Rx: Preparing for Surgery

(Adapted from The Healthy Mind, Healthy Body Handbook by David S. Sobel, MD and Robert Ornstein, PhD, DRx (Box 176, Los Altos, California 94023) May not be reproduced without written permission.

A growing body of evidence now indicates that by preparing yourself psychologically for surgery, you can enhance your chances of success, minimize trauma and discomfort, and recover faster. As with a sporting event, the better prepared you are mentally, the better your body responds. Here is a look at some of the research along with practical tips for making it work for you.

Getting ready for surgery is a lot like getting ready for a big athletic event. You’ve got to understand the rules of the game, devise a good game plan, and make sure you’re prepared – physically and mentally. As patients, we tend to feel that our fate is entirely in the hands of the surgeon and the medical staff. Evidence now indicates, however, that there’s a lot we can do before surgery to help the process, minimize trauma and discomfort, and recover faster. As with a sporting event, the better prepared you are mentally, the better your body responds.

Researchers analyzed the results of over 190 studies of mental preparation for surgery and found that 80% of the patients showed significant benefits: quicker recovery, fewer complications, less post surgical pain, less need for pain medication, less anxiety and depression, and an average of 1.5 fewer days in the hospital.

You can take advantage of these findings by making and following your own plan for psychological preparation. Doctors are fond of saying “the way a patient goes into anesthesia is the way a patient will come out.” It certainly seems true that those who feel relaxed, optimistic, and in control are likely to feel better and recover faster than those who feel highly anxious and vulnerable.

The best way for you to reduce the stress of surgery depends somewhat on your own coping style and on how much information and involvement you prefer. In this article you’ll find a wide range of suggestions on how to prepare for surgery. Pick and choose the ones that feel right to you.

Believe You Need It
Americans are the most operated-on people in the world. More than 50 million surgeries are performed in this country each year and not all of these operations are really necessary. Only about 20% are in response to an emergency such as a severe injury; 80% are “elective,” meaning that the patient can choose when and where to have the operation, if at all.

The numbers of operations performed varies widely from country to country, state to state, city to city, and even from surgeon to surgeon. In fact, the best indicator of the amount of surgery in a given community is the number of surgeons in the community, not the prevalence of disease! The more surgeons, the more surgery.

Even the rates of surgery for a given condition can vary widely within a community. One study showed that the rates of hysterectomy (removal of the uterus) were four times higher in one town than the one next to it. Given all this, the very first step in getting yourself psychologically ready for surgery may to be more confident that it’s the right course for you. When surgery is recommended for you or a family member, ask questions. If you have doubts, get a second opinion. See the suggestions in the box on page 3.

Make the Operation “Your Own.”
This is your operation. Make sure that you receive the support you need. A hospital can be a confusing and insensitive environment. It’s appropriate to ask directly and repeatedly for what you need, whether it is a blanket, a pain medication, information, or someone to hold your hand.

Learn To Relax
Anxiety causes tension, and tension increases pain. So take steps to help yourself relax. If you already have a favorite relaxation exercise such as focusing on your breath or counting backwards, use it. If not, learn one and practice it ahead of time. You’ll also find your technique helpful during brief procedures such as having blood drawn or an IV set up.

The hospital will ask you to sign an “informed consent” form for the anesthesia. Ask to do this a few days in advance. Reading a list of possible complications, however rare, may not be the best way to relax before your surgery.

Give Your Body Instructions
Autonomic nervous system functions such as pain, bowel contractions, blood flow, and even immune functioning were once considered beyond voluntary control. But research shows that we can learn to influence these processes to some degree and speed recovery. It appears our bodies have built-in healing systems activated by positive instructions, thoughts, words, suggestions, and images. There have been a number of studies to show that giving our bodies specific, detailed instructions for healing can speed recovery. Make your own audio tape with the scripts or choose a commercially available tape.

Choose What You Hear
Contrary to popular belief, general anesthesia does not completely shut off your brain during an operation. Studies demonstrate that anesthetized patients are sometimes aware of speech or sounds around them though they do not usually remember it afterwards. Your body may respond to what you hear. So wear ear plugs or, better yet, listen to an audio tape.

