Readers might have noticed a brief break in my usual posting: (1) I have had covid with an extended time needed to recovery (moral of that story: keep your vaccinations current! I did and I still ended up with post-covid fatigue); and (2) last week I had bilateral cataract surgery and yes, it’s good and yes it’s still weird.
Whatever, I have had a break from my series on trauma and I promise I’ll get back to that shortly. BUT I wanted to post about my experience with surgery.
I’ve not had a lot of surgery, but I have had a few experiences with procedures (colonoscopy anyone?!), my hysterectomy (yay!), and now cataracts. And I’ve taken our labradoodle Miss Molly May for two significant joint surgeries – and have written about that before here.
As someone who is familiar with health service delivery, and who has heard a lot of sad stories about poor surgery/healthcare encounters, I’m always evaluating my own experiences against both what seems to be good care, and what research suggests is useful.
Cutting to the chase. Miss Molly’s recent second tibial plateau leveling osteotomy has gone really well with the same kind of attention paid to her (and our) overall wellbeing that I loved the first time. So lots of personal attention, reassurance about ‘normal’ and ‘expected’ recovery, attention to keeping all of us calm so she can be supported in her recovery, and really good suggestions for keeping her rather active brain stimulated while not allowing her to bounce all over the place! The whole dog-and-her-family was considered, in that biopsychosocial way that Engel (1980) first intended.
My cataract surgery was also a great experience. Here’s why: the information provided by Dr Malcolm McKellar and the Christchurch Eye Surgery team was spot on. Lots of detailed information, clearly written, taking the whole process from initial referral right through to post-op recovery as a coherent whole. Step-by-step on a time-line showing when things were happening, what I should expect, and what to do if things weren’t going along the expected trajectory. Practical answers to things like traveling to and from the appointments, where to park, what to bring (yes, headphones for the waiting room – fabulous idea for keeping this jitterbug calm!).
What might have helped me more? One tiny piece that would have reduced my anxiety just a tad. If someone had just asked me ‘what is your main concern about this surgery and what’s going to happen’ I would have told them – I really was worried about seeing the sharp instruments coming towards my eyes!! As it happens I wasn’t asked, and I needlessly worried about what I would experience. For those who haven’t had this kind of surgery, the answer is that you don’t see anything distinct coming towards your eyes because (a) your pupils have been really dilated so everything is blurry and (b) your face is covered in a tent thing, your eyes are anaesthetised, and all you see are bright blobs and a kind of kaleidoscope effect as the new lens is put in.
So the question that nobody asked me was ‘what is your main concern about the surgery?’ This is different from ‘what questions do you have about your surgery?’ or ‘do you have any worries?’ By asking about my main concern, it didn’t have to be a ‘worry’ or a ‘question’ – it was simply my main concern. An alternative might have been ‘what’s on your mind about the surgery?’
In any event, had this question been asked of me, I would have said ‘the sharp instruments coming for my eye’ – and because it’s me, I would have said this in a joking way. Which may have suggested to people that I wasn’t actually too worried – but I was pretty anxious about that specific image. And it did cause me to feel quite wound up and find it hard to relax (despite the headphones with the soothing music).
So… here’s a thought for preparing for surgery. Ask the person ‘what is your main concern’ and then listen – and even if the person responds in a lighthearted way, take the time to be sincere, find out what the main concern is and give appropriate reassurance specific to that concern. Reassurance is far more reassuring if it directly addresses the worries the person identifies. For example, my main concern was seeing things coming towards my eye – if someone had just said ‘you can’t see anything clearly, it’s all blurry and blobby and bright lights’ then I’d have been reassured.
There’s some good research exploring reassurance for pain. Typically people are more reassured by cognitive or informational reassurance than affective or emotional reassurance. It takes longer to give informational reassurance, but it lands better (doesn’t feel so patronising) and the effect of informational reassurance lasts longer (Holt, Pincus and Vogel, 2015). And what’s needed for reassurance differs over time (Hasenbring & Pincus, 2015) and should form the foundation of any patient-centred consultation for musculoskeletal conditions (Belton, Birkinshaw & Pincus, 2022). What doesn’t help much is ‘generic reassurance’ which can come across as patronising and dismissive (Linton, McCracken & Vlaeyen, 2008).
Why is the process of reassurance so important? Well, in a recent study looking at pain in people undergoing minor gynaecological procedures (IUD insertions, colposocopy, hysteroscopy) we found that there is very little guidance given to clinicians about how to offer reassurance. This hasn’t changed much in the years since the first low back pain guidelines where clinicians were advised to ‘offer reassurance’ – and, like many recommendations for communication in healthcare, leaves the approach almost entirely up to the clinician. And many clinicians simply have no idea of the worries or concerns of the people they see, and even less knowledge of how best to answer them. We can and should do better. Feeling psychologically safe while receiving healthcare should be a given.
Belton, J., Birkinshaw, H., & Pincus, T. (2022). Patient-centered consultations for persons with musculoskeletal conditions. Chiropr Man Therap, 30(1), 53. https://doi.org/10.1186/s12998-022-00466-w
Engel, G. L. (1980). The clinical application of the biopsychosocial model. The American Journal of Psychiatry, 137(5), 535-544.
Holt, N., Pincus, T., & Vogel, S. (2015). Reassurance during low back pain consultations with GPs: a qualitative study. British Journal of General Practice, 65(639), e692-e701.
Hasenbring, M. I., & Pincus, T. (2015). Effective Reassurance in Primary Care of Low Back Pain: What Messages From Clinicians are Most Beneficial at Early Stages? Clin J Pain, 31(2), 133-136. https://doi.org/10.1097/AJP.0000000000000097
Linton, S., McCracken, L., & Vlaeyen, J. (2008). Reassurance: Help or hinder in the treatment of pain. Pain, 134(1–2), 5-8. https://doi.org/http://dx.doi.org/10.1016/j.pain.2007.10.002