Do People Seeking Care for Musculoskeletal Symptoms Experience Greater Agency and Better Experience Based on Written Information About Their Illness?

Abstract

Objectives

Current patient-facing health information may unintentionally reinforce unhelpful and less adaptive mindsets regarding musculoskeletal symptoms. This prospective randomized trial evaluated the impact of psychologically-informed educational material, explicitly designed to promote healthier interpretations of bodily sensations according to cognitive science principles, on patient experience when compared to standard professional society materials.

Methods

In this trial, 133 adults presenting to an upper extremity specialist with one of eight common non-traumatic musculoskeletal conditions were randomly assigned to review health information produced by either: 1) a professional musculoskeletal society or 2) revised material created by the authors and psychologist collaborators. Participants completed surveys containing validated measures assessing personal health agency (PAM-13), perceived clinician empathy (JSPPPE) and emotional response to the material.

Results

There were no significant differences based on the type of material reviewed. However, on multivariable analysis, participants diagnosed with rotator cuff tendinopathy, ganglion cyst, or carpal and cubital tunnel syndrome reported more negative emotional responses compared to those with lateral epicondylitis, regardless of the type of written material reviewed.

Conclusions

Cognitively-informed musculoskeletal health information was acceptable to patients but did not yield measurable improvements in emotional response, agency, or perceived empathy when compared to standard material. During the visit, diagnosis-specific factors may influence patient reactions more than information framing.

Practice Implications

Patients find clear, accessible material designed to cultivate the healthiest possible interpretation of bodily sensations acceptable and non-distressing. Future interventions should explore diagnosis-specific tailoring of information or repeated exposure to impact outcomes.

Level of Evidence

II.

Keywords

health communication patient education cognitive behavioral therapy musculoskeletal care orthopedic surgery health literacy

Introduction

Background

Unhelpful thoughts and feelings of distress (worry and despair) related to bodily sensations have notable and consistent associations with levels of discomfort and incapability among individuals experiencing musculoskeletal symptoms, such as pain, stiffness, weakness, and paresthesia.^1–5 Recent studies demonstrate a much stronger association of measures of thoughts and feelings than measures of pathophysiology severity with levels of discomfort and incapability.^2–4 This is especially relevant for common non-traumatic upper extremity conditions, including rotator cuff tendinopathy, lateral epicondylitis, thumb and finger arthritis, carpal and cubital tunnel syndrome, de Quervain tendinopathy, ganglion cyst, trigger digit, and Dupuytren disease—which often involve permanent or prolonged symptoms that can be associated with maladaptive interpretations over time. These lines of evidence, along with our understanding of placebo and nocebo effects (the beneficial or harmful changes in our native physiology that occur based on a healthy or unhealthy mindset regarding sensations and context),^6,7 highlight the importance of helping people develop a healthier inner narrative regarding their body and its sensations.^2,4,5

Rationale

Current written and electronic musculoskeletal health information tends to reinforce unhelpful automatic thoughts, including catastrophic thinking about pain and fear of painful movement (kinesiophobia).^8–10 For example, a study of YouTube videos about carpal tunnel syndrome (CTS) found that nearly 80% contained at least one statement likely to reinforce common misconceptions, such as the belief that CTS is caused by hand use or that splinting can alter the natural history of the condition.⁸ Similarly, an analysis of YouTube educational content on elbow enthesopathy (tennis elbow) found that 65% of videos promoted inaccurate or unhelpful beliefs, including the mischaracterization of the condition as an “injury” or the suggestion that imaging and surgery are routinely necessary.¹⁰ Misleading or inaccurate information is also prevalent in patient handouts from professional societies. One study identified an average of 1.9 misleading statements and 2.1 biased statements per 100 words of content.⁹ Examples include unsupported claims that rest alters the natural history of trigger finger or that magnetic resonance imaging is necessary for the diagnosis of CTS. Additionally, most handouts were written at or above a seventh-grade reading level, posing barriers to comprehension for individuals with limited health literacy.⁹ Collectively, such materials may inadvertently promote fear and hinder effective patient engagement in musculoskeletal care by triggering common unhelpful thoughts rooted in human mental shortcuts (heuristics) that contribute to systematic errors in thinking (cognitive biases).¹¹ For instance, health information may inadvertently validate a patient's automatic thought that pain signals damage or that use of the affected limb will make their condition worse. Evidence suggests that the wording of medical information can instead be intentionally crafted to promote healthful thoughts and emotions.^12,13

