Background: People that have more intense symptoms and greater incapability might have less rapport with the clinicians that care for them.Objective: This study tested the hypothesis that perceived clinician empathy is related to pain intensity and magnitude of incapability among people seeing a musculoskeletal specialist.Patient Involvement: After a consult with a musculoskeletal specialist, 211 adult patients completed a survey recording demographics, and measures of pain intensity, incapability, and perceived clinician empathy.Results: Higher perceived empathy was associated with being in a committed relationship and, to a modest degree (r =-0.16) lower pain intensity in bivariate and multivariable analyses.Discussion: People experiencing greater pain may be slightly less likely to perceive the clinician as empathetic.Practical value: Study of the relationship between the patient's experience of care and patient and clinician personal factors can inform efforts to improve patient experience. Advances may depend on experience measures with more normal distributions and less ceiling effect.

The chemical analysis and antibacterial activity of three types of propolis collected three different races of Apis mellifera bee in the same apiary were investigated. Propolis samples were investigated by GC/MS, 48 compounds were identified 32 being new for propolis. The compounds identified indicated that the main plant sources of propolis were Populus alba, Populus tremuloides and Salix alba. The antimicrobial activity against Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa and Candida albicans was evaluated. Ethanolic extracts of propolis samples showed high antibacterial activity against Gram-positive cocci (Staphylococcus aureus), but had a weak activity against Gram-negative bacteria (Escherichia coli and Pseudomonas aeruginosa) and yeast (Candida albicans). Propolis sample collected by Apis mellifera caucasica showed a higher antibacterial activity than collected by Apis mellifera anatolica and Apis mellifera carnica.

This study assessed the association of anger, anxiety, and depression, and cognitive bias with pain and activity tolerance among patients with a musculoskeletal illness or injury expected to last more than a month. 102 Patients completed emotional thermometers to quantify symptoms of anger, anxiety, depression; the abbreviated Pain Catastrophizing Scale; a pain intensity scale; Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computer Adaptive Test; the Spielberger State-Trait Anxiety Inventory and demographic questionnaires. Controlling for potential confounding in multivariable analysis we found greater activity intolerance was associated with retired work-status and greater depressive symptoms, but not with greater symptoms of anger. In addition, greater pain intensity was associated with greater symptoms of depression and greater catastrophic thinking, but not with greater symptoms of anger. Anger emotions do not contribute to symptom intensity and activity intolerance in musculoskeletal illness. Attention can be directed at addressing psychological distress and cognitive bias.

Introduction and importance:Gastrointestinal tract perforations as a result of foreign body ingestion are rare. Most ingested foreign bodies pass the intestines without complications. However, in 1 % of cases intestinal perforation occurs. We present the case of a 56-year old patient with an extensive surgical medical history who presented at the emergency department with progressive abdominal pain two weeks after accidental SARS-CoV-2 swab ingestion. Case presentation:On presentation patient was tachycardic and had generalized abdominal tenderness. A CT scan showed free intraperitoneal air and fatty infiltration of the ileocecal anastomosis (after an ileocoecal resection at the age of 46) continuing to the distal sigmoid. Emergency exploratory laparotomy revealed a covid swab in the abdominal cavity with an indurated area of the sigmoid without perforation. Post-operative care was uneventful, and patient was dismissed after four days. Clinical discussion:Due to his medical history and the fact he was advised to regularly self-test for COVID, he routinely performed an oropharyngeal swab. Unfortunately, this resulted in swallowing the swab. A perforation tends to happen in regions of acute angulation, such as an anastomosis. Although the CT scan suggested the perforation was at the ileocecal anastomosis, no perforation was found during surgery, while the swab was found loose in the peritoneal cavity. Conclusion:Initial treatment should focus on endoscopic removal. In the case of gasto-intestinal perforation, surgery becomes the treatment of choice. A foreign body can migrate to peritoneal cavity without peritonitis or visible perforation perioperative.

