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Psychological aspects of surgery
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Psychological aspects of surgery
The most common psychiatric problems identified in surgical patients • Mood disorder (comprising two highly correlated symptom dimensions – anxiety and depression) • Adjustment disorders • Abnormal illness behaviour and somatization • Cognitive impairment • Substance abuse
Margaret Evison
1
Surgery can be a major life event, depending on its seriousness and its meaning for the patient. It is usually seen as stressful and can be demanding of the individual’s coping resources. The vulnerability of patients to psychological morbidity can be increased by preceding illness and upset, the surgery and its consequences, anaesthesia and hospitalization, and postoperative difficulties. Patients with appreciable physical illness have at least twice the rate of psychiatric disorder found in the general population; hospitalized patients show high levels of psychological distress, with the prevalence of psychiatric disorders in non-psychiatric hospital wards as high as 37.3%. Generally, hospitalized surgical patients show higher levels of psychological distress than hospitalized medical patients.
differences in the level of perceived stress associated with different surgical procedures, and substantial individual differences in the level of distress with the same surgical procedure: the perceived distress depends on the meaning an individual assigns to it, the availability of resources to manage it and the efficacy of self-management. Thus perceived pain, distress and anxiety are not solely proportional to the amount of tissue injury and predictable pain associated with the surgery. Levels of distress also change with repetition of the treatment.
Impact of psychological distress There are many reasons for taking seriously the psychological care of patients. There is growing evidence that functions of the nervous and immune system are interactive, though it remains unclear whether depressive illness and anxiety disorders lead to an impairment in resistance to somatic illness, as opposed to mood disorder being secondary to physical illness. Whatever the mechanism, depression accompanying chronic medical illness is associated with increased morbidity, length of stay in hospital and overall disability. Psychological distress impairs quality of life, reduces the ability of patients to adhere to and benefit from treatments for medical conditions and attempts at self-management, and is associated with poor outcome for physical illness and less patient satisfaction. Medical care is more costly and complex when physical disorder is accompanied by psychological comorbidity. The costs associated with non-compliance, apart from the prolongation of suffering caused by illness, include extra visits to the doctor, longer recovery times, extra time off work and avoidable hospitalization. While no major sociodemographic variables or personality characteristics have been found to be associated with non-compliance, there is evidence that patient mood, patient perceptions and quality of communication with the surgical team affect this. Figure 2 describes the results of a study of hospital doctors’ management of psychological problems.
The role of the surgical team The primary responsibility for the assessment and treatment of many psychological problems – whether at initial consultation, during a hospital stay or follow-up – falls to the surgical team. The team needs the skills to identify problems in patients, to offer appropriate psychological care when possible, and to know when and how to refer further. The most common problems presenting to the team are shown in Figure 1. Delirium and organic brain disorders, diagnostic problems, severe depression and disturbed behaviour are often referred to formal hospital psychiatric services, depending on availability of services and the preparedness of doctors and patients to use them. Awareness by the surgical team of the importance of dealing with psychological problems, and the extra time it may involve, is more than offset by the savings that result from reductions in inappropriate medical investigations and treatments.
Levels of psychological distress Levels of distress in patients are highest on the day before surgery and following recovery from anaesthesia, but then continue to be high, suggesting that psychological vulnerability is linked not only to the threat of anaesthesia and surgery, but also to ongoing discomforts and uncertainties, and so to recovery. There are wide
Patient factors When assessing psychological distress, it is useful to consider patient vulnerability factors.
Margaret Evison is a Consultant Clinical Psychologist and the Psychological Support Coordinator, based at the Richard Dimbleby Cancer Information and Support Service, within Guy’s and St Thomas’ NHS Foundation Trust, London, UK. She qualified from the University of Melbourne, Australia, and has a particular interest in clinical health psychology in cancer care.
THE FOUNDATION YEARS 1:1
Past psychiatric history can indicate previous patterns of coping with stressful life events, and any previous history of significant body image problems.
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© 2005 The Medicine Publishing Company Ltd
COMMUNICATION SKILLS
best be dealt with by encouraging same-physician consultation, understanding the patient’s needs and beliefs, and helping the patient focus on the psychological needs that can be met. In the past medical history of patients prone to excessive surgery, there may be a childhood history of abuse and deprivation, a family history of multiple surgeries, a history of pain-related surgeries, particularly for similar pains, and multiple physician contacts and disappointment with therapeutic results. These patients often present with persistent unrelieved pain, a conviction of an organic cause, an insistence that the physician should cure it, and nonresponses to other interventions.
Results of a study of hospital doctors’ management of psychological problems1 A study of 194 hospital doctors in Oxford and their management of psychological problems found that 67% of surgeons believed that psychological factors could influence the course and outcome of the physical disorder, and 73% believed that it was an important part of their work. However, almost half (44%) said that it was impractical for hospital surgeons to assess and treat emotional problems, and 78% would like more time to talk to their patients. Hospital surgeons were significantly less interested in emotional problems than physicians, and felt less responsible for them. Nevertheless, 60% of surgeons agreed that the variety of social and emotional care enhanced interest in their work.
