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SURGERY PREPARATION II: DESIGNING A PROGRAM

by William W. Deardorff, Ph.D, ABPP.


4 Credit Hours - $79
Last revised: 12/07/2009

Course content © Copyright 2009 - 2017 by William W. Deardorff, Ph.D, ABPP. All rights reserved.



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COURSE OUTLINE

 

Introduction to the Course

Learning Objectives

Overview of a Surgery Preparation Intervention

     Individualized versus Pre-Packaged Programs

Gathering Information about the Surgery

     Coping Style of the Patient

     Understanding and Remembering Medical Information

     Informed Consent

     Information Gathering and the Internet

Cognitive Restructuring

     Preparing the Patient for the Cognitive Behavioral Approach

     Reviewing the Rational Behind Cognitive Behavioral Techniques

     Self-Talk

     The ABCDE Model

          The Three Column Technique

          Styles of Negative Self-Talk

          Challenging Negative Self-Talk

Relaxation Techniques

          Deep Breathing

          Cue-Controlled Relaxation

          Guidelines for Practicing Deep Relaxation

          Obstacles to Practice

     Hypnosis

     Visualization, Imagery, Distraction and Humor

Preparing for Surgery: Interacting with the Healthcare System

     Doctor-Patient Communication Problems and Medical Errors

     Assertiveness Training and Surgery Preparation

          Non-assertive or Submissive

          Aggressive Communication

          Passive-Aggressive

          Assertive Communication

The Doctor-Patient Relationship

Surgery Preparation and Psychosocial Environments

     Family and Friends

     Work and Co-Workers

     Spiritual Issues

Post-Operative Pain Control

     Acute Pain Management Guidelines

     Develop a Pain Control Plan

     Understand Key Concepts in Pain Medication Management

The Business of Surgery Preparation

     Offer the Program in the Surgeon’s Office

     Target Specific Surgery Types

     Offer the Program at the Local Hospital

     Insurance Companies

     Billing and Reimbursement

References

 

INTRODUCTION TO THE COURSE

 

This is the second course in the Surgery Preparation series.  The first course (Surgery Preparation I: Conceptual Models) presented an overview of the field of psychoneuroimmunology as it relates to the process of surgery.  In addition, the various conceptual models of surgery preparation were discussed.  This information provides the rationale for completing a surgery preparation intervention.  

 

This course reviews various surgery preparation interventions and designing a program.  These techniques include cognitive restructuring, relaxation training and imagery, psychosocial interventions, assertiveness training, spiritual issues and pain control.  The course will also review findings in the areas of helping the patient understand and remember medical information, gathering information about the surgery, avoiding medical errors in the hospital, and tailoring the surgery preparation program to the patient’s coping style.

 

A brief overview of ideas for integrating surgery preparation into one’s practice is also discussed.  These “tips” include such things as targeting specific types of surgery, working with a surgery group practice, offering the program at a local hospital as well as billing and reimbursement issues.

 

LEARNING OBJECTIVES

 

·                     Explain cognitive-behavioral interventions for surgery preparation

·                     Describe the difference between information-seekers versus information-avoiders

·                     List three different types of relaxation techniques

·                     List the psychosocial environments that might be targets of surgery preparation

·                     Discuss three patient activities to improve post-operative pain control

   

OVERVIEW OF A SURGERY PREPARATION INTERVENTION

 

The first part of a preparation for surgery intervention should include assessment of the patient.  Having an understanding of common patient fears and worries (as presented in Course I) can help guide the patient assessment (Johnson, 1988; Trousdale, McGrory, Berry, Becker & Harmsen, 1999).    In addition, it is important to obtain an initial evaluation of the patient’s understanding of the surgery and related issues.  This initial assessment can be completed by obtaining answers to the areas listed as follows (Block, 1996; Deardorff and Reeves, 1997; Horne, et. al., 1994).

 

 

Assessing the Patient’s Understanding of Surgery

 

 

What the patient believes is going to happen

 

Their beliefs about why they must have the operation and their anticipated outcome

 

Their knowledge about the operation and postoperative recovery

 

Their previous experience with the surgical process

 

Their understanding about the psychological preparation for surgery program

 

Home, work and family  information

 

Some information about the patient’s motivation for participating in his or her own treatment

 

 

These are very general categories of patient assessment.  The preparation for surgery intervention actually represents a process of ongoing assessment and adjustment of intervention strategies, as dictated by the biopsychosocial model (See Surgery Preparation Course I).  Other important areas of assessment will be discussed under the various treatment components.

 

Individualized versus “Pre-Packaged” Programs

 

Just as there are many conceptual models of psychological preparation for surgery interventions, there are also a variety of methods for developing these types of programs.  Differences occur across programs both in the structure (e.g., individualized, group, or a combination thereof) and content or specific components (e.g., cognitive behavioral, relaxation training, music therapy, etc).  Surgery preparation programs that are individualized involve the patient working with a healthcare professional one-on-one (e.g., psychologist, social worker, nurse, or health educator).  In this approach, the preparation program is completely individualized and can be constantly modified and customized based upon patient issues that are presented.  Although this can be a very effective approach, it is often not feasible due to cost, time constraints, and staff resources.  Therefore, most surgery preparation programs offer a blend of individualized and group treatment with pre-formatted structured components.  No research studies could be located that have investigated whether one approach works better than another (e.g. individual versus group).   

 

Common psychological preparation for surgery program components that fall under the general category of cognitive-behavioral interventions will be reviewed.  These might also be termed “individual self-regulation” approaches as discussed in the previous course.  These are techniques that are implemented by the individual and directly targeting internal processes such as thoughts, emotions, and physiological status.  Subsequently, psychosocial interventions or those that might be termed “social self-regulation”, will be reviewed.

 

GATHERING INFORMATION ABOUT THE SURGERY

 

One of the core components of any psychological preparation for surgery program is helping patients gather relevant information about the surgery process.  The information gathering is impacted by several factors including the coping style of the patient, the patient’s ability to understand and remember important medical information, and the doctor-patient relationship. 

 

Coping Style of the Patient

 

Information-seekers versus information-avoiders.  The provision of information regarding surgery details has generally been found to enhance surgical outcome but this result is impacted by the patient’s coping style.  As reviewed in the previous chapter, some patients are information-seekers while others are information-avoiders.  For information-seekers, the general rule is “the more information the better.”  Alternatively, information-avoiders do much better with only general information about the surgery experience and may even do worse if too much detail is provided.  A very simple set of questions to assess a patient’s coping style relative to information gathering can be found in the Table.  In addition, actual measures that assess an individual’s information-seeking style have been developed (Miller, 1987).  Prior to providing medical information, the patient’s coping style should be assessed in some manner.

 

 

Information-Seekers versus Information-Avoiders

 

 

Does the patient tend to agree or disagree with the following statements?

 

Investigating books, magazines, and television programs about medical conditions and surgeries makes the patient feel more comfortable, confident and in control.

 

The patient prefers to gather very specific and detailed information about his or her health condition.

 

Detailed medical information does not bother the patient

 

 

Early research in surgery preparation demonstrated that patients who possessed accurate information about their surgery, did better overall.  Realistic information allowed patients to develop accurate expectations and coping strategies.  Later research showed that the provision of information was best tempered by the coping style of the patient.  Patients who tend to agree with the above statements are “information-seekers” and do better with more specific and detailed information.  Those who disagree with the above statements do better with very general information.  The patient’s coping style relative to information gathering should be assessed in the early stages of surgery preparation and the intervention designed accordingly.

 

External locus of control and self-efficacy.  In a recent study the effects of patients’ external health locus of control (EHLC) and self-efficacy (SE) on surgery preparation for surgery outcomes were studied in a group of patients facing coronary artery bypass graft surgery (Shelley & Pakenham, 2007).  As discussed by Shelley and Pakenham (2007), and reviewed in this course, two general strategies have been used to improve surgical outcomes: information instruction and cognitive coping.  The authors were interested in how patients’ coping styles might impact the successfulness of surgery preparation.  EHLC refers to “the belief that outcomes in ambiguous health-related situations, such as CABG, are the result of powerful others, including doctors, other care providers, family and friends” (Shelley & Pakenham, p. 184).  EHLC has been found to be a predictor of outcomes to CABG and lower levels of EHLC are associated with improved health outcomes.  SE refers to the patient’s confidence in his or her ability to behave in ways that will lead to desire outcomes.  Studies have related SE to improved patient participation in health care. Given these findings, Shelly and Pakenham (2007) hypothesized that patients who were “matched” on SE and EHLC (high on both, or low on both) would show improved outcomes in response to a surgery preparation program.   Conversely, the researchers hypothesized the “unmatched” patients (one high and the other low) would be better off with standard care (no surgery preparation). The results are complicated but generally supported the hypothesis.

 

This study, and others to be reviewed subsequently, underscores the importance of matching the surgery preparation program to the coping style of the patient.  If a patient is an information-avoider with high EHLC (believes outcome is in the hands of the doctors) and low SE (low confidence that his or her own behavior can impact the treatment outcome), doing an intensive preparation for surgery program with a high level of education has a great likelihood of actually making the patient more distressed about the surgery.   

 

Understanding and Remembering Medical Information

 

Research has consistently demonstrated that surgical patients are dissatisfied with the amount of preoperative information that they receive (see Deardorff & Reeves, 1997; Pizzi, Goldfarb, & Nash, 2001; Webber, 1990 for reviews).  In addition, even if information is provided, several problems have been found including the “readability” of the written information, patients’ level of understanding, and recall for medical information. 

 

Although the situation has improved somewhat, since the Webber (1990) review, surgical consent forms often contain highly detailed information written at a level that is far beyond that which most patients can understand (Pizzi et al., 2001).  Generally, it has been found that surgical informed consent documents are written at the level of a scientific journal or specialized academic magazine.  Clearly, this is beyond the readability capacity of most laypersons facing a surgery.  As concluded by Webber (1990), “in summary, written materials are desired and appreciated by patients; however, more attention needs to be given to producing them at a reading level appropriate to their intended audience” (page 1095).  Possibly due to their frustration in attempts to understand the information, it has been found that about 40% or less of patients actually read surgical informed consent forms carefully (Deardorff & Reeves, 1997).

 

As an example of the “readability” problems, Christopher, Foti, Roy-Bujnowski & Appelbaum (2007) completed a review of 154 clinical mental health research studies that utilized informed consent forms.  All forms were assessed using several standard “readability” formulas.  The overall mean readability scores for the informed consent forms ranged from grades 12 to 14.5.  In addition, the higher the risk of the study, the higher the mean readability score of the forms. 

 

A review of medical informed consent studies reached similar conclusions (Pizzi et al., 2001).  The results of the National Assessment of Adult Literacy most recently completed survey in 2003 (http://nces.ed.gov/NAAL; accessed 6-20-2009) are now being analyzed and published.  Part of the 2003 survey included a measure of health literacy defined as, “the ability to use literacy skills to read and understand written health-related information encountered in everyday life”.  Although it is beyond the scope of this discussion to define the complex classification system used in the survey, 75 million Americans are estimated to possess Basic and Below Basic health literacy skills with 114 million at the Intermediate level and only 12 million at the Proficient level.  It is very unlikely that Americans with Basic or Below Basic health literacy (and probably a vast majority in the Intermediate group) would be able to read and comprehend most informed consent forms since they are written at a 12 to 15 years of education readability level (See Pizzi et al., 2001 for a review).   Research findings in this area present serious problems for the practitioner in obtaining informed consent. Given these findings, one critical aspect of surgery preparation is to help the patient understand the operation and facilitate the informed consent process.

 

In addition to the readability of patient education materials, research has indicated that patients generally remember very little of the information presented to them regarding their surgery and this is true whether the information is provided in written or verbal form (see Deardorff, 1986; Ferguson, 1993; Shuldman, 1999; Webber, 1990 for reviews).  This memory problem may be due to the nature of the information being presented, the fact that surgery patients are quite distracted due to the entire surgical experience process, or some other issues.  Thus, although highly understandable and appropriate information may be provided to surgery patients, they may not recall this information.  

 

It is not surprising that patients are often dissatisfied with the doctor-patient relationship and are reluctant to request information from their surgeon, family doctor, or other healthcare professionals involved in the pre-surgical process.  As part of a surgery preparation program, it is important to teach patients how to ask questions and where to go for answers.  In the following chapter, simple assertiveness training techniques are reviewed and these will often be used in psychological preparation for surgery interventions.  Also, patients can be informed that they can get information from many sources, not just their doctor’s office (although that is the best place to start).  Other sources might include the hospital, the library, governmental agencies such as the National Institute of Health (NIH) and the Internet.  Another good source of information is specific professional and lay public societies such as the following.  Many of these groups have patient education divisions that can provide excellent information:

 

In order to help surgery patients with the information gathering process, a variety of questions have been established as part of a more self-guided preparation for surgery program (See the Table, adapted from Deardorff and Reeves, 1997).  Patients can be taught to get these questions answered pre-operatively as necessary for their particular surgery and from the appropriate information source (which may not always be the doctor’s office).   

 

 

Questions Patients Can Ask About Their Surgery

 

 

About the Medical Condition and Surgery

 

What is wrong with me?  What is my diagnosis?

 

Why do I need the surgery?

 

How will the surgery improve my condition?

 

What other treatment options are available and have these been adequately tried?

 

What will happen if I don't have the surgery or delay it until a later date?  How long can I delay the surgery if I decide to do so?

 

What are the risks of the surgery?  Do the benefits of the surgery outweigh the risks?  

 

If the surgery is successful, what results can I expect?  If it is not successful (or only partially successful), then what remaining symptoms can I expect?

 

Can you describe the surgery to me in simple language?

 

Do you have a brochure or information sheet which describes the surgery?      

 

How will I feel after the surgery?  (in the recovery room, the following day, etc)

 

How can I expect to feel each day in the hospital after the surgery?  What will I be able to do, and what should I try and do, each day in the hospital after the surgery?

 

What complications might arise after surgery or after being discharged from the hospital?  What is the best way to manage these complications if they arise? With whom should I discuss these issues?

 

Will I need assistance at home after I am discharged from the hospital?  Should I arrange for that now?  Will I go directly home after discharge or is there the possibility of going to a rehabilitation or transitional care unit/facility?

 

Once I go home, what will my level of functioning be and for how long?

 

Blood Transfusion

 

Is it possible that I may need a blood transfusion during the surgery?  

 

Can I give blood in advance in case I need it during the surgery? 

 

Where should I go to give blood before my operation? 

 

Is there enough time before surgery to give the blood that I may need?

 

What are the risks in giving and receiving my own blood?

  

What to do Before the Surgery

 

What pre-surgical tests or evaluations are necessary?

 

Who will be doing these and when should they be done?

 

Should I make sure my family physician knows about the surgery?

 

Will my family doctor be involved in my post-operative care?  Does he or she need any special medical records?

 

Do I need to be on a special diet before or after the surgery.  If so, can you explain it in detail?

 

Will this operation be done on an outpatient or inpatient basis?

 

In what hospital will the operation be done? 

 

Is the surgery and hospitalization pre-approved by the insurance company?

 

Hospitalization approval letter received from insurance company?

