The effect of psychological intervention on recovery from surgery and heart attacks: an analysis of the literature

Is It a Mind Game? Do Visual and Psychological Perceptions Differ Between Aesthetic Surgery Patients and Healthy Controls?

AIM

Aesthetic plastic surgery allows for the reshaping of the human body. Most research on aesthetic surgery has focused primarily on improving self-confidence. In this study, we aimed to assess the visual perception, body appreciation, body image quality of life, and satisfaction with life among aesthetic surgery patients, and compare these outcomes with those of healthy controls.

METHODS

A total of 57 aesthetic surgery patients and 56 healthy controls, with no history of psychiatric disorders, were included in the study. All participants completed the Motor-Free Visual Perception Test (3rd Edition), the Body Appreciation Scale (BAS), the Body Image Quality of Life Inventory (BIQLI), and the Satisfaction with Life Scale (SWLS). Participants with a history of psychiatric disorders and the surgeon's own revision patients were excluded.

RESULTS

MVPT-3 scores were significantly lower in aesthetic surgery patients compared to healthy controls. Additionally, as the number of operations increased, MVPT-3 scores decreased. A similar trend was observed between MVPT-3 and BIQLI/BAS scores, where lower body image quality and appreciation were associated with reduced visual perception scores. Interestingly, satisfaction with life was not significantly affected.

CONCLUSION

Evaluating visual perception in patients seeking multiple surgeries may help prevent negative outcomes and contribute to more positive surgical experiences.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Editorial Commentary: Psychological Resilience Promotes Positive Outcomes After Surgery

The significance of psychological factors in orthopaedic surgery has long been underestimated. High psychological resilience plays an important role in achieving a positive postoperative outcome in terms of mental health, pain, and functional outcomes. This underscores the need for a more holistic approach to patient care, one that considers not only the physical aspects of treatment but also the emotional and psychological well-being of patients. This may involve implementing strategies to enhance resilience, providing support resources for coping with the challenges of surgery and recovery, and fostering open communication between patients and healthcare providers. Patients who feel supported and empowered throughout their surgical journey are likely to experience improved overall satisfaction with their care. Patient emotional well-being is integral to achieving optimal recovery.

Contemporary Supportive Therapy: A Review of History, Theory, and Evidence

Supportive psychotherapy interventions were developed as a part of psychodynamic psychotherapy work, and supportive psychotherapy was historically considered to be the default form of therapy only for lower-functioning patients. These roots unfortunately have resulted in supportive psychotherapy being viewed as an inferior form of treatment. In reality, supportive psychotherapy is a practical and flexible form of psychotherapy that helps patients with a wide range of psychiatric illnesses, including mood disorders, anxiety disorders, posttraumatic stress disorder, schizophrenia, personality disorders, eating disorders, body dysmorphic disorder, and substance use disorders. In addition, supportive psychotherapy can be well-suited to higher-functioning patients, as well as to patients who are chronically lower-functioning. There is also evidence to support the use of supportive psychotherapy in patients with certain medical illnesses, including coronary artery disease, some gastrointestinal illnesses, HIV infection, and certain types of cancer. The goals of supportive psychotherapy include helping patients to understand emotional experiences, improving affective regulation and reality-testing, making use of their most effective coping strategies, and engaging in collaborative problem solving to reduce stressors and increase effective engagement with support systems.

Acceptability and face validity of two mental health screening tools for use in the routine surgical setting

Background

Preoperative assessment of mental health rarely occurs within routine surgery. Any screening tool selected to form part of this process must be deemed practical, acceptable and valid by clinicians and consumers alike. This study aims to assess the acceptability and face validity of two existing mental health screening tools to select one for further development and use in the routine surgical setting.

Methods

A survey of clinicians and consumers was conducted from October 2020 to March 2021 at a tertiary hospital in Sydney, Australia. Using a Likert scale (1–5, lowest to highest rating), the clinicians evaluated four domains for acceptability and two for validity (six overall) and the consumers four domains for acceptability and one for validity (five overall) on the preoperative use of the amended Kessler Psychological Distress Scale (K10) and the Somatic and Psychological Health Report-12 (SPHERE-12). Consensus was achieved through a rating of 4 or 5 being given by 70% or more of participants with domains able to remain unchanged. Free text responses were analysed into themes.

Results

A total of 73 participants (51 clinicians; 22 consumers) were included. The K10 received consensus scores (≥ 70%) in four out of six domains for clinicians (4/4 acceptability; 0/2 validity), and all five domains for consumers (4/4 acceptability; 1/1 validity). The SPHERE-12 received consensus scores (≥ 70%) in three domains for clinicians (3/4 acceptability; 0/2 validity), and three domains for consumers (3/4 acceptability; 0/1 validity). Six qualitative themes were described including (1) amendments to tool structure and language; (2) scale response options; (3) difficulty with somatic questions; (4) practicality and familiarity with K10; (5) challenges for specific patient cohorts and (6) timing considerations for patients.