Denial plays a part in the adjustment to acute medical illness. It is a normal initial response and is effective against short-term stressors or minor illness, but inappropriate in the long term, though it may reduce emotional distress. Patients who deny the severity or the implications of their symptoms are slower to take health-oriented measures, more often need emergency hospital admissions and acquire significantly less information about their physical condition. It is important to determine the level of severity and the persistence of the denial; if denial presents substantially later in the course of an illness, it represents a different and less adaptive coping process. Family pressures can influence it when there is a perceived threat to a close family member; however, the patient’s wish to reduce the emotional burden on the family by withholding or avoiding is not necessarily denial.
1 Mayou R, Smith E B O. Hospital doctors’ management of psychological problems. Br J Psychiatryy 1986; 148: 193–7.
2
Social isolation is associated with an overall twofold elevation in the relative risk of all-cause mortality. The size of support networks, and the quality of relationships in terms of frequency of contacts and the presence of confidants, appear to buffer the effects of stress. There is a positive relationship between social support and numerous outcome measures. Patients undergoing surgery are likely to need more support emotionally, and are vulnerable to changes in established personal relationships. Hospitalization, being bed-ridden or relatively immobile, the over-protectiveness of partners and friends, false reassurance and the avoidance of open communication about aspects of the surgery can all feel isolating and rejecting.
Coping style: the intensity and nature of stress can be influenced by the coping strategies used to combat it. Different descriptions of coping behaviour include active and passive coping, ‘monitoring’ rather than ‘blunting’, and ‘fighting spirit’, all of which relate generally to the individual’s preparedness to be more active in adapting to the situation. While these may be dimensions of underlying personality or learned dispositions to cope, their effectiveness has to be related to disease status, disease stage and the appropriateness of specific coping responses in a particular environment (e.g. a hospital ward). While psychological preparation for surgery seems important for some patients (‘the work of worrying’), avoidant coping can be adaptive for stressors of relatively short duration. In the longer term, active coping appears to be more beneficial. The distinction between emotion-focused coping and problem-focused coping at different stages of surgery can be a useful one; when patients are unable to be physically active in the management of problems, they can be rehearsing aspects of coping mentally (cognitive problemfocused coping) or they can be dealing with the emotional aspects of the surgery and its implications for them.
Objective recent life stress is associated with increased responsivity to surgical stress. Severity of symptoms may be linked to poorer disease progression, as well as to mood and personality variables. Previous surgical experience and the reported experience of others can significantly affect mood and attitude to surgery. Personality: patients who are anxious by disposition, with relatively unstable coping mechanisms and a proneness to psychoneurosis, are likely to use maladaptive coping strategies in what is perceived as a threatening situation, compared with patients with low trait anxiety. Patients who are naturally anxious are prone to greater distress, somatization, pain and excessive surgery. Anaesthesia can be particularly difficult in patients for whom control is important. Patients with personality disorder may be more distressed and find interactions with hospital staff difficult.
Socio-economic status, ethnic and cultural variables affect family support patterns, marginalization, lifestyle and beliefs about the body, diet and health, and should be understood if possible. Poverty and economic powerlessness make patients more vulnerable. Doctors experience greater communication difficulties with those from different ethnic and cultural backgrounds. At issue is not only the patient’s command of English, but also the clinician’s use of technical language and medical jargon. The use of interpreters, nurses as patients’ advocates and cultural consultants can provide information on how people from different cultures view illness and establish pathways to healing.
Somatization and proneness to excessive surgery: about 30–70% of patients seen in hospital outpatient clinics have no physical pathology. The request for physical treatment in the absence of physical pathology, but with underlying emotional pathology, can
THE FOUNDATION YEARS 1:1
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© 2005 The Medicine Publishing Company Ltd
COMMUNICATION SKILLS
Marital status: being married is linked to longevity and decreased likelihood of mortality from almost every cause of death.
time and inexperience in handling psychological needs. Support provided by other patients is not to be underestimated, because of their empathy with patient concerns.
Gender: women are more prone to neurotic/affective disorders than men. In addition, they may be more vulnerable because of a history of sexual and childhood abuse. Perceived helplessness and invasion of the privacy of one’s body with surgery and under anaesthetic may reverberate with earlier similar memories and cause distress.
Communication The consultation between doctor and patient is important, as it provides patients with an opportunity to explain their problems and concerns to the doctor, and allows relevant information and advice about treatment to be received by the patient. Despite the introduction of communication skills training into the medical student curriculum, the process and outcome are not always satisfactory to patients. Complaints often focus on deficits in communication and patient dissatisfaction with the consultation. Patients’ perceptions of their vulnerability to an illness, the severity of that illness, the likely effectiveness of treatment and the cost and barriers to treatment, are all related to compliance, patient satisfaction and mood. These perceptions are all influenced by the quality of the doctor–patient consultation. Communication is a two-way process, relying on verbal and non-verbal skills. Consultations differ in the extent to which they are doctor-centred or patient-centred; these differences are established by both doctor and patient needs and expectations. Doctors’ attitudes vary as to how much patients should be actively involved in consultation and decision-making about the management of clinical problems. Differences also exist in the extent to which doctors concentrate on the technical or psychosocial aspects of care and respond to emotional agendas and non-verbal cues. An active coping style in a patient influences not only the seeking out of information about problems and treatments, but also the extent to which the doctor or the patient determines what is discussed. A patient-centred consultation seems generally preferable, but it will depend partly on patient expectations and beliefs: patients may want a clear diagnosis and an understanding of a health problem, or less information and more emotional support and empathy. These expectations should be established early. Patient disclosure is inhibited by focusing on purely physical aspects early, by giving advice and reassurance, and by using closed, leading and multiple questions. It is promoted by asking questions about psychological morbidity, by being empathic, by making educated guesses about how a patient is feeling, and by summarizing patients’ comments. It can be useful to establish the impact of the illness on several important areas – daily functioning, the relationship with the partner, mood and, if necessary, body perception. Longer consultations do not necessarily result in better outcomes.