BACKGROUND:Greater symptoms of depression are associated with greater symptom intensity during recovery from musculoskeletal injury. It is not clear that more severe trauma is associated with greater symptoms of depression as one might expect. The goal of this study was to systematically review the existing evidence regarding the association of Injury Severity Score (ISS) with symptoms of depression during recovery from musculoskeletal injury. METHODS:Two independent reviewers used PubMed and Embase to identify studies that measured both ISS and symptoms of depression. Among the 17 studies satisfying inclusion criteria, 5 studies assessed the correlation of symptoms of depression and ISS on their continuum; 3 studies compared the mean of symptoms of depression for people above and below a specific ISS level; five compared mean ISS above and below a threshold level of symptoms of depression; and four compared dichotomized ISS and dichotomized depression. Four of the 17 evaluated factors associated with symptoms of depression in multivariable analysis. RESULTS:In bivariate analysis, 12 of 17 studies (71%) found no association between ISS level and symptoms of depression. Three studies found a bivariate association that did not persist in multivariable analysis. Two studies reported slight associations in bivariate analysis, but did not perform multivariable analysis. CONCLUSIONS:The knowledge that symptoms of depression are common during recovery, in combination with the finding of this review that they have little or no relationship with injury severity, directs clinicians to anticipate and address mental health during recovery from physical trauma of any severity.

Background: There is some evidence that previsit strategies can make in-person visits more productive and efficient. We compared between people who received a phone call before a musculoskeletal specialty visit and people who did not with respect to several factors: (1) decision conflict (difficulty deciding between two or more options), (2) perceived clinician empathy after an in-person visit, and (3) arrival for the scheduled in-person appointment. We also recorded the specialist's opinion that the phone call alone could adequately replace an in-person visit while maintaining quality, safety, and effectiveness. Materials and Methods: In this prospective randomized-controlled trial, 122 patients were enrolled and randomized to receive a previsit phone call by an orthopedic surgeon before a scheduled visit or not. After the in-person visit, patients completed a (1) demographic questionnaire including age, gender, race/ethnicity, marital status, level of education, work status, and comorbidities; (2) Decision Conflict Scale; and (3) Jefferson Scale of Patient Perceptions of Physician Empathy. Results: No significant difference was found between the two groups in decision conflict, perceived empathy, or not attending the scheduled visit. Of the 55 successful phone calls, the surgeon felt that 50 (91%) had the potential to safely and effectively replace an in-person visit. Conclusion: Although a previsit phone call did not reduce decision conflict or improve the patient experience as measured after one visit, there may be merit in studying an increased number of touch points, particularly with some subsets of illness featuring substantial stress or misconceptions. The identified potential for the application and transfer of specialty expertise through telephone alone also merits additional study.

Abstract Background Mental health has a notable and perhaps underappreciated relationship with symptom intensity related to musculoskeletal pathophysiology. Tools for increasing awareness of mental health opportunities may help musculoskeletal specialists identify and address psychological distress and unhealthy misconceptions with greater confidence. One such type of technology—software that identifies emotions by analyzing facial expressions—could be developed as a clinician-awareness tool. A first step in this endeavor is to conduct a pilot study to assess the ability to measure patient mental health through specialist facial expressions. Questions/purposes (1) Does quantification of clinician emotion using facial recognition software correlate with patient psychological distress and unhealthy misconceptions? (2) Is there a correlation between clinician facial expressions of emotions and a validated measure of the quality of the patient-clinician relationship? Methods In a cross-sectional pilot study, between April 2019 and July 2019, we made video recordings of the clinician’s face during 34 initial musculoskeletal specialist outpatient evaluations. There were 16 men and 18 women, all fluent and literate in English, with a mean age of 43 ± 15 years. Enrollment was performed according to available personnel, equipment, and room availability. We did not track declines, but there were only a few. Video recordings were analyzed using facial-emotional recognition software, measuring the proportion of time spent by clinicians expressing measured emotions during a consultation. After the visit, patients completed a demographic questionnaire and measures of health anxiety (the Short Health Anxiety Inventory), fear of painful movement (the Tampa Scale for Kinesiophobia), catastrophic or worst-case thinking about pain (the Pain Catastrophizing Scale), symptoms of depression (the Patient Health Questionnaire), and the patient’s perception of the quality of their relationship with the clinician (Patient-Doctor Relationship Questionnaire). Results Clinician facial expressions consistent with happiness were associated with less patient health anxiety (r = -0.59; p < 0.001) and less catastrophic thinking (r = -0.37; p = 0.03). Lower levels of clinician expressions consistent with sadness were associated with less health anxiety (r = 0.36; p = 0.04), fewer symptoms of generalized anxiety (r = 0.36; p = 0.03), and less catastrophic thinking (r = 0.33; p = 0.05). Less time expressing anger was associated with greater health anxiety (r = -0.37; p = 0.03), greater symptoms of anxiety (r = -0.46; p < 0.01), more catastrophic thinking (r = -0.38; p = 0.03), and greater symptoms of depression (r = -0.42; p = 0.01). More time expressing surprise was associated with less health anxiety (r = -0.44; p < 0.01) and symptoms of depression (r = -0.52; p < 0.01). More time expressing fear was associated with less kinesiophobia (r = -0.35; p = 0.04). More time expressing disgust was associated with less catastrophic thinking (r = -0.37; p = 0.03) and less health anxiety (GAD-2; r = -0.42; p = 0.02) and symptoms of depression (r = -0.44; p < 0.01). There was no association between a clinicians’ facial expression of emotions and patient experience with patient-clinician interactions. Conclusion The ability to measure a patient’s mindset on the clinician’s face confirms that clinicians are registering the psychological aspects of illness, whether they are consciously aware of them or not. Future research involving larger cohorts of patients, mapping clinician-patient interactions during consultation, and more sophisticated capture of nonverbal and verbal cues, including a broader range of emotional expressions, may help translate this innovation from the research setting to clinical practice. Clinical Relevance Tools for measuring emotion through facial recognition could be used to train clinicians to become aware of the psychological aspects of health and to coach clinicians on effective communication strategies both for gentle reorientation of common misconceptions as well as for appropriate and timely diagnosis and treatment of psychological distress.