Conclusion

Adequate acceptability was established for the K10. However further development is required to strengthen its validity for this specific surgical cohort and purpose. Future research to determine the feasibility and acceptability of implementing and using the K10 in the routine surgical setting is now needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00672-w.

History of depression is associated with worsened postoperative outcomes following colectomy

AIM

Depression is a prevalent disorder that is associated with adverse health outcomes, but an understanding of its effect in colorectal surgery remains limited. The purpose of this study was to examine the impact of history of depression among patients undergoing colectomy.

METHOD

United States patients from Marketscan (2010-2017) who underwent colectomy were included and stratified by whether they had a history of depression within the past year, defined as (1) a diagnosis of depression during the index admission, (2) a diagnosis of depression during any inpatient or (3) outpatient admission within the year, and/or (4) a pharmacy claim for an antidepressant within the year. The primary outcomes were length of stay (LOS) and inpatient hospital charge. Secondary outcomes included in-hospital mortality and postoperative complications. Logistic, negative binomial, and quantile regressions were performed.

RESULTS

Among 88 981 patients, 21 878 (24.6%) had a history of depression. Compared to those without, patients with a history of depression had significantly longer LOS (IRR = 1.06, 95% CI [1.05, 1.07]), increased inpatient charge (β = 467, 95% CI [167, 767]), and increased odds of in-hospital mortality (OR = 1.37, 95% CI [1.08, 1.73]) after adjustment. History of depression was also independently associated with increased odds of respiratory complication, pneumonia, and delirium (all P < 0.05).

CONCLUSION

History of depression was prevalent among individuals undergoing colectomy, and associated with greater mortality and inpatient charge, longer LOS, and higher odds of postoperative complication. These findings highlight the impact of depression in colorectal surgery patients and suggest that proper identification and treatment may reduce postoperative morbidity.

Comparison of Reconstructive Plastic Surgery Rates and 30-Day Postoperative Complications Between Patients With and Without Psychiatric Diagnoses

BACKGROUND

Psychiatric comorbidity is associated with greater 30-day postoperative complication rates in various surgical specialties, but is not well characterized for reconstructive plastic surgery.

OBJECTIVES

The aim of this study was to compare reconstructive plastic surgery rates and 30-day postoperative complications between patients with and without psychiatric diagnoses.

METHODS

This was a retrospective cohort study comparing patients with and without psychiatric diagnoses. Data for January 1, 2007 to December 31, 2015 were collected from the IBM MarketScan Commercial and Medicare Supplemental Databases. Rates of reconstructive plastic surgery, demographic data, covariant diagnoses, and 30-day postoperative complications were collected. Differences between the 2 groups were assessed by multivariable logistic regression.

RESULTS

Among 1,019,128 patients (505,715 with psychiatric diagnoses and 513,423 without psychiatric diagnoses) assessed, reconstructive plastic surgery rates were between 4.8% and 7.0% in those with psychiatric diagnoses, compared with 1.6% in patients without psychiatric diagnoses. The greatest odds of undergoing reconstructive plastic surgery were in patients with body dysmorphic disorder (BDD) (adjusted odds ratio [aOR], 3.16; 95% confidence interval [CI], 1.76-5.67) and anxiety disorder (aOR, 3.08; 95% CI, 2.97-3.17). When assessing 1,234,206 patients (613,400 with psychiatric diagnoses and 620,806 without psychiatric diagnoses), all of whom underwent reconstructive plastic surgery, 2-fold greater odds of any 30-day postoperative complication was associated with psychiatric diagnoses (aOR, 2.01; 95% CI, 1.28-3.11), as well as greater odds of specific complications (surgical site infection, bleeding, and hospital admission). Eating disorder diagnosis was associated with the greatest odds of a complication (aOR, 4.17; 95% CI, 3.59-4.86), followed by nasal surgery (aOR, 3.65; 95% CI, 2.74-4.89), and BDD (aOR, 3.16; 95% CI, 1.76-5.67).

CONCLUSIONS

Diagnosis of a psychiatric condition is associated with greater rates of reconstructive plastic surgery, and 2-fold greater odds of 30-day postoperative complications.