Health literacy is broadly defined as the ability to obtain, process, and understand basic health information needed to make appropriate medical decisions.¹⁴ An important, but often underappreciated, aspect of health literacy is a patient's capacity to recognize and reconsider their automatic thoughts and beliefs.^15–18 This is particularly important in musculoskeletal care, where symptoms such as pain, weakness or sensory changes can be alarming despite usually being benign.^14,19,20 Individuals may find it validating to receive information that aligns with their automatic thoughts and feelings, even if it reinforces misconceptions, while more accurate information that introduces new ways of thinking may initially feel uncomfortable or be dismissed.^12,21 Still, evidence suggests people will make better health choices, feel better, and do more if they have an accurate understanding of their body and its sensations.^14,19,20 One such way possible to achieve this is to craft messages using principles from Cognitive Behavioral Therapy (CBT), a psychological approach that helps individuals identify and reframe unhelpful thoughts and behaviors. In this context, CBT-informed messaging aims to validate distress while promoting more balanced and empowering interpretations of symptoms.

Although cognitive-behavioral interventions have demonstrated clear benefit in formal clinical settings,^14,19,21,22 it remains unclear whether written psychologically-informed educational materials can positively shape patient experience when delivered as a standalone resource. This randomized trial addresses that gap by evaluating the feasibility and impact of such materials in a musculoskeletal outpatient setting, directly examining their association with clinical outcomes including emotional response, perceived clinician empathy, and patient self-efficacy. Given the notable prevalence of maladaptive beliefs and their established link to incapability, developing scalable, psychologically-informed educational resources presents a valuable opportunity to enhance the quality and effectiveness of musculoskeletal care.

Questions

In a study of people presenting for upper extremity musculoskeletal specialty care, we randomized participants to view information prepared either by a professional society (known to reinforce unhelpful thinking and misinterpretations regarding sensations),⁹ or information prepared based on cognitive science principles. The null hypothesis was that there would be no difference between the two groups in: (1) patient activation scores (that is, a person's knowledge, confidence, and willingness to manage their own health), (2) patient-rated clinician empathy, and (3) emotional response to the material.

Methods

Study Design and Setting

In this prospective randomized trial, adult patients presenting to one of two musculoskeletal upper extremity specialty clinics between July 2023 and May 2024 with one of eight common non-traumatic conditions were randomized to receive one of two types of educational material regarding their condition. After verbal consent was obtained, participants were randomized 1:1 using an online random number generator (available from: https://numbergenerator.org/) to review information published on either 1) the itsanarmproblem.com website (informed by CBT principles) or 2) the American Society for Surgery of the Hand (ASSH) website (not informed by CBT principles). Both materials addressed common upper extremity conditions, however the tone, content and structure differed considerably. ASSH material (control) presents symptoms primarily as structural problems and focusses on treatment options within a traditional biomedical framework. Conversely, the CBT-informed material (intervention) emphasizes the normalization of symptoms, validation of emotions, and reassurance regarding the benign nature of most common sensations. It also encourages patient self-efficacy in managing their condition.

Information was accessible on their personal device via a QR code and could be opened be participants at any point during their clinic visit, including before or after medical consultation. After the visit, participants completed a brief online survey on REDCap (Vanderbilt University; Nashville, TN).

Participants

Patients were eligible to participate in the study if they were new to the clinic, aged 18 years or older, able to read English, and diagnosed with one of eight common upper extremity musculoskeletal conditions: 1) rotator cuff tendinopathy; 2) lateral epicondylitis (“tennis elbow”); 3) trapeziometacarpal (thumb base) or DIP/PIP (finger) arthritis; 4) carpal or cubital tunnel syndrome; 5) de Quervain tendinopathy; 6) ganglion cyst; 7) trigger finger; and 8) Dupuytren disease. Those with cognitive or physical impairment preventing tablet use were excluded.

