Optimizing the Patient for Surgery The Pre-op Psychological Survey

B By MICHAEL J. ASKEN, PhD, and DANIELLE E. LADIE, MD, MPH, FACS

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.