LEVEL OF EVIDENCE: 4

Experiences of Hearing Loss and Audiological Rehabilitation for Older Adults With Comorbid Psychological Symptoms: A Qualitative Study

Purpose There is a well-established relationship between hearing loss and psychological symptoms. To ensure audiological rehabilitation is provided appropriately for older adults with comorbid psychological symptoms, a greater understanding of their preferences and experiences is needed. This study sought to understand experiences of hearing loss and audiological rehabilitation from the perspective of older adults with comorbid psychological symptoms (e.g., depression, anxiety, psychosis). Design A qualitative study using in-depth semistructured interviews was conducted with older adults who had attended audiological rehabilitation within the last year and scored above established cutoffs on measures of depression, anxiety, and psychosis. A thematic analysis generated themes that related to participants' experiences of hearing loss and audiological rehabilitation. Results Participants included 14 older adults (eight men and six women) with an average age of 70.5 years (SD = 4.45, range: 64-80) who received hearing aids or a cochlear implant. Three major themes emerged from the analysis of participant interviews. "The cumulative impact of hearing loss and psychological symptoms" theme describes the two-way, additive relationship between hearing ability and psychological symptoms. "The experience of loss throughout hearing loss and audiological rehabilitation" captures subjective losses, the impact they have, and how participants cope with them. In contrast, "The experience of gain throughout hearing loss and audiological rehabilitation" describes the participants' reported gains, their related impacts, and coping strategies. Conclusions The experiences of participants revealed that the presence of comorbid psychological symptoms can influence the experience of hearing loss and audiological rehabilitation. These findings have implications for how audiological rehabilitation is provided to ensure optimal outcomes for adults with hearing loss and comorbid psychological symptoms. Supplemental Material https://doi.org/10.23641/asha.12985955.

Perceived quality of surgical care in association with patient-related factors and correlation to reported postoperative complications in Finland: a cross-sectional study

OBJECTIVE

To study if patient-related factors are associated with patient-evaluated quality of care in surgery. To examine if there is an association with postoperative complications and patient-evaluated low quality of care.

DESIGN

A correlation cross-sectional study, in addition, a phone call interview at 30 days postoperatively to examine complications.

SETTING

The data on patients admitted for non-cardiac general and orthopaedic surgery at a central hospital in Southwestern Finland were collected in two phases during an 8-month period.

PARTICIPANTS

436 consecutive consenting and eligible in-ward non-cardiac general surgery and orthopaedic surgery adult patients. Ambulatory, paediatric and memory disorder patients were excluded. 378 patients completed the questionnaire (Good Nursing Care Scale for Patients (GNCS-P)).

METHODS

Perceived quality of care was examined by the GNCS-P questionnaire. Patient-related factors were obtained from electronic patient records and questionnaire. A telephone interview related to postdischarge complications was conducted 30 days after discharge.

MAIN OUTCOME MEASURES

Patient evaluation of quality of care at discharge, its association with patient-related factors and patient-reported postdischarge complications.

RESULTS

The overall quality was evaluated high or very high by the patients. The lowest overall quality of care rate was assessed by surgical patients living alone (p=0.0088) and patients who evaluated their state of health moderate or poor (p=0.0047). Surgical patients reporting postoperative complications after discharge evaluated lower overall quality of care (p=0.0105) than patients with no complications.

CONCLUSION

Patient demographic factors do not seem to influence the perceptions of the quality of care. Instead, subjective state of health and living conditions (living alone) may have an influence on the patient experience of quality of care. The perceived quality of care in healthcare staff technical and communication skills may have an association with reported postoperative complications.

Placebo effects and racial and ethnic health disparities: an unjust and underexplored connection

While a significant body of bioethical literature considers how the placebo effect might introduce a conflict between autonomy and beneficence, the link between justice and the placebo effect has been neglected. Here, we bring together disparate evidence from the field of placebo studies and research on health inequalities related to race and ethnicity, and argue that, collectively, this evidence may provide the basis for an unacknowledged route by which health disparities are exacerbated. This route is constituted by an uneven distribution of placebo effects, resulting from differences in expressions of physician warmth and empathy, as well as support and patient engagement, across racial and ethnic lines. In a discussion of the ethical implications of this connection, we argue that this contribution to health disparities is a source of injustice, consider ways in which these disparities might be ameliorated and suggest that this conclusion is likely to extend to other realms of inequality as well.

Predictive coding: A contemporary view on the burden of normality and forced normalization in individuals undergoing epilepsy surgery

Following epilepsy surgery, a good psychosocial outcome is not necessarily contingent on a good seizure outcome. Increasingly, it is believed that "successful" surgery is a combination of both an acceptable and expected seizure status as well as the individual's perception of improvements in quality of life (QOL). The factors that create this optimal outcome remain an ongoing area of research in the epilepsy community. That being said, there have been some major breakthroughs in observing and understanding poor outcomes seen in a subset of postoperative patients with epilepsy. Characteristics of burden of normality and forced normalization are two phenomena that have been evident in cases of poor postoperative outcomes. In this review, we provide a summary of research and concepts used to explain these poor QOL outcomes for a seemingly successful surgery and suggest a contemporary view in understanding the mechanism of forced normalization through understanding the brain as a predictive organ. Using such a predictive coding model together with recommendations of other studies, we suggest the crucial need for a preoperative intervention addressing patient predictions and expectations to optimize on the benefits achievable through epilepsy surgery.

