A healthy 40-year-old woman donates a kidney to her child. Hours after surgery, she goes to her child's bedside and is discharged the next morning. Conversely, an otherwise healthy 40-year-old woman has a nephrectomy for cancer. She is bedridden for days and is discharged a week later. Despite no complications, she requires opioids long after surgery and develops chronic pain syndrome.
We have all experienced this phenomenon: 2 patients with the same risk profile, same surgery, even the same surgeon, who have completely different outcomes. The root of these differences has long been studied, with the majority of attention focused on preoperative conditions, perioperative complications, and other measurable factors. But perhaps, more than an albumin level or HgbA1C, positive psychology may help explain why some patients excel and others languish.
MOVING BEYOND THE PROBLEM-BASED APPROACH TO CARE
Positive psychology is the scientific study of human flourishing – a state of optimal functioning encompassing growth, fulfillment, and thriving. Its central tenet is that wellbeing does not result from removing abnormal psychological conditions (eg, depression or anxiety). Instead, wellbeing is an active process. The wellbeing theory has 5 elements: positive emotion, engagement, positive relationships, meaning, and achievement.1,2 Attaining these 5 elements leads to flourishing.
In contrast, surgery is problem-focused. We identify patients by their problems and view them by their barriers to discharge. This ideology also permeates our own identities: as surgeons, we pride ourselves on our ability to fix problems. However, this mindset equates good health with the absence of pathology, rather than the presence of wellbeing. This gap may underlie why some patients with a “surgical problem” fail to thrive after their ailment is addressed. As surgeons, it may be possible to leverage the surgical episode to build positivity and facilitate lasting wellness for our patients.
BRINGING POSITIVE PSYCHOLOGY TO THE BEDSIDE
Positivity and optimism are powerful forces for health, with experiments demonstrating this link in various illnesses including cardiovascular disease, infectious disease, and cancer.3–6 Patients’ experiences of illness and recovery are profoundly affected by their mental models and emotional states. What can we learn from our kidney donor? Her surgical journey is not “problem-based,” but rather borne of altruism, fulfilling all 5 domains of flourishing: positive emotion (love and caring), engagement (having full ownership of the act), meaning (acting for something larger than herself), positive relationships (with her child), and accomplishment (enhancing her child's life). Not every patient can emulate the remarkably positive mental model of a mother donating to her child. We can; however, begin to modify care systems to reinforce elements of positive psychology for patients.
MOTIVATING POSITIVITY AND ENGAGEMENT IN SURGICAL PATIENTS
Surgery is a major event in our patients’ lives and thus well-suited to motivate both physical and psychological change. Ideally, perioperative care should include:
Physical Training: Inactivity is a critical risk factor for complications and is associated with a 1.2-fold increased hazard of all-cause mortality.4 Prehabilitation programs aim to optimize preoperative wellbeing by encouraging patients to exercise before surgery. In our experience, better clinical outcomes can be achieved even with walking for 2 weeks before surgery.5–8 Such modest activity may seem unlikely to impact wellness from a physiological perspective, but we hypothesize that these programs work partly by empowering patients to engage in their own recovery.
Mindset training: These activities should activate the 5 elements of flourishing. There are numerous evidence-based mindset exercises.9,10 Here are 3 that, together, activate all 5 domains of positive psychology:
- “Who” exercise: The patient will form a “support team” of meaningful relationships to facilitate their recovery. The patient should also document their personal identity. For example, “My support team is my husband Jim and my daughter Nancy. I am a mother, a retired accountant, and a gardener.”
- “Why” exercise: The patient documents the reasons they are seeking care. The patient should also document three gratitudes daily. For example, “I have abdominal pain preventing me from gardening. I want to get back to growing my tomatoes. I am grateful for my family, my garden, and today's sunshine.”
- “How” exercise: The patient should document how they will optimally engage in their care. For example, “Today I will increase walking and document 3 things I am grateful for.”
BUILDING POSITIVE PSYCHOLOGY INTO THE SYSTEM
Throughout the perioperative process, from the initial clinic visit to the postoperative visits, it is important to recognize the patient's goals and encourage a continued sense of autonomy and empowerment. This care undoubtedly adds effort and cost. However, surgeons must highlight the importance of these exercises, the team must reinforce them, and exercises must be efficiently integrated into the system of care. The following section offers examples of both large and small-scale actions to incorporate positive psychology training into routine care.
