, we coded the first 300 studies that fit our inclusion criteria. There were 61 studies that were excluded due to being nonorthopedic-related or commentary articles. A flowchart can be seen in Figure 2 showing the route to obtaining our included studies. Among the studies in our sample, observational studies were the most included (61%; 183/300). Other study types included case series/case reports (12.7%; 38/300), clinical trials (4.7%; 14/300), literature reviews (6.7%; 20/300), basic science (0.7%; 2/300), systematic reviews (6.0%; 18/300), and surgical techniques (8.3%; 25/300). The rest of the characteristics extracted can be found in Table 1.

Figure 2:

Flow diagram of study selection.

Our final results show that 157 (52.2%) studies adhered to PCL according to the AMAMS. Of the 143 (47.7%) studies that were not adherent to PCL, 51 studies (35.7%) had more than one type of non-PCL language. The term “amputee,” which is being labeled as identity-first language (IFL), was found in 101 articles (33.7%). Further investigation found that 73.3% (74/101) of the studies that contained IFL were found to have other non-PCL terms. Among the other studies in the sample that did not contain IFL, non-PCL was found 34.7% (69/199) of the time. This analysis was conducted due to the discrepancies in the stigmatization of the term “amputee.”

Among the statistical analyses conducted, we found no significant associations between the use of PCL and the type of study conducted, the continent of origin, journal fidelity to AMA/ICMJE guidelines, study funding, fidelity to methodological guidelines (Table 1), or year of publication (Figure 3). We did find statistical significance between non-PCL use and upper extremity amputation studies compared to lower extremity studies and multi-limb studies (p=0.007) (Table 1). This finding states that upper extremity amputation studies were more prone to utilizing non-PCL terminology compared to lower extremity and multi-limb amputation studies. The most common non-PCL terminology utilized was “(condition) person/patient.”

Figure 3:

Regression of the percent of articles adherent of person-centered language (PCL) by year. Regression analysis for the percent of articles adherent to PCL guidelines from 2012 to 2020 was nonsignificant (coefficient: 0.72, standard error [SE]=1.06; T=0.67, p=0.517).

Discussion

Our study found that nearly 48% of the studies in our sample did not adhere to PCL guidelines. We also found that “amputee” was utilized in more than one-third of the studies within our sample. A large majority (73.3%) contained stigmatizing terminology toward patients with amputations. In comparison, 44% of the studies that did not utilize the term “amputee” had non-PCL present in the manuscript. The most common non-PCL term identified in our sample is “stump,” which was generally utilized to refer to the amputated extremity. The second most common instance of non-PCL was describing a person by the condition that they have ((condition) “patient”). Examples of this were “amputation patient” and “diabetic patient.”

Although there has been a study looking at PCL within the amputation literature [26], to our knowledge, there have been no studies looking at PCL within the orthopedic literature. Editorials have been written about the use of stigmatizing language within orthopedics, but our study is the first primary study to identify it within research. This is essential because we understand that stigmatizing language can negatively affect various populations. An example is when patients experiencing alcohol use disorder are referred to as “addicts.” The term “addicts” has been shown to be associated with reduced patient compliance, lower patient care due to clinician bias, and lower health outcomes [32], [33], [34], [35], [36]. As a result, researchers must be careful with their word selection to minimize the level of stigmatization and social bias within their manuscripts. For example, one of the non-PCL terms we looked at was “stump.” The term “stump” is appropriate to utilize when describing a medical procedure, such as when describing “suturing of the stump” at the end of the surgery, or “fitting a prosthesis for the stump.” However, when the term “stump” is associated with a person who has had an amputation, the term becomes a euphemistic descriptor (non-PCL). Therefore, we agree with studies such as Headley et al. [26] that recommend the use of the term “residual limb” instead of “stump.” By following this, orthopedic and osteopathic physicians are adhering to steps that minimize psychosocial stressors on patients that have to undergo amputations.