Learning to listen in primary care: some educational challenges

Effective clinician listening and communicating directly affects patients' health, satisfaction with healthcare, and complaints. This influences healthcare policy and clinician training/assessment. Listening skills and consultation frameworks underpin training but are often poorly used in everyday clinical work. Primary care doctors provide continuity of care using listening skills to develop long term relationships. Additionally, they listen to patients and colleagues in other ways such as surveys, participation groups, and significant event reviews. All these factors challenge educators to offer systematic training which ensures that future primary care clinicians/leaders develop conscious competence in listening at different levels and in differing contexts.

The leading edge in nursing research

The following is the opening address given by Professor Alison Tierney at the Royal College of Nursing's International Nursing Research Conference held at Heriot Watt University, Edinburgh, on April 3, 1998

Preventive Health Behavior Advice

Preventive health behavior on the part of heart patients is essential to reduce cardiac risk, improve the opportunity for recovery after myocardial infarction (MI), and enhance the patient's likelihood of survival. Since physicians often manage older patients differently than younger ones, it is important to determine whether preventive health advice differs by age. This study of 246 recovering MIpatients has shown that important areas of differences emerge that appear to favor younger patients. These involve preventive behavior information, advice, and physician referrals. Also indicated by the data was that older patients were offered significantlyfewer opportunitiesfor enrollment in cardiac rehabilitation programs and received significantly less instruction in practices that are beneficial to cardiac health. Discriminant function analyses performed on the data identified specif ic referral patterns in which age of patient was a majorfactor. Reasonsfor the discrepant patterns are offered, including the possibility of age-related stereotyping of older heart patients.

EEG based patient emotion monitoring using relative wavelet energy feature and Back Propagation Neural Network

In EEG-based emotion recognition, feature extraction is as important as the classification algorithm. A good choice of features results in higher recognition rate. However, there is no standard method for feature extraction in EEG-based emotion recognition, especially for real time monitoring, where speed of computation is crucial. In this work, we assess the use of relative wavelet energy as features and Back Propagation Neural Network (BPNN) as classifier for emotion recognition. This method was implemented in simulated real time emotion recognition by using a publicly accessible database. The results showed that relative wavelet energy and BPNN achieved an average recognition rate of 92.03%. The highest average recognition rate was achieved when the time window was 30s.

Effectiveness of psychological support in patients undergoing primary total hip or knee arthroplasty: a controlled cohort study

BACKGROUND

We hypothesised that psychological support would have a significant improvement on the mental and physical recovery of patients undergoing primary total hip or knee arthroplasty.

MATERIALS AND METHODS

200 patients were consecutively alternately assigned (1:1) to receive routine care (control group) or, in addition, psychological support from a professional psychologist (experimental group). The psychological support was provided at the pre-operative visit, during the hospitalisation period and at the rehabilitation centre.

RESULTS

Upon discharge, based on the 'Hospital Anxiety and Depression Scale, a state of anxiety was observed in 12.8 % and 78.9 % of the patients in the experimental and in the control group, respectively (p < 0.0001). A state of depression was observed in 12.8 % and 73.7 % of the patients in the experimental and in the control group, respectively (p < 0.0001). With regard to the 'Physical Component Scale' of the SF-36 questionnaire, a similar temporal trend of values was observed in the two study groups, significantly increasing over time in both groups, taking into consideration both the joint population and the two hip and knee populations separately (p < 0.0001). With regard to the 'Mental Component Scale' of the SF-36 questionnaire, in both the joint population and the two hip and knee populations separately, an exact opposite temporal trend was observed in the experimental group compared to the control group (p < 0.0001), with generally higher scores in the experimental group (p < 0.0001). In patients with hip arthroplasty, the average time to reach the physiotherapy objective (i.e., the patient ability to walk 50 metres independently and to climb 10 steps) was 6.7 ± 1.8 days (range 4-12) in the experimental group and 7.9 ± 2.2 days (range 0-13) in the control group (p = 0.0015).

CONCLUSIONS

In summary, there was a lower incidence of anxiety and depression and better mental well-being in the group of patients who received the psychological support. Within the hip arthroplasty group, the patients who received the psychological support reached the physiotherapy objective 1.2 days earlier than the patients in the control group (p = 0.0015).

LEVEL OF EVIDENCE

Level 3, Non-randomized prospective controlled cohort.