This study assessed the correlation of 9 questions addressing communication effectiveness (the Communication Effectiveness Questionnaire [CEQ]) with other patient-reported experience measures (PREMs; satisfaction, perceived empathy) as well as patient-reported outcome measures (PROMs; pain intensity, activity tolerance) in patients with musculoskeletal illness or injury. In a cross-sectional study, 210 patients visiting an orthopedic surgeon completed the CEQ and measures of satisfaction with the visit, perceived empathy, pain intensity, and activity tolerance. We evaluated correlations between CEQ and other PREMs and CEQ and PROMs. We measured ceiling effects of the PREMs. Communication effectiveness correlated moderately with other PREMs such as satisfaction (ρ = 0.54; P < .001) and perceived empathy (ρ = 0.54; P < .001). Communication effectiveness did not correlate with PROMs: pain intensity (ρ = −0.01; P = .93) and activity tolerance (ρ = −0.05; P = .44). All of the experience measures have high ceiling effects: perceived empathy 37%, satisfaction 80%, and CEQ 46%. The observation of notable correlations of various PREMs, combined with their high ceiling effects, direct us to identify a likely common statistical construct (which we hypothesize as “relationship”) accounting for variation in PREMs, and then develop a PREM which measures that construct in a manner that results in a Gaussian distribution of scores. At least within the limitations of current experience measures, there seems to be no association between illness (PROMs) and experience (PREMs).

Patient-reported outcomes (PROs) are integral to determining the success of foregut surgical interventions and psychoemotional factors have been hypothesized to impact the quality of life of patients. This study evaluates the correlation between PROs-specifically the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) and the Laryngopharangeal Reflux Symptom Index (LPR-RSI)-and the recently validated Esophageal Hypervigilance Anxiety Scale (EHAS). We hypothesize that patients with higher EHAS scores have significantly elevated GERD-HRQL LPR-RSI compared to those with normal scores. EHAS has been developed and validated in chronic esophageal disorders, but clinical impact is unknown. In this retrospective study, 197 patients (38% men, average age 56 ± 16) completed the following surveys:(1) EHAS, (2) GERD-HRQL, and (3) LPR-RSI. All patients referred for surgical evaluation of GERD completed the surveys as part of their pre-operative workup and post-operative follow-up In bivariate analysis, EHAS correlated with both GERD-HRQL (r 0.53, P = <0.001) and LPR-RSI (r 0.36, P = 0.009). Accounting for potential confounding with sex and age in multivariable linear regression models, a higher GERD-HRQL score (β 0.38; 95% CI 0.29 to 0.48; P = <0.001; Semipartial R2 0.20) and a higher LPR-RSI score (β 0.21; 95% CI 0.13 to 0.29; P = <0.001; Semipartial R2 0.08) were independently associated with higher EHAS. The observed relationship between mental health and GERD symptom intensity is consistent with the biopsychosocial paradigm of illness. Future studies focused on post-surgical outcomes following the incorporation of EHAS into perioperative care is needed to evaluate its effectiveness as a clinical decision support tool in ARS.