Studies show that people who heard soothing music before, during, and after surgery needed less sedative. One investigator calculates that music in the operating room equals roughly two and a half milligrams of Valium. And a Japanese study found that listening to music before and during surgery reduced stress hormones in the blood.

Verbal suggestions can be heard subconsciously. In one study, women who underwent abdominal surgery while listening to taped suggestions needed 24% less pain medications the day after surgery than patients who were given a blank tape. In a similar study, hysterectomy patients who listened to positive suggestions during surgery left the hospital one and a half days earlier, and had fewer complications than those who were given blank tapes.

Some Fear is Good
Uncontrolled anxiety may impair your healing. But don’t be afraid of being a little afraid – you have good reason. Studies show we may need a certain level of fear and arousal to prepare us for the stress of surgery.

Think Positively
Try to think of your surgery as a positive event with positive outcomes. Remember why you are doing this: to improve your health and live a fuller life. Think of your hospital experience as a chance to relax, read books, catch up on sleep, meet new people, and, of course, get well.

Research shows that people who take control of their own thoughts and feelings suffer less pre- and post-operative stress.

Watch for thoughts like: “I feel so helpless, there’s nothing I can do. I can’t stand it, this is too difficult.” Try substituting more positive thoughts: “I can get through this. The discomfort will pass. We’re all doing everything we can to insure a safe operation and a speedy recovery. I will feel better and be healthier soon.”

Develop a Pain Control Plan
Putting up with severe pain is neither heroic nor wise. And with today’s pain control treatments, it’s unnecessary. Good pain control is important for your recovery. You can start walking, do your deep breathing exercises, cough, and get your strength back more quickly. You’ll be less likely to develop complications like pneumonia or blood clots. You may even be able to leave the hospital sooner.

Find out what kind of pain to expect with your surgery and work out a plan with your doctors and nurses both before and after.

Some tips:

• Don’t wait for pain to get severe before asking for pain medication. Short-term use of narcotic pain medications is not addicting.
• Measure and report your pain repeatedly on a scale of zero to 10. This helps you and the medical staff track your progress.
• Speak up. Don’t be shy about reporting your pain or telling someone when the medication isn’t working.
• Also try non-drug approaches such as breathing and relaxation exercises, imagery, music, distraction, massage, heat, and ice.

Get up!
Rest is great – so is getting some gentle exercise and movement as soon as possible after your operation. Too much inactivity increases the risk of inflammation of the veins and blood clots. So walk around wherever you can, and do exercises your condition allows or the staff recommends.

Choose a Room with a View
In one study, patients who had a room with a view of a wooded scene after surgery suffered less postoperative distress, required less strong pain medications, and were discharged from the hospital one day sooner than those who looked out on a brick wall. If you can’t have a real view, bring in your own pictures or photographs of nature or watch nature programs on TV.

[Sidebar] Healing Instructions for Your Body
Studies show that we can improve and speed recovery from surgery by giving our bodies specific, detailed instructions for healing. Below are some instructional “scripts.” Record them on an audio tape or place them on note cards and have someone read them to you or repeat them to yourself. Do this frequently in the days before, during, and after your surgery.

Pain Control
Note: Relaxing the muscles around the site of the incision can help reduce discomfort after surgery. This usually results in less need for postoperative pain medications, and may speed recovery and discharge from the hospital.

Your script:
“All of my muscles in my (area of surgery) will be completely relaxed as I come out of the operation. It is very important that all of these muscles remain completely relaxed, limp like a rag doll, so that the blood will flow easily into the area and heal me, and so that the pain medicine will work more easily and better. With relaxed muscles I will recover more quickly and more comfortably. So all of the muscles in my (area of surgery) will be completely relaxed after surgery, and will stay relaxed.”

Bowel Activity
Note: After abdominal or pelvic surgery, the stomach and intestines usually go on strike. In one study, patients were given specific preoperative instructions about restoring bowel function. They recovered more quickly, passed gas sooner, began eating earlier, and were discharged from the hospital an average of a day and a half sooner than patients who just received a general reassurance.

Your script:
“Because I need to eat food to bring nutrients to my body, it is important that my stomach and intestines begin to move and function as soon as possible after my operation. Abdominal operations cause my stomach and intestines to stop moving for a short time. This will be kept to a minimum in my case, because I will be very relaxed and comfortable. My stomach will pump and gurgle, and I will become very hungry soon after the operation. My stomach and intestines will begin to move and churn so that I can eat (_____ my favorite food) soon after the operation.”