Effects of Theodore Millon's Teaching, Mentorship, Theory, and Scientific Contributions on Health Psychology and Behavioral Medicine Research and Practice

This article summarizes the impact of Theodore Millon's work on the disciplines of health psychology and behavioral medicine over the past 5 decades spanning from the late 1960s to present. The article is written from my perspectives as a graduate student mentored by Millon on through my faculty career as a collaborator in test construction and empirical validation research. Several of the most recent entries in this summary reflect projects that were ongoing at the time of his passing, revealing the innovation and visionary spirit that he demonstrated up until the end of his life. Considering that this summary is restricted to Millon's contributions to the disciplines of health psychology and behavioral medicine, this work comprises only a small portion of his larger contribution to the field of psychology and the areas of personality theory and psychological assessment more broadly.

Training Medical Students in Behavioural and Cognitive Strategies

It is argued that psychologists have an important role in ensuring appropriate training of medical students in behavioural and cognitive strategies. This paper outlines the innovative medical curriculum at the University of Newcastle and describes the contribution of cognitive psychology to the problem-solving method which underlies the curriculum. It also describes the medical school's approach to training students in interactional skills. One focus of the interactional skills training is to provide practical skills which incorporate behavioural and cognitive strategies to address common, preventable health problems, such as excessive alcohol consumption.

The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To determine whether the patient-clinician relationship has a beneficial effect on either objective or validated subjective healthcare outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Electronic databases EMBASE and MEDLINE and the reference sections of previous reviews.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Included studies were randomized controlled trials (RCTs) in adult patients in which the patient-clinician relationship was systematically manipulated and healthcare outcomes were either objective (e.g., blood pressure) or validated subjective measures (e.g., pain scores). Studies were excluded if the encounter was a routine physical, or a mental health or substance abuse visit; if the outcome was an intermediate outcome such as patient satisfaction or adherence to treatment; if the patient-clinician relationship was manipulated solely by intervening with patients; or if the duration of the clinical encounter was unequal across conditions.

RESULTS

Thirteen RCTs met eligibility criteria. Observed effect sizes for the individual studies ranged from d = -.23 to .66. Using a random-effects model, the estimate of the overall effect size was small (d = .11), but statistically significant (p = .02).

CONCLUSIONS

This systematic review and meta-analysis of RCTs suggests that the patient-clinician relationship has a small, but statistically significant effect on healthcare outcomes. Given that relatively few RCTs met our eligibility criteria, and that the majority of these trials were not specifically designed to test the effect of the patient-clinician relationship on healthcare outcomes, we conclude with a call for more research on this important topic.

Mental health affects the quality of life and recovery after liver transplantation

There has been little research examining the effects of mental health before liver transplantation on quality of life (QOL) and recovery after transplantation. Therefore, the purpose of the current study was to examine how pretransplant depression and anxiety affect mental health, QOL, and recovery after transplantation. Eighty-two transplant recipients provided data when they were listed for transplantation and 6 months after transplantation. Pretransplant anxiety predicted posttransplant anxiety (P < 0.001), and there was a trend in predicting posttransplant depression (P = 0.06). Pretransplant depression predicted posttransplant depression (P = 0.03), and there was a trend in predicting posttransplant anxiety (P = 0.06). Additionally, pretransplant anxiety predicted posttransplant QOL for several domains, including Body Pain, Role Limitations Due to Emotional Problems, and Mental Health, as well as the Mental Health Composite Score (P < 0.05). However, in comparison with anxiety, pretransplant depression independently predicted outcomes for more QOL domains, which included Physical Functioning, Role Limitations Due to Physical Problems, General Health, Vitality, and Social Functioning, as well as the Physical Composite Score (P < 0.05). Patients with depression at the baseline were more likely to report incomplete recovery 6 months after transplantation (P < 0.001). With respect to baseline anxiety, there was a trend suggesting that these patients were also more likely to report incomplete recovery (P = 0.09). These findings highlight the importance of evaluating transplant candidates both before and after transplantation for anxiety and depressive symptoms. Once patients with these symptoms are identified, they can be referred for treatment, which may lead to better posttransplant outcomes for mental health, QOL, and recovery.

Perioperative psycho-educational intervention can reduce postoperative delirium in patients after cardiac surgery: a pilot study

OBJECTIVE

Postoperative delirium after cardiac surgery is associated with many consequences such as poorer functional recovery, more frequent postoperative complications, higher mortality, increased length of hospital stay, and higher hospital costs. The aim of this study was to evaluate the efficacy of perioperative psycho-educational intervention in preventing postoperative delirium in post cardiac surgery patients.

METHOD

We conducted a comparative retrospective study between 49 patients who had received perioperative psycho-educational intervention and 46 patients who had received standard care. The primary outcome was the incidence of postoperative delirium. Secondary outcomes included length of ICU stay, and severity and duration of postoperative delirium among the patients who had developed delirium.