 

Number of hospitalization days pre-approved by the insurance company?

 

What if more days are required as recommended by the surgeon.  How does one get approval and who is responsible for that?

 

What doctors can I expect to see in the hospital and why?

 

When will you first see your surgeon in the hospital after the surgery?

 

Will your surgeon be in town and managing your case the entire time you are in the hospital?

 

 

Informed consent 

 

Inadequate informed consent has been the basis for successful lawsuits in surgery. Patients have made the case that if they had adequate informed consent, they would have not undergone the elective surgery or would have chosen some other treatment option (See Benton, 2001; Benzel and Benton, 2001).  These cases were made even though the usual consent forms had been signed by the patients.   As concluded by Benzel and Benton (2001, p. 33), “One of the main problems with the consent process is that it is just that-a process.  Usually, it does not take place only during the final counseling of the patient regarding risks, benefits and alternatives of an operation.  To one degree or another, it take place during each physician-patient encounter that precedes an operation”. Making sure a patient acquires accurate and understandable medical information is important to all areas of surgery practice and is part of the surgery preparation process.  

 

Information Gathering and the Internet 

 

With the explosion of the use of the Internet and medically-related websites, it is important to address this issue specifically with patients.  The Internet can be a powerful tool in terms of medical information gathering related to any surgery.  However, a strong caveat is in order relative to this information resource.  There is a great deal of misinformation being promulgated through this media.  In encouraging patients to gather information about their surgery, they should be warned about this issue. They should also be encouraged to review the type of information that they are gathering from the Internet and the healthcare professional managing the surgery preparation intervention.

 

Incorrect information can have deleterious effects on surgery outcome since the patient might develop unrealistic and inaccurate expectations.  According to the self and social regulation models, patients would then “act” on this incorrect information.  Judicious use of the Internet for information gathering is appropriate.  However, in some cases, (especially with information-seekers) it may be appropriate to actually discourage Internet access for the purposes of gathering surgical information.  This might be appropriate when a patient becomes almost obsessed with gathering information about surgical options from different sources and viewpoints.  The multiple conflicting messages, similar to getting five or ten surgical opinions, can reach a point of information “chaos” for the patient.  Alternatively, patients might be guided to websites that are known to contain accurate information.  Most of the Websites that are associated with University Medical Centers (e.g. ending in .edu), are maintained by governmental institutions (e.g. through the National Institute of Health and ending in .gov), or are associated with a professional organization (ending in .org) can be trusted as reliable sources of information.  Also, those of professional organizations related to surgery are generally reputable and the information can be trusted.  Examples include the following:

 

 

Example Websites for Surgery Information Gathering

 

 

Spine Surgery: North American Spine Society (www.spine.org)

 

Bariatric Surgery: American Society for Bariatric Surgery (www.asbs.org)

 

Organ Transplantation: Government Information (http://organdonor.gov)

 

Plastic Surgery: American Society of Plastic Surgeons (www.plasticsurgery.org)

 

Orthopedic Surgery: American Academy of Orthopaedic Surgeons  (http://www.aaos.org)

 

 

Cognitive techniques used in the preparation for surgery generally revolve around cognitive restructuring techniques. Also, cognitive-behavioral interventions usually include some type of deep relaxation training.  For the purposes of this discussion, we will also place hypnosis under the cognitive-behavioral category.  This section will provide a brief overview, along with a special emphasis on applicability to the surgery patient. 

 

COGNITIVE RESTRUCTURING

 

The philosophy of cognitive restructuring is guided by observations that were made in the very remote past.  For instance, William Shakespeare in Hamlet stated that “there is nothing either good or bad, but thinking makes it so.”  Centuries before the time of Shakespeare, the philosopher, Epictetus stated in the first century, “men feel disturbed not by things, but by the views which they take of them.”  These principles have recently been rediscovered and refined (Beck, 1979; Ellis, 1975; Meichenbaum, 1977).  Several basic tenets guide the cognitive restructuring approach:

 

 

Basic Philosophy of Cognitive Restructuring

 

 

It is not the situation that causes a specific emotional response, but rather an individual’s thoughts or cognitions about the situation. 

 

Thoughts influence how we behave including what we choose to do or not do and the quality of our performance.

 

Thoughts can be considered “behaviors” that are susceptible to change. 

 

Changing cognitions to be more positive or “coping-oriented” can influence the surgical patient’s coping abilities and, therefore, enhance outcome. 

 

 

Preparing the Patient for the Cognitive Behavioral Approach

 

The steps for preparing the pre-surgical patient for the cognitive behavioral approach include the following:

 

(1) Dispel the myth that the patient has been referred for surgery preparation because of any type of “weak will” or other negative reason.

 

(2) Explain that surgery preparation is commonly done with all patients in order to normalize the experience.

 

(3) Discuss that psychological preparation for surgery can enhance the patient’s outcome and make the entire surgery process proceed much more smoothly.  Review the research on the findings that surgery preparation will produce actual physical changes that facilitate healing and recovery.

 

(4) Discuss the rationale behind the various interventions (e.g. cognitive behavioral, relaxation training, etc).

 

The more the patient accepts the rationale behind surgery preparation, the more likely he or she will embrace and practice the techniques.

 

Reviewing the Rational Behind Cognitive Behavioral Techniques with the Patient

 

The patient can be told that the cognitive behavioral model (and the method for changing one’s thoughts) has been termed the “ABCDE” model and it can be a very useful tool in dealing with chronic pain. The specifics of the ABCDE model will be discussed shortly, but it is important for the patient to have an understanding of how thoughts and emotions operate. This was reviewed previously in more technical terms and the following presents a manner in which these concepts can be presented to patients.

 

Self-Talk

 

We would all agree that we constantly have thoughts and images going through our head related to evaluating the world around us. In addition we are constantly evaluating the sensations that are going on inside of us as well. These thoughts have been termed “automatic” thoughts because they often occur automatically, almost out of our awareness. Automatic thoughts have the characteristics of being very fast, virtually out of awareness or unconscious, and highly believable. As we shall see shortly, automatic thoughts have great power over our emotions and behaviors. At first, the nature of the automatic thoughts may not be readily apparent even though it is influencing your emotions and your body's health. 

 

Many of the cognitive researchers have observed that individuals under stress have a tendency to engage in negative automatic thoughts. Negative automatic thoughts, or “self-talk”, have the following characteristics:

 

 

Characteristics of Negative Self-Talk

 

 

Self-talk occurs as specific, discrete messages that often are expressed in shorthand

 

Self-talk is highly believable to the person no matter how unhealthy or irrational it is

 

Self-talk is experienced as highly spontaneous and difficult to "turn off"

 

Unhealthy self-talk is often expressed in terms of "should, ought, never, always and must"

 

Self-talk is unique to you as an individual

 

 

THE ABDCE MODEL

 

Facing a surgery can be a particularly stressful event, easily resulting in a cascade of negative automatic thoughts. Based on these findings, the ABCDE model was adapted to surgery preparation. The ABCDE model can be explained to the patient in the following manner: 

 

 

Presenting the ABCDE Model to the Patient

 

 

A is the Activating Event or Antecedent Event, which is simply the event to which you are responding. This could be an outside event, such as sitting in a traffic jam, or an internal event, such as a severe pain. 

 

B is your automatic thought or Belief about the activating event. For instance your belief about being in the traffic jam might be "Oh no, this is awful. I will never make the meeting in time. I should have left earlier." Alternatively your belief might be "There's nothing I can do about this traffic jam. I'll take this time to listen to the radio and be as relaxed as possible. I'll leave earlier in the future."

 

In this traffic example the first set of thoughts are negative automatic thoughts and the second set of thoughts are coping or rational thoughts. The difference in the makeup of these thoughts can certainly be seen and will be discussed more fully in a later section.

 

C is the Consequent Emotion that results from the automatic thoughts. Most people think that A causes C, but in reality, C is caused by B. A person's emotional response to a situation is caused by his or her beliefs about the situation and not by the situation itself.

 

D is the Disputing Thoughts that are used to change automatic negative thoughts. These are used to help change the way a person thinks about stressful situations from a negative standpoint to a coping standpoint. In working with patients on doing this exercise, we like to term this process the power of realistic thinking.

 

E is the Evaluation part of using the disputing thoughts to challenge the negative automatic thoughts. This process will be discussed further.

 

 

The following simple examples will help the patient understand just how the ABCDE model operates.

 

EXAMPLE 1

 

Activating Event:  You experience a mild increase in your heart rate and feel "uncomfortable and jittery."

 

Belief: I'm having a heart attack!!!

 

Consequent Emotion: Fear, anxiety, panic.

 

Resulting Behavior: Call doctor or go to emergency room.

 

In this situation the symptoms are being interpreted as a possible heart attack. The subsequent emotions and behavior follow from this belief. Suppose an alternative belief was that "I just drank four cups of coffee and the caffeine is causing the symptoms." With this explanation the emotions and resulting behavior would be entirely different.

 

EXAMPLE 2

 

Activating Event: You hear a noise at the bedroom window in the middle of the night.

 

Belief: There is an intruder trying to get in.

 

Consequent Emotion: Fear, panic.

 

Resulting Behavior: Call police, hide, and grab a weapon.

 

Again, in this example, the emotions and behavior follow from the belief that there is danger. Alternatively if the belief was that the noise was caused by the wind blowing a tree branch against the window, the emotional response and behaviors would be entirely different. It should be noted that in each of these examples the situations prompting the beliefs are exactly the same. The only difference is how the information is interpreted by the person in terms of beliefs. These beliefs are what caused the emotional response and behavior, not the situation itself!

 

These examples illustrate how our thoughts influence our emotions and behavior. But how can we use this information to help with surgery preparation? This is done through the use of the "three-column" and the "five-column" techniques. The power in using this approach comes from changing the negative automatic thoughts to "realistic, coping, and nurturing" thoughts. By changing the thoughts about the surgery experience, the patient can change his or her emotional responses and behaviors throughout the process.

 

THE THREE-COLUMN TECHNIQUE

 

The ABC and ABCDE models can be utilized in a three- and five-column technique. A three-column worksheet can be seen in the Table.  This allows the patient to begin to carefully identify negative automatic thoughts.   Once this is mastered, the technique is expanded to a five-column technique to be reviewed subsequently.

 

 

Activating Event

 

 

Beliefs

 

Consequent Emotions

 

 

Preparing for a major surgery after a chronic disability

 

 

My body is weak and fragile.  It will never be the same.

 

 

Fear

 

 

My pain is going to get worse and worse.

 

Anxiety and Hopelessness

 

 

 

I can’t handle this surgery.  I hate the hospital.

 

 

Fear and Anxiety

 

 

My family is going to leave me.

 

 

Depression

 

 

I should be better by now.  The surgery didn’t work.  I should never have allowed this to happen.

 

 

Frustration, Anger, Guilt, and Helplessness

 

 

If I move the wrong way, I’ll do myself in. I’ll wait until the pain is gone, then I’ll exercise.

 

 

Helplessness and Fear

 

 

What if the surgery doesn’t work?  I bet it won’t.  I’m either cured, or I’m not.

 

 

Anger and Hopelessness

 

 

I feel worthless.  The future looks awful.

 

Hopelessness

 

 

The three columns represent the A, B, and C events discussed previously. It is useful to make several copies of a blank ABC worksheet in order to practice identifying activating events, beliefs, and consequent emotions. The three-column technique is a tool to enable the patient to run the automatic negative thoughts in slow motion. The patient can use the three-column technique to analyze thoughts and feelings whenever a stressful situation presents itself. An activating event can be any stressor, such as pain, a situation, a memory, or an interaction with another person. At first it can be difficult for the patient to "flesh out" the beliefs or automatic negative thoughts about a situation. Automatic negative thoughts often contain such words as “should, ought, must, never, and always”. As can be seen in the previous examples, phrases with these words are common in negative thinking.  It is best to have the patient practice just the three-column technique for a week.  In the follow up session the chart should be reviewed to ensure that the patient understands the concepts and is being compliant with the charting.  Any problems can then be resolved early on.

 

Negative thinking often takes on certain styles or patterns and these are important to identify and discuss with the patient.  Briefly, these styles can be summarized as follows:

 

STYLES OF NEGATIVE SELF-TALK

 

Over the years, cognitive researchers have identified a variety of “irrational” or negative styles of thinking.  Although many of these negative styles have been identified, only the most common as applicable to the surgery patient, will be reviewed.  For further details regarding negative styles of thinking, the reader is referred to other sources (Beck, 1979; Ellis, 1975; McKay & Fanning, 1991; Meichenbaum, 1977).

 

Catastrophizing

 

Imagining the worst possible scenario and then acting as if that will actually happen characterize this type of negative thinking.  It will often include a series of "What if's" such as:

 

·         What if I never get better

·         What if I get worse

·         What if the surgery doesn’t work

·         What if........

 

In catastrophic thinking, the dire predictions are not based on facts but rather pessimistic beliefs.

 

Filtering

 

This thinking style involves focusing on only the negative aspects of a situation to the exclusion of any positive elements or options. This type of negative self-talk has also been termed “tunnel vision” since it causes the patient to look at only one element of a situation to the exclusion of everything else.  This style will commonly include searching for evidence of "how bad things really are" and discounting any positive or coping focus.  Examples include:

 

     There is nothing that will help my situation

     This situation is awful

     Everything in my life is rotten due to this condition

     Nobody really cares

     I can’t stand it

     The doctors and surgeons have nothing to offer

     I've tried, everything and nothing has helped at all

 

Discounting and “Yes-Butting” often characterize this style of negative thinking.  No matter what positive option or coping method is suggested, the person engaging in filtering will discount it with a "Yes-But".  For instance, a person requires a surgical procedure, which will cause a limitation in certain activities while also improving the person’s overall health and quality of life.   When this is discussed as being very positive overall, the person retorts "Yes, but I will have these limitations”.  This type of thinking continues to foster helplessness, hopelessness and depression.

 

Black and White Thinking

 

This type of thinking amounts to seeing things either one way or the other and has also been termed “all-or-nothing” thinking.  In this style, there is no middle-ground or shades of gray.  People and things are either good or bad.  Events and situations are either great or horrible.    This type of thinking is typified by:

 

     I'm either cured or I'm not

     I either have pain or I don't

     The surgery either works or it doesn't

     This doctor is either good or bad

     My family is supportive or they’re not

 

This type of thinking undermines any small steps towards improvement, severely limits one's options, and filters out any positive aspects of a situation.

 

Overgeneralization 

 

This is the process of taking one aspect of a situation and applying it to all other situations.  It involves generalizing reactions to situations in which such reactions are not appropriate.   For instance:

 

     With this pain I’ll never be able to have any fun

     People don't want to be around me

     My wife told me to try and do something about the pain.

     She must be ready to leave me

     I will always be sad

     I will never be able to get beyond this medical problem

 

As can be seen, this style of negative self-talk will take one incident and make it apply to many other situations, which result in the person reaching an incorrect conclusion.  Overgeneralization is often indicated by such key words as all, every, none, never, always, everybody and nobody.