Following landmark trials, carotid endarterectomy (CEA) has proven to be beneficial in neurologically symptomatic patients with a carotid artery diameter reduction of ≥50% on digital subtraction angiography, excluding near occlusions.1Naylor A.R. Ricco J.B. de Borst G.J. Debus S. de Haro J. Halliday A. et al.Editor's choice – management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European society for vascular surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 3-81Abstract Full Text Full Text PDF PubMed Scopus (431) Google Scholar The standard quantification method to assess the degree of carotid artery stenosis is to determine the diameter reduction. Currently, the diameter reduction method has been applied to computed tomography angiography (CTA) and magnetic resonance angiography images. However, this method might not be optimal for assessment of stenosis with irregular plaques as the area of the residual lumen is often asymmetric.2Samarzija K. Milosevic P. Jurjevic Z. Erdeljac E. Grading of carotid artery stenosis with computed tomography angiography: whether to use the narrowest diameter or the cross-sectional area.Insights Imaging. 2018; 9: 527-534Crossref PubMed Scopus (8) Google Scholar Alternatively, measurement of the cross sectional area on CTA takes the asymmetric shapes of a stenosis into account, as confirmed by studies that suggest that measurement of cross sectional area reduction might provide a more accurate estimate of the degree of stenosis, especially for irregular plaques.2Samarzija K. Milosevic P. Jurjevic Z. Erdeljac E. Grading of carotid artery stenosis with computed tomography angiography: whether to use the narrowest diameter or the cross-sectional area.Insights Imaging. 2018; 9: 527-534Crossref PubMed Scopus (8) Google Scholar, 3Ota H. Takase K. Rikimaru H. Tsuboi M. Yamada T. Sato A. et al.Quantitative vascular measurements in arterial occlusive disease.Radiographics. 2005; 25: 1141-1158Crossref PubMed Scopus (87) Google Scholar, 4Zhang Z. Berg M. Ikonen A. Könönen M. Kälviäinen R. Manninen H. et al.Carotid stenosis degree in CT angiography: assessment based on luminal area versus luminal diameter measurements.Eur Radiol. 2005; 15: 2359-2365Crossref PubMed Scopus (39) Google Scholar In a completely concentric stenosis, the reduction in lumen diameter can be directly translated to the reduction in cross sectional area (50% diameter reduction correlates with 75% area reduction).3Ota H. Takase K. Rikimaru H. Tsuboi M. Yamada T. Sato A. et al.Quantitative vascular measurements in arterial occlusive disease.Radiographics. 2005; 25: 1141-1158Crossref PubMed Scopus (87) Google Scholar In contrast, there are also suggestions that there is overall no significant difference between diameter and area reduction of carotid artery stenosis on CTA.5Carnicelli A.P. Stone J.J. Doyle A. Chowdhry A.K. Mix D. Ellis J. et al.Cross-sectional area for the calculation of carotid artery stenosis on computed tomographic angiography.J Vasc Surg. 2013; 58: 659-665Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar However, there is currently no consensus to what extent measurement of cross sectional area reduction differs from measurement of diameter reduction in a clinical setting. In daily clinical practice, some radiologists already measure cross sectional area reduction to determine the degree of stenosis, but it is unclear to what extent this occurs. Therefore, a questionnaire was generated to evaluate which method radiologists use preferentially, and distinguished three types of plaque: regular/non-ulcerated, irregular/ulcerated, and calcified. This questionnaire was made available to visitors to the 41st annual meeting of the European Society of Neuroradiology held in the Netherlands in September 2018. One respondent was excluded for not answering all three questions in order to determine the method used regarding the type of plaque. The answers of 92 respondents (83 neuroradiologists, eight neuroradiology residents, and one neurosurgeon) were analysed. The questionnaire based survey had several limitations. For instance, selection and response bias may have occurred as the majority of respondents (73%) were practising in Europe, 17% of whom were from the Netherlands, and the response rate was unknown. Therefore, the percentages generated in this survey must be considered with caution. Furthermore, the method of measurement (manual or [semi-]automated) was not specified. The method used to assess the degree of carotid artery stenosis in this survey varied according to the type of plaque (Table 1). The diameter reduction method is used most often in regular/non-ulcerated and calcified plaques (67% and 62%, respectively). However, the cross sectional area reduction method is also used, especially in irregular/ulcerated plaques (45%; either using the area reduction method exclusively or using both the diameter and area reduction methods). The area reduction method was used as the sole method for an irregular/ulcerated plaque in 32%. The results of the questionnaire are remarkable. The current guideline does not consider measuring area reduction to be an option for determining the degree of stenosis.1Naylor A.R. Ricco J.B. de Borst G.J. Debus S. de Haro J. Halliday A. et al.Editor's choice – management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European society for vascular surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 3-81Abstract Full Text Full Text PDF PubMed Scopus (431) Google Scholar Although it is unclear to what extent measurement of the area reduction differs from measurement of the diameter reduction, in individual patients it is clear that the degree of carotid artery stenosis can vary depending on which method is used.2Samarzija K. Milosevic P. Jurjevic Z. Erdeljac E. Grading of carotid artery stenosis with computed tomography angiography: whether to use the narrowest diameter or the cross-sectional area.Insights Imaging. 2018; 9: 527-534Crossref PubMed Scopus (8) Google Scholar, 3Ota H. Takase K. Rikimaru H. Tsuboi M. Yamada T. Sato A. et al.Quantitative vascular measurements in arterial occlusive disease.Radiographics. 2005; 25: 1141-1158Crossref PubMed Scopus (87) Google Scholar, 4Zhang Z. Berg M. Ikonen A. Könönen M. Kälviäinen R. Manninen H. et al.Carotid stenosis degree in CT angiography: assessment based on luminal area versus luminal diameter measurements.Eur Radiol. 2005; 15: 2359-2365Crossref PubMed Scopus (39) Google Scholar, 5Carnicelli A.P. Stone J.J. Doyle A. Chowdhry A.K. Mix D. Ellis J. et al.Cross-sectional area for the calculation of carotid artery stenosis on computed tomographic angiography.J Vasc Surg. 2013; 58: 659-665Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Consequently, it may affect decision making for patient eligibility for CEA; some patients may undergo CEA unnecessarily owing to the variability in measurements between the diameter and area reduction. Also, conversely, some patients might be deprived of CEA unnecessarily.Table 1Overview of the quantification method used by the 92 respondents to determine the degree of carotid artery stenosis, according to each type of plaqueQuantification methodRegular/non-ulcerated plaquesIrregular/ulcerated plaquesCalcified plaquesDiameter reduction62 (67)49 (53)57 (62)Area reduction18 (20)29 (32)22 (24)Both (diameter and area reduction)11 (12)12 (13)9 (10)No answer1 (1)2 (2)4 (4)Data are presented as n (%). Seven different respondents did not answer one of three questions according to the type of plaque. Open table in a new tab Data are presented as n (%). Seven different respondents did not answer one of three questions according to the type of plaque. This questionnaire based survey shows that the quantification method of carotid artery stenosis on CTA varies according to the type of plaque, and includes measurement of area reduction, in particular for irregular/ulcerated plaques. To select patients for CEA the area reduction method should be used with caution, because the relationship between the results of cross sectional area reduction and diameter reduction measurement remains unclear. Although the area reduction method seems promising, there is currently no evidence for using this method to select patients for CEA and this method needs validation before it can be implemented for use in clinical practice. Despite variation in the method used to determine carotid stenosis as shown in this survey, it is believed area reduction measurement should be the preferred method to determine the degree of stenosis as there is evidence that this method is more accurate than the diameter reduction method, especially for irregular plaques.2Samarzija K. Milosevic P. Jurjevic Z. Erdeljac E. Grading of carotid artery stenosis with computed tomography angiography: whether to use the narrowest diameter or the cross-sectional area.Insights Imaging. 2018; 9: 527-534Crossref PubMed Scopus (8) Google Scholar, 3Ota H. Takase K. Rikimaru H. Tsuboi M. Yamada T. Sato A. et al.Quantitative vascular measurements in arterial occlusive disease.Radiographics. 2005; 25: 1141-1158Crossref PubMed Scopus (87) Google Scholar, 4Zhang Z. Berg M. Ikonen A. Könönen M. Kälviäinen R. Manninen H. et al.Carotid stenosis degree in CT angiography: assessment based on luminal area versus luminal diameter measurements.Eur Radiol. 2005; 15: 2359-2365Crossref PubMed Scopus (39) Google Scholar However, firstly, consensus should be reached if measurement of cross sectional area reduction differs from measurement of diameter reduction in a clinical setting, and, secondly, future studies must show whether new cutoff values should be determined when using the area reduction method to identify patients that will benefit from carotid de-obstruction. The authors thank the European Society of Neuroradiology for enabling them to circulate the questionnaire at their conference.

