Preparation for Surgery: A Mind-Body Approach
John L Reeves, II, Ph.D., Director of Behavioral Medicine Services of the Pain Center of Cedars-Sinai Medical Center and Adjunct Associate Professor, UCLA School of Dentistry
Most people find surgery to be an extremely stressful event that gives rise to a great deal of fear and anxiety. Few people realize, however, that steps can be taken to help prepare a person for surgery so that stress is minimized and surgical outcome is improved. Of the 50 million surgeries that are performed annually in the United States, about 30 million are elective, which means that many people have the time to prepare themselves. Yet, the reality is that on average very few people actually go through some sort of structured pre-surgery program. Most surgeons do not offer such programs to their patients and often are not aware of the ways in which they can help reduce stress and promote healing. In addition, almost no hospitals offer surgical preparation programs.
Fears about surgery
Over 200 studies on preparing patients for surgery have been published so it is not an area where little information is available, yet most patients and their surgeons never discuss it. The majority of patients commonly and frequently report fear and anxiety. Most patients indicate that their fears include:
those that arise from not having enough information about what will take place during the surgery;
concerns about whether or not the procedure will be a success;
concerns about post-operative pain and the course of recovery;
fears about being separated from home and being in a strange hospital environment;
worries about how the family will cope during this time;
fears that mistakes will be made during the surgery and/or that the patient won't survive the surgery;
fear of waking during the surgery.
Although it seems obvious that discussing these fears beforehand with the surgeon could alleviate many of them, research indicates that this does not happen very often. About 58% of patients surveyed felt that their physician had not provided them with adequate explanations prior to their surgery. Sixty-nine percent felt that their physician did not spend enough time with them. These findings are corroborated by research on patient-physician communication, which indicated that surgeons spent on average seven minutes per patient explaining the surgery. Additional studies indicate that patients usually talk about their concerns for only 18 seconds before their physician interrupts them. Not all the fault lies with the physicians - recent studies found that 60% of all patients do not read the complex consent and hospital forms, and those who do read them retain only 30% to 50% of what they have read.
Stress and surgical outcome
The amount of stress that a patient feels before surgery is important and should not be taken lightly. Patients who have high stress, anxiety and fear tend to have poorer surgical outcomes, more pain, increased use of analgesics, longer hospital stays and more post-operative complications. Furthermore, patients with more fear and anxiety are less likely to be compliant with coughing and breathing exercises, which help to reduce the likelihood of pneumonia, and less compliant with getting out of bed and moving around, which reduces phlebitis and enhances wound healing. High anxiety and stress also tend to lead to an increased use of anesthesia, muscle relaxants and pain medication and are associated with more side effects such as vomiting, nausea, headaches and incision pain.
A growing body of scientific evidence also suggests that pre-surgery stress, anxiety and fear alter the functioning of the body's endocrine and immune systems. These changes affect the release of important chemicals in the brain, which in turn may affect wound healing and other post-surgery processes. A variety of scientific studies indicate that stress has a negative effect on healing. For example, caretakers of Alzheimer's patients (a group that is highly stressed) showed deficits in immune function, and when given a standardized puncture wound, took 24% (nine days) longer to heal than those who were not so stressed. These findings have been supported further by systematic studies with medical students who showed slower wound healing and cellular immune response during exam periods.
Pain also has an adverse effect on the functioning of the immune system. When pain is blocked, the immune function improves thus reducing infection rates and enhancing healing. Researchers have found that giving anesthesia to block pain before it is experienced is highly effective because reducing pain signals to the brain reduces the chances of permanent central nervous system changes that can cause prolonged pain. Epidural anesthesia is very effective for this purpose and is recommended for many surgeries.
In summary, research indicates that patients who have lower levels of fear and anxiety prior to surgery are more likely to have significant positive experiences and outcomes. They are likely to require less anesthesia during surgery and less post-operative pain medication. Fewer complications following surgery are likely, and the amount of time required for healing and recovery is likely to be shortened, thus requiring shorter hospitalization stays. Additionally, patients are likely to be more satisfied with their surgery and will place fewer demands on the health care system. All these factors lead to a potential for increased savings in healthcare dollars.
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What can patients do to prepare themselves for surgery?
The elements that make up good surgical preparation are well-researched psychological interventions that are applied to the surgical environment. An analysis of many studies that have looked at these techniques discovered that 60% to 75% of all patients demonstrated 20% to 28% improvement in surgical outcomes as a result of using at least one of these techniques. The improvement was greater for patients who were provided with two or more of the interventions.
The key elements to preparing for surgery include:
Information gathering. The most important information to get is that which will help you decide whether or not to have the surgery, and information about what the surgery entails, what you should do or not do before the surgery, information about hospitalization, information about what to expect in terms of pain and what can be done to control pain, and information about post-operative recovery.
Communication techniques. The ability to communicate well with health care professionals is essential for patients preparing for surgery. Patients are encouraged to be assertive in order to obtain the information they need. Learning new communication techniques can help patients to identify appropriate information resources and can help to facilitate problem solving.
Relaxation training. There are many different ways to achieve the relaxation response, including relaxed breathing, imagery and visualization, hypnosis, music, and cue-controlled relaxation.
Cognitive coping skills. These skills include techniques that change how you talk to yourself about stressful events. They include a variety of skills including analyzing one's self-talk, challenging the old way of thinking and then reframing it in a more productive way. Affirmations also can be important.
Optimism. Optimism may be more personality driven, but some scientific evidence suggests that people with optimistic outlooks have better immune function and cope better with stress.
Pain control. Most physicians do not spend enough time discussing surgical pain prior to the surgery. Doing so, however, can help to alleviate a patient's stress and to minimize unnecessary post-operative pain. Patients are encouraged to develop with their surgeons a pain control plan that includes the types of medications needed, how they will be delivered, and identifying who will be responsible for pain control and anesthesia options. Many people have misconceptions about the use of pain medications that include fear of addiction and dependence. Patients should discuss any concerns or misgivings they have with their physician to clarify the pros and cons of specific medications.
Spirituality. For many patients, spiritual beliefs play an important role in their well being and in coping with health-related problems. Prayer has been shown to be helpful for patients who pray and also for patients who are prayed for. Prayer can be a way to create the relaxation response.
Management of the psychosocial environment. It is important to anticipate and prepare for the changes that surgery will create in the home, family and work environments. Family, friends and colleagues may need information on what to expect, and tasks and duties may need to be redistributed. Time may need to be planned differently. The patient may need special help during the post-operative recovery period, which if planned for in advance, will go more smoothly and comfortably for all involved. In most cases, the needs of the patient, family and friends can be met when the potential problems can be identified and addressed up front.
If a surgical preparation program is not available through your hospital, you can develop one for yourself.
An excellent resource is Preparing for Surgery: A Mind-Body Approach to Enhance Healing and Recovery, a step-by-step manual written by Dr. Reeves and his colleague, William Deardorf. It may be borrowed from the Resource Center's library or purchased ($17.95 plus tax) in Reflections. Additionally, please note that the Resource Center offers a variety of groups and classes that teach relaxation and other mind-body techniques. For information, call the Center at 310-794-6644.