 

Mind Reading

 

This negative self-talk "trap" involves making assumptions about what other people are thinking without actually knowing.  The person will then act on these assumptions (which are usually erroneous) without checking them out for accuracy.  Examples of this might include the following:

 

     I know my wife thinks I'm less of a man due to my condition

     I know my husband thinks I'm exaggerating my pain

     My doctor doesn't really think I'll get better even though she tells me I will

     They're not telling me everything about my problem

 

If the patient accepts these assumptions as facts, then his or her behavior will follow accordingly, and will likely create a self-fulfilling prophecy.  As example, a patient’s spouse might ask, "How do you feel today".  Instead of taking his or her comment at face value, the patient believes he or she really means "Are you still letting that problem bother you".  So the patient responds, "How do think I feel today! The same as always, that's how."   One can easily guess how this scenario would be completed.

 

Shoulds

 

 "Should" statements are key elements in negative self-talk. In this style of negative self-talk, the patient operates from a list of inflexible and unrealistic rules about their own actions as well as that of others.  Examples of such thinking include:

 

     I should be getting better

     I should never have allowed this to happen

     I should have known not to have had that procedure (or surgery)

     My employer should have protected me

     I should be tougher

     My family should be more helpful

 

Should thinking also includes terms like "ought, must, always, and never".  Should thinking is judgmental and often involves an individual measuring his or her performance against some irrational perfect standard.  It has the effect of making the patient feel worthless, useless and inadequate.  When directed at others, it will have the effect of making the patient feel angry and resentful in those relationships.  As discussed in the previous chapter, the process of “upward comparison” phenomenon in social self-regulation is the finding that patients may have a tendency to compare themselves with other patients who are “doing better”.  This process might involve  “should” irrational thinking (“I should be recovering as fast as he is…”).

 

Blaming

 

In blaming, the person makes something or someone else responsible for a problem or situation.  There is some comfort in being able to attach responsibility for one’s suffering to someone else.  Unfortunately, blaming can often cause a person to avoid taking responsibility for their own choices and opportunity for improvement.  This type of negative thinking is very often seen in cases of industrial injury, automobile accidents, or other such trauma.  Examples include:

 

     My boss is to blame for my injury.  If....

     They should have mopped up that water I slipped on.  It's all their fault

     That guy who hit me owes me everything for the pain I'm suffering

     I'm to blame for this lousy medical problem

 

Blaming as a form of negative self-talk can be focused either externally or internally.  Internally focused blaming (self-blame) takes on the form of, “It’s all my fault”.  Self-blame is often an excuse for not taking responsibility and can lead to depression, hopelessness and helplessness. Blaming can be very destructive in keeping the patient from focusing on what needs to be done to get better rather than whom or what is to blame.

 

CHALLENGING NEGATIVE SELF-TALK

THROUGH RE-FRAMING

 

As the patient practices identifying negative automatic thoughts, certain patterns will usually emerge.  Most often, individuals will tend towards a certain style of negative automatic thinking.  This can help identify future types of negative automatic thoughts.  Once the negative automatic thoughts are identified, cognitive preparation for surgery involves helping the patient engage in challenging these thoughts as well as thought re-framing.  Challenging negative self-talk can be accomplished by training patients to ask themselves the following questions:

 

 

Challenging Negative Self-Talk

 

 

What is the evidence for that conclusion? 

 

Is this statement always true?

 

What is the evidence for that conclusion being false?

 

Among all possibilities is this belief the healthiest one to adopt?

 

Am I looking at the entire picture?

 

Am I being fully objective?

 

 

Having the patient subject his or her self-talk to these questions will help identify negative versus positive (or coping) messages.  After helping the surgical patient identify and challenge any negative self-talk, it is important to facilitate the process of substituting positive, realistic, or coping self-talk.  These coping thoughts can be written down in the thoughts and feelings diary and then practiced through rehearsal.  Bourne (1995) has developed the following rules to help patients write positive coping self-talk statements. 

 

 

Rules for Developing Coping Thoughts

 

 

Avoid negatives

 

When having patients write positive coping statements teach them to avoid using negatives.  For instance, instead of saying, “I can’t be nervous about going to the hospital” a patient can say “I will be confident and calm about going to the hospital”.  The first type of statement can be anxiety producing in and of itself which will defeat the purpose of the coping thought.

 

Keep coping thoughts in the present tense 

 

Since most negative self-talk occurs in the here-and-now, it should be countered by coping thoughts that are in the present tense.  Instead of a patient saying, “I will be happy when this surgery is over” he or she might say, “I am happy about ...... right now”.  Teaching surgery patients to begin self-statements with, “I am learning to...” and “I can...” is very beneficial for cognitive restructuring.

 

Keep coping thoughts in the first person

 

Whenever possible have patients keep their thoughts in the first person.  This can be done by having patients begin coping thoughts with “I” or by being sure that “I” occurs somewhere in the sentence.

 

Make coping thoughts believable 

 

Coping thoughts should be based in reality.  This will insure that the patient will have some belief in his or her own coping self-talk.  As a patient practices the positive self-talk, it becomes more and more believable.  A person’s coping thoughts should not be broadly positive, Pollyannaish and unrealistic; otherwise the patient will completely discount them as untrue.   For instance, the coping thought of “I can’t wait to have surgery. I’m sure I will completely enjoy the entire experience” is unrealistic and not believable.  Rather, the thought, “I will be able make the surgery experience as positive as possible and I will be looking forward to beginning the recovery process” is much more tenable. 

 

 

Examples of positive or coping self-talk, which can challenge each of the negative styles, are as follows.  These examples can be reviewed with patients to help them understand how the thought reframing process works. 

 

Catastrophizing

 

For catastrophizing, the patient should be reminded that no one can predict the future.  Tell the patient that it is probably in his or her best interest to predict a realistic or positive outcome rather than a catastrophic and “What if....” outcome.  Explain to the patient that acting “as if” things will turn out OK is usually the best course of action. 

 

     No one can predict the future

     If I’m going to engage in “What if’s” I might as well choose healthy ones

     If I believe in myself, I’ll be able to handle any situation including this surgery

 

Filtering

 

If a patient is filtering out everything except the most negative aspects of a situation, he or she needs to learn to shift focus. First,  teach the patient to redirect his or her attention onto active strategies that can be used to make the situation more manageable.  Help the patient look at the situation realistically rather than magnifying the negative aspects. Then, have the patient focus on the positive aspects of the situation.  Patients should be encouraged to avoid the negative thought, “I can’t stand it”.

 

     I can handle this situation (surgery)

     I’ve developed a number of resources to make this surgery turn as positive as possible

     I am doing this surgery for the positive reasons of....

     I’m looking forward to getting beyond the surgery and beginning to heal and recover

     I’ve had the surgery and now I can focus on getting better

 

Black and White Thinking

 

Thinking in Black and White will always set the patient up for disappointment since there will be no allowance for gradual improvement. The first step in changing this thinking is to help the patient identify when he or she is using absolute words like “all, every, always, never, and none”.  The second step is to have the patient focus on how the situation may be changing in gradual steps.  Lastly, remind the patient there are always different options, not just the two extremes of black and white.

 

     I am making progress in the following areas....

     My ultimate goal is....and I’m moving towards it in the following ways.....

 

Overgeneralizing

 

In overgeneralizing the patient is taking one element of a situation and applying it to everything else.  A patient can stop overgeneralizing by being reminded to evaluate each aspect of a situation realistically and independently.

 

     I’ve been able to get through a lot of situations and I’ll get through this one

     Just because my last hospitalization was unpleasant, this one doesn’t have to be

 

Mind Reading

 

Nobody can read another person’s mind although individuals often have the tendency to act as if it is possible.  This causes a person to act and feel towards others based upon inaccurate conclusions.  For instance, a patient might think, “I know my doctor doesn’t like me” based simply on “mind reading”.  Remind patients that nobody can read another person’s mind and it important to “check it out”.

 

     I can’t be sure about what he/she thinks unless I check it out

     I need to act based on the facts, not on what I assume

 

Shoulds

 

 If a patient has a propensity towards using the words “should, ought, must”, then he or she is either self-discounting or is judging others by standards that are unrealistic.  These types of statements seek to lower a patient’s self-confidence and self-esteem.  To help patients evaluate when this is happening, teach them to ask themselves, “Is this standard realistic?”, “Is this standard flexible?” and “Does this standard make my life and situation better?”.

 

     I do not have to be perfect

     Forget the should’s, ought’s, and must’s.

     I am doing the best I can

     I am doing what I can to get better and I will reward myself for that

 

Blaming

 

 If patients are tending towards self-blame, they should be reminded that they tried to make the best choice at the time and can continue to make healthy choices from now on.  If they are blaming others, have them assess realistically how they went about making their choices and remind them of what aspects of the situation are in their control and realm of responsibility.

 

     They are doing the best they can

     I did the best I could

     From now on, I will..........

 

As can be seen from the previous examples, as well as the common surgical patient fears listed in the previous chapter, presurgical automatic negative thoughts are not uncommon and there are specific coping thoughts to address this aspect of surgical preparation.  The results of these exercises are the five-column worksheet and illustrated in the following Table.  The patient can be given several blank 5-column worksheets for practice.

 

 

Activating Event

 

 

Beliefs

 

Consequent Emotions

 

 

Disputing Thoughts

 

Evaluation

 

Preparing for a major surgery after a chronic disability

 

 

My body is weak and fragile.  It will never be the same.

 

 

Fear

 

I can strengthen my body after surgery.  There are techniques I can use to help ease the pain.

 

 

Less Fear and More Confidence

 

 

My pain is going to get worse and worse.

 

Anxiety and Hopelessness

 

 

I will strive to become as functional as possible.  No one can predict the future.

 

 

More Sense of Control

 

 

I can’t handle this surgery.  I hate the hospital.

 

 

Fear and Anxiety

 

I can get through this.  I can look forward to discharge and recovery.

 

 

Less Anxiety, Less Hospital Stress

 

 

My family is going to leave me.

 

 

Depression

 

My family will help me especially if I help myself.

 

 

More Feelings of Comfort and Support

 

 

 

I should be better by now.  The surgery didn’t work.  I should never have allowed this to happen.

 

 

Frustration, Anger, Guilt, and Helplessness

 

I will continue to work on getting better.

 

More Hopefulness

 

 

If I move the wrong way, I’ll do myself in. I’ll wait until the pain is gone, then I’ll exercise.

 

 

Helplessness and Fear

 

I will begin to move and exercise slowly.

 

Less Frustration

 

 

What if the surgery doesn’t work?  I bet it won’t.  I’m either cured, or I’m not.

 

 

Anger and Hopelessness

 

No one can predict the future.

 

Less Anger and More Control

 

 

I feel worthless.  The future looks awful.

 

Hopelessness

 

 

There are things I can do to lead a quality life.

 

 

More Hopefulness

 

RELAXATION TECHNIQUES

 

Some of the correlates of the stress response have been discussed in Course I, and have been found to impede wound healing.  A common component of a preparation for surgery program is teaching patients the relaxation response.  It is important to distinguish between the relaxation response and simply “relaxing.”  Engaging in an enjoyable and sedentary activity may be relaxing, but this does not necessarily induce what researchers have termed “the relaxation response.”  The relaxation response is a specific physiological state that is essentially the opposite of the body’s condition when it is under stress.  The relaxation response was first described in the early 1970’s (Benson, 1975).  Learning to elicit the relaxation response can only be achieved through regular practice of some type of relaxation exercise.  The following Table demonstrates the physiological difference between the stress response and the relaxation response.  As can be seen, the relaxation response is directly incompatible with the stress response.  Teaching patients to elicit the relaxation response is a powerful tool in preparation for the surgery experience.  It is a tool that can be utilized by the patient both pre- and post-operatively.  It not only helps the patient manage various stressors, but also can help with pain control.

 

 

Physiologic State

 

Stress Response

 

Relaxation Response

Metabolism

Increases

Decreases

Blood Pressure

Increases

Decreases

Heart Rate

Increases

Decreases

Blood Flowing to the Muscles of the Arms and Legs

Increases

Stable

Muscle Tension

Increases

Decreases

Slow Brain Waves

Decreases

Increases

 

There are many different types of exercises for learning the relaxation response.  These include such things as breathing techniques, progressive muscle relaxation, visualization, meditation, among others.  It is beyond the scope of this chapter to review the various types of relaxation exercises and the reader is referred elsewhere for more details (Davis, Eshelman, & McKay, 1995; Deardorff & Reeves, 1997; Goleman & Gurin, 1993).  In choosing among the various possibilities that could be used as part of a surgery preparation program, there are a few guidelines to keep in mind.  First, there is often not much time to complete a preparation for surgery program prior to the scheduled operation; therefore, the breathing technique should be easy to learn and practice.  Second, the breathing exercise should be something that the patient can complete even during the postoperative phase of surgical recovery.  For instance, some type of progressive muscle relaxation (in which the patient alternates between tensing certain muscle groups and relaxing) may not be feasible after a major surgery. 

 

Deep Breathing

 

One of the most straight forward and simple to learn relaxation exercises is deep breathing.  It allows the patient to learn relaxation quickly and easily with a minimum time commitment of daily practice. In addition, the deep breathing exercise can easily be placed on audiotape to help patients with their home practice sessions.  An example of a deep breathing exercise for patients is as follows:

 

1.   Lie down on your back.  Bend your knees and move your feet about eight inches apart with your toes turned slightly outward.  This will help straighten your spine and keep you comfortable as you practice the breathing exercise.  If you have back pain, you may want to place a pillow under your knees for extra support.

2.   Mentally scan your body for any tension.

3.   Place one hand on your abdomen and one hand on your chest.

4.   Inhale slowly and deeply through your nose into your abdomen, so that your hand rises as much as feels comfortable.  Your chest should move only a little and should "follow" your abdomen.

5.   When you feel at ease with step #4, you can practice the deep breathing cycle.  In the deep breathing cycle, you should practice inhaling through your nose while smiling slightly.  Once you inhale deeply and diaphragmatically, exhale through your mouth.  This is done by gently blowing the air out of your lungs and making a "whooshing" sound like the wind.  Doing this will help relax the muscles of your mouth, tongue, and jaw.

6.   Take long slow deep breathes that raise and lower your abdomen.  Focus on the sound and feeling of breathing as you become more and more relaxed.

7.   Continue this deep breathing pattern for five or 10 minutes at a time, once or twice a day.  Once you have done this daily for a week, you might like to extend your deep breathing exercise period to 15 or 20 minutes.

8.   At the end of each deep breathing session, take time to once again scan your body for tension.  Compare the tension you feel at the conclusion of the exercise with that you were feeling at the beginning of the exercise.

9.   As you become more proficient at deep breathing, you can practice it anytime during the day, in addition to your regularly scheduled sessions.  Simply concentrate on your abdomen moving up and down and the air moving in and out of your lungs.

10.        Once you have learned to use the deep breathing technique to elicit the relaxation response, you can practice it whenever you feel the need.

 

CUE-CONTROLLED RELAXATION

 

Cue-controlled relaxation can help make the relaxation response even more useable for the surgery patient.  In cue-controlled relaxation, the patient is taught to use a specific “cue” to signal the relaxation response.  The relaxation cue could basically be anything, but is commonly a phrase (saying “relax”), a visual reminder, or a muscular signal.  A very useable technique discussed by Deardorff and Reeves (1997) involves having the patient simply touch his or her thumb and index finger while thinking about relaxing.  This type of cue works well especially when the patient is in a situation where using a verbal or visual cue is not possible. 