Blood Loss
Note: Research has demonstrated that when people are given appropriate verbal instructions, they can learn to redirect blood flow in their bodies, and, to some degree, control blood loss. In one study, patients undergoing extensive spinal surgery received specific instructions on how to control blood flow. They lost half the amount of blood (500 cc versus 900 cc) compared with those who received either general relaxation instructions or no preoperative preparation.

Your script:
“Blood vessels contain smooth muscle; they contract or relax to alter blood flow to specific areas. So that I’ll have very little blood loss during my surgery, it is very important that during the operation, blood moves away from my (_____ area of surgery) to other parts of my body. After the operation, blood will return to that area and bring nutrients to heal my body quickly and completely.”

Immune Function
Note: Surgery can depress the immune system, which in turn can lead to a longer recovery time. Research shows that patients can learn to voluntarily enhance immune function. In one study subjects were taught how to induce a relaxed, hypnotic state and create an image of neutrophils, a type of white blood cell that defends against bacterial and fungal infection. For example, one subject imagined her neutrophils as ping pong balls with honey oozing out, causing them to stick to everything they touched. Tests of blood samples after this exercise showed an increase in the stickiness of neutrophils!

Your script:
“My immune system helps my wounds heal and protects me against infections. My immune system will become active before, during, and after surgery. My antibodies and white blood cells will attack and carry away any bacteria that have gotten into the wound, and prevent infections. My tissues will heal quickly and smoothly. My recovery will be speedy and complete.”

Scripts adapted from the research of Henry L. Bennett, PhD and Elizabeth A. Disbrow, MA of the University of California, Davis, Medical Center.

[sidebar] Building Confidence:Do I Really Need Surgery Now?

Getting a Second Opinion
Before consenting to any treatment or diagnostic procedure that carries significant risk or cost, consider getting a second opinion. In fact, many health insurance plans now require it before elective surgery. Some studies show that the second surgeon disagrees with the first about the need for surgery in over 25 percent of the cases – especially for operations of the womb (hysterectomy), coronary arteries, tonsils, gallbladder, varicose veins, back, knee, nose, and prostate gland.

Your second opinion should be from a surgeon not associated with or recommended by the first. You may also want to consult a non-surgeon to see if there are realistic alternatives. For example, for some patients, changes in diet, exercise, stress management, and cholesterol lowering medications may offer an alternative to coronary artery bypass surgery.

If you get conflicting opinions, have the doctors talk to each other to clarify their recommendations. Or get yet another opinion. Then weigh the opinions and make the decision for yourself.

Questions to Ask Your Doctor
Experts estimate that one in five operations are not necessary at all, and that many more could be prevented if we changed our lifestyles.

So ask your surgeon:
Why do I need this operation now?

Are there any other alternatives?

Can something less invasive be tried first?

What will happen if I don’t have surgery now?

How is this surgery supposed to help me?

What is the success rate?

Is the gain worth the risks and costs?

[sidebar] Know Your Coping Style
When it comes to coping with stressful situations like surgery, most people fall into one of two basic styles – avoidant or vigilant. Both styles have useful elements. Both taken to extremes, can be harmful. The key is to know your style so you can do what works best for you to feel more relaxed, confident and in control.

Avoidant Copers don’t want to be overwhelmed with information or to be asked to make too many decisions. They distract themselves, concentrate on pleasant thoughts, don’t ask too many questions. If this is your style, immersing yourself in details of surgery may raise rather than relieve your anxiety. Some information you need to know, but you may want to spare yourself the details. Your best strategy may be to put your trust in the surgical team and believe that all will work out for the best.

Vigilant Copers feel more comfortable and in control when they ask a lot of questions and get detailed information. If this is your style, go for it – get as much information as you can.
If there are choices to be made, you be the one to make them, and base your decision on carefully weighed information.

[sidebar] Tips for Communicating with Your Doctor

What to tell your doctor:
Along with your medical history, you should discuss the following with your doctor.

Do you smoke?
Smoking greatly increases the risk associated with anesthesia. Quitting at least two weeks before surgery is extremely important.

Do you have concerns or fears about surgery?