RESULTS

The incidence of postoperative delirium was significantly lower in the intervention group than that in the control group (12.24% vs. 34.78%, P = 0.009). Among the patients who had developed postoperative delirium, there was no statistical difference between the two groups regarding secondary outcomes.

CONCLUSIONS

Our results show that the patients who received perioperative psycho-educational intervention were associated with a lower incidence of postoperative delirium after cardiac surgery than those who received standard care. Clinicians would be able to implement this psycho-educational intervention as part of routine practice to reduce delirium.

A systematic review of evidence on the links between patient experience and clinical safety and effectiveness

OBJECTIVE

To explore evidence on the links between patient experience and clinical safety and effectiveness outcomes.

DESIGN

Systematic review.

SETTING

A wide range of settings within primary and secondary care including hospitals and primary care centres.

PARTICIPANTS

A wide range of demographic groups and age groups.

PRIMARY AND SECONDARY OUTCOME MEASURES

A broad range of patient safety and clinical effectiveness outcomes including mortality, physical symptoms, length of stay and adherence to treatment.

RESULTS

This study, summarising evidence from 55 studies, indicates consistent positive associations between patient experience, patient safety and clinical effectiveness for a wide range of disease areas, settings, outcome measures and study designs. It demonstrates positive associations between patient experience and self-rated and objectively measured health outcomes; adherence to recommended clinical practice and medication; preventive care (such as health-promoting behaviour, use of screening services and immunisation); and resource use (such as hospitalisation, length of stay and primary-care visits). There is some evidence of positive associations between patient experience and measures of the technical quality of care and adverse events. Overall, it was more common to find positive associations between patient experience and patient safety and clinical effectiveness than no associations.

CONCLUSIONS

The data presented display that patient experience is positively associated with clinical effectiveness and patient safety, and support the case for the inclusion of patient experience as one of the central pillars of quality in healthcare. It supports the argument that the three dimensions of quality should be looked at as a group and not in isolation. Clinicians should resist sidelining patient experience as too subjective or mood-oriented, divorced from the 'real' clinical work of measuring safety and effectiveness.

The patient-provider relationship in chronic pain

The relationship between patient and provider has long been the subject of study within the psychotherapy literature, with the available data suggesting a modest, but reliable, association between the strength of this relationship and treatment outcome. Conversely, there has been little work focused on the patient-provider relationship in chronic pain settings despite the complexities and difficulties that are often involved in this area. This review provides a brief, broad overview of the literature on the patient-provider relationship and identifies key aspects that are specifically relevant to chronic pain settings. In addition to reviewing the literature in this area, a series of recommendations for future clinical and academic work are offered.

Communication as a core skill of palliative surgical care

Excellence as a surgeon requires not only the technical and intellectual ability to effectively take care of surgical disease but also an ability to respond to the needs and questions of patients. This article provides an overview of the importance of communication skills in optimal surgical palliation and offers suggestions for a multidisciplinary team approach, using the palliative triangle as the ideal model of communication and interpersonal skills. This article also discusses guidelines for advanced surgical decision making and outlines methods to improve communication skills.

Symptoms of anxiety and depression are correlates of angina pectoris by recent history and an ischemia-positive treadmill test in patients with documented coronary artery disease in the pimi study

Objective. We tested the association of specific psychological characteristics in patients having stable coronary disease with the reporting of anginal symptoms during daily activities, and positive exercise testing. Methods. One hundred and ninety-six patients with documented CAD enrolled in the Psychophysiological Investigations of Myocardial Ischemia (PIMI) Study completed an anginal history questionnaire and a battery of psychometric tests. They also underwent standardized exercise treadmill tests. Results. Patients with a recent history of angina were more likely to be female, and had higher Beck Depression (P = .002), State Anxiety (P = .001), Trait Anxiety (P = .03), Harm Avoidance (P = .04) and Muscle Tension (P = .004) scores than patients who had no recent history of angina. Along with several treadmill variables indicating more severe disease state and reduced exercise tolerance, patients who developed angina on a positive treadmill test also displayed higher scores on the Beck Depression Inventory (P = .003) and State Anxiety (P = .004) scales. Conclusions. Several psychological characteristics, and most notably anxiety and depression, are strong correlates of recent angina and angina in the presence of ischemia provoked by treadmill testing.

Influence of yoga on postoperative outcomes and wound healing in early operable breast cancer patients undergoing surgery

CONTEXT

Pre- and postoperative distress in breast cancer patients can cause complications and delay recovery from surgery.

OBJECTIVE

The aim of our study was to evaluate the effects of yoga intervention on postoperative outcomes and wound healing in early operable breast cancer patients undergoing surgery.