Age: age affects levels of psychological distress, as there is evidence of less anxiety and depression in later life. Older people have fewer existential worries and less difficulty in dealing with medical problems. However, they encounter more problems dealing with the practical limitations of their illness and treatment. Alcohol abuse increases psychological distress and causes psychological morbidity.
Management factors The hospital as a source of stress Hospitalization is often conceptualized as a source of stress. Patients worry about many aspects of hospital admission (Figure 3). Some of these worries are inevitable because of the unpredictable nature of procedures and outcomes, but they are exacerbated by lack of information, poor communication about diagnosis, prognosis and treatment, and insufficient recognition of concerns. Some of these difficulties may be particular to wards with unusual clinical conditions, and to some patients, such as disabled or psychiatric patients. Care can be taken to reduce the impact of environmental factors, particularly sleep deprivation, constant noise, the presence of monitoring equipment and lack of orienting cues. Support on the ward is valuable; frequent visits from spouses have predicted a faster recovery of patients from cardiac surgery. However, support from partners can be limited by the worry of being a threat to loved ones, and nurse support can be limited by an inability to perceive patient concerns, as well as lack of
Aspects of hospitalization that can be sources of stress for patients • Investigations and treatments that may involve pain and uncertainty of outcome • Being away from family and home • Being in an unfamiliar environment that lacks privacy and is shared by other sick people • Dependency on hospital staff • Perceived dangers of medication • Getting on with other patients • Loss of control through anaesthesia and surgery • Awareness or death during anaesthesia • Needle phobia • Nausea and vomiting • Postoperative pain
Information needs to be appropriate, timely and comprehensible to the patient. Patients need time and space to assimilate, and may need to return to certain issues. The use of frightening key words can block further understanding. Anxiety inhibits concentration; the doctor’s consultation style and empathy will affect the level of anxiety and the understanding of the content of the message. The presence of a trusted partner or friend and comfort in the physical environment can help to reduce tension. Factual information and decisions should be backed up where possible by written information or provided in another format. Although patients with deteriorating health are likely to be more psychologically distressed, awareness of the prognosis itself does not cause depression; false reassurance reduces patient confidence, inhibits disclosure and
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COMMUNICATION SKILLS
increases patient and family anger. Doctors should be prepared to explore patients’ unvoiced concerns with them as necessary. As well as increased emphasis on doctor and nurse communication training, there are some interesting interventions aimed at patients. For example, brief training packages made available to patients before a consultation increase their level of participation, and make it more likely that their concerns are dealt with and that they understand information provided by the doctor.
phobia, and sexual problems. Patients undergoing surgery that causes mutilation, such as in the treatment of some head and neck cancers and breast cancer, are vulnerable to body image problems and psychological morbidity. Patients should be asked about how they feel about the change to or loss of the affected part, how it affects daily life, relationships and mood, and whether they are able to look at that area of their body. Fatigue is the primary subjective problem during postoperative convalescence. It is relative to the amount of surgical trauma and can persist for some time. It can also be linked to depression; the withdrawal of hospital support, unexplained physical symptoms, infections caught in hospital, relative immobility, poor appetite,
Specialist nurses can offer information and practical, as well as emotional, support. They can monitor patients’ adjustment and recognize those who need further help and refer on as appropriate. This can result in a fourfold reduction in psychological morbidity. Monitoring each patient once within two months of discharge is as effective as regular monitoring; patients who develop problems later can contact their specialist nurse if they need to. Specialist nurses require effective training in communication, regular supervision and the availability of a clinical psychologist, psychiatrist or counsellor should patients need more specialized treatment. The disadvantage of their use is that other health professionals may leave most of the psychological care of patients to them.
Psychological preparation for surgical patients Information Providing information about surgery helps patients feel in control and may be seen to represent caring. Although general information has little effect on outcome measures, many patients value it; patients require information for informed consent and in that context alone it is regarded as justified, and even a right. The provision of clear sensory information about impending medical procedures combined with procedural information is effective in terms of reducing negative affect, reported pain and other distress. The provision of procedural information alone shows no benefit.
Communicating bad news or talking to very ill patients is stressful; burnout in cancer specialists has been attributed to their perceptions that they had insufficient training in communication skills, which is then linked to low self-efficacy and poor outcome expectancy. Preoperative preparation Generally, reviews of the usefulness of psychological preparation for surgery have concluded that prepared patients have better outcomes than those who receive a placebo intervention or standard care. Some psychological preparation strategies to consider are shown in Figure 4.
Cognitive coping This involves establishing patient concerns and then teaching patients to change their negative thoughts about surgery or the hospital to more realistic or positive ones. It is effective in reducing postoperative pain and distress, and allows patients to exercise control.