 

Cue-controlled relaxation is based on classical conditioning principles originally developed by Pavlov.  In Pavlov’s original experiment in the early 1900’s, it was found that dogs would salivate in response to a bell or a light if the stimulus had previously been “paired” with the salivation response.  Cue-controlled relaxation training works on the same principle.  The critical component of cue-controlled relaxation is that the cue must be repeatedly paired with the relaxation response prior to being able to use the technique effectively.  Thus, a patient might practice the deep breathing exercises for a week or to the point of being able to reliably elicit the relaxation response.  Once the patient has achieved this level of mastery, the relaxation response can be paired to a specific cue.  This is done by focusing or completing the cue while in a state of deep relaxation. 

 

Cue-controlled relation is extremely beneficial as part of a preparation for surgery program.  This skill can be used for a number of purposes including invoking the relaxation response in almost any situation, to help the patient refocus concentration on relaxing and coping, to help with the cognitive restructuring process, to help manage acute pain, and to help control nausea and vomiting (Deardorff and Reeves, 1997).  For more information on cue-controlled relaxation, see Pain Management Course II.

 

GUIDELINES FOR PRACTICING DEEP RELAXATION

 

It should be explained to patients that learning the relaxation response is similar to acquiring any other skill: it takes practice.  It is not uncommon for patients to attain deep relaxation when they do the exercise but have trouble making practicing it a priority.   Regular practice is essential to firmly establish the relaxation response as a skill that can be used efficiently at any time.  At the beginning of learning the skill it may take the patient 20 to 30 minutes to achieve deep relaxation; whereas, after practicing it may take only a few deep breaths to accomplish the same result.  As discussed by Deardorff and Reeves (1997), the following guidelines will help patients structure their relaxation practice and ensure that the skill is acquired in a timely manner.

 

Practice once or twice a day.  It is important to have patients practice the breathing exercises once or twice per day.  Practicing at least once per day is mandatory in order to learn to elicit the deep relaxation response.  As one practices regularly, patients may find that the amount of time required to elicit the relaxation response decreases.

 

Practice in a quiet location.  It is important for patients to practice the breathing exercises in a quiet location where they will not be disturbed or distracted.  For instance, patients should be told to not allow the phone to ring while practicing or be able to hear outside distracting noises.  It can often be useful for patients to use something like a fan or air conditioner to block out outside noise if that is a problem.

 

Give a five-minute warning.  It can be useful to have the patient give other family members a five-minute warning when he or she begins breathing exercises.  This can help a patient take care of "loose ends" prior to practicing the deep breathing.  For instance, if a patient tends to be worried about a number of things "to do," it can be helpful to have him or her make a short list prior to doing the relaxation exercise.  This will help the patient be able to focus on the deep relaxation exercise rather than "trying to remember" what "needs" to be done after relaxing.

 

Practice at regular times.  It is important to have patients set up regular practice times, as this will increase the likelihood or follow through on deep relaxation exercises.  These times should be when a patient is most likely to follow through on completing the exercises.  The regular practice times should not be when the patient is so tired (for instance, right after a big meal or just prior to bed) that he or she is likely to fall asleep.

 

Practice on an empty stomach.  As discussed above, practicing deep relaxation after a big meal increases the likelihood that a patient will fall asleep in the middle of trying to relax.  Also, the process of digestion after meals can disrupt deep relaxation.  Therefore, it is recommended that patients try and practice on an empty stomach if possible.

 

Assume a comfortable position.  A patient should be in a comfortable position when practicing deep relaxation exercises.  A common position is lying flat on one’s back with the legs extended out and arms comfortably at the sides.  Depending upon the patient’s medical condition and surgery, assuming this posture may not be possible.  In that case, some other position can be used (e.g. knees up with a pillow underneath, sitting or even standing).   If a patient is tired or sleepy, relaxation exercises can be practiced sitting up, as opposed to lying down, to prevent falling asleep.

 

Loosen clothing.  It is useful to have patients loosen any tight clothing and take off such things as shoes, watch, glasses, jewelry, and other constrictive apparel when practicing relaxation.  Again, the object is to have the patient be as comfortable as possible while practicing.

 

Assume a passive attitude.  It is important for patients to complete the deep relaxation exercise while adopting an attitude of "allowing" the relaxation response to happen.  The patient should not "try" and relax or "control" his or her body. 

 

OBSTACLES TO PRACTICE

 

Relaxation training is a critical component of a preparation for surgery program.  Therefore, it is important to make every effort to ensure that patients practice and master this skill.  The previously presented guidelines can help in that regard.  However, patients may present other “obstacles” to practicing that will have to be addressed.  Some of the more common obstacles to practicing relaxation are as follows along with techniques for helping patients overcome these issues. 

 

There is no time to relax.  Complaints about not having enough time to practice the relaxation are probably one of the most common obstacles encountered in a preparation for surgery program.  In this case, it is important to help the patient prioritize the relaxation practice.  This issue is especially salient presurgically since patients sometimes feel “overwhelmed” by the number of issues they have to address prior to the operation.  Helping patients schedule a specific time for relaxation practice can help in this regard.  In addition, they should be reminded that the relaxation practice (e.g. twice per day) takes less than 30 minutes, and even less time after regular practice.

 

It is boring. Some patients have trouble completing the relaxation exercises stating that they are “boring.” These patients will typically deal with stress by becoming quite “busy” and, in general, have trouble “being still” as a personality style.  When this type of obstacle occurs, it is important to remind the patient that the relaxation response skill is critical to the success of the preparation for surgery program.  These patients will often need to be convinced of the “value” of relaxing and not see it as simply wasting time.  In more extreme cases, it might be useful to have these patients practice a more “active” type of relaxation exercise.  This might include something like imagery or some other similar procedure that requires the patient to “do something” during the relaxation exercise.  For patients with this personality style, the act of “doing something” versus being passive may be more appropriate.

 

No place to relax.  This obstacle presents itself when the patients complain that they don’t have any quiet place to practice the relaxation exercises on a regular basis.  Again, when this issue is explored more thoroughly, it is often related to the patient not making relaxation practice a priority.  As discussed by Deardorff and Reeves (1997), the following patient recommendations can be helpful to overcome this obstacle. 

 

             Put the phone on an answering machine and unplug the phone in your bedroom.  Give your family the "five-minute warning" that you will be unavailable for the next 20 minutes while you practice the exercises. 

             Close the door to the room in which you are going to practice and place a "Do Not Disturb" sign on the door knob. 

             During the five-minute warning period, be sure the family demands are placed on hold or managed by another household member. 

             If there is not room enough to "get away" from these distractions, you might have to practice when the other people in the household are out of the house.

 

HYPNOSIS

 

Hypnosis has been extensively used as a component of preparation for surgery programs (Blankfield, 1991; Lynch, 1999; Kessler and Dane, 1996; Wood and Hirschberg, 1994).  In fact, one of the early known uses of hypnosis was as an anesthetic agent with a surgery patient in the United States in 1836 (Wood and Hirschber, 1994).  There are a variety of techniques for hypnotic induction and these will not be reviewed here.  Reviews of the literature show that hypnosis training for surgical patients might include a single session or multiple pre-surgical consultations (see Wood and Hirschber, 1994 for a review). One important finding that has implications for the cost effectiveness of this procedure is that many of the programs consist of audiotaped hypnosis exercises that can be practiced by the patient on their own. 

 

The content of the hypnotic suggestions can be quite variable from inducing simple relaxation to suggestions for enhanced wound healing.  Some of the more common hypnotic suggestions used in helping patients cope with the surgical experience can be found elsewhere  (Deardorff and Reeves, 1997; Wood and Hirschberg, 1994).  Similar to developing the relaxation response, patients must practice the hypnotic exercises prior to using them to manage pre and postoperative situations.  Again, if the patient practices these on a regular basis, the hypnotic state can be induced quite rapidly and in almost any stressful situation related to the surgery. 

 

If hypnosis is part of the preparation for surgery program, misconceptions about hypnosis should be discussed with the patient.  Patients are often fearful of the term “hypnosis” due to common misconceptions.  Some of these popular erroneous beliefs about hypnosis are as follows (adapted from Deardorff and Reeves, 1997):

 

Hypnosis is a state of deep sleep or unconsciousness. A person is not asleep when under hypnosis.  In fact, hypnosis is a state of relaxed attention in which the person is able to hear, speak, move around, and think independently.  The brain waves of a hypnotized person are similar to those of someone who is awake and reflexes, such as the knee jerk, which are absent in the sleeping person, are present when hypnotized. 

 

Hypnosis allows someone else to control the patient’s mind.  Books, movies, and stage hypnotists have capitalized on perpetuating this myth and it is perhaps the biggest misconception that keeps people from pursuing and benefiting from hypnosis.  A patient cannot be hypnotized against his or her will and once hypnotized, a person cannot be forced or coerced into doing something they find objectionable or do not want to do.

 

A hypnotized person might not be able to come out of a trance.  It is actually more difficult to become hypnotized than it is to slip out of hypnosis.  Patients frequently become alert when a hypnotherapist stops talking, inadvertently says something inconsistent with the person’s beliefs, leaves the room, or is otherwise distracted.  If left alone when hypnotized, most people reorient, alert themselves, and awaken naturally.

 

A hypnotized person will give away secrets.  When hypnotized, a person is aware of everything that happens both during and after hypnosis, unless he or she wants to accept and follow specific suggestions for amnesia.  Thus, secrets cannot be forced from a person unwilling to divulge them.

 

The patient believes that he or she probably cannot be hypnotized.  Some people are more responsive than others to hypnosis, but nearly everyone can achieve some level of hypnosis and can benefit from it with practice.  Stumbling blocks to hypnosis include trying too hard, fears or misconceptions about hypnosis, and unconscious desires to hang on to troublesome symptoms.  A licensed psychologist, physician, or dentist experienced in hypnosis can help a person overcome these stumbling blocks.

 

VISUALIZATION, IMAGERY, DISTRACTION AND HUMOR

 

Imagery, visualization, distraction and humor are powerful techniques, which can form an integral part of a preparation for surgery program.  Imagery is thought to be one of the basic ways in which the mind stores information in the unconscious.  In fact, imagery techniques for physical healing date back many hundreds of years.  From a very early time, it has been known that the thoughts and images that come from our imagination can have very real physiological consequences.  In fact, sometimes our brains cannot differentiate whether we are experiencing something that is really occurring or whether it is simply an image coming from our imagination (e.g. dreaming, etc).  The rationale for imagery in surgery preparation can be explained to the patient in the following manner.

 

There are many examples of images affecting our physical state in day-to-day life.  Think about the last time you watched a scary movie.  During the course of the movie, you may have noticed your heartbeat increasing, your palms becoming sweaty, your breathing accelerating, and your respiration increasing.  All of these very real physical responses occurred to something that was not real.  The movie was simply the activating your imagination to which the body responded.

 

Another example of our bodies responding to our imagination is dreams.  When we experience a nightmare we will have a physical reaction as if it was actually happening.  Also, a dream about a very pleasant time may invoke very strong physical and emotional reactions.  Another example of our imaginations evoking a physical response is dreams that have a sexual content.

 

The above observations demonstrate that our imaginations are, in fact, a normal way of thinking.  The power of our imaginations has been utilized in a variety of areas in health care.  Specifically, using the ability to imagine can have very positive effects, such as:

 

 

Positive Effects of Imagery

 

 

To help achieve a more fully, deep, relaxed state 

 

This is the use of imagery as a relaxation technique.  It is most often done after the initial deep relaxation state is achieved through the breathing exercises discussed in the previous section.

 

To enhance physical healing 

 

Many imagery exercises are designed to activate the body’s natural ability to heal itself.  This might include such images as white blood cells attacking and dissolving germs or injured tissues receiving the valuable nutrients from increased blood flow.   

 

To provide a method for pain relief

 

Imagery can help the patient remove him or herself from the experience of pain while it is occurring.  Using the imagery techniques, a patient can mentally “go to another place” to decrease the perception of pain and discomfort.  Also, there are specific images for reducing the experience of pain more directly such as turning the volume down on the pain or changing the color of an imaginary “ball of pain” to something more relaxed.

 

To help with improving sleep    

 

Sleep disturbances are not uncommon when a patient is anticipating surgery, when is in unfamiliar hospital surroundings, and is recovering at home after surgery.  Imagery can be very helpful for promoting sleep.  Often this imagery will involve a “passive” technique in which the patient will imagine his or her body feeling the physical sensation of relaxing (e.g. “warm and heavy”).

 

To promote muscle relaxation and decrease anxiety

 

This type of imagery will involve such things as imagining the muscles “unwinding” like the knots in a twisted rope, a “ball of tension” in the body that dissipates with exhaling, or one’s muscles becoming more “smooth” and loose.

 

To provide a powerful distraction from a stressful medical procedure

 

This type of imagery is very effective when a patient is undergoing an unpleasant medical procedure which causes discomfort or pain.  Guided imagery, in which the patient “guides” his or her imagination through a sequence of events such as walking on the beach or down a forest path, is particularly powerful in this purpose.

 

 

As can be seen from these examples, there are many ways in which imagery can be used for health issues, including the surgery process.  The imagery discussed subsequently will focus on its use, specifically for surgical issues and healing.

 

Guidelines for Practicing Imagery

 

The following are guidelines for developing an effective imagery exercise.  It is important to remind the patient that imagery is a natural process and he or she is always in complete control. 

 

Record an imagery exercise.  Recording an imagery exercise on audiotape can help a great deal in terms of the patient’s regular practice and making the imagery experience as powerful as possible.  The clinician can record an imagery exercise during the course of surgery preparation exercise, or some patients prefer to make their own.  Using a tape recording can also be a good technique for developing the deep relaxation response through the breathing exercises discussed in the previous section.

 

Develop an image with which the patient is quite familiar.    Generally, people have an easier time of conjuring up all aspects of the image if it is something that they have actually experienced in the past.  For instance, a patient may choose a beach or forest scene, which is a place that they have visited (and, of course, had a pleasurable time).  There are standard imagery exercises, some of which are presented in the following section.  These can be modified to fit with the patient’s own personal experiences. The use of images developed from the patient's memories and experiences does not have to contain the entire memory. The patient can draw from bits and pieces of different memories in order to form a complete image.  

 

Use all five senses in developing the image.  It is most powerful if the patient utilizes all five senses in developing the image (sight, sound, touch, smell, and taste).  For instance, in a beach scene for relaxation, the image should include the view of the ocean and beach, the smell of the salty sea air, the sounds of sea gulls and the waves crashing, the salty taste of the ocean air, and the feel of bare feet walking on the warm sand.

 

Use an image that is pleasing to the patient.  The old adage that “one person’s feast is another person’s poison” applies to imagery as well.  Imagery is a very personal and individualized experience.  It is important to be sure that the patient’s imagery is pleasing to him or her (and not as defined by the clinician). 

