By Michael J. Asken, PhD, and Danielle E. Ladie, MD, MPH, FACS
Re-posted from General Surgery News, November 2021
It is obvious that optimizing the patient prior to surgery is essential for maximizing desirable outcomes. While these efforts typically focus on managing comorbidities and assessing physiologic parameters, “comprehensive” optimization is achieved by including attention to the psychological status of the surgical patient.
With evolving specialization in surgery and increasing sophistication of procedures, psychological evaluations have become integral in the evaluation of patients for certain operations, such as bariatric, transplant and pain-related orthopedic surgeries.1,2 The benefits of psychological “preparation” of surgical patients has been proposed as an important consideration.3,4
Less developed, in contrast to specialized psychological evaluations, is a simple and broad approach to assessing every patient’s psychological state in a manner appropriate for use by the surgeon involved in the case. Psychological preparation of the patient requires a first step of evaluation through a preoperative psychological survey (POPS).
While not an in-depth, diagnostic or psychopathology-oriented evaluation (hence the term “survey”), the qualitative POPS addresses a variety of areas of patient functioning that can bear directly on the quality and satisfaction of the surgical experience for both the patient and surgical team. A more specific and comprehensive evaluation may become indicated as a result of information elicited from such a general psychological inquiry.
There are two reasons why an assessment like the POPS is indicated: Surgery is a psychological, as well as physical, experience and psychological factors affect the surgical course, outcome and recovery.5-10
Although the POPS could be delegated to another member of the surgeon’s team, we strongly suggest the surgeon engage the patient. We describe the POPS as a “discussion” with the patient that provides direct and useful information to the surgeon, illuminating issues that the surgeon will want to ensure are addressed. Perhaps, as importantly, this interaction can convey the sincerity of the surgeon’s concern for the patient’s overall well-being, enhance the perception of a positive bedside manner and bolster the quality of the surgeon–patient relationship.
When engaging the patient, the following items should be considered:
1. Discuss the patient’s perceptions of past surgical experiences.
The goal here is to illuminate psychological and emotional residuals (both positive and negative) that might still linger from those experiences. Did all go smoothly and as expected? Were there aspects that were uncomfortable, frustrating, angering or anxiety-arousing? What views of surgery—trust or fear—did past experiences create for the patient?
2. Discuss the patient’s view of others’ experiences with the same or similar procedures.
What has the patient heard from friends or relatives about the pending surgery? Are these stories exaggerated, especially in a negative way? The plethora of television medical dramas, social media commentary and internet (mis)information can influence a patient’s perception of their situation.
3. Discuss the patient’s understanding of their condition and need for the procedure.
The patient should have a substantial understanding of their condition, how the surgery will affect their condition and, consequently, a positive acceptance (if not enthusiasm) of the surgery. The reality is that patients do not always fully comprehend, or may be confused about, aspects of their condition and care.
4. Discuss the patient’s understanding of the procedure itself.
This is where you want the patient to tell you what they understand about their situation. What you told them is crucial, but what they heard, retained and understand is essential.
5. Discuss the patient’s short-term expectations.
Explore what the patient understands will happen going into the procedure, immediately after and in the ensuing 24 to 48 hours. Is there a realistic expectation of hospital length of stay, pain levels and fatigue? Discussion of postoperative sensations, such as stitches pulling, itching, numbness or oozing can be valuable. When these events occur unexpectedly, there is a tendency to interpret them in a negative manner (“my wound is tearing open!”).
6. Discuss the patient’s long-term expectations.
Ultimately, you want to hear that the patient has an accurate and reasonable expectation of time and any postoperative rehabilitation that is required. You want to listen for their understanding of what the procedure will accomplish and perhaps what it will not. Unrealistic expectations lead to a difficult postoperative course, strained interactions, disappointment and anger.6
7. Discuss current life stresses.
Stress is common, but a burned-out, dejected, pessimistic patient is not in an optimal state for surgery. While the acute need for surgery may preclude immediate intervention for stresses, their acknowledgment, especially with a commitment to help with follow-up postoperatively, can provide a sense of relief and a more optimistic outlook for the patient.