METHODS

Ninety-eight recently diagnosed stage II and III breast cancer patients were recruited in a randomized controlled trial comparing the effects of a yoga program with supportive therapy and exercise rehabilitation on postoperative outcomes and wound healing following surgery. Subjects were assessed at the baseline prior to surgery and four weeks later. Sociodemographic, clinical and investigative notes were ascertained in the beginning of the study. Blood samples were collected for estimation of plasma cytokines-soluble Interleukin (IL)-2 receptor (IL-2R), tumor necrosis factor (TNF)-alpha and interferon (IFN)-gamma. Postoperative outcomes such as the duration of hospital stay and drain retention, time of suture removal and postoperative complications were ascertained. We used independent samples t test and nonparametric Mann Whitney U tests to compare groups for postoperative outcomes and plasma cytokines. Regression analysis was done to determine predictors for postoperative outcomes.

RESULTS

Sixty-nine patients contributed data to the current analysis (yoga: n = 33, control: n = 36). The results suggest a significant decrease in the duration of hospital stay (P = 0.003), days of drain retention (P = 0.001) and days for suture removal (P = 0.03) in the yoga group as compared to the controls. There was also a significant decrease in plasma TNF alpha levels following surgery in the yoga group (P < 0.001), as compared to the controls. Regression analysis on postoperative outcomes showed that the yoga intervention affected the duration of drain retention and hospital stay as well as TNF alpha levels.

CONCLUSION

The results suggest possible benefits of yoga in reducing postoperative complications in breast cancer patients.

Psychodynamic psychiatry in the general medical setting

For more than half a century analytically trained psychiatrists have been making observations about psychodynamic factors impacting on medical illness and treatment. Some of these reports have been subsequently supported by evidence-based research while others have been found to be clinically useful to varying degrees even if not substantiated by research. In this article we have presented some of the highlights of the application of psychodynamics to the treatment of physical illness in the general medical setting. It is not meant to be a comprehensive review but we hope it will demonstrate how psychodynamic thinking has permeated many aspects of care in the general medical setting. Topics considered include onset of disease (giving up complex, specificity, role of stress, anniversary reactions), reactions to illness (psychological defenses, fantasies, role of psychotherapy), specific conditions (pregnancy, cancer, human immunodeficiency virus, conversion and alexithymia, heart disease, death and dying), and the doctor-patient relationship.

Communication skills in palliative surgery: skill and effort are key

Excellence as a surgeon requires not only the technical and intellectual ability to effectively take care of surgical disease but also an ability to respond to the needs and questions of patients. This article provides an overview of the importance of communication skills in optimal surgical palliation and offers suggestions for a multidisciplinary team approach, using the palliative triangle as the ideal model of communication and interpersonal skills. This article also discusses guidelines for advanced surgical decision making and outlines methods to improve communication skills.

Do psychological variables affect early surgical recovery?

Background

Numerous studies have examined the effect of psychological variables on surgical recovery, but no definite conclusion has been reached yet. We sought to examine whether psychological factors influence early surgical recovery.

Methods

We performed a systematic search in PubMed, Scopus and PsycINFO databases to identify studies examining the association of preoperative psychological variables or interventions with objectively measured, early surgical outcomes.

Results

We identified 16 eligible studies, 15 of which reported a significant association between at least one psychological variable or intervention and an early postoperative outcome. However, most studies also reported psychological factors not influencing surgical recovery and there was significant heterogeneity across the studies. Overall, trait and state anxiety, state anger, active coping, subclinical depression, and intramarital hostility appeared to complicate recovery, while dispositional optimism, religiousness, anger control, low pain expectations, and external locus of control seemed to promote healing. Psychological interventions (guided relaxation, couple support visit, and psychiatric interview) also appeared to favor recovery. Psychological factors unrelated to surgical outcomes included loneliness, perceived social support, anger expression, and trait anger.

Conclusion

Although the heterogeneity of the available evidence precludes any safe conclusions, psychological variables appear to be associated with early surgical recovery; this association could bear important implications for clinical practice. Large clinical trials and further analyses are needed to precisely evaluate the contribution of psychology in surgical recovery.