BACKGROUND:Misperception that an established, gradual-onset disease such as osteoarthritis started when the symptoms were first noticed might lead to testing and treatment choices that are inconsistent with what matters most to a patient. In the present study, the primary null hypothesis was that there are no factors associated with patient-reported symptom duration (in months). The secondary null hypotheses were that there are no factors independently associated with (1) a sudden versus gradual perception of disease onset, (2) an event or injury-related versus age-related perceived cause of disease onset, and (3) the magnitude of physical limitations. METHODS:In this cross-sectional study, 121 patients with an atraumatic, established, gradual-onset condition of the upper extremity completed a demographic questionnaire, measures of mental health (symptoms of depression and anxiety, worst-case thinking, and self-efficacy [the ability to adapt and continue with daily activity] when in pain), measurement of the magnitude of upper extremity-specific limitations, and questions about the perceived course and cause of the disease. RESULTS:The median patient-reported symptom duration was 12 months (interquartile range, 3 to 36 months). Twenty-two patients (18%) perceived their disease as new, and 29 patients (24%) believed that the condition was related to ≥1 event (injury) rather than being time and age-related. In multivariable analysis, patients with Medicare insurance were independently associated with longer reported symptom duration (in months). Greater self-efficacy was associated with longer symptom duration in bivariate, but not multivariable, analysis. No factors were independently associated with a sudden versus gradual onset of symptoms. Hispanic ethnicity and federal, county, or no insurance were independently associated with the perception that the problem was caused by an injury or event. CONCLUSIONS:Approximately 1 in 5 patients misperceived new symptoms as representing a new disease, often as a type of injury. Misperception of the pathology as new had a limited association with unhealthy thoughts and is likely generally responsive to reorientation. We speculate that gentle, strategic reorientation of misperception can protect patients from choices inconsistent with their values.