Postoperative care Encouraging active coping and early mobilization of surgical patients can be beneficial when appropriate.
Relaxation Behavioural and hypnotic relaxation are particularly useful in reducing blood pressure, panic attacks, pain and anxiety. However, this has been described as an avoidant mode of coping and has been linked to rises in endocrine responses rather than reduction. It may preclude the psychological preparation that is implied with other interventions.
Pain: while pain is related to the level of surgical trauma, it is also influenced by personality variables. Pain and depression are often linked, though it is unclear if depression is causally related to chronic pain or if, as is more likely, pain causes depression. However, the presence of comorbid depression reduces the patient’s capacity to tolerate pain. The cognitive behavioural model focuses on the role of perceived control over pain and the perceived interference of pain in daily activities. Pleasurable activities are avoided because of fear of the pain, and this acts as a stimulus to depress mood. Patients can be encouraged to modify their beliefs about pain and its effects on their activities. Patients’ self-reporting of pain is more important in pain assessment than behavioural or vital signs of it. Patients may choose to deny pain for a number of reasons – cultural, personal (the need to be seen as stoical), fear of medication, high pain tolerance and low expectations of pain relief.
Behavioural instruction Teaching skills and and exercises that will be useful after surgery, such as leg and foot exercises, deep breathing and turning the body in bed, can facilitate postoperative recovery. Modelling Watching a film or an actor replay someone undergoing the procedure, overcoming anxiety and coping well can encourage psychological preparation and positive thinking. Reassurance Few reviews have suggested that reassurance alone is effective.
Altered body image and loss of body function after surgery can precipitate a chronic anxiety or depressive disorder, impairment in social and interpersonal relationships, avoidance behaviour and
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ETHICAL AND LEGAL
limited opportunities for social support, limited coping and the possibility of financial and other concerns, can all influence fatigue and postoperative mood.
Confidentiality and computers
Further training
David Jones
In response to the gap between the need for and the provision of psychological support in general hospitals in the UK, two useful joint working party reports hve been published by the Royal College of Psychiatrists with the Royal Colleges of Physicians and of Surgeons, which look in more detail at service provision, the recognition of psychological morbidity in patients and many of the issues raised above. At present doctors are given some psychiatric teaching and communication skills training as students. This may continue as young doctors with access to further communication skills training, including breaking bad news: as well, greater emphasis is often given now to dealing with patients in a more patient-centred and whole-person way, and there can be increasing awareness of this aspect of patient care. Further consideration could be given to other training possibilities, such as on-the-job teaching or supervision by psychological and psychiatric staff, which can help with guidelines for referral on to more specialist support services. Screening programmes can alert clinical teams to psychological morbidity in patients, encouraging further discussion of other important aspects of patient experience.
Keeping patient information confidential is not a new issue (it is one of the professional responsibilities placed on doctors by the GMC), but because of the rapid rise in electronic processing it has acquired greater emphasis. In addition, there is increasing dependence on information technology in health care and a greater need for information to be made more widely available. To address the consequent security implications, the UK government has produced new guidelines and there have been changes to the law. While much of the provision of security may lie at a corporate level, individual health workers also have obligations, dictated by these guidelines and laws. Information security is about preserving confidentiality, integrity and availability of information (Figure 1). Security can never be perfect and there is an element of mutual incompatibility with this triad. Making information more easily available, even for authorized access, can compromise confidentiality and the more the information is made available by accessing, updating and transmitting, the more likely its integrity may suffer. Failure of these three principles can cause problems. Service disruption can occur if vital information is unavailable; there can be loss of privacy; patient harm can result if vital information is incorrect or unavailable, and financial loss can be incurred with the replacement of lost equipment and information. There are also the wider issues of falling foul of the law and loss of public confidence.
Department of Health directives In the UK, a number of government documents relate to information technology. The most relevant are the Department of Health’s prescription for the future use of information technology Information for Health and the more technical Building the Information Core. These describe computer systems, using lifelong electronic records, which are available round the clock to health workers in all disciplines across the whole NHS. In England, the development of these systems is subject to the National Programme for Informa-
FURTHER READING Mayou R, Smith E B O. Hospital doctors’ management of psychological problems. Br J Psychiatry 1986; 148: 194–7. Salmon P. Psychology of medicine and surgery. London: Wiley, 2000. The Royal Colleges of Physicians and Psychiatrists. Joint working party report on the psychological care of medical patients: recognition of need and service provision. London: The Royal College of Physicians and the Royal College of Psychiatrists, 1995. The Royal Colleges of Physicians and Psychiatrists. Joint working party report on the psychological care of medical patients: a practical guide, 2nd edn. London: The Royal College of Physicians and the Royal College of Psychiatrists, 2003. The Royal Colleges of Physicians and Psychiatrists. Joint working party report on the psychological care of surgical patients. London: The Royal College of Surgeons of England and the Royal College of Psychiatrists, 1997 (under revision).
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David Jones is Consultant Anaesthetist at the Royal Gwent Hospital, Newport, Wales. He qualified from Manchester University and trained in anaesthesia in Birmingham and Cardiff. He gained an MSc in medical informatics at the University of Wales, Cardiff. His interests include daycase anaesthesia, diving medicine and informatics.