 

As an example of the importance of individualized images, consider the standard relaxation image called "The Beach Scene."  While this may be relaxing to most people, other people may find it quite distressing.  I was very much reminded of this while leading a group relaxation/imagery exercise with a colleague. We chose the beach scene as a standard image to have the group develop.  At the end of the exercise, we asked the group members to comment on their experience with the image.  Although most everyone found it very relaxing and pleasant, one woman felt it was quite distressing and anxiety producing.  She discussed that she absolutely “hated” going to the beach.  For her, going to the beach meant not being able to find a place to park, suffering through sunburn, eating sandwiches with sand and ants in them, and listening to the radio with bad reception.  There was no part of the beach scene that she found relaxing.  This example underscores that structured imagery exercises such as the beach scene serve only as examples from which you can develop the patient’s own personalized image.

 

Sneak up on the image.  Sometimes it can be difficult to immediately focus on an entire image at one time.  In trying to create the total image at once, the patient may find it stressful if he or she is unable to do so adequately.  This is especially the case when a person is trying to use the imagery in the situation of attempting to manage a stressful situation.  It has been discovered that it can be useful to "sneak up on the image" as suggested by Margo McCaffrey, R.N.

 

In order to avoid becoming frustrated in creating the scene, sneaking up on the image simply involves constructing it slowly.  For example, if you are using a forest scene as your chosen image, you can begin by imagining that you are at home preparing to go to the forest, or that you are on the drive to the forest.  You can imagine driving to the trailhead, getting out of the car, and slowly walking into the beautiful mountain scene, which is your final goal image.  Using this technique of sneaking up on the image helps ensure that the imagery is relaxing and that you adopt an attitude of "letting it happen," rather than trying too hard.

 

Use one image at a time.  It is best to only try and imagine one total image at a time.  Trying to maintain several images at once is stressful and usually does not accomplish the goal of imagery.

 

Precede the imagery with a relaxation exercise.  Using a deep relaxation exercise, prior to doing the imagery can greatly facilitate the use of imagery.  Although not required, it is highly recommended approaching an imagery exercise in this fashion.  This process includes choosing one of the breathing exercises as discussed previously.  Have the patient practice with the breathing exercise until he or she is skilled at eliciting the deep relaxation response.  Once this is mastered, the patient can then add an imagery exercise as suggested in this section. Each session of deep relaxation and imagery should total about ten to twenty minutes.   All of the guidelines for practicing the relaxation exercises also apply to the imagery experience. 

 

Practice the image.  It is important to regularly practice imagery in order to develop the skill.  This is the same as developing any other skill such as riding a bike or playing a sport.  The ability to create a mental image utilizing all of the five senses may be difficult at first but it does improve with practice.  Therefore, if your images are not vivid initially, don’t worry about it.  As you practice, you will notice more details coming into focus, along with feeling like you are actually in the image more and more.  Making a tape recording of your image can facilitate practice sessions, as discussed above.

 

Develop a technique to end your image.  It is important to develop a technique to end your image rather than stopping it abruptly.  One of the most common side effects of using imagery is a slight sense of drowsiness afterwards.  This can be avoided by using a technique for ending the image.  One of the most common methods is to count silently from one to five.  Then, on the last count, you inhale deeply, open your eyes, and say to yourself, "I feel alert and relaxed."     Another example of an ending statement is as follows: 

 

In a moment, you will notice becoming more alert, refreshed, and awake.  As I count from one to five, I would like you to become more awake, renewed and energized.  When I get to five, you can open your eyes, feeling refreshed.  One....gradually becoming more alert.....Two....becoming more and more awake..Three.. beginning to slowly move your fingers, hands, and arms...Four...almost back to an alert state...you can now begin to move your toes, feet, and legs...and...Five ...opening your eyes and finding yourself fully awake, alert, renewed, and refreshed.

 

After completing an imagery exercise, the patient should get up slowly due to the risk of orthostatic hypotension (sudden drop in blood pressure when changing for a sitting/reclining position to a standing position).

 

Don't worry if the image is not completely vivid.  The patient can get the beneficial effects of imagery, even if the image does not have a great amount of detail or is not particularly vivid.  As discussed above, the more the patient practices, the more likely the details of the images will emerge and the patient will notice a sense of actually being there.  It is not helpful for the patient to judge his or her performance, or making this in any way stressful.

 

Incorporate affirmations or prayer into the imagery.  As part of the imagery exercise, the patient can incorporate affirmations or prayers as they so desire.  For instance, affirmations such as, "I am letting go," "I am at peace," and "All of the tension is flowing from my body" are common for relaxation and imagery training. 

 

STANDARD IMAGERY EXERCISES

 

The following imagery exercises are given as examples and are fairly standard, having been developed over a number of years.   In these examples, it can be seen how the guidelines for developing imagery as discussed previously have been utilized.  These examples can be utilized with patients, or more individualized and personal ones can be developed.  As discussed previously, it is most beneficial to customize the image to the patient’s own individual experience.  In the examples, the series of dots represent places where the clinician should pause in order to develop a nice, slow pace to the exercise.

 

The standard image exercises that will be presented are called

 

"Passive Muscle Relaxation"

"The Beach Scene"

"Pain Reduction"

"Ball of Healing Energy." 

 

For all of the following exercises, it is assumed that the patient will have already completed a breathing exercise to elicit the relaxation response.  If a tape is made for patient use, put the breathing exercises at the beginning of the tape and then incorporate the imagery sequence after the breathing exercises.  It is also important to end the image as discussed previously.  In the first example, all of these phases (breathing exercise, imagery, ending the imagery) are presented.

 

Passive Muscle Relaxation

 

As you feel ready, allow your eyes to slowly close....Take in a full, deep breath through your nose, allowing your lungs to fill completely.  Let the air go all the way in, breathing down into the bottom of your lungs.  Notice the cool sensation in your nose as the air rushes in....Then, breath out through your mouth while slightly pursing your lips....Notice that the air you exhale is warm and moist....Release all of the air in your lungs as you exhale completely...Slowly repeat this cycle several times....Breathing in through your nose and out through your mouth...Remember, there is nothing else to think about except becoming completely and deeply relaxed....

 

[Pause 3 to 5 minutes here before doing the breathing]

 

You may have noticed the healthy breathing exercise has already helped you become quite relaxed....As you allow yourself to relax more and more fully, begin to focus your attention on your fingers and hands...As you mentally focus your attention on your fingers and hands, I would like you to notice the sensations that are coming from that part of your body....You may notice your hands resting on another part of your body or elsewhere...Simply focus on  the sensations coming from your fingers and hands...Imagine what it would feel like for your hands and fingers to become more and more relaxed....Let go of any excess tension you may feel in your fingers or hands.

 

As you continue to relax and breath peacefully, slowly move your mental attention to the sensations coming from your forearms and upper arms...As your fingers and hands continue to relax, allow that feeling of relaxation to move into your forearms and upper arms...You might notice your hands or arms feeling warm or heavy as they relax..Or you may notice them feeling cool and light...  Simply focus on what the relaxation response feels like for you. 

 

As your arms continue to relax with every breath, allow the feeling of relaxation to move into your head, neck, and shoulders...Notice what it would be like for your forehead to relax completely....Allow the muscles around your eyes to relax...As you relax the muscles of your jaw you may notice that your lips separate slightly...Allow your shoulders to relax completely....Mentally scan these parts of your body, and imagine letting go of any tension that you notice....Just allow the wave of relaxation to extend throughout your arms and upper body. 

 

When you are ready, focus your attention on the sensations coming from your stomach and back...Again, notice the relaxation response move slowly down your body as you let go of any tension in your stomach and back...Imagine what it would be like for all of the muscles in your stomach and back to unwind and loosen up completely...It is as if you are inhaling relaxing and exhaling tension with every breath....There is nothing else for you to focus on right now except enjoying the feelings of relaxation throughout your upper body. 

 

As you continue to enjoy those feelings of relaxation, imagine the pleasurable sensation moving into your upper legs...Allow the relaxation response to move further and further down your body.  ...Nothing else to focus on except enjoying the relaxation response.  When you are ready, allow the relaxation response to move further down into your ankles, feet, and all the way to your toes.  Notice how the relaxation spreads throughout all the muscles of your legs and feet.  Again, you may notice your entire body becoming heavier and heavier, or lighter and lighter.  You may also notice a tingling sensation as part of the relaxation response....These are all normal feelings as part of relaxing....  Simply focus on what the relaxation sensation feels like for you....You may also notice a warming sensation or, perhaps, a cooling sensation.  Enjoy the sensation of your entire body being deeply relaxed.  As you relax further, take a few moments to enjoy the sensation of relaxation....

 

[Pause here for 1 or 2 minutes]

 

In a moment, you will notice becoming more alert, refreshed, and awake.  Even so, remember you can call upon the relaxation response at any time you like throughout the day....Simply take a deep breath and tell yourself to “relax” as you exhale....This will recall the relaxation sensation....

 

As I count from one to five, I would like you to become more awake, renewed and energized.  When I get to five, you can open your eyes, feeling refreshed.  One....gradually becoming more alert.....Two....becoming more and more awake..Three.. beginning to slowly move your fingers, hands, and arms...Four...almost back to an alert state...you can now begin to move your toes, feet, and legs...and...Five ...opening your eyes and finding yourself fully awake, alert, renewed, and refreshed.

  

The Beach Scene 

 

It is about five in the afternoon on a midsummer day...You are walking along a shady path that opens up to a very beautiful and expansive beach...As you walk from the path onto the sandy beach, you notice that it is virtually deserted....The beach extends off in both directions farther than you can see....The sun has not yet begun to set, but it is getting very low on the horizon...The sun is a deep and golden yellow, the sky full and a brilliant blue, and the sand is a glistening white in the sunlight....As you walk on the sand in your bare feet, you notice it rubbing between your toes... The sand is warm and comfortable...You notice the taste and smell of the salt in the ocean air...There is the residue of salt deposited on your lips from the ocean spray...You can slightly taste its presence...You can hear the roaring sound of the surf as it rhythmically comes in and washes out from the shore...You hear the far-off cry of a sea‑gull as you continue to walk along the beach...You notice yourself becoming more and more relaxed as you continue walking down the beach....You realize that you have nothing else to think about except enjoying this moment...You feel the warm sea breeze blowing against your face, as well as the warmth of the sun on your body...You feel more and more content as you enjoy the surroundings of this beautiful beach....As you continue to walk, you notice a place where it would be quite comfortable to simply sit down and relax against a sand dune.... As you sit, you are look out over the beach, the waves, and the sun on the horizon...The sun has started to set, causing the sky to turn many colors including scarlet, pink, gold, orange, amber, and crimson.  You allow yourself to settle deeply into the comfortable sand dune as you enjoy the sun's reflection off the water.  The sand forms perfectly to your body as you settle in.....As you sit you allow yourself to relax more and more.  You find yourself relaxed, peaceful, and content.

 

Breathing Out Pain

 

Continue to breathe comfortably and slowly, feeling your body relax more and more each time you breathe out....If you wish, the next time you breathe in, imagine that your breath goes to that part of your body in which you are experiencing pain or discomfort.... Imagine your inhaling brings with it valuable oxygen and nutrients your body needs.....Your deep breath also brings with it a sense of calm and comfort....As you slowly exhale, you might imagine that just a bit of the pain and discomfort is exhaled along with your breathing out... As you exhale some of this pain and discomfort, the tissues left behind seem to be more relaxed, healthy, and comfortable....This reduction in pain may be only slightly noticeable at first, but it seems to become more and more powerful with each breath.....Each time you breath in, imagine the air flowing to that area of pain and discomfort....It brings with it a sensation of health and comfort....Then, each time you breathe out the air, notice the area of pain and discomfort becoming smaller and smaller.... As you breathe out, you are exhaling discomfort and pain....Breathe in the relaxation and breathe out the pain.

 

Healing Energy

 

As you continue to relax, focus once again on your breathing.  Notice how you are slowly breathing in...Feel the air going into your lungs....Notice your lungs filling completely with air as you inhale....Then, notice the air rushing out of your lungs and mouth as you exhale.....Enjoy the experience as you become more and more relaxed each time you inhale and exhale....As you continue to relax, you may begin to imagine a ball of white light forming in the area of your chest and lungs....This is a ball of healing energy....It may not be particularly clear or distinct and that is perfectly fine.....Whatever its shape and texture, simply notice what your ball of healing energy looks like....Focus for a few seconds on this ball of healing energy in your chest area....When you feel ready, you may begin to notice this ball of white healing energy move to an area of your body which is feeling pain or discomfort....Notice the ball of healing energy moving slowly to that part of your body....Imagine that ball of healing energy settling in that part of your body...As it settles there,  imagine it helping the tissues becoming more and more healthy....Imagine the white ball of healing energy bringing with it valuable nutrients and healing power....As the power of the healing ball of energy begins to work, you might notice a warming or cooling sensation in that part of your body....You might also notice a slight tingling sensation.....Simply focus on what the healing experience feels like for you as the healing ball of energy begins to work.....As you exhale, you might notice the ball of energy moving away from your body, taking with it toxins, tension, and injured tissue....Each time you inhale, imagine the ball of healing energy going to your area of discomfort with its healing energies....Each time you exhale, notice the ball of energy move away, taking with it some of the pain, discomfort, and tissue damage....When you breathe in, it brings with it valuable relaxation and healing power....Each time you breathe out, it removes discomfort, pain, and toxins.

 

PREPARING FOR SURGERY: INTERACTING WITH

THE HEALTHCARE SYSTEM

 

Both the biopsychosocial and the social self-regulation models of surgery preparation include an emphasis on inter-personal influences on surgery preparation.  The previous chapter focused primarily on individual self-regulation or intra-personal techniques that can be used for enhancing surgical outcome.  This section will focus on helping the patient with surgery preparation within a social context. 

 

Doctor-Patient Communication Problems and Medical Errors

 

The doctor-patient communication gap.  Communication issues between the surgical patient and those involved in his or her medical care are of the utmost importance and can significantly impact surgical outcome. As previously reviewed, information gathering is a critical component to any preparation for surgery program.  In an ideal world, patients could attain accurate and understandable information from their healthcare providers as well as other sources.  Unfortunately, research indicates that this is simply not the case.  Consider the following statistics (See Deardorff & Reeves, 1997 for more details):

 

 

Problems with Patient Information-Gathering

 

 

A recent survey of consumers by the American Medical Association indicated that 58% of patients felt their physician did not provide adequate explanations about their condition. 

 

69% of patients felt that their physician did not spend enough time with them. 

 

60% of patients do not read complex consent and hospital forms. 

 

Research has demonstrated only a 30-50% retention for surgical information in medical patients. 

 

A majority of HMO complaints against physicians involve communication issues. 

 

 

Effective communication between doctor and patient has been found to enhance patient recall of information, compliance with treatment recommendations, satisfaction with care, psychologic well-being, and overall treatment outcomes (see Levinson & Chaumeton, 1999; Stewart, 1995 for a review).  Certainly, research indicates that patient concerns about obtaining appropriate information are not unfounded.  For instance, it has been found that general practice physicians and surgeons spend an average of between 7 minutes and 13 minutes per patient visit.  In addition, it is likely that a patient will be interrupted by their doctor within the first 18 seconds of their explanation of symptoms (Beckman & Frankel, 1984).  However, the entire doctor-patient communication problem cannot be placed with the physicians.  There are research findings that suggest that patients share some of the responsibility for not getting what they need from their healthcare providers.  For instance, Kaplan and Greenfield (1989) determined that the average patient asked fewer than 4 questions in a 15 minute visit with their doctor.  In addition, one of the more frequently asked questions was, “will you validate my parking?.” 