Variables, Outcome Measures, Data Sources, and Bias

Demographic information was obtained from participants, including gender, age, ethnicity, marital status, level of education, work status, annual household income, and insurance status. Distress and misconceptions regarding sensations were each assessed through 3 targeted survey questions derived from a factor analysis of commonly used measures of unhelpful thoughts (Appendix A).²² Additionally, participants’ knowledge, skills and confidence in self-managing their health were assessed using the Patient Activation Measure (PAM-13) –a validated and standardized measure of personal health agency.^23,24 Thirteen items are rated on a 4-point Likert scale from 1 (strongly disagree) to 4 (strongly agree) and summed, resulting in a total score between 0 and 100. PAM scores are then used to subdivide patients into 4 distinct categories: 1) disengaged and overwhelmed (indicated by PAM score between 0 and 47); 2) becoming aware, but struggling (indicated by PAM score between 48 and 55); 3) taking action (indicated by PAM score between 56 and 72); and 4) maintaining behaviours and pushing further (indicated by PAM score between 73 and 100). Participants were also asked to rate their perception of the clinician's empathy using the 5-item Jefferson Scale of Patient's Perceptions of Physician Empathy (JSPPPE), where scores range from 5 to 35 and higher scores indicate greater perceived clinician empathy.²⁵ Finally, emotional response (resonance with) the instructive material was measured using five items (see Appendix A), each rated using a slider scale of agreement from 0 (not at all) to 100 (completely). The mean of the 5 slider results was then calculated.

Statistical Analysis & Sample Size Calculation

Variables were reported using descriptive statistics, including mean, standard deviation, percentage and frequency. Continuous variables were studied using Student t-tests, Mann-Whitney tests, slider rating, Significance Analysis of Microarray (SAM) and Pearson correlation. Categorical variables were compared using chi-square and Fisher's exact tests. Factors associated with response variables were determined through bivariate analysis. Statistical significance was set at P < 0.05. All variables with P < 0.10 were moved to linear regression or negative binomial regression.

A minimum sample size of 127 patients was calculated using a power of 0.8 and Type I error (alpha) of 0.05. This calculation was based on a regression model with six predictors and the assumption that a change in explanatory variables would account for 5% or more of the variability in outcome variable. The complete model would account for at least 20% variability. As a result, target enrolment was set to 140, approximately 10% above minimum sample size, to account for possible incomplete survey completion. Data was analyzed and processed using STATA version 18.0 (StataCorp LLC, Texas, USA).

Demographics, Description of Study Population

There were 133 patients (87 men, 46 women) with a mean age of 57 years (standard deviation 15 years, range 19 to 85 years) included in the study (Table 1). Fifty-seven participants were randomized to review health information produced by a professional society and 76 participants to review information based on cognitive science principles. It is unclear why the randomization method resulted in an imbalance between groups, however we speculate that it was a deficiency of the online random number generator that was used.

Table 1.

Demographics and Baseline Values for the 133 Participants.

Variables	Value % (N)
Gender
Women	35% (46)
Men	65% (87)
Work Status
Employed	50% (66)
Unemployed	6% (8)
Retired	35% (47)
Other (student, homemaker etc)	9% (12)
Marital Status
Married or partner	66% (88)
Single	17% (23)
Divorced or separated	11% (14)
Other	6% (8)
Education
High school or less	18% (24)
2-year college	13% (17)
4-year college	41% (55)
Post-college graduate degree	28% (37)
Handouts
Professional association	43% (57)
Psychologically informed	57% (76)
Income
< $$24,000	13% (17)
$$24,001—$$46,000	18% (24)
$$46,001—$$75,000	23% (30)
$$75,001—$$121,000	23% (31)
>$$121,001	23% (31)
Insurance
Medicare	34% (45)
Medicaid/county safety net	10% (13)
Commercial	24% (32)
Other	32% (43)
Diagnosis
Rotator cuff tendinopathy	8% (11)
Lateral epicondylitis (tennis elbow)	7% (10)
Trapeziometacarpal (thumb base) arthritis	10% (13)
Carpal and cubital tunnel syndrome*	13% (17)
de Quervain tendinopathy	9% (12)
Ganglion cyst	17% (22)
Trigger digit	28% (37)
Dupuytren contracture	8% (11)
	Mean ± SD
Age (years)	57 ± 15
Patient activation measure	41 ± 7.2
Perceived clinician empathy	9.4 ± 3.2
Emotional response to the written material	80 ± 19

*There were only 3 people with cubital tunnel syndrome, so we pooled them with carpal tunnel syndrome.

Patient Activation Measure (PAM-13) scores range from 0 to 100, with higher scores indicating greater personal health agency.

Jefferson Scale of Patient's Perceptions of Physician Empathy (JSPPPE) scores range from 5 to 35, with higher scores indicating greater perceived clinician empathy.

Emotional response scores range from 0 to 100, with higher scores indicating greater resonance with instructive material.

Results

Factors Associated with Patient Activation Score

There were no significant factors associated with levels of patient activation in bivariate analysis, including the type of material reviewed (Table 2).