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© 2005 The Medicine Publishing Company Ltd
Psychological aspects of surgery
The most common psychiatric problems identified in surgical patients • Mood disorder (comprising two highly correlated symptom dimensions – anxiety and depression) • Adjustment disorders • Abnormal illness behaviour and somatization • Cognitive impairment • Substance abuse
Margaret Evison
1
Surgery can be a major life event, depending on its seriousness and its meaning for the patient. It is usually seen as stressful and can be demanding of the individual’s coping resources. The vulnerability of patients to psychological morbidity can be increased by preceding illness and upset, the surgery and its consequences, anaesthesia and hospitalization, and postoperative difficulties. Patients with appreciable physical illness have at least twice the rate of psychiatric disorder found in the general population; hospitalized patients show high levels of psychological distress, with the prevalence of psychiatric disorders in non-psychiatric hospital wards as high as 37.3%. Generally, hospitalized surgical patients show higher levels of psychological distress than hospitalized medical patients.
differences in the level of perceived stress associated with different surgical procedures, and substantial individual differences in the level of distress with the same surgical procedure: the perceived distress depends on the meaning an individual assigns to it, the availability of resources to manage it and the efficacy of self-management. Thus perceived pain, distress and anxiety are not solely proportional to the amount of tissue injury and predictable pain associated with the surgery. Levels of distress also change with repetition of the treatment.
Impact of psychological distress There are many reasons for taking seriously the psychological care of patients. There is growing evidence that functions of the nervous and immune system are interactive, though it remains unclear whether depressive illness and anxiety disorders lead to an impairment in resistance to somatic illness, as opposed to mood disorder being secondary to physical illness. Whatever the mechanism, depression accompanying chronic medical illness is associated with increased morbidity, length of stay in hospital and overall disability. Psychological distress impairs quality of life, reduces the ability of patients to adhere to and benefit from treatments for medical conditions and attempts at self-management, and is associated with poor outcome for physical illness and less patient satisfaction. Medical care is more costly and complex when physical disorder is accompanied by psychological comorbidity. The costs associated with non-compliance, apart from the prolongation of suffering caused by illness, include extra visits to the doctor, longer recovery times, extra time off work and avoidable hospitalization. While no major sociodemographic variables or personality characteristics have been found to be associated with non-compliance, there is evidence that patient mood, patient perceptions and quality of communication with the surgical team affect this. Figure 2 describes the results of a study of hospital doctors’ management of psychological problems.
The role of the surgical team The primary responsibility for the assessment and treatment of many psychological problems – whether at initial consultation, during a hospital stay or follow-up – falls to the surgical team. The team needs the skills to identify problems in patients, to offer appropriate psychological care when possible, and to know when and how to refer further. The most common problems presenting to the team are shown in Figure 1. Delirium and organic brain disorders, diagnostic problems, severe depression and disturbed behaviour are often referred to formal hospital psychiatric services, depending on availability of services and the preparedness of doctors and patients to use them. Awareness by the surgical team of the importance of dealing with psychological problems, and the extra time it may involve, is more than offset by the savings that result from reductions in inappropriate medical investigations and treatments.
Levels of psychological distress Levels of distress in patients are highest on the day before surgery and following recovery from anaesthesia, but then continue to be high, suggesting that psychological vulnerability is linked not only to the threat of anaesthesia and surgery, but also to ongoing discomforts and uncertainties, and so to recovery. There are wide
Patient factors When assessing psychological distress, it is useful to consider patient vulnerability factors.
Margaret Evison is a Consultant Clinical Psychologist and the Psychological Support Coordinator, based at the Richard Dimbleby Cancer Information and Support Service, within Guy’s and St Thomas’ NHS Foundation Trust, London, UK. She qualified from the University of Melbourne, Australia, and has a particular interest in clinical health psychology in cancer care.
THE FOUNDATION YEARS 1:1
Past psychiatric history can indicate previous patterns of coping with stressful life events, and any previous history of significant body image problems.
6
© 2005 The Medicine Publishing Company Ltd
COMMUNICATION SKILLS
best be dealt with by encouraging same-physician consultation, understanding the patient’s needs and beliefs, and helping the patient focus on the psychological needs that can be met. In the past medical history of patients prone to excessive surgery, there may be a childhood history of abuse and deprivation, a family history of multiple surgeries, a history of pain-related surgeries, particularly for similar pains, and multiple physician contacts and disappointment with therapeutic results. These patients often present with persistent unrelieved pain, a conviction of an organic cause, an insistence that the physician should cure it, and nonresponses to other interventions.
Results of a study of hospital doctors’ management of psychological problems1 A study of 194 hospital doctors in Oxford and their management of psychological problems found that 67% of surgeons believed that psychological factors could influence the course and outcome of the physical disorder, and 73% believed that it was an important part of their work. However, almost half (44%) said that it was impractical for hospital surgeons to assess and treat emotional problems, and 78% would like more time to talk to their patients. Hospital surgeons were significantly less interested in emotional problems than physicians, and felt less responsible for them. Nevertheless, 60% of surgeons agreed that the variety of social and emotional care enhanced interest in their work.