 

Medical errors.  Unfortunately, medical errors are more common than is generally realized amongst the patient population (See “Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact, a Report to the President; available at http://www.quic.gov/report/errors6.pdf).  Medical errors range from mistakes in hospital meals to blatant surgical mistakes (See the Agency for Healthcare Research and Quality report: Medical Errors: The Scope of the Problem. Fact sheet, Publication No. AHRQ 00-P037. Available at http://www.ahrq.gov/qual/errback.htm).

 

One of the more common mistakes in the hospital is medication error (Leape, Bates, Cullen et al, 1995).  The Journal Of The American Medical Association estimates that doctor- or hospital-related mistakes could be at least partially responsible for 180,000 deaths annually (Leape, 1994).  A recent 2006 report (“Preventing Medication Errors” available from the National Academies Press at http://www.nap.edu) by the Institute of Medicine, found that medication errors are surprisingly common.

 

Probably two of the most important medical errors for a patient to monitor during an inpatient stay are medication interaction and infection.  The hospital setting is one of the most likely and most risky places to get infected.  According to the Centers For Disease Control and Prevention, approximately 5-10% of hospitalized patients pick up an infection translating into 1.75 and 3.5 million per year (see Benson, 1996; Cohen, 1995).  CDC officials estimate that failure to follow standardized infection control practices causes at least one-third of hospital acquired infections.  These procedures include such simple tasks as healthcare professionals washing their hands prior to performing any type of physical contact with the patient.  In a comprehensive review of 37 studies on hand washing, it was found that doctors and nurses typically wash their hands only 40% of the time prior to physical contact with the patient  (Griffin, 1996).  Unfortunately, the hospital setting is one place where the patient is more prone to be infected with an antibiotic resistant bacteria, or “super bug” (Cohen, 1995).

 

Due to the frequency of medical errors, the Agency for Healthcare Research and Quality (AHRQ), has developed “20 tips to help prevent medical errors.”  The following list summarizes these 20 tips.  Many of these recommendations will be included as part of the following section and should be provided to patients as part of a surgery preparation program.

 

 

Example Patient Handout for Avoiding Medical Errors

 

 

The single most important way you can help to prevent errors is to be an active member of your health care team.   

 

Make sure that all of your doctors know about everything you are taking.  This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs. 

 

Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.

 

When your doctor writes you a prescription, be sure you can read it.

 

Ask for information about your medicines in terms you can understand-both when your medicines are prescribed and when you receive them.

 

When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed?

 

If you have questions about the directions on your medicine labels, ask.

 

Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if you’re not sure how to use it.

 

Ask for written information about the side effects your medicine could cause.

 

If you have a choice, choose a hospital at which many patients have the procedure or surgery you need.

 

If you are in the hospital, consider asking all health care workers who have direct contact with you whether they have washed their hands.

 

When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will use at home.

 

If you are having surgery, make sure that you, your doctor and your surgeon all agree and are clear on exactly what will be done.

 

Speak up if you have questions or concerns.

 

Make sure that someone, such as your personal doctor, is in charge of your care.

 

Make sure that all health professionals involved in your care have important health information about you.

 

Ask a family member or friend to be there with you and to be your advocate (someone who can help you get things done and speak up for you if you can’t).

 

Know that “more” is not always better.

 

If you have a test, don’t assume that no news is good news.

 

Learn about your condition and treatment by asking your doctor and nurse, and by using other reliable sources.

 

Note: 20 Tips to Help Prevent Medical Errors. Patient Fact Sheet. AHRQ Publication No. 00-PO38, February 2000. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/consumer/20tips.htm

 

 

Providing healthcare professionals with accurate medical information. It is important for patients to gather appropriate information regarding their surgical experience.  Equally as critical is making sure that healthcare professionals have accurate information about a patient’s medical history and other variables that might impact their surgical experience.  Since many different doctors and healthcare professionals might be involved in the surgery process, having patients complete a “medical fact sheet” as part of a surgery preparation program will help avoid treatment “errors” and give the patient an increased sense of control.  An example of a medical fact sheet can be found in Deardorff & Reeves (1997).

 

The need for this type of medical fact sheet is becoming more and more critical given changes in the healthcare system that place much more responsibility on the patient.  Medical errors are unfortunately more common than the general public realizes and patients can play an active role in preventing them.  Provision of information, as well as the information gathering process discussed in chapter three, is consistent with all of the preparation for surgery models.   

 

ASSERTIVE TRAINING AND SURGERY PREPARATION

 

Consistent with several models of surgery preparation (e.g. biopsychosocial, self efficacy, and empowerment, social self-regulation, etc.), assertiveness skills are essential for a patient to implement many of the preparation for surgery recommendations.  Being appropriately assertive can help surgery patients obtain the necessary information preoperatively as well as protecting them from medical errors.  The following section will present a brief outline of assertiveness training and skills.  The reader is referred to other sources for more detailed information (Alberti & Emmons, 1974; Bourne, 1995; Bower & Bower, 1991; Deardorff & Reeves, 1997; McKay, Davis & Fanning, 1983).   There are four types of communication styles:

 

 

Types of Communication Styles

 

 

Non-Assertive or Submissive 

 

This is behavior characterized by “giving in” to another person’s preferences while discounting your own rights and needs.  If an individual engages in this behavior, the people around him or her may not even be aware that the patient is being non-assertive or submissive because the individual’s needs are never expressed.  Of course, surgical patients who engage in submissive behavior are more likely to be the victims of the mistakes of others around them. 

 

Aggressive Communication

 

This is a communication style in which the patient expresses his or her wants and desires in a hostile or attacking manner.  This behavior is often done in conjunction with being insensitive to the rights and feelings of others around them.  Coercion and intimidation may be part of the aggressive communication style.  Typically, aggressive communication increases the level of conflict in any situation.  Aggressive behavior as part of a surgery preparation program is likely to result in either healthcare professionals withdrawing from the patient  (being passive-aggressive) or counter-attacking in a similarly aggressive manner.  Either situation is likely to lead to deleterious effects relative to surgery outcome. 

 

Passive-Aggressive Behavior

 

Passive-aggressive behavior is a way of expressing anger in a passive manner.  This is often seen in pain problems in which the original injury is the result of a work-related or other accident.  In these cases, the patient is often angry at the employer or other party who is perceived as having “caused” the injury.  The patient will then, either consciously or unconsciously, use the pain behaviors to “get back at” the perceived perpetrator.  Often, patients engaging in passive-aggressive communication have no insight into their behavior.  Unfortunately, the patient is the one that is likely to sustain the most negative outcome.

 

Assertive Communication 

 

The last of the four communication styles is assertive communication.  An individual who uses assertive communication is able to express his or her wants and/or desires while respecting the right of others.  It involves communicating in a simple and direct fashion without attacking, manipulating, or discounting those around you (Alberti & Emmons, 1974; Bourne, 1995; Bower & Bower, 1991; Deardorff & Reeves, 1997).

 

 

As discussed by Deardorff and Reeves (1997), “communicating in an assertive fashion allows you to express your needs and desires while keeping those around you comfortable and non-defensive” (page 175).  Assertive communication is characterized by the following and should be taught as part of surgery preparation:

 

Use assertive non-verbal behavior.  Body language can communicate a great deal beyond what a patient expresses verbally.  Assertive behavior includes staying calm, establishing eye contact and maintaining an open posture.  Alternatively, non-assertive behavior includes such things as looking down at the floor while communicating, avoiding eye contact, speaking softly, and turning slightly away from the person with whom one is talking.  A component of assertiveness training related to surgery preparation would involve teaching the patient non-verbal assertiveness skills. 

 

Keep requests simple.  An effective assertive request is most often delivered in a simple, direct, and straight forward fashion.  This might include asking for only one thing at a time in an easy to understand format. 

 

Be specific.  Being specific involves helping the patient determine wants, needs, and feelings so that he or she can be very concrete in expressing them to healthcare professionals or other individuals within their psychosocial environment.  This is the difference between saying “I would like to get more help from your office staff regarding my surgery,” versus “I would appreciate your office staff helping me with the following issues regarding my surgery: insurance pre-approval, scheduling my blood donation, and giving me information about postoperative pain control.”  The latter request is specific, direct, and non-aggressive. 

 

Teach patients to use “I” statements.  Assertive communication often begins with “I” statements.  These would be things like:

 

I need to…

I would appreciate it if…

I would like to…

 

Teaching patients to use “I” statements in their communication is one of the primary components of assertiveness training.  Patients should also be taught to avoid “you” statements, since these often sound threatening and put the other person on the defensive. 

 

Address requests to behaviors and not personalities.  It is important to teach patients to address their request to behaviors of another person rather than “personality features.”  For instance, if a surgery patient needs help with housework postoperatively, it is preferable to say “I would like you take over the heavy household chores while I am recovering from my surgery” rather than “I know you tend to be careless about housekeeping, but would you help me with the chores while I am recovering from my surgery.”  This guideline also applies to requesting behaviors while in the hospital. 

 

Teach patients not to apologize for their requests.  Another component of assertiveness training is teaching patients not to apologize for their requests.  Patients who tend to be more submissive or non-assertive will often make requests in an apologetic manner.  They might make a request in the form of, “I am really sorry to have to ask, but is it possible for you to help me prepare for my surgery.”  This type of request has a low probability of being acknowledged and communicates that the person making the request does not really feel deserving or have the right to ask. 

 

Learning to say “No”.  Learning to say “no” is an important assertiveness skill to teach patients going through surgery.  This will help the patient set important limits on the demands of family, friends, work, and others.  More submissive and non-assertive individuals have trouble saying no since they feel “guilty.”  Teaching patients to set appropriate limits is extremely important especially during the postoperative recovery phase when “pacing” is essential for enhanced recovery from many types of major surgery. 

 

The “Broken Record” technique.  The Broken Record Technique is an effective assertiveness tool that patients can utilize easily.  It simply involves repeatedly making a request or saying “no” until the patient’s communication is acknowledged.  For those just learning assertiveness skills, there may be a tendency to make a request and then “back down” if any resistance is encountered.  Or, the patient might try and come up with more and more reasons why his or her request is justified.  In this latter process, every time the patient expresses another reason for the request, it becomes weaker and weaker as if trying desperately to convince the other person that the request has merit.    The Broken Record Technique can help patients feel comfortable making their request and then following through.  An example might be a post-operative surgery patient who wants to make sure his doctor washes her hands before examining him:

 

Patient:  “I would appreciate it if you would wash your hands before…..”

Doctor: “Don’t worry about it.  It will be fine.  I really am in a hurry.”

Patient: “I understand you’re in a hurry, but I would like you to wash your hands…..”

Doctor: “You really need not be concerned. I just need to take a quick look.”

Patient: “I still would like you to wash your hands.”

 

THE DOCTOR-PATIENT RELATIONSHIP

 

Part of preparing for surgery is teaching patients how to work effectively with their doctors, including their surgeon.  According to empowerment theory, patients and healthcare professionals work in a “partnership” in the patient’s overall care.  Any preparation for surgery program should have a component that teaches patients how to effectively interact with their healthcare team.  Effective interaction allows for efficient gathering of information, accurate communication of needs, improved patient satisfaction, and enhanced outcome overall.  The social self-regulation model of surgery preparation suggests that interactions between the patient and caregiver will primarily be “task-focus.”  As such, the primary goal is for the patient to obtain necessary information and guidance throughout the surgical experience.  As discussed previously, there is often discordance between the surgeon and patient’s perceptions and goals.  Ineffective physician-patient communication can compromise compliance, health status, and patient satisfaction (Temple, Toews, Fidler, Lockyer, Taenzer, & Parboosingh, 1998; Stewart, 1995).

 

Levinson and Chaumeton (1999) investigated communication between surgeons and patients during the course of routine office visits.  There was a mix of general and orthopedic surgeons in the study.  The average office visit was 13 minutes and surgeons talked more than patients.  The typical surgical consultation consisted of “relatively high amounts of patient education and counseling.”  Consultations had a narrow biomedical focus with little discussion of the psychologic aspects of the patients’ problems.  Surgeons infrequently expressed empathy towards patients and social conversation was brief.  The authors make the point that the results are “consistent with the work of physicians in this setting because they often see patients referred to them for a surgical intervention” (page 132).  It might be argued that it is not the role of the surgeon to address emotional and/or psychosocial issues.  Even so, the importance of these findings for a surgery preparation program is to give the patient appropriate expectations regarding visits with his or her surgeon.  Patients should expect that the office visit will be relatively brief, that a great deal of information will be provided, and that the emotional/psychosocial issues will not be addressed.  If patients go in with expectations that are different than these, there will be a high likelihood of dissatisfaction with the visit and overall care. 

 

Beyond giving patients appropriate expectations about interactions with their surgeon, the preparation for surgery program can teach them how to effectively work with all members of their healthcare treatment team.  The following recommendations are adapted from Deardorff and Reeves (1997) and Ferguson (1993).

 

 

Enhancing the Doctor-Patient Visit

 

 

Help Patients Plan Their Doctor Visit In Advance 

 

An important component of a preparation for surgery program is gathering information.  Patients should be taught to develop a list of questions and concerns to address with their surgeon during the office visits.  These should be very specific and not overwhelming in terms of scope and length (a patient who develops a list of 100 questions will be extremely frustrated when only two or three of them are addressed during the office visit).  Therefore, helping patients be realistic about the number of questions that they want answered during the course of an office visit is important. 

 

Teach Patients to Be Assertive

 

Teaching patients basic assertiveness skills, as discussed previously, can very much enhance their overall surgery experience as well as their outcome.  These skills can be useful in terms of gathering information during office visits, as well as getting other needs and concerns addressed.  Once again, patients should be taught to be reasonable in using the assertiveness skills.  If patients “go overboard”,  or are seen as aggressive and overly demanding by their healthcare team, the healthcare providers will often react in a passive-aggressive manner without even realizing it.  Of course, this sets up a very negative interaction that will likely have deleterious effects on surgery outcome. 

 

Help Patients Direct Their Questions to the Appropriate Person 

 

Healthcare professionals will often take for granted that patients have an understanding of the medical system.  Generally, this is not the case, and patients will often be confused about information resources.  Thus, patients may attempt to obtain information from their surgeon when the most appropriate person might be a physician’s assistant, nurse, or some other individual.  Of course, this inaccurate patient expectation would likely lead to dissatisfaction. 

 

Remind Patients to Bring Someone Else to Doctor Visits 

 

Having patients bring someone else to their doctor visits can be important in many ways.  Patients are often quite nervous and preoccupied during the course of a visit with their surgeon.  Under these circumstances, they are likely to miss the opportunity to ask important questions, as well as not remembering medical information that they are given.  As discussed by Ferguson (1993) and Deardorff and Reeves, (1997), bringing another individual to the doctor’s appointment can help calm the patient, make sure that various concerns are addressed, and help the patient with medical information recall.

