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The Importance of Presurgical Psychological Screening

 From time immemorial, it seems,surgeons have gone about their work with one goal in mind: to use their technicalskills to improve a patient’s physical condition. Their focus was on thespecific procedure, and the patient was more or less a passive participant

But what if the patient were notfully prepared psychologically for the surgery, had unrealistic expectationsabout its benefits, or was unlikely to follow the post-surgery guidelines thatcould lead to the best outcome?

In recent years, these concerns have helpedbroaden the context of surgery and in many cases have brought a new member tothe larger surgical team, before the actual surgery: the mental health clinician.Increasingly, surgery is viewed in a fuller context; what happens before and after are very important as well.

To explore this burgeoning area ofinterest, David B. Sarwer, PhD, and Andrew R. Block, PhD, have edited Presurgical Psychological Screening:Understanding Patients, Improving Outcomes, recently published by theAmerican Psychological Association. Block is a board-certified clinical healthpsychologist with the Texas Back Institute. Sarwer is a professor of Psychologyin Psychiatry at Penn Medicine, where he is director of clinical services atthe Center for Weight and Eating Disorders and director of the Albert J.Stunkard Weight Management Program. He is principal or co-principalinvestigator on several grants from the National Institutes of Health, studyingthe psychological and behavioral aspects of obesity and, more specifically,bariatric surgery.

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Sarwer’s years of research on suchtopics as body image, plastic and bariatric surgery, and diet have not goneunnoticed by the popular press. In November, he was interviewed in the Huffington Post by a licensedpsychotherapist/social worker who described Sarwer as a “multi-talentedpsychologist” and “one of America's leading body image researchers.” An honorlast July from the American Society of Metabolic and Bariatric Surgeryconfirmed Sarwer’s stature among professionals as well: he received the 2012Circle of Excellence Award, the first time the Society has bestowed the awardon a mental-health professional.

In acknowledging the award, Sarwernoted that, since the inception of Penn’s Metabolic & Bariatric SurgeryProgram 15 years ago, he has been working with Dr. Noel Williams and otherbariatric surgeons. “I’m humbled to see our role in clinical care, as well asour research contributions to the field, recognized in this way.” (The chapteron bariatric surgery, in fact, was written by Sarwer and others affiliated withPenn’s Center for Weight and Eating Disorders, including Thomas Wadden, PhD, itsdirector.)

The new book came about as Sarwerand Block began to see the field of presurgical psychological screening (PPS)gaining wider acceptance. There are chapters on various procedures, includingspine surgery (written by Block), bone marrow and stem cell transplant,gynecologic surgery, and others. In the book’s chapter on cosmetic surgery,written by Sarwer, he observes that plastic surgeons “had long been interestedin the psychological factors that motivate individuals to undergo theseprocedures as well as the psychological changes that frequently occur postoperatively.”It appears, however, that other surgeons were not as quick to realize theimportance of such factors.

“As surgical techniques andequipment evolve ever more rapidly, it is perhaps natural to think of surgeryas a technological process,” write Sarwer and Block in their introduction.“However, as the rapidly expanding field of PPS demonstrates, it is criticalthat surgeons expand their vision beyond the physical causes of medicalconditions. Emotional distress, substance abuse, personality disorders, andwillingness to comply with medical regimens – all these and many otherpsychological issues can strongly influence the outcome of surgery.”

Even when the surgery is a success,the patient may not experience any improvement in his symptoms. That’s why,Sarwer and Block assert, “maximizing the likelihood of successful surgicaloutcome is in everyone’s interest.”

Sometimes, those issues mayactually stop the surgery from happening. In Sarwer’s chapter on cosmeticsurgery, he cites the American Psychiatric Association’s definition of bodydysmorphic disorder: “a preoccupation with a slight or imagined defect inappearance that leads to substantial distress or impairment in social,occupational, or other areas of functioning.” The case example he includes atthe end of the chapter describes a 55-year-old woman who came to a plasticsurgeon with concerns about some wrinkling around her mouth that she said madea scar from a childhood accident more visible. But in the surgeon’s view, thescar was “more or less invisible from conversational distance.” The patientagreed to a psychological evaluation, where she repeated her belief that thescar left her looking deformed. Again, the mental health professional thoughtthe scar was scarcely visible. The professional also got her to talk about herreluctance to leave her house and her pattern of applying and reapplying makeupto hide her scar. The result: she agreed to delay surgery and engage inpsychotherapy.

The mental healthprofessional/clinician can function as a valuable member of the surgical team –but Sarwer and Block argue that patients must be intimately involved as well,primarily through compliance. As they put it, “For the surgery to achieve itsgoals, patients must be active participants in their recovery. Appropriate useof medications, exercise, diet, follow-up visits with the medical treatmentteam, and many more activities are often critical for success.” The mentalhealth clinician can help evaluate how likely the patients are to followthrough in this way.

The editors make clear thatpresurgical psychological screening should not be seen as a predictor ofpostoperative outcomes. Instead, PPS assesses risk: how are patients likely todo during surgery and after? Sarwer and Block also emphasize that suchscreening is relatively new. In their introduction, they note that “it iscritical that surgeons expand their vision beyond the physical causes ofmedical conditions. . . . It is our hope that this book will increase the useand effectiveness of PPS so that patients can obtain the best possibletreatment outcomes.”

 

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