Denial plays a part in the adjustment to acute medical illness. It is a normal initial response and is effective against short-term stressors or minor illness, but inappropriate in the long term, though it may reduce emotional distress. Patients who deny the severity or the implications of their symptoms are slower to take health-oriented measures, more often need emergency hospital admissions and acquire significantly less information about their physical condition. It is important to determine the level of severity and the persistence of the denial; if denial presents substantially later in the course of an illness, it represents a different and less adaptive coping process. Family pressures can influence it when there is a perceived threat to a close family member; however, the patient’s wish to reduce the emotional burden on the family by withholding or avoiding is not necessarily denial.
1 Mayou R, Smith E B O. Hospital doctors’ management of psychological problems. Br J Psychiatryy 1986; 148: 193–7.
2
Social isolation is associated with an overall twofold elevation in the relative risk of all-cause mortality. The size of support networks, and the quality of relationships in terms of frequency of contacts and the presence of confidants, appear to buffer the effects of stress. There is a positive relationship between social support and numerous outcome measures. Patients undergoing surgery are likely to need more support emotionally, and are vulnerable to changes in established personal relationships. Hospitalization, being bed-ridden or relatively immobile, the over-protectiveness of partners and friends, false reassurance and the avoidance of open communication about aspects of the surgery can all feel isolating and rejecting.
Coping style: the intensity and nature of stress can be influenced by the coping strategies used to combat it. Different descriptions of coping behaviour include active and passive coping, ‘monitoring’ rather than ‘blunting’, and ‘fighting spirit’, all of which relate generally to the individual’s preparedness to be more active in adapting to the situation. While these may be dimensions of underlying personality or learned dispositions to cope, their effectiveness has to be related to disease status, disease stage and the appropriateness of specific coping responses in a particular environment (e.g. a hospital ward). While psychological preparation for surgery seems important for some patients (‘the work of worrying’), avoidant coping can be adaptive for stressors of relatively short duration. In the longer term, active coping appears to be more beneficial. The distinction between emotion-focused coping and problem-focused coping at different stages of surgery can be a useful one; when patients are unable to be physically active in the management of problems, they can be rehearsing aspects of coping mentally (cognitive problemfocused coping) or they can be dealing with the emotional aspects of the surgery and its implications for them.
Objective recent life stress is associated with increased responsivity to surgical stress. Severity of symptoms may be linked to poorer disease progression, as well as to mood and personality variables. Previous surgical experience and the reported experience of others can significantly affect mood and attitude to surgery. Personality: patients who are anxious by disposition, with relatively unstable coping mechanisms and a proneness to psychoneurosis, are likely to use maladaptive coping strategies in what is perceived as a threatening situation, compared with patients with low trait anxiety. Patients who are naturally anxious are prone to greater distress, somatization, pain and excessive surgery. Anaesthesia can be particularly difficult in patients for whom control is important. Patients with personality disorder may be more distressed and find interactions with hospital staff difficult.
Socio-economic status, ethnic and cultural variables affect family support patterns, marginalization, lifestyle and beliefs about the body, diet and health, and should be understood if possible. Poverty and economic powerlessness make patients more vulnerable. Doctors experience greater communication difficulties with those from different ethnic and cultural backgrounds. At issue is not only the patient’s command of English, but also the clinician’s use of technical language and medical jargon. The use of interpreters, nurses as patients’ advocates and cultural consultants can provide information on how people from different cultures view illness and establish pathways to healing.
Somatization and proneness to excessive surgery: about 30–70% of patients seen in hospital outpatient clinics have no physical pathology. The request for physical treatment in the absence of physical pathology, but with underlying emotional pathology, can
THE FOUNDATION YEARS 1:1
7
© 2005 The Medicine Publishing Company Ltd
COMMUNICATION SKILLS
Marital status: being married is linked to longevity and decreased likelihood of mortality from almost every cause of death.
time and inexperience in handling psychological needs. Support provided by other patients is not to be underestimated, because of their empathy with patient concerns.
Gender: women are more prone to neurotic/affective disorders than men. In addition, they may be more vulnerable because of a history of sexual and childhood abuse. Perceived helplessness and invasion of the privacy of one’s body with surgery and under anaesthetic may reverberate with earlier similar memories and cause distress.
Communication The consultation between doctor and patient is important, as it provides patients with an opportunity to explain their problems and concerns to the doctor, and allows relevant information and advice about treatment to be received by the patient. Despite the introduction of communication skills training into the medical student curriculum, the process and outcome are not always satisfactory to patients. Complaints often focus on deficits in communication and patient dissatisfaction with the consultation. Patients’ perceptions of their vulnerability to an illness, the severity of that illness, the likely effectiveness of treatment and the cost and barriers to treatment, are all related to compliance, patient satisfaction and mood. These perceptions are all influenced by the quality of the doctor–patient consultation. Communication is a two-way process, relying on verbal and non-verbal skills. Consultations differ in the extent to which they are doctor-centred or patient-centred; these differences are established by both doctor and patient needs and expectations. Doctors’ attitudes vary as to how much patients should be actively involved in consultation and decision-making about the management of clinical problems. Differences also exist in the extent to which doctors concentrate on the technical or psychosocial aspects of care and respond to emotional agendas and non-verbal cues. An active coping style in a patient influences not only the seeking out of information about problems and treatments, but also the extent to which the doctor or the patient determines what is discussed. A patient-centred consultation seems generally preferable, but it will depend partly on patient expectations and beliefs: patients may want a clear diagnosis and an understanding of a health problem, or less information and more emotional support and empathy. These expectations should be established early. Patient disclosure is inhibited by focusing on purely physical aspects early, by giving advice and reassurance, and by using closed, leading and multiple questions. It is promoted by asking questions about psychological morbidity, by being empathic, by making educated guesses about how a patient is feeling, and by summarizing patients’ comments. It can be useful to establish the impact of the illness on several important areas – daily functioning, the relationship with the partner, mood and, if necessary, body perception. Longer consultations do not necessarily result in better outcomes.