 

 

SURGERY PREPARATION AND PSYCHOSOCIAL ENVIRONMENTS

 

Addressing the psychosocial environment as part of a surgery preparation program might include helping the patient with such things as important personal relationships (family, friends, and co-workers) and spiritual concerns as they impact the surgical experience.

 

Family and Friends

 

One of the most important variables in terms of enhancing postoperative recovery from surgery may be the patient’s family environment.  As discussed previously under the conceptual model of social self-regulation, it is important for the patient and his or her family to have similar adaptive goals.  In addition, according to social self-regulation theory, the family can help enhance the patient’s surgical outcome by providing tangible assistance, as well as emotional and informational support. 

 

A preparation for surgery program should contain a component of working with the family of the patient prior to the surgery. There is evidence that including the patient’s family in the preparation for surgery will enhance results versus intervening with the patient alone (See Raliegh, Lepczyk & Rowley, 1990).   Most of the concepts of surgery preparation that have been discussed as interventions for the patient  can also be applied to family members.  This would include such things as information gathering, cognitive issues, interacting with the medical system.  It is important for family members to have appropriate and realistic expectations regarding the course of the patient’s recovery from surgery.  If they expect too much, or too little, the patient is less likely to do well.  Preparing the home environment for the postoperative recovery period can also be an important focus of a preparation for surgery program.  This might include organizing the actual living space of the patient for surgery recovery, obtaining any necessary assistive devices beforehand, and arranging home healthcare if necessary, among other things. 

 

Assessing and intervening in the social system is especially important in the case of a patient with a chronic pain problem that is being addressed by the surgery (e.g. back pain, neck pain, etc).  Most chronic pain patients have a “partner in pain” as described by Engel (1959), Szazs (1968) and Waddell (1998), also termed an “associate victim” (Halmosh & Israeli, 1984; Waddell, 1998).  There is usually one main partner who provides most of the “social support”, although other members of the patient’s family and friends will assist.  As Waddell describes it,

 

“Chronic pain patients and their partners play active, mutually supporting roles, and the pain may become a major focus in their whole relationship.  Their whole social milieu may become pervaded by pain and disability, medical values and health care.  Chronic pain and caring may become almost full-time careers, with both partners equally committed.  In extreme cases, this may actually provide a more satisfying emotional relationship for both of them” (1998; p. 208-209).

 

In this case, there may be a great “cost” for the patient to give up the chronic pain even if the surgery is technically a success.  These issues are usually identified as part of the pre-surgical evaluation. If the patient is going to have surgery, and these issues are present, they must be successfully addressed as part of a surgery preparation program.  If they are not, the surgery is likely to be a technical success but a clinical failure. An example of this might be the chronic back pain patient who has been disabled for years and is fully ensconced in the sick role.  If psychosocial issues are not addressed prior to surgery (such as becoming more independent, etc), the spinal fusion may be technically “perfect” but the patient will show no change in pain complaints, level of disability, etc., post-operatively.

 

Work and Co-workers

 

One of the most valued social roles for an individual is his or her work.  Work provides such values as (Waddell, 1998):

 

     Income

     Activity

     Occupies and structures our time

     Creativity/mastery

     Social Interaction

     Sense of Identity

     Sense of Purpose

 

Given the pervasive importance of work values, this is another important area of surgery preparation.  Surgery patients will often have significant concerns related to how the operation will impact their work abilities.  This might include such issues as how long will they be disabled from work due to the surgery process, how will they survive financially, will they ever be able to return to full-time and unrestricted work, among other things.  Any surgery preparation program should be sure that these issues are addressed with patients in some manner.  Patients can be helped to develop strategies to deal with the work and financial issues in the most effective manner possible.  Unfortunately, many surgery patients are so concerned and distracted by the surgery approaching that they forget to deal with the work and financial issues until it is too late.  When this happens, usually post-operatively, it can create an extreme level of stress that negatively impacts the patient’s ability to recover. 

 

Spiritual Issues

 

Aside from preparing the family system for a patient’s operation, the individual’s spiritual issues are also rarely addressed by the medical system, including the surgery experience.  For instance, a review of over 1,000 articles in primary care physician journals revealed that only 11 studies (1.1 percent) examined religious considerations.  In another review, it was found that, in the last 200 years, only about 200 studies out of hundreds of thousands of English medical journal articles, investigated some aspect of spiritual faith.  Benson (1996) concludes that these findings show just how “taboo” the topic of God has become in the recent history of Western medicine.

 

Even though Western Medicine rarely incorporates spirituality as part of the treatment and healing process, it is often an important part of the patient’s life.  According to a Gallup poll, conducted in 1990, 95 percent of Americans say they believe in God, and 76 percent say they pray on a regular basis.  In addition, spiritual beliefs have been found to correlate with health benefit, including surgery outcome (see Deardorff & Reeves, 1997; Larson, 1993; Levin, 1994; Matthews, Larson, & Barry, 1994; Oxman, Freeman, & Manheimer, 1995; Pressman, Lyons, Larson, & Strain, 1990 for more detailed reviews of this issue).  Some of the more interesting results are as follows:

 

 

Spirituality and Health

 

 

Levin (1994) reviewed hundreds of epidemiologic studies and concluded that belief in God lowers death rates and increases health. 

 

In a study completed at Dartmouth Medical School, it was found that, of 232 patients who had undergone elective open heart surgery for either coronary artery or aortic valve disease, the "very" religious were three times more likely to recover than those who were not (Oxman, Freeman, & Manheimer, 1995).

 

In a study of hospitalized male patients, 20% reported that religion is "the most important thing that keeps me going" and almost 50% rated religion as very helpful in coping with their illness (Larson, 1993).  Religious coping helped these men to be significantly less depressed.

 

It has been found in various research studies that church attenders have nearly one-half the risk of heart attack and lower blood pressure, even after taking into account the effects of smoking and socioeconomic status (see Larson, 1993; Matthews, Larson, & Barry, 1994 for reviews).

 

Of 300 studies on spirituality in scientific journals, the National Institute for Health Care Research found nearly three-fourths showed that religion had a positive effect on health (Larson, 1993).

 

Pressman, Lyons, Larson, & Strain, (1990) studied 30 elderly women recovering from surgical corrections of their broken hip to determine relationships between religious beliefs and health.  At comparable time periods post-operatively, those with strong religious beliefs were able to walk significantly further and were less likely to be depressed than those who had no religious beliefs.

 

 

As can be seen from the above findings, religious and spiritual beliefs form a vital part of the way a majority of people view and cope with life, as well as being associated with health benefits.  The following summarizes what these beliefs can provide relative to enhancing surgery outcome:

 

A sense of meaning and purpose.  Spiritual beliefs can give an individual a sense of meaning and purpose that help him or her “rise above”  or cope more effectively with the stress related to surgery.

 

Setting healthy priorities.     Spirituality provides a framework to set priorities and place stressors in perspective.  This can help the individual maintain a sense of inner security and safety relative to the surgery experience through having a connection with God.  This feeling of connection with the ultimate Power causes surgical and other stressors to be placed in a healthy perspective.

 

Comfort in the face of illness and crises.  Spiritual beliefs can give the individual great comfort in the face of a health crisis, such as going through a major surgery. 

 

Security, safety, and peace of mine.  A sense of security, safety and peace of mind is especially important when approaching major life stressors such as surgery.  Through spiritual beliefs, this sense can be fostered by the patient knowing that his or her higher power is close by.  Peace of mind is developed through "letting go" and "turning over" one’s  anxiety and fear associated with the surgical procedure and recovery process.

 

Self-confidence.  Self-confidence is often enhanced in individuals with spiritual beliefs since they feel that they were created by God making them lovable and worthy of respect. 

 

Guidance.  The surgical patient with spiritual beliefs will often feel a sense of guidance due the their relationship with God.  Since God is "all knowing,"  the individual believes that God is “all knowing” and can be drawn upon for wisdom when asking for guidance.

 

A preparation for surgery program may or may not specifically include a spiritual component.  However, it is important for the healthcare professional completing the program with patients to be aware of these issues.  The spiritual component should at least be acknowledged and patients should be specifically “allowed” (and encouraged) to discuss this aspect of their lives relative to the surgery.  If spirituality is important to an individual patient, he or she can be helped to use those beliefs as part of surgery preparation in a variety of ways such as developing coping self-talk statements and incorporating prayer into their deep relaxation exercise which can greatly enhance the commitment to practice  (see Deardorff & Reeves, 1997; Benson, 1996 for a discussion of these issues). In addition, patients can also be helped in facilitating appropriate psychosocial spiritual support relative to their surgery and post-operative recovery whether it is from their church, synagogue, family members, friends or some other network.

 

POST-OPERATIVE PAIN CONTROL

 

Postoperative pain control is one of the primary concerns of surgery patients and research has indicated that it is frequently not well controlled.  As discussed in Surgery Preparation Course I, psychoneuroimmunology research has demonstrated that pain leads to negative bodily responses that can impede wound healing, suppress immune system function, and delay recovery from surgery.  Therefore, a critical component of a preparation for surgery program is to help the patient ensure that adequate postoperative pain control will be achieved.  One would think that the healthcare system would be expert at providing adequate pain control after surgery, but this is not the case.  In fact, many studies have found that post-operative pain control is grossly inadequate, even though this need not be the case (American Pain Society, 2001; Peebles & Schneiderman, 1991; Warfield & Kahn, 1995).  

 

The area of pain control is placed under the category of social self-regulation since the patient will need to interact with a variety of other systems (e.g. doctors, nurses, and family members) to ensure that adequate pain control postoperatively takes place.  Although many hospitals have established pain services which specifically manage post-operative pain in the hospital setting, the following discussion will assume that this may or may not be available to the patient.  Excellent information about pain control issues can also be found at a number of websites such as: www.ampainsoc.org, www.iasp-pain.org, www.painmed.org, www.painfoundation.org, and www.paincare.org.

 

Acute Pain Management Guidelines

 

According to the American Pain Foundation (2001a), pain is a “major healthcare crisis” as evidenced by the statistics that over 50 million Americans suffer from chronic pain and another 25 million experience acute pain as a result of injury or surgery.  Recognition of the widespread inadequacy of acute pain control prompted Congress, through the Agency for Health Care Policy and Research (AHCPR), to commission a multidisciplinary panel of experts to develop guidelines for the management of acute postoperative pain.  This led to the publication and distribution of the Practice Guidelines for Acute Pain Management (AHCPR, 1992).  Other professional groups also published acute pain treatment guidelines at that time (American Pain Society, 1992; International Association for the Study of Pain, Ready & Edwards, 1992).

 

The specific problem of acute pain management in hospitals was addressed shortly thereafter.  Recently, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established “new” standards for the assessment and management of pain in accredited hospitals and other health care settings (JCAHO, 2000).  These standards require that JCAHO-accredited hospitals maintain specific functions and activities related to pain assessment and management for patients.  These are summarized as follows (Chapman, 2000):

 

             Recognize the right of patients to appropriate pain assessment and management.

             Screen for pain in a variety of ways, document the results, and perform regular follow-up assessments.

             Ensure that the staff is competent in pain assessment and management.

             Establish policies and procedures related to support appropriate use of pain medications.

             Educated patients and their families about pain management.

             Address patient needs for pain management as part of discharge planning.

             Maintain a pain control improvement plan.

 

In addition to the new JCAHO standards, the “Pain Care Bill of Rights” has been developed (American Pain Foundation, 2000b; see the Table).  The Pain Care Bill of Rights can be given to surgery patients as part of the preparation program. 

 

 

Pain Care Bill of Rights

 

 

As a person with pain, you have:

 

The right to have your report of pain taken seriously and to be treated with dignity and respect by doctors, nurses, pharmacists and other healthcare professionals.

 

The right to have your pain thoroughly assessed and promptly treated.

 

The right to be informed by your doctor about what may be causing your pain, possible treatments, and the benefits, risks and costs of each.

 

The right to participate actively in decisions about how to manage your pain.

 

The right to have your pain reassessed regularly and your treatment adjusted if your pain has not been eased.

 

The right to be referred to a pain specialist if your pain persists.

 

The right to get clear and prompt answers to your questions, take time to make decisions, and refuse a particular type of treatment if you choose.

 

 

Although not always required by law, these are the rights you should expect, and if necessary demand, for your pain care.

 

 

A list of these “Rights” along with a Pain Action Guide can be downloaded for free from the American Pain Foundation website (www.painfoundation.org).  The topic headings that are covered in the Pain Action Guide are as follows:

 

 

Summary of The Pain Care Action Guide

 

 

How do I talk with my doctor or nurse about pain?   

 

Speak up! Tell your doctor or nurse that you’re in pain.

 

Tell your doctor or nurse where it hurts. 

 

Describe how much your pain hurts.

 

Describe what makes your pain better or worse. 

 

Describe what your pain feels like.

 

Explain how the pain affects your daily life.

 

Tell your doctor or nurse about past treatments for pain. 

 

How can I get the best results possible?

 

Take control.

 

Set goals.

 

Work with your doctor or nurse to develop a pain management plan.

 

Keep a pain diary.

 

Ask your doctor or nurse about non-drug, non-surgical treatments. 

 

Ask your doctor or nurse about ways to relax and cope with pain.

 

If you have questions or concerns, speak up. 

 

If you're going to have surgery, ask your doctor for a complete pain management plan beforehand.

 

If you’re a patient in a hospital or other facility and you’re in pain, speak up.

 

Pace yourself.

 

If you’re not satisfied with your pain care, don't give up.

 

 

Develop a Pain Control Plan

 

Similar to the Pain Action Guide, but more detailed, Deardorff and Reeves (1997) have developed a pain control plan as part of a surgery preparation program.  As part of a surgery preparation program, patients should be encouraged to do the following:

 

Determine if there is a hospital-based surgical pain service.  Many hospitals have an established surgical pain control service that is responsible for postoperative pain management.  Typically, hospitals that have set a high priority on pain relief by committing to having a surgical pain service provide the most effective pain management.  If a patient’s surgeon operates in more than one hospital, and there are no other medical factors related to hospital choice, encourage patients to use the one with the established pain service.  Also, it is important for the surgical patient to have one individual or service in charge of pain control in order to avoid confusion.  This guideline applies to the hospitalization episode as well as the post-discharge recovery period.

 

Talk to their doctors about pain control.  In helping patients develop a pain control plan with their surgeon and surgical team, they should be encouraged to complete the following tasks:

 

     Talk with nurses and doctors about pain control methods that have been either effective or ineffective in the past.

     Talk with nurses and doctors about any concerns related to pain medicine.

     Tell doctors and nurses about any allergies to medicines. These should have been recorded on the patient’s medical fact sheet.

     Talk with your doctors and nurses about medicines being taken for other health problems. 

 

Find out what to expect relative to pain.  Previously reviewed research suggests there may be a tendency for surgeons, doctors and other healthcare professionals to minimize discussions about what the patient may feel following the surgery.  It is possible that they believe this silence will reduce the patient’s anxiety and distress, but that is not the case.  Patient should obtain answers to the following questions as part of their surgery preparation program.  Having this information prior to the pain experience will greatly enhance a patient’s sense of control, security and self-efficacy.