8. Discuss the patient’s usual way of coping with challenges.
A gentle, but effective way to approach this is by discussing how the patient usually deals with challenges and stressors. You might hope to hear approaches such as “I read up on things,” “I lean on my friends” and “My faith sustains me.” While usual perioperative support is still important here, such statements are a good foundation for the response to surgery. Responses like “I don’t know” and “I get pretty down” suggest a psychological infrastructure that would probably benefit from greater professional support.
9. Discuss current care and relationships with medical/nursing staff.
Despite best efforts, and for many reasons, patients don’t always perceive that they received the kind of care they expected. While never acceptable, frustration, anger, anxiety or fear of returning to a floor or team’s care is especially concerning going into surgery. A deteriorating relationship with staff is a risk for psychological morbidity.11
10. Discuss current/past counseling history and assess mental status.
Discussion of these last areas often is the most difficult and sensitive for both the surgeon and patient. Generalizing problems with the term “stress” (everyone has it!) can reduce intrusiveness. Asking “how are you doing” is an effective way to start and listen for current, acute or ongoing anxiety or depressive thinking. Surgeon discomfort here should not be a rationale for avoiding this assessment. It is often extremely valuable as a baseline in the face of postoperative concerns like delirium and other cognitive changes.
The preoperative psychological assessment has the potential to provide important information to the surgeon for optimizing patient readiness for surgery. Obviously when concerns are revealed, addressing them in some manner from reassurance to psychiatric/psychological consultation is indicated.
The ability, interest and comfort of surgeons to engage productively in such discussions will vary greatly. We are not suggesting a prescription for how to evaluate a patient psychologically, but rather the value of generally increasing awareness of the patient’s psychological state and needs. Again, we differentiate POPS from in-depth psychological, neuropsychological or psychiatric evaluations that are essential in certain surgical scenarios and clinical situations.
What is suggested is a thoughtful discussion with the patient. The content and extent are to be determined by each individual surgeon and situation. Some patients (with an avoidant coping style) will be reluctant to engage fully and they should not be pressed.3 However, completing a POPS through discussion allows an opportunity for unique concerns to emerge while cultivating the relationship.
References
- Block A, Sarwer D, eds. Pre-surgical Psychological Screening: Understanding Patients, Improving Outcomes. American Psychological Association; 2012.
- Kumnig M, Jowsey-Gregoire S. Pre-operative psychological evaluation of transplant patients: challenges and solutions. Transplant Res Risk Manage. 2015;7:35-43.
- Johnston M, Vogele C. Benefits of psychological preparation for surgery: a meta-analysis. Ann Behav Med. 1993;15(4):245-256.
- Salzmann S, Salzmann-Djufri M, Wilhelm M, et al. Psychological preparation for cardiac surgery. Curr Cardiol Rep. 2020;22:172.
- Burton D, King A, Bartley J, et al. The surgical anxiety questionnaire: development and validation. Psychol Health. 2019;34(2):129-146.
- Cody EA, Mancuso CA, Burket JC, et al. Patient factors associated with higher expectations for foot and ankle surgery. Foot Ankle Int. 2017;38(5):472-478.
- Orri M, Boleslawski E, Regimbeau JM, et al. Influence of depression on recovery after major noncardiac surgery: a prospective cohort study. Ann Surg. 2015;262(5):882-889.
- Rasouli M, Menendez M, Sayadipour A, et al. Direct cost and complications associated with total joint arthroplasty in patients with pre-operative anxiety and depression. J Arthroplasty. 2016;31(2):533-536.
- Ghoneim M, O’Hara M. Depression and post-operative complications: an overview. BMC Surg. 2016;16(5). doi:10.1186/s12893-016-0120-y
- Nixon D, Schafer K, Cusworth B, et al. Preoperative anxiety effects on patient-reported outcomes following foot and ankle surgery. Foot Ankle Int. 2019;40(9):1007-1011.
- Williams H, Jajja M, Baer W, et al. Perioperative anxiety and depression in patients undergoing abdominal surgery for malignant disease. J Surg Oncol. 2019;120:389-396.
Dr. Asken is the director at Provider Well-Being, UPMC Central PA Region, Harrisburg, Pa. Dr. Ladie is a transplant surgeon and the vice chair, Department of Surgery, UPMC Central PA Region, Harrisburg, Pa.