Patient experience measures such as satisfaction are increasingly tracked and incentivized. Satisfaction questionnaires have notable ceiling effects that may limit learning and improvement. This study tested a Guttman-type (iterative) Satisfaction Scale (GSS) after a musculoskeletal specialty care visit in the hope that it might reduce the ceiling effect. We measured floor effects, ceiling effects, skewness, and kurtosis of GSS. We also assessed factors independently associated with GSS and the top 2 possible scores. In this cross-sectional study, 164 patients seeing an orthopedic surgeon completed questionnaires measuring (1) a demographics, (2) symptoms of depression, (3) catastrophic thinking in response to nociception, (4) heightened illness concerns, and (5) satisfaction with the visit (GSS). Bivariate and multivariable analyses sought associations of the explanatory variable with total GSS and top 2 scores of GSS. Accounting for potential confounding using multivariable analysis, lower satisfaction was independently associated with greater symptoms of depression (β: −0.03; 95% CI: −0.05 to −0.00; P = .047). The top 2 scores of the GSS were independently associated with women (compared to men: odds ratio [OR]: 2.12, 99% CI: 1.01-4.45, P = .046) and lower level of education (masters’ degree compared to high school; OR: 0.16, 95% CI: 004-0.61, P = .007). The GSS had no floor effect, a ceiling effect of 38%, a skewness of −0.08, and a kurtosis of 1.3. The 38% ceiling effect of the iterative (Guttman-style) satisfaction measure is lower than ordinal satisfaction scales, but still undesirably high. Alternative approaches for reducing the ceiling effect of patient experience measures are needed.