Table 2.

Bivariate Analysis of Factors Associated with Emotional Response, Perceived Clinician Empathy, and Patient Activation.

Variables	Clinician Empathy		Patient Activation Measure		Positive Response
Variables	Pearson Coefficient	P-Value	Pearson Coefficient	P-Value	Pearson coefficient	P-Value
Age	0.04	0.63	−0.07	0.41	0.10	0.24
Unhelpful thoughts	0.06	0.49	−0.06	0.52	−0.20	0.02
Feelings of distress	−0.01	0.87	−0.04	0.63	−0.15	0.09
Gender	Mean ± SD	P-value	Mean ± SD	P-value	Mean ± SD	P-value
Women	9.7 ± 2.9	0.34	43 ± 5	0.19	81 ± 20	0.28
Men	9.3 ± 3.3		41 ± 8		79 ± 17
Work Status
Employed	9.3 ± 3.3	0.71	42 ± 8	0.56	79 ± 21	0.95
Unemployed	10 ± 4		41 ± 4		78 ± 21
Retired	9.7 ± 3.0		42 ± 6		82 ± 16
Other (student, homemaker etc)	8.6 ± 2.6		39 ± 9		81 ± 15
Marital Status
Married or partner	9.6 ± 2.9	0.33	42 ± 7	0.35	82 ± 18	0.36
Single	8.7 ± 3.6		42 ± 5		74 ± 20
Divorced or separated	9.1 ± 4.2		39 ± 9		78 ± 20
Other	10 ± 3		38 ± 12		84 ± 25
Education
High school or less	8.8 ± 3.4	0.62	39 ± 8	0.14	79 ± 20	0.99
2-year college	9.4 ± 3.1		42 ± 4		80 ± 20
4-year college	9.4 ± 2.9		42 ± 7		82 ± 16
Post-college graduate degree	9.9 ± 3.4		42 ± 8		78 ± 22
Handouts
Professional association	9.6 ± 3.4	0.66	42 ± 7	0.43	79 ± 19	0.30
Psychologically informed	9.3 ± 3.0		41 ± 7		81± 19
Income
< $$24, 000	9.1 ± 3.5	0.87	43 ± 6	0.35	75 ± 21	0.65
$$24,001—$$46,000	9.0 ± 3.7		39 ± 9		80 ± 19
$$46,001—$$75,000	9.7 ± 3.5		41 ± 8		79 ± 21
$$75,001—$$121,000	9.8 ± 2.9		42 ± 4		83 ± 18
>$$121,001	9.3 ± 2.5		43 ± 8		81 ± 15
Insurance
Medicare	10 ± 3	0.10	42 ± 6	0.87	80 ± 18	0.03
Medicaid/County Safety Net	8.7 ± 3.8		43 ± 5.0		68 ± 20
Commercial	9.5 ± 2.9		42 ± 6.0		78 ± 21
Other	8.8 ± 3.2		41 ± 9.4		86 ± 16
Diagnosis
Rotator cuff tendinopathy	9.5 ± 4.3	0.44	42 ± 7.5	0.69	63 ± 15	0.002
Lateral epicondylitis (tennis elbow)	9.1 ± 2.2		44 ± 4.2		90 ± 10
Trapeziometacarpal (thumb base) arthritis	8.8 ± 3.6		43 ± 4.9		77 ± 18
Carpal and cubital tunnel syndrome	9.0 ± 4.4		42 ± 5.6		69 ± 25
de Quervain tendinopathy	8.3 ± 3.0		41 ± 10		80 ± 19
Ganglion cyst	11 ± 3.2		40 ± 7.1		77 ± 19
Trigger finger	9.4 ± 2.6		41 ± 8.3		88 ± 15
Dupuytren contracture	9.6 ± 2.3		43 ± 6.1		85 ± 12

The variables work status, level of education, marital status, and insurance status were pooled due to low numbers. All variables with P < .10 were moved to multivariable analysis.

SD = standard deviation.

Factors Associated with Patient-Rated Clinician Empathy

There were no factors associated with patient rating of clinician empathy in bivariate analysis, including the type of material reviewed (Table 2).

Factors Associated with Emotional Response

In multiple linear regression analysis, accounting for factors with significant associations in bivariate analysis (lower levels of unhelpful thoughts, diagnosis, and insurance status; Table 2), a more negative emotional response was associated with diagnoses of rotator cuff tendinopathy (RC −19 [95% CI −36 to −2.5], p=0.02), carpal and cubital tunnel syndrome (RC −19 [95% CI −33 to −4.8], p=0.01), and ganglion cyst (RC −13 [95% CI −26 to −0.6], p =0.04) relative to the reference of lateral epicondylitis, but not with the type of material reviewed (Table 3).

