Fear Of Surgery

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I have an appointment for gastric bypass in the near future. But I am so scared to have it done. What do you think? Thanks, Debbie

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I have an appointment for gastric bypass in the near future. But I am so scared to have it done. What do you think? Thanks, Debbie

Dear Debbie,

I think you've asked a great question, because you are the voice for all of us who have faced surgery or other significant medical treatment or are looking forward to it. Whether it's massive obesity, a bad heart, a cancer, or a "simple" hernia repair, we ask ourselves, how can this be, and will I do OK or become a statistic? Will I survive intact, will I lose part of me that I need, or simply, will I live to see my grandchildren grow up? Can I afford the surgery? Could I afford the consequences of a complication? What if I lose my job or can't find one? What about the house or the apartment? These are all daunting, and sometimes existential questions that haunt us in the wee hours in the days and weeks before treatment.

Matters are particularly tough for the bariatric surgery folks as a group, because nearly half have had issues with major depression during their lifetime and 16% at the time of surgery. Thirty-eight percent have problems with clinically significant anxiety during their lifetime and 24% at the time of surgery. It's tough enough to deal with presurgery fears if your frame of mind is strong and you have great social support, but if you are already down and fearful by nature or because of past experience, the lead-up to surgery can seem like Mount Everest during a snow storm.

Fear can actually be a good thing...up to a point. Then it becomes paralyzing. Fear can be a great motivator, but like any emotion it needs to be managed with care. So, how do you manage your presurgical fears? It depends on the cause of the fear and how you handle your emotions in general. What are your fearing, and where is the fear coming from? Can you pin it down a little. What are some steps you can take to deal with it?

First, consider the big picture. It's important to put surgery and its aftermath in perspective in comparison with your obese condition. You are not going for good looks so much as better physical and emotional function, and relief from your medical conditions. Surgery does have its risks, but so does your current situation. With surgery people live longer, and in a great many cases, they have far fewer medical problems. Their life experience expands rather than continuously contracting. There's hope for a better future, rather than resignation to a continual and sometimes rapid decline. In short, is the cure better than the disease? The answer is a definite yes in most cases.

Second, remember that obesity surgery is in most cases safer than most other major abdominal surgeries. The mortality rate for bariatric surgery at Centers of Excellence surgeons and hospitals ranges from 0.03% for adjustable gastric band to 0.16% for sleeve gastrectomy and 0.18% for gastric bypass. If your surgeon performs bariatric operations on a regular basis, perhaps at least two to three a week, the surgeon and the team have the procedures well worked out. Over time, the "bugs" are eliminated. Surgeons and hospitals that only occasionally perform complex procedures can fall into many more traps. "They don't know what they don't know." Likewise with the office team. In a busy practice, the office staff knows what to look for and how to make things run smoothly.

Third, make sure you can trust your surgeon and his or her hospital. Then trust them. Here are some of the questions to ask. Is your surgeon experienced? Does he or she work in a top notch environment? Does he or she have a great team? Can you communicate with your surgeon and the team? Does your surgeon have the reputation for being there for his or her patients if the going gets tough? Does your surgeon's practice have a meaningful web presence as an extension of the practice?

One benefit of the three to six month work-up process that the insurance companies demand is an opportunity to have more exposure to your surgical team. You have a chance to get to know everyone and get a feel for their commitment. It's very hard to measure the quality of medical work. There are so many intangibles, and the so called "quality measures" that insurance companies, proprietary web sites, and government agencies report are just early attempts to measure success. They are not well refined tools. Unfortunately, they are often based on imprecise and usually out of date data.

Both the American Society for Metabolic and Bariatric Surgery and the American College of Surgery have Centers of Excellence Programs. These programs certify hospitals and individual surgeons if they have the necessary facilities, personnel, training, experience, and track record to meet very high standards. There are good surgeons who are not Center of Excellence surgeons, and there are good hospitals that are not COE hospitals. And going to a COE surgeon and hospital does not guarantee a successful outcome. But if you are being treated by a COE surgeon at a COE hospital, you have assurance that their work has been reviewed and validated by national organizations.

Will your surgeon be there for you if you have problems or questions? This is a very important question. I think we all assume that this is the case, but it's not always so. You should ask your surgeon about his or her call schedule, ask who will answer and how your problems will be managed if you call with concerns. First ask your surgeon. Second, ask his or her staff. Third, ask his or her previous patients. Ask at support groups and ask on his or her web site. Get a variety of opinions. Look for the pattern. Remember that individual people can be disgruntled for a variety reasons, sometimes of their own making. And some people make a career of complaining and feeling aggrieved. So always consider your source.

Fourth, don't go it alone: family and friends. We all do better with some team work. Enlist the help of your loved ones, your friends, and to the extent possible, your coworkers. Bring your family into the educational process so that they know as much about the surgery as you do. Bring them to the office visits, the education seminars, the meeting with the dietician, and the support groups. It's not just about the surgery, it's about the lifestyle, the cooking, the playtime, the accountability, the support. Family and friends who really understand your situation will more likely be part of your foundation for success, rather than overt or unintentional saboteurs. Many hands make work light, and that comes to emotional as well as physical work.

Fourth, don't go it alone: psychologist or psychiatrist. Work with your mental health provider or consultant during your preparation for surgery. If you are already seeing someone, bounce your fears off of them. If you are going in for a mandated psychiatric check up, use the visit to talk about your fears and concerns. Often a few visits with a mental health provider before surgery can make a world of difference to you and your family. Go back after surgery. There are lots of changes in store for you, and some objective, professional psychological support can make a world of difference.

Fourth, don't go it alone: primary care physician. Work with your primary care physician. Get his or her input, ask for help to get optimally prepared for surgery, and make appointments to check in after surgery to have your changing medical needs addressed. If your primary care physician or nurse practitioner is an obstacle, ask "why". Maybe there are some very good reasons that you should heed. There are some primary care providers who are fundamentally opposed to surgery because they truly believe that weight loss can always be achieved through diet and exercise. In the past most felt that way. Now many have seen the good results of surgery and are either open minded or actively encourage surgery for selected patients. If you have exhausted your efforts to lose weight and you need surgical help, you deserve a PCP who will be in your corner and support you. If you have any questions about your PCP, ask him or her their opinion. Get it out on the table. Listen to the answer, because he or she may be totally correct. But if your doc is just opposed to surgery on a theoretical basis, it may be time to respectfully change docs. There's no shame in establishing an new patient-physician relationship, any more than changing an attorney-client relationship, or finding an new place of worship that meets your philosophical needs. You need your professional consultants to work with you and for you.

Fourth, don't go it alone: spiritual guidance. If you are religious, have a meeting with your faith leader to discuss your fears and concerns. There is tremendous strength in faith. Members of your congregation will be there for you, too, if you feel like confiding in them. They are part of your extended family, your family in God.

Fifth, get in best the medical and physical shape that you can get into. Work with your primary care physician, your consultants, and your surgeon to optimize your medical condition. For instance get your diabetes, hypertension, and sleep apnea under control. Knowing that you are as fit as you can be will give you self confidence and reduce anxiety. Get stronger. Any amount of activity or exercise you can do will improve your fitness and decrease anxiety. Stretching