One study we want to highlight within our sample was the American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary for Limb Salvage or Early Amputation published by Potter and Bosse [37]. The clinical practice guidelines (CPGs) for orthopedics is published by the American Academy of Orthopaedic Surgeons (AAOS). Our study found that the summary for the CPG contained non-PCL terminology such as “burden,” and IFL terminology not recognized by amputation organizations such as “HELET patients” (high-energy lower extremity trauma). The use of the term “burden” is problematic due to the negative connotation that it brings and an implication of helplessness [38]. Stigmatization has been shown to have psychological and health implications [8, 39], [40], [41]. In addition, Potter and Bosse [37] show that patients that experienced HELET require screening for psychosocial risk factors, suggesting susceptibility to psychologic distress. Due to CPGs guiding orthopedic clinical decision-making, stigmatizing language should be especially avoided within these manuscripts to prevent the introduction of social bias to patient care [32, 42]. Therefore, we ask that future CPG authors avoid the use of stigmatizing language within the guidelines and summaries.

The terminology surrounding amputations is complicated. Terminology such as “amputee” has been shown to be accepted by the community, as shown by organizational names such as the Amputee Coalition [43]. Therefore, we do not want to infringe on the rights of an individual to identify themselves. However, it should be noted that our data found that the use of the term “amputee” had a higher rate of non-PCL terms being incorporated into a manuscript compared to when it was not utilized. This shows that authors were more prone to utilizing stigmatizing language when utilizing the term “amputee.” These results could be due to authors not having a clear understanding of the appropriate language for individuals experiencing amputations; therefore, it would be beneficial for authors to learn about stigmatizing language through courses. In addition, stigmatizing language can be avoided by journals implementing direct policies through their author guidelines, requiring the use of PCL. Finally, reviewers can help with removing stigmatizing language from literature by identifying its use during the review process.

Osteopathic medicine was built with an emphasis on patient-centered care. With this emphasis, it is essential for osteopathic physicians to follow PCL. The Institute of Medicine and the APA led a movement to shy away from labeling people based on their condition, and they have an emphasis on care toward a patient’s needs and preferences [17, 44]. This movement was conducted as a means of rejecting the stigma present in the scientific community when referring to patients with various disorders [22], [23], [24], [25], [26, 30, 45]. This rejection of patient stigma is a push to highlight the patient as an individual rather than a disorder and is in line with the philosophy of osteopathic medicine. Rogers et al. [21] promote that patients deserve individualized attention that is highlighted by a quality relationship with their physician. Also, it is highlighted that an “osteopathic physician is the advocate for the patient” [21]. By following PCL, physicians promote the individuality of the patient by highlighting that they are not a disorder. In addition, by removing the stigma of non-PCL verbiage, osteopathic physicians are given the opportunity to advance the advocacy of the patient.

Although we conducted our study with methodological rigor, there are a few limitations we have identified to our research. First, our study includes the potential for subjective analysis of non-PCL terminology. We attempted to reduce this effect by utilizing predefined terminology and search criteria. Secondly, due to our cross-sectional study design, results should not be generalized beyond the scope of our study. Due to our initial study identifying PCL within orthopedic literature, more research is warranted to determine the extent of stigmatizing language usage within orthopedic research. Also, although we have a sample with substantial power of 300 articles, we did not search all 687 articles. In addition, there is the possibility of bias with our search terms in identifying amputation literature by adding our non-PCL terminology; however, that was done as a means of extracting all literature published within the 22 journals of our sample set related to amputations.

For future directions, we would like to see research looking at other forms of non-PCL language within the orthopedic literature. Examples can be related to diabetes-related literature utilizing “diabetic patients” rather than “patients with diabetes.” Also, we ask for literature summarizing other common non-PCL terminology that can be identified within orthopedics. Finally, we ask that journals identify and highlight non-PCL terminology during the review process to prevent utilizing it in final manuscripts.

Conclusions

Our findings show that amputation literature within the top orthopedic journals has limited following of PCL. In addition, we found that the use of the term “amputee,” which is widely accepted by the amputation community, resulted in a greater rate of non-PCL terminology within orthopedic amputation literature. Words should be utilized with proper attention and care within the medical literature to eliminate the incorporation of structural stigma within orthopedic research and care. Efforts should be implemented within orthopedics to avoid the use of stigmatizing language, regarding individuals who underwent amputations, in order to minimize psychosocial stressors such as the loss of self-esteem and feelings of isolation.