Operating Room Time-out
- Large-scale change: During time-out, the patient's preferred identity, why statement, and how statement are reviewed before induction of anesthesia, along with allergies, preoperative antibiotics, and other aspects of the time-out.
- Small-scale change: During time-out, the surgeon personalizes the planned procedure. For example, “In this procedure, we will resect Mrs. Chen's breast cancer, helping her achieve her goal of seeing her granddaughter's high school graduation in 2 years.”
Clinical Documentation
Building change into documentation is a key step towards reinforcing patient-centered conversations.
Clinical documentation, including consent forms, the H&P, and daily progress notes, should include the following statements (informed by the exercises above):
- “Who” statement: Describe the patient's preferred personal identity. Name the individuals in the patient's support team.
- “Why” statement: Describe the reasons the patient is seeking care. For example, “The patient has abdominal pain limiting activity. Goals include returning to gardening.”
- “How” statement: Describe how the patient plans to engage in care. For example, “Mrs. Lopez will walk 5,000 steps daily before surgery and will complete gratitude exercises.”
- Small-scale change:
In daily progress notes, patients’ long-term goals can be included in their identifying 1-liner, whereas short-term goals to be accomplished over the next 24 hours can be included in the daily plan. Nurses, surgeons, physical therapists, and all other team members can help patients set short-term goals, such as “walking three times today” or “learning to change my ostomy appliance.”
Rounding
- Large-scale change: Begin patient discussions by reaffirming the who, why, and how statements above. End by establishing positive reflections on the previous day's care, suggesting opportunities for improvement. Keeping a focus on both short-term and long-term goals of care is critical. For example: “Ms. Jones is a 54-year-old retired teacher who is post-operative day (POD) 2 from a laparoscopic sigmoidectomy for recurrent diverticulitis. She is supported by her husband, Chris, and her daughter, Camille. Her reason for surgery is to go to Peru without fear of recurrent attack. Yesterday, she met her goal of getting to the chair three times and today her goal is to walk 3 laps. Long-term, her goal is to go home by POD4 and recover to hike Machu Picchu in 6 months.”
- Small-scale change: In the identifying 1-liner, reinforce the patient's goals. For example, “Ms. Jones is a 54-year-old woman who is POD2 from a laparoscopic sigmoidectomy for diverticulitis, who underwent surgery to go to Peru this summer without worrying about another diverticulitis attack.” Although this small action may seem trite or repetitive, injecting this reminder of a patient's humanity may prompt busy clinicians out of their habitual workflow and open the door for more personal connections between patient and clinician.
These suggestions starkly contrast how we classically approach patients, but this begs clarification of our aim in patient care: in treating our patients, are we prioritizing our goals or theirs? Emphasizing how and why our patients want to be treated could have positive outcomes, including more culturally sensitive care, respect of patient autonomy which may lead to cost-saving measures, and improved patient-clinician relationships with increased patient satisfaction.
DOING THE IMPOSSIBLE
Integrating these interventions into routine care requires effort, and it would be remiss to ignore the many barriers to revamping our systems. These include time constraints, especially given our increasingly shift-based culture, work hour restrictions for trainees, and the considerable burden already posed by documentation and other clerical tasks. Another obstacle is the fragmented nature of care, where multiple teams are responsible for various aspects of a patient's surgical trajectory. However, existing tools, such as electronic health record templates, may facilitate wellbeing-centered documentation, serving as a universal reminder to all clinicians of the patient's identity and goals. Finally, shifting surgical culture from a problem-based mindset that prizes efficiency towards a more holistic perspective of the patient may be difficult. However, rather than dismiss these ideas, we should promote dialogue about the need for surgery to evolve towards more compassionate, positive, and patient-centered care to benefit both patients and the surgical team.
Elevating surgical care to the next level requires consideration of the patient's mental model alongside their comorbidities. We must advance from simply fixing problems to helping our patients flourish after surgery. This cultural shift may be daunting, but beginning with small-scale changes in our systems is the first step.
REFERENCES
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