Table 3.

Multiple Linear Regression Analysis of Factors Associated with More Positive Emotional Response to Material.

Variables	Regression Coefficient (95% Confidence Interval)	P-Value	Semi Partial Correlations (R²)
Unhelpful thoughts regarding sensations*	−1.2 (−2.4 to 0.1)	0.06	0.02
Diagnosis
Lateral epicondylitis (tennis elbow)	Reference Value
Rotator cuff tendinopathy	−19 (−36 to −2.5)	0.02	0.03
Trapeziometacarpal (thumb base) arthritis	−12 (−27 to 1.7)	0.08	<0.001
Carpal and cubital tunnel syndrome	−19 (−33 to −4.8)	0.01	<0.001
de Quervain tendinopathy	−11 (−25 to 3.5)	0.14	0.01
Ganglion cyst	−13 (−26 to −0.6)	0.04	<0.001
Trigger finger	−0.5 (−13 to 12)	0.93	0.05
Dupuytren contracture	−1.5 (−17 to 14)	0.85	0.03
Insurance
Medicare	Reference Value
Medicaid/MAP	−3.7 (−15 to 7.9)	0.53	0.003
Commercial	0.7 (−7.8 to 9.3)	0.86	<0.001
Other	7.6 (−0.5 to 16)	0.06	0.022

R2 = 0.27, Adjusted R2 = 0.19.

Bold highlighting indicates statistical significance, P<0.05.

*Feelings of distress excluded due to collinearity with unhelpful thoughts.

Discussion

Health information intended for patients often includes words and concepts with the potential to reinforce unhelpful thoughts and feelings of distress regarding their body and its sensations. We studied how people seeking care for musculoskeletal symptoms engage with information designed using cognitive science principles compared to information from a professional society. The information based on cognitive science principles was crafted to limit reinforcement of, and begin to gently reorient, common misconceptions based on mental short cuts (heuristics) that are part of human intelligence. We found that the type of material reviewed was not associated with levels of patient activation, perception of clinician empathy, or emotional response to the material. Greater unhelpful thinking was associated with less positive emotional response to both standard and cognitive science-informed materials in bivariate, but not in multivariable analysis that accounted for specific diagnoses.

Limitations

The results of this study can be considered in light of several limitations. First, it was conducted in a specialty care setting, which may limit the generalizability of findings to other healthcare environments, such as people reviewing material on the internet, and people seeking non-specialty medical care. Based on population data linking mindset with symptom intensity,¹ it is plausible that individuals seeking specialty care may be more likely to hold unhelpful cognitive biases or have higher expectations regarding diagnosis and interventions. Such individuals might therefore also be more likely to disengage with educational materials that challenge or fail to validate their beliefs. Indeed, there is some evidence that reinforcement of unhealthy mindsets can be perceived as validating and empathetic.^21,26

Second, while this study included a diverse range of upper limb musculoskeletal conditions, it did not account for variation in levels of pathophysiology severity, symptom duration, previous treatment history, or other clinical factors that could influence patient engagement with educational materials. Our view is that our enrolment strategy should have a representative spectrum of these factors, and that variation in these is somewhat unlikely to alter the observed results. Third, we did not test association of the type of material reviewed on levels of thoughts, feelings, discomfort, or incapability. This was intentional as we did not expect a single piece of written material to have an immediate impact. Existing evidence supports the effectiveness of cognitive behavioural interventions delivered interactively and longitudinally, often over weeks to years^19,20,27,28 and that is currently the favored approach.

Fourth, the study's design required pairing of two types of information across eight diagnostic categories, effectively generating sixteen distinct condition-content combinations. This design, while necessary to address the study aims, led to relatively small subgroup sizes, which may limit the precision of between-group comparisons. Additionally, the randomization method resulted in an unequal distribution of participants between groups (57 vs 76). While both arms retained sufficient sample size and any imbalance occurred at random, this imbalance introduces some unpredictability. Future studies might consider using stratified or block randomization methods to ensure more balanced group allocation.