Patient satisfaction with physician-patient communication during telemedicine

The quality of physician-patient communication is a critical factor in treatment outcomes and patient satisfaction with care. To date, few studies have specifically conducted an in-depth evaluation of the effect of telemedicine (TM) on physician-patient communication in a medical setting. Our objective was to determine whether physical separation and technology used during TM have a negative effect on physician-patient communication. In this noninferiority randomized clinical trial, patients were randomized to receive a single consultation with one of 9 physicians, either in person (IP) or via TM. Patients (n = 221) were recruited from pulmonary, endocrine, and rheumatology clinics at a Midwestern Veterans Administration hospital. Physician-patient communication was measured using a validated self-report questionnaire consisting of 33 items measuring satisfaction with visit convenience and physician's patient-centered communication, clinical competence, and interpersonal skills. Satisfaction for physician's patient-centered communication was similar for both consultation types (TM = 3.76 versus IP = 3.61), and noninferiority of TM was confirmed (noninferiority t-test p = 0.002). Patient satisfaction with physician's clinical competence (TM = 4.63 versus IP = 4.52) and physician's interpersonal skills (TM = 4.79 versus IP = 4.74) were similar, and noninferiority of TM was confirmed (noninferiority t-test p = 0.006 and p = 0.04, respectively). Patients reported greater satisfaction with convenience for TM as compared to IP consultations (TM = 4.41 versus IP = 2.37, noninferiority t-test p < 0.001). Patients were equally satisfied with physician's ability to develop rapport, use shared decision making, and promote patient-centered communication during TM and IP consultations. Our data suggest that, despite physical separation, physician-patient communication during TM is not inferior to communication during IP consultations.

Psychologic considerations in the management of oral surgical patients

Entering the often-sterile milieu that characterizes most surgical and presurgical environments sets into motion, for most patients, emotional or psychologic reactions. At times, these inner stirrings may manifest in the form of outward behaviors, such as expressions of anxiety or anger or verbalizations suggestive of depression. The essential psychologic issue is that undergoing any surgery--minor, major, elective, or urgent--is far from an emotionally neutral event for typical oral surgical patients.

Which patients improve: characteristics increasing sensitivity to a supportive patient-practitioner relationship

Supportive social relationships, including a positive patient-practitioner relationship, have been associated with positive health outcomes. Using the data from a randomized controlled trial (RCT) undertaken in the Boston area of the United States, this study sought to identify baseline factors predictive of patients' response to an experimentally applied supportive patient-practitioner relationship. To sort through the hundreds of potential attributes affecting the patient-practitioner relationship, we applied a false discovery rate method borrowed from the field of genomics and bioinformatics. To our knowledge such a method has not previously been applied to generate hypotheses from clinical trial data. In a previous RCT, our team investigated the effect of the patient-practitioner relationship on symptom improvement in patients with irritable Bowel syndrome (IBS). Data were collected on a sample of 289 individuals with IBS using a three-week, single blind, three arm, randomized controlled design. We found that a supportive patient-practitioner relationship significantly improved symptomatology and quality of life. A complex, multi-level measurement package was used to prospectively measure change and identify factors associated with improvement. Using a local false discovery rate procedure, we examined the association of 452 baseline subject variables with sensitivity to treatment. Out of 452 variables, only two baseline factors, reclusiveness, and previous trial experience increased sensitivity to the supportive patient-practitioner relationship. A third variable, additional opportunity during the study for subjects to discuss their illness through experiential interview, was associated with improved outcomes among subjects who did not receive the supportive patient-practitioner relationship. The few variables associated with differential benefit suggest that a patient-centered supportive patient-practitioner relationship may be beneficial for most patients. This may be especially important for reclusive individuals. Within the context of our study, additional study attention in the form of repeated experiential interviews compensated for a lack of positive patient-practitioner support. A supportive patient-practitioner relationship may also help overcome low provider expectations for subjects with previous trial experience. These results converge with the results of the parent trial, implicating the importance of the social world in healing.

A tool for self-assessment of communication skills and professionalism in residents

BACKGROUND

Effective communication skills and professionalism are critical for physicians in order to provide optimum care and achieve better health outcomes. The aims of this study were to evaluate residents' self-assessment of their communication skills and professionalism in dealing with patients, and to evaluate the psychometric properties of a self-assessment questionnaire.

METHODS

A modified version of the American Board of Internal Medicine's (ABIM) Patient Assessment survey was completed by 130 residents in 23 surgical and non-surgical training programs affiliated with a single medical school. Descriptive, regression and factor analyses were performed. Internal consistency, inter-item gamma scores, and discriminative validity of the questionnaire were determined.

RESULTS

Factor analysis suggested two groups of items: one group relating to developing interpersonal relationships with patients and one group relating to conveying medical information to patients. Cronbach's alpha (0.86) indicated internal consistency. Males rated themselves higher than females in items related to explaining things to patients. When compared to graduates of U.S. medical schools, graduates of medical schools outside the U.S. rated themselves higher in items related to listening to the patient, yet lower in using understandable language. Surgical residents rated themselves higher than non-surgical residents in explaining options to patients.

CONCLUSION

This appears to be an internally consistent and reliable tool for residents' self-assessment of communication skills and professionalism. Some demographic differences in self-perceived communication skills were noted.