From time immemorial, it seems, surgeons have gone about their work with one goal in mind: to use their technical skills to improve a patient’s physical condition. Their focus was on the specific procedure, and the patient was more or less a passive participant
But what if the patient were not fully prepared psychologically for the surgery, had unrealistic expectations about its benefits, or was unlikely to follow the post-surgery guidelines that could lead to the best outcome?
In recent years, these concerns have helped broaden the context of surgery and in many cases have brought a new member to the larger surgical team, before the actual surgery: the mental health clinician. Increasingly, surgery is viewed in a fuller context; what happens before and after are very important as well.
To explore this burgeoning area of interest, David B. Sarwer, PhD, and Andrew R. Block, PhD, have edited Presurgical Psychological Screening: Understanding Patients, Improving Outcomes, recently published by the American Psychological Association. Block is a board-certified clinical health psychologist with the Texas Back Institute. Sarwer is a professor of Psychology in Psychiatry at Penn Medicine, where he is director of clinical services at the Center for Weight and Eating Disorders and director of the Albert J. Stunkard Weight Management Program. He is principal or co-principal investigator on several grants from the National Institutes of Health, studying the psychological and behavioral aspects of obesity and, more specifically, bariatric surgery.
Sarwer’s years of research on such topics as body image, plastic and bariatric surgery, and diet have not gone unnoticed by the popular press. In November, he was interviewed in the Huffington Post by a licensed psychotherapist/social worker who described Sarwer as a “multi-talented psychologist” and “one of America's leading body image researchers.” An honor last July from the American Society of Metabolic and Bariatric Surgery confirmed Sarwer’s stature among professionals as well: he received the 2012 Circle of Excellence Award, the first time the Society has bestowed the award on a mental-health professional.
In acknowledging the award, Sarwer noted that, since the inception of Penn’s Metabolic & Bariatric Surgery Program 15 years ago, he has been working with Dr. Noel Williams and other bariatric surgeons. “I’m humbled to see our role in clinical care, as well as our research contributions to the field, recognized in this way.” (The chapter on bariatric surgery, in fact, was written by Sarwer and others affiliated with Penn’s Center for Weight and Eating Disorders, including Thomas Wadden, PhD, its director.)
The new book came about as Sarwer and Block began to see the field of presurgical psychological screening (PPS) gaining wider acceptance. There are chapters on various procedures, including spine surgery (written by Block), bone marrow and stem cell transplant, gynecologic surgery, and others. In the book’s chapter on cosmetic surgery, written by Sarwer, he observes that plastic surgeons “had long been interested in the psychological factors that motivate individuals to undergo these procedures as well as the psychological changes that frequently occur postoperatively.” It appears, however, that other surgeons were not as quick to realize the importance of such factors.
“As surgical techniques and equipment evolve ever more rapidly, it is perhaps natural to think of surgery as a technological process,” write Sarwer and Block in their introduction. “However, as the rapidly expanding field of PPS demonstrates, it is critical that surgeons expand their vision beyond the physical causes of medical conditions. Emotional distress, substance abuse, personality disorders, and willingness to comply with medical regimens – all these and many other psychological issues can strongly influence the outcome of surgery.”
Even when the surgery is a success, the patient may not experience any improvement in his symptoms. That’s why, Sarwer and Block assert, “maximizing the likelihood of successful surgical outcome is in everyone’s interest.”
Sometimes, those issues may actually stop the surgery from happening. In Sarwer’s chapter on cosmetic surgery, he cites the American Psychiatric Association’s definition of body dysmorphic disorder: “a preoccupation with a slight or imagined defect in appearance that leads to substantial distress or impairment in social, occupational, or other areas of functioning.” The case example he includes at the end of the chapter describes a 55-year-old woman who came to a plastic surgeon with concerns about some wrinkling around her mouth that she said made a scar from a childhood accident more visible. But in the surgeon’s view, the scar was “more or less invisible from conversational distance.” The patient agreed to a psychological evaluation, where she repeated her belief that the scar left her looking deformed. Again, the mental health professional thought the scar was scarcely visible. The professional also got her to talk about her reluctance to leave her house and her pattern of applying and reapplying makeup to hide her scar. The result: she agreed to delay surgery and engage in psychotherapy.
The mental health professional/clinician can function as a valuable member of the surgical team – but Sarwer and Block argue that patients must be intimately involved as well, primarily through compliance. As they put it, “For the surgery to achieve its goals, patients must be active participants in their recovery. Appropriate use of medications, exercise, diet, follow-up visits with the medical treatment team, and many more activities are often critical for success.” The mental health clinician can help evaluate how likely the patients are to follow through in this way.
The editors make clear that presurgical psychological screening should not be seen as a predictor of postoperative outcomes. Instead, PPS assesses risk: how are patients likely to do during surgery and after? Sarwer and Block also emphasize that such screening is relatively new. In their introduction, they note that “it is critical that surgeons expand their vision beyond the physical causes of medical conditions. . . . It is our hope that this book will increase the use and effectiveness of PPS so that patients can obtain the best possible treatment outcomes.”