Our sample size (n=133) was adequate for testing our primary hypothesis with the effect size we felt was relevant. However, the study sample had a slight gender imbalance (65% men) and was notably more educated (70% college degree) than the general U.S. population (30% college degree).²⁹ This high level of educational attainment may have facilitated greater engagement with the professional society materials used in the study as a control, which are typically written at a level requiring more advanced health literacy.⁹ Additionally, we did not enrol non-English speaking patients, despite their comprising a substantial proportion of our typical patient population. The associations detected are likely to be reproducible, although specific rates are may reflect characteristics unique to our sample.

Factors Associated with Patient Activation

The finding that no factors were associated with levels of patient personal health agency, including the type of material reviewed, is consistent with evidence of a limited ability of decision aids and similar single exposure informational material to alter health mindsets.^29–32 We were satisfied that the material did not diminish feelings of personal health agency. There is evidence that levels of patient activation are associated with patient age, education level, health literacy, health status, and socioeconomic factors,^22,33,34 which suggests that personal health agency is at least partially modifiable. While it is important that educational material avoid reinforcing less healthy mindsets and encourage personal health agency, a single exposure to such material is likely not sufficient to bolster personal health agency —at least in the short term.³⁵

Factors Associated with Patient-Rated Clinician Empathy

The observation that no factors, including the type of educational material reviewed, were linked to levels of patient-rated clinician empathy suggests that information intended to reorient common misconceptions may not harm the patient-clinician relationship. This aligns with previous research which has emphasized that empathy is primarily conveyed through interpersonal interactions and non-verbal cues rather than through supplementary educational materials or logistical components of a consultation (i.e., wait time, visit duration).^36–39 We note evidence that emotional and psychological factors also play a role in patient experience of the clinician's empathy.⁴⁰ Patients experiencing notable and persistent symptoms may have a heightened need for reassurance and validation, which may be more effective in personal interactions than written material. In other words, in the care of individual patients, the focus may be better placed on relationship-building and effective communication strategies than on written materials in order to address unhelpful thoughts and distress.

Factors Associated with Emotional Response to Written Material

The observation that certain musculoskeletal diagnoses (including rotator cuff tendinopathy and ganglion cyst) were associated with a more negative emotional response to the informative material might be related to levels of unhelpful thinking, given that greater unhelpful thinking had a small but statistically significant correlation with a more negative response to the material in bivariate analysis (Table 2). It may be that a patient's preconceptions of these diseases may be most distant from the facts and evidence, making informational material less appealing and more difficult to digest in any form. There is evidence that emotional responses to health information can vary based on individual factors and the nature of the health condition, including perceived severity and personal relevance of the condition.⁴¹

Conclusions & Practice Implications

Based on the findings of this study, patient information on hand and upper extremity conditions can be crafted according to cognitive science principles without generating a more negative emotional response or diminishing perceived clinician empathy, but it is not sufficient to increase personal health agency—at least in the short term. In our view, given the evidence that mindsets are a key aspect of musculoskeletal health, taking care not to reinforce common misinterpretations of bodily sensations and any associated distress can be considered an ethical imperative. Given evidence of notable room for improvement in professional society generated material and handouts from electronic medical records, we recommend use of published debiasing checklists to help ensure that patient-facing material is as healthful as possible.^8,9 These findings may also have relevance beyond musculoskeletal care, particularly in other circumstances where a key aspect of health and care is guidance of people to more adaptive interpretations of their body and its sensations. We believe that health information should support this goal by encouraging the healthiest possible inner narrative. Future studies can address methods for increasing personal health agency, which will likely include, in part, the gentle and compassionate reorientation of common misconceptions and normalization of these misconceptions based on the mental shortcuts (heuristics) that are part of human intelligence.

Footnotes

Acknowledgements

N/A

ORCID iDs

Emily H. Jaarsma

Ali Azarpey

David Ring

Amin Razi

Ethics Declaration

Ethical approval for this study was obtained from the University of Texas at Austin Institutional Review Board (approval number: STUDY00004831).

Author Contributions (CRediT)

EJ: Conceptualization, Methodology, Project administration, Writing (original draft, review and editing).

AA: Conceptualization, Investigation, Data curation, Writing (review and editing).

DA: Conceptualization, Investigation, Data curation, Writing (review and editing).

DR: Conceptualization, Methodology, Supervision, Resources, Writing (original draft, review, editing).

AR: Conceptualization, Data curation, Formal analysis, Visualization, Writing (review and editing)

All authors contributed to the interpretation of data, discussed the results, and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Sharing Statement

The de-identified data that support the findings of this study are available from the corresponding author upon reasonable request.

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