Age: age affects levels of psychological distress, as there is evidence of less anxiety and depression in later life. Older people have fewer existential worries and less difficulty in dealing with medical problems. However, they encounter more problems dealing with the practical limitations of their illness and treatment. Alcohol abuse increases psychological distress and causes psychological morbidity.
Management factors The hospital as a source of stress Hospitalization is often conceptualized as a source of stress. Patients worry about many aspects of hospital admission (Figure 3). Some of these worries are inevitable because of the unpredictable nature of procedures and outcomes, but they are exacerbated by lack of information, poor communication about diagnosis, prognosis and treatment, and insufficient recognition of concerns. Some of these difficulties may be particular to wards with unusual clinical conditions, and to some patients, such as disabled or psychiatric patients. Care can be taken to reduce the impact of environmental factors, particularly sleep deprivation, constant noise, the presence of monitoring equipment and lack of orienting cues. Support on the ward is valuable; frequent visits from spouses have predicted a faster recovery of patients from cardiac surgery. However, support from partners can be limited by the worry of being a threat to loved ones, and nurse support can be limited by an inability to perceive patient concerns, as well as lack of
Aspects of hospitalization that can be sources of stress for patients • Investigations and treatments that may involve pain and uncertainty of outcome • Being away from family and home • Being in an unfamiliar environment that lacks privacy and is shared by other sick people • Dependency on hospital staff • Perceived dangers of medication • Getting on with other patients • Loss of control through anaesthesia and surgery • Awareness or death during anaesthesia • Needle phobia • Nausea and vomiting • Postoperative pain
Information needs to be appropriate, timely and comprehensible to the patient. Patients need time and space to assimilate, and may need to return to certain issues. The use of frightening key words can block further understanding. Anxiety inhibits concentration; the doctor’s consultation style and empathy will affect the level of anxiety and the understanding of the content of the message. The presence of a trusted partner or friend and comfort in the physical environment can help to reduce tension. Factual information and decisions should be backed up where possible by written information or provided in another format. Although patients with deteriorating health are likely to be more psychologically distressed, awareness of the prognosis itself does not cause depression; false reassurance reduces patient confidence, inhibits disclosure and
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increases patient and family anger. Doctors should be prepared to explore patients’ unvoiced concerns with them as necessary. As well as increased emphasis on doctor and nurse communication training, there are some interesting interventions aimed at patients. For example, brief training packages made available to patients before a consultation increase their level of participation, and make it more likely that their concerns are dealt with and that they understand information provided by the doctor.
phobia, and sexual problems. Patients undergoing surgery that causes mutilation, such as in the treatment of some head and neck cancers and breast cancer, are vulnerable to body image problems and psychological morbidity. Patients should be asked about how they feel about the change to or loss of the affected part, how it affects daily life, relationships and mood, and whether they are able to look at that area of their body. Fatigue is the primary subjective problem during postoperative convalescence. It is relative to the amount of surgical trauma and can persist for some time. It can also be linked to depression; the withdrawal of hospital support, unexplained physical symptoms, infections caught in hospital, relative immobility, poor appetite,
Specialist nurses can offer information and practical, as well as emotional, support. They can monitor patients’ adjustment and recognize those who need further help and refer on as appropriate. This can result in a fourfold reduction in psychological morbidity. Monitoring each patient once within two months of discharge is as effective as regular monitoring; patients who develop problems later can contact their specialist nurse if they need to. Specialist nurses require effective training in communication, regular supervision and the availability of a clinical psychologist, psychiatrist or counsellor should patients need more specialized treatment. The disadvantage of their use is that other health professionals may leave most of the psychological care of patients to them.
Psychological preparation for surgical patients Information Providing information about surgery helps patients feel in control and may be seen to represent caring. Although general information has little effect on outcome measures, many patients value it; patients require information for informed consent and in that context alone it is regarded as justified, and even a right. The provision of clear sensory information about impending medical procedures combined with procedural information is effective in terms of reducing negative affect, reported pain and other distress. The provision of procedural information alone shows no benefit.
Communicating bad news or talking to very ill patients is stressful; burnout in cancer specialists has been attributed to their perceptions that they had insufficient training in communication skills, which is then linked to low self-efficacy and poor outcome expectancy. Preoperative preparation Generally, reviews of the usefulness of psychological preparation for surgery have concluded that prepared patients have better outcomes than those who receive a placebo intervention or standard care. Some psychological preparation strategies to consider are shown in Figure 4.
Cognitive coping This involves establishing patient concerns and then teaching patients to change their negative thoughts about surgery or the hospital to more realistic or positive ones. It is effective in reducing postoperative pain and distress, and allows patients to exercise control.
Postoperative care Encouraging active coping and early mobilization of surgical patients can be beneficial when appropriate.
Relaxation Behavioural and hypnotic relaxation are particularly useful in reducing blood pressure, panic attacks, pain and anxiety. However, this has been described as an avoidant mode of coping and has been linked to rises in endocrine responses rather than reduction. It may preclude the psychological preparation that is implied with other interventions.
Pain: while pain is related to the level of surgical trauma, it is also influenced by personality variables. Pain and depression are often linked, though it is unclear if depression is causally related to chronic pain or if, as is more likely, pain causes depression. However, the presence of comorbid depression reduces the patient’s capacity to tolerate pain. The cognitive behavioural model focuses on the role of perceived control over pain and the perceived interference of pain in daily activities. Pleasurable activities are avoided because of fear of the pain, and this acts as a stimulus to depress mood. Patients can be encouraged to modify their beliefs about pain and its effects on their activities. Patients’ self-reporting of pain is more important in pain assessment than behavioural or vital signs of it. Patients may choose to deny pain for a number of reasons – cultural, personal (the need to be seen as stoical), fear of medication, high pain tolerance and low expectations of pain relief.
Behavioural instruction Teaching skills and and exercises that will be useful after surgery, such as leg and foot exercises, deep breathing and turning the body in bed, can facilitate postoperative recovery. Modelling Watching a film or an actor replay someone undergoing the procedure, overcoming anxiety and coping well can encourage psychological preparation and positive thinking. Reassurance Few reviews have suggested that reassurance alone is effective.
Altered body image and loss of body function after surgery can precipitate a chronic anxiety or depressive disorder, impairment in social and interpersonal relationships, avoidance behaviour and
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limited opportunities for social support, limited coping and the possibility of financial and other concerns, can all influence fatigue and postoperative mood.
Confidentiality and computers
Further training
David Jones
In response to the gap between the need for and the provision of psychological support in general hospitals in the UK, two useful joint working party reports hve been published by the Royal College of Psychiatrists with the Royal Colleges of Physicians and of Surgeons, which look in more detail at service provision, the recognition of psychological morbidity in patients and many of the issues raised above. At present doctors are given some psychiatric teaching and communication skills training as students. This may continue as young doctors with access to further communication skills training, including breaking bad news: as well, greater emphasis is often given now to dealing with patients in a more patient-centred and whole-person way, and there can be increasing awareness of this aspect of patient care. Further consideration could be given to other training possibilities, such as on-the-job teaching or supervision by psychological and psychiatric staff, which can help with guidelines for referral on to more specialist support services. Screening programmes can alert clinical teams to psychological morbidity in patients, encouraging further discussion of other important aspects of patient experience.
Keeping patient information confidential is not a new issue (it is one of the professional responsibilities placed on doctors by the GMC), but because of the rapid rise in electronic processing it has acquired greater emphasis. In addition, there is increasing dependence on information technology in health care and a greater need for information to be made more widely available. To address the consequent security implications, the UK government has produced new guidelines and there have been changes to the law. While much of the provision of security may lie at a corporate level, individual health workers also have obligations, dictated by these guidelines and laws. Information security is about preserving confidentiality, integrity and availability of information (Figure 1). Security can never be perfect and there is an element of mutual incompatibility with this triad. Making information more easily available, even for authorized access, can compromise confidentiality and the more the information is made available by accessing, updating and transmitting, the more likely its integrity may suffer. Failure of these three principles can cause problems. Service disruption can occur if vital information is unavailable; there can be loss of privacy; patient harm can result if vital information is incorrect or unavailable, and financial loss can be incurred with the replacement of lost equipment and information. There are also the wider issues of falling foul of the law and loss of public confidence.
Department of Health directives In the UK, a number of government documents relate to information technology. The most relevant are the Department of Health’s prescription for the future use of information technology Information for Health and the more technical Building the Information Core. These describe computer systems, using lifelong electronic records, which are available round the clock to health workers in all disciplines across the whole NHS. In England, the development of these systems is subject to the National Programme for Informa-
FURTHER READING Mayou R, Smith E B O. Hospital doctors’ management of psychological problems. Br J Psychiatry 1986; 148: 194–7. Salmon P. Psychology of medicine and surgery. London: Wiley, 2000. The Royal Colleges of Physicians and Psychiatrists. Joint working party report on the psychological care of medical patients: recognition of need and service provision. London: The Royal College of Physicians and the Royal College of Psychiatrists, 1995. The Royal Colleges of Physicians and Psychiatrists. Joint working party report on the psychological care of medical patients: a practical guide, 2nd edn. London: The Royal College of Physicians and the Royal College of Psychiatrists, 2003. The Royal Colleges of Physicians and Psychiatrists. Joint working party report on the psychological care of surgical patients. London: The Royal College of Surgeons of England and the Royal College of Psychiatrists, 1997 (under revision).
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David Jones is Consultant Anaesthetist at the Royal Gwent Hospital, Newport, Wales. He qualified from Manchester University and trained in anaesthesia in Birmingham and Cardiff. He gained an MSc in medical informatics at the University of Wales, Cardiff. His interests include daycase anaesthesia, diving medicine and informatics.
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