 

     Will there be much pain after surgery?

     What will the pain likely feel like?

     Where will the pain occur?

     How long is the pain likely to last?

     How long will it be before you are able to be active?

     Will there be any side effects to the treatment (such as nausea)? How long will these last?

 

Discuss pain medication options.  There are many pain management options available to patients. Some of these involve the use of pain medications and others do not. It is important for patients to understand these options prior to surgery. Have patients find out about the different types of pain medications options as well as the mode of delivery (e.g. oral, injection, PCA, etc).  This can be provided as a simple informational handout to the surgery patient.

 

Understand time-contingent scheduling and patient-controlled analgesia.  As most healthcare professionals are aware, there have been two major advances in the way pain medications are scheduled and this has resulted in significant improvements in postoperative control of pain.  These are time-contingent scheduling and patient-controlled analgesia.  These concepts should be taught to patients as part of a surgery preparation program.   

 

Time-contingent scheduling.  Time-contingent scheduling involves giving the pain medication at set times, whether or not the pain is severe.  Instead of waiting until pain gets worse or “breaks through” the effect of the pain medicine, the patient is given the medicine at set times during the day to keep the pain under control. Thus, time determines when the medication is delivered rather than the severity of the pain (which is prn or “as-needed” dosing).  By giving medications in this time-contingent manner, a steady-state level of pain medication in the blood can be achieved by adjusting the doses. Time-contingent dosing avoids the “peaks and valleys” of pain which are characteristic of as-needed dosing and is one of the most important advances in the effective use of pain medications.  It reduces the roller coaster ride characteristic as-needed scheduling. This type of dosing is commonly used when the patient is in the hospital and should actually be maintained during the acute recovery phase.

 

Patient-Controlled Analgesia (PCA). The second major advancement in medication scheduling and delivery is called Patient-Controlled Analgesia or PCA. This technique involves the use of a special medication “pump” that allows the patient to deliver predetermined amounts of pain medication through a catheter into a vein when a button is pushed. The PCA puts the patient in charge of pain management by allowing increased control over pain medicine delivery.  Built-in safety measures prevent the patient from administering too much medication. The results for the patient are immediate because he or she does not have to wait for the nursing staff to respond to requests for medications. In addition, the PCA can be programmed to deliver medication through the night automatically to insure that pain control is achieved around the clock.

 

PCA is the method of choice for controlling pain following most major surgeries.  A great many research studies have found that patients using PCA are much more comfortable, use less pain medication overall, can be discharged from the hospital earlier, and are generally more satisfied with their care (see Carron, 1989; Ferrante, Ostheimer, & Covino, 1990; Warfield & Kahn, 1995; Williams, 1996; 1997 for reviews). Although recent research has found that a patient’s use of the PCA is impacted by psychological variables such as anxiety, fear of pain medication, stoicism, a lack of “readiness” to take control of the pain, and not wanting to be seen as a “complainer” (Gil, Ginsberg, Muir, Sykes, & Williams, 1990; Perry, Parker, White, & Clifford, 1994; Wilder-Smith & Schuler, 1992; Williams, 1996; 1997).

 

Talk to the surgeon or anesthesiologist about anesthesia.  Many advances have been made in anesthesia options and patients should discuss these with the appropriate physician. Many surgery preparation programs recommend that patients meet with their anesthesiologist in advance of the scheduled surgery.  This discussion should include the patient’s previous experience with anesthesia and whether any problems occurred.

 

Investigate non-medication approaches for pain control.  There are several non-medication techniques that can be very effective for pain control. Most pain is best treated with a combination of medications and non-medication approaches. The non-medication approaches listed below are readily available, easy to use, low risk and inexpensive. Patients can be easily taught about these techniques as part of a surgery preparation program and use them both pre- and post-operatively.  Even though these techniques are readily available, they are often not suggested unless a surgery patient makes a specific request.     

 

Patient Education.   This involves patient instruction on any aspect of surgical recovery that they use to help with pain control.  Instruction might include such things as coughing exercises if necessary, deep breathing, proper body mechanics, physical restrictions, etc. Patients given such instruction prior to surgery report less pain, require fewer pain medications and have shorter hospital stays. 

 

Cognitive-Behavioral and Relaxation Techniques: These techniques have been previously reviewed and can help not only with overall surgical recovery and outcome, but also with pain control. 

 

Heat and Cold: The application of heat and cold is used to reduce pain sensitivity, reduce muscle spasms, and decrease congestion in an injured area (for example, the site of surgery). The initial application of cold decreases tissue injury response, and later, heat is used to promote clearance of tissue toxins and accumulated fluids.

 

Massage and Exercise: Massage and exercise are used to stretch and regain muscle and tendon length and range of motion. With orthopedic surgeries these techniques can be especially important.

 

Transcutaneous Electrical Nerve Stimulation (TENS): TENS is a technique that can promote pain control and healing. TENS involves placing adhesive pads (electrodes) in specific locations related to the pain following surgery or injury. The electrodes are connected by thin wires to a small pocket-sized battery operated stimulator which produces electrical current that the patient can adjust. The electrical current, which feels like a tingling sensation, is thought to decrease pain by raising the threshold of the nerves in the spinal cord which respond to injury. TENS may also promote healing by reducing inflammation and increasing mobilization following surgery.

 

Learn to stay ahead of the pain.   The most important thing for patients to remember regarding effective pain management is to stay ahead of the  pain.  This is done by teaching patients to take pain medications and use non-medication techniques when the pain first begins or before it starts. If the pain escalates and gets out of control, it becomes more and more difficult to bring under control.

 

Inquire about post-discharge pain control.  Patients who are experiencing pain at the time of discharge from the hospital are generally given oral medications to take with them.  These are usually to be taken using a strict time-contingent scheduling with a gradual tapering as pain subsides.  If a patient is taking too much pain medication before the surgery it may put them at risk for inadequate pain control or side-effects following surgery.  In this case, part of surgery preparation program might be a time-contingent tapering or modification of pain medications prior to the surgery.

 

Understand Key Concepts in Pain Medication Management

 

Patients should understand that a large body of research has demonstrated that if pain medication is given for a legitimate reason (e.g. related to surgery), addiction to analgesics is very unlikely (Cleary & Backonja, 1996; Porter, 1980; Portney, 1994; Zenz, Strumpf & Tryba, 1992). The fear of addiction is prevalent among individuals facing surgery and may cause the patient to be reluctant to take appropriate doses of medication for adequate pain control.  To ease patient fears,  it is important to help them (and healthcare professionals) understand the difference between important pain medication concepts:  tolerance, pseudotolerance, physical dependence, addiction, and pseudoaddiction (See American Academy of Pain Medicine, the American Pain Society & American Society of Addiction Medicine, 2001):  

 

 

Pain Medication Concepts

 

  

Tolerance is a well-known property of all narcotics. It is the need for an increased dosage of a drug to produce the same level of analgesia that previously existed. Tolerance also occurs when a reduced effect is observed with a constant dose. Tolerance occurs at a chemical level in the body primarily through the liver producing more enzymes to neutralize the effects of the medicine. Some physicians believe that a certain level of opioid use can be reached for pain control and stabilized over the long term without the need for increasing the dose due to tolerance, but this is controversial.

 

Pseudotolerance is the need to increase dosage that is not due to tolerance but due to other factors such as changes in the disease, inadequate pain relief, change in medication, increased physical activity, drug interactions, lack of compliance, etc. Patient behavior indicative of pseudotolerance may include drug seeking, “clock watching” for dosing, and even illicit drug use in an effort to obtain relief. Pseudotolerance can be distinguished from addiction in that the behaviors resolve once the pain is effectively treated.

 

Physical Dependence is also a well-known and understood physical process. It is a state of adaptation that is manifested by a specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. The withdrawal syndrome might include such things as tremors, cramps, agitation, sleep disruption, and diarrhea. The patient might also notice an increase in the pain over the short term. Physical dependence is not a problem if patients are warned to avoid abrupt discontinuation of the drug, a tapering regimen is used, and opioid antagonist (including agonist-antagonist) drugs are avoided.

 

Addiction is a psychological dependence on the medication for its psychic effects and is characterized by compulsive use. The medication is sought after and used even when it is not needed for pain relief. Addiction includes aspects of tolerance and dependency due to chemical events associated with long-term use. It should be noted that although addiction includes tolerance and dependence, the reverse is not necessarily true. One can show tolerance and dependence without showing addiction. In fact addiction is a well-known, although relatively rare, occurrence in patients using narcotics for pain relief.

 

Pseudoaddiction is drug-seeking behavior that seems similar to addiction, but is due to unrelieved pain. The behavior stops once the pain is relieved, often through an increase in pain medication. If the patient complains of unrelieved pain and shows drug-seeking behavior, careful assessment is required to distinguish between addiction and pseudoaddiction.

 

 

Patients (and healthcare professionals) often confuse these concepts. Both tolerance and dependence commonly occur in pain medication use and can be readily managed by the physician specializing in this area.  Tolerance can be managed by adding other non-addictive medicines that help the narcotics work better and/or emphasizing non-medication pain control techniques.  Dependence is addressed by slowly tapering the pain medication and, possibly, adding other medication to control withdrawal symptoms, as appropriate. 

 

Putting It All Together

 

Most surgery preparation programs focus primarily in self-regulation techniques.  Although these approaches are certainly important, a great deal is missed if the psychosocial factors are not taken into account.  A comprehensive surgery preparation program will intervene both for the individual surgery patient and in the social network. Figure 4-1 shows the process of putting together a preparation for surgery program.   

 

In summary, the program begins with assessment of the patient and proceeds to assembling program components, implementing the intervention, and following up to enhance outcome (see Figure).  It is important to emphasize that the preparation for surgery program is extremely flexible and can be adapted to the individual patient’s needs, the program structure (individual, group, or a combination thereof) and/or the time available before the operation.  For instance, although the number of possible surgery preparation program components is extensive, not all interventions will be used with every patient.  Also, the program can be adjusted to emphasize more of a patient self-guidance focus, if necessary.  

    

A last consideration is follow-up with the patient after the surgery.  Surgery preparation programs often end with the surgery, and this is a mistake.  Follow-up after the surgery is very important to increase the probability that the patient will continue to utilize the surgery preparation and pain management techniques throughout the postoperative period.   Depending upon the situation, the follow-up treatment might include postoperative visits in the hospital, outpatient sessions after the patient is discharged and is ambulatory, or simple telephone calls.

 

THE BUSINESS OF SURGERY PREPARATION

 

After clinicians become familiar with surgery preparation techniques, they must successfully integrate preparing for surgery into their practice.   There are several ways to approach marketing, and given the clinician’s particular situation, one or all of them might be pursued.  These ideas include the following:

 

Offer the Program in the Surgeon’s Office

 

Probably one of the best and most sure ways of gaining access to surgery patients is with­in the offices of a group surgery practice. Offering the preparation for surgery program either in a group format or individually within the surgeon's office makes it easier for the patient and the physician, as well as increasing the probability that patients will follow through on the recommendation. When approaching surgeons with this proposal, it is important to be as organized and succinct as possible. Focus on making the process easy to implement within another doctor's office and highlight how the program will benefit the surgeon. A few sugges­tions include: (a) prepare patient pamphlets for the waiting room that describe the program, (b) design referral slips in the form of a prescription pad that the surgeon or assistant can use to make the referral, and (c) make the surgeon a part of the program so that patients see it as being a benefit of the surgery practice.

 

Adequate space is often an issue in any office. A useful method to address this problem is to use the waiting room of the practice in the evenings to do the preparation for surgery groups. Of course, paying an overhead fee for the use of the space is appropriate. Lastly, the logistics of running the groups should be almost transparent to the surgery practice. The clini­cian or a designate should handle scheduling, questions about the program, and other program-related issues so that these responsibilities do not fall upon and overburden the surgery practice. Be­coming too much of an administrative "hassle" is the death knell of this type of arrangement.

 

Target Specific Surgery Types

 

It can be useful to target a certain surgery population for marketing for at least two rea­sons. First, providing successful preparation for surgery treatment almost always requires that the clinician have knowledge about the specific procedure (e.g., what the procedure involves, amount of time in the hospital, what the postoperative course is usually like, possible compli­cations, what the psychological issues are likely to be, etc.).  For instance, if you choose spine surgery or bariatric surgery, you should be well versed in the pre-operative, peri-operative, and post-operative course of treatment.  You will likely spend more time with the patient than many of his or her physicians and, therefore, will be a valuable source of information. 

 

Second, some surgeries are high­ly amenable to advanced scheduling, which allows adequate time for the surgery preparation program. Excellent examples of surgeries that are very amenable to surgery preparation programs include scheduled C-sections, most spine surgeries, many heart surgeries, certain organ transplantations, bariatric surgery, cosmetic surgeries, and others.

 

Offer the Program at the Local Hospital

 

Another marketing method is to make an arrangement with a local hospital to offer a preparation for surgery program. It can be formulated to the hospital administration as being similar to offering child-birthing classes. Hospitals are always looking for ways to stand out in the public eye. Being able to advertise that they offer a unique program such as preparing for surgery is an excellent item that they can use as part of their marketing to the public as well as doctors.

 

Insurance Companies

 

Insurance companies are another area for potential marketing, although this is bound to be the most frustrating and probably least fruitful. Although you can do a dynamite presenta­tion on how referring patients to a preparation for surgery program can benefit the insurer (e.g., increased patient satisfaction, decreased complications, shorter hospital stays, and over­all cost-savings), it can be virtually impossible to get beyond the "red tape" to actually im­plement the idea.

 

One type of insurance company that might be more amenable to this type of program is an HMO.  Most HMO’s are a closed system and they are more interested in a prevention program that can save them money over the long-term.  If they understand that surgery preparation programs will decrease complications and result in less time in the hospital, they become more excited about the idea. 

 

Billing and Reimbursement

 

Depending on a number of factors, practice in this area can often be done outside the constraints of mental health managed care in one of two ways. First, because the program is very amenable to a group format, it can be offered in a structured "class" format rather than as psychological treatment. Patients simply sign up to take the surgery preparation class and pay a fee for the entire class when they register. Under this approach, it would not matter if the clinician were on the managed care panel of any of the class members, because the program is not being offered as treatment. It is important to remember that, if the program is offered as a class, it should be done as such for all members of the group. It would not be prudent to have some members of the class participate on an insurance basis (implying treatment) while others are doing it as a "class."

 

The class method of running the program is probably the best approach because it really decreases the amount of administrative overhead (e.g., patient and insurance billing, getting pre-approvals, etc.) and increases patient motivation to attend each meeting, as it is prepaid. Any patient who required individual treatment beyond the groups (for instance, in the case of medical phobias) could be seen on a different basis at that time. Doing the surgery prepara­tion program as a class follows a model similar to the child-birthing classes or a stress­ management class one might take at a local college or hospital.

 

Second, it is occasionally possible to get approval to provide this treatment under the pa­tient's medical benefits because it directly relates to a surgical intervention. This can be somewhat of a long and arduous process requiring pre-certification documentation to be sup­plied about the program, why it should be considered medical treatment, and a referral letter of medical necessity from the surgeon.

 

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