Express your concerns and your hopes for the outcome of the operation. This will alert the surgeon to your needs and set the stage for better communication.

What to ask your doctor:

How often have you performed this operation?
In general, the more often a surgeon performs an operation in a particular hospital, the lower the rates of mortality for that surgeon and that hospital.

What are the risks, including risk of death and of non-lethal complications?

Will I need blood, and should I donate and store my own?

What are my options for anesthesia?

Find out what kinds of anesthetics are available and appropriate for you, and choose your preference. As a general rule, select the least invasive and risky type of anesthesia that produces the desired results.

Can I do this as an outpatient?

There are a number of advantages to having surgery as an outpatient, including reduced stress, cost, risk of hospital-acquired infection, and disruption to family life. Some 30 percent of all surgery now falls into the outpatient category, including breast biopsies, cataract surgery, dilatation and curettage, sterilization, some plastic surgery, some orthopedic procedures, and some hernia repairs.

Should I continue taking my usual medications before or after surgery?

How long before surgery should I not eat or drink?

Who else will be involved on the surgical team?

How long will recovery take?

What can I do to speed it?

Will I be able to return to work and normal activities?

When will you or other members of the surgical team visit me in the hospital?

What will the operation cost?

What complications should I report to a doctor?

Resources for More Information on Preparing for Surgery

Books:
Bennett, Henry L and Elizabeth A. Disbrow: “Preparing For Surgery And Other Medical Procedures,” in Mind/Body Medicine, edited by Daniel Goleman and Joel Gurin, Yonkers, NY: Consumer Reports Books, 1993. Excellent review chapter by pioneering researchers in this field.

Bradley, Edward L.: A Patient’s Guide to Surgery. Yonkers, NY: Consumer Reports Books, 1994.

Huddleston, Peggy: Prepare for Surgery, Heal Faster: A Guide of Mind-Body Techniques. Cambridge, MA: Angel River Press, 1996.

Inlander, Charles B. and Ed Weiner: Take This Book to the Hospital With You. New York: Pantheon, 1991. The People’s Medical Society’s consumer guide to surviving a hospital visit.

Inlander, Charles B: Good Operations, Bad Operations. New York: Penguin Books, 1993. A detailed consumer’s guide to the risks, benefits and controversies of 100 of the most common surgical and diagnostic procedures from the staff of the People’s Medical Society.

Lewis, John: So Your Doctor Recommended Surgery. New York: Henry Holt, 1990. Discusses in plain language common surgical procedures.

Macho, James and Cable, Greg: Everyone’s Guide to Outpatient Surgery. Kansas City, Missouri: Somerville House Books, 1994. Excellent discussion step by step descriptions of scores of surgical procedures telling the patient what to expect, what to ask, and how to best work within the system. Each section written by experts or teams of experts.

Youngson, Robert M.: The Surgery Book: An Illustrated Guide to 73 of the Most Common Operations. New York: St. Martin’s Press, 1993. Covers why have the operation, goals of the operation, step-by-step how it is done, immediate and long-term effects. Illustrated with line drawings.

Audiotapes:
Huddleston, Peggy: Prepare for Surgery, Heal Faster: Relaxation/Healing Audio Tape. Angel River Press, Box 1038, Cambridge, MA 02140-0009 (Tel: 617-497-9431). An audiotape with imagery, suggestions, and relaxation exercises.

Naparstek, Belleruth. Health Journeys: Surgery Audio Cassette. Image Paths, Inc., 2635 Payne Avenue, Cleveland, OH 44114. Beautifully produced relaxation and imagery tape for surgical preparation with soothing background music.

Patient Comfort, Inc., 141618 Tyler Foote Rd., Nevada City, CA 95959, (800)-213-3223. Provides a selection of audiotapes and materials for surgical preparation including tapes by psychologist Henry Bennett giving specific body instructions for recovery.

Rodgers, Linda. P.I.P. Surgical Audiotape Series (70 Maple Avenue, Katonah, NY 10536, Telephone: 914-232-6405). A series of tapes for use before surgery, during surgery and after surgery with general information, reassurance, and positive suggestions with soothing background music.

Excerpted with permission from the Quarterly Newsletter, Mind/Body Health Newsletter. For subscription information call 1-(800)-222-4745 or visit the Institute for the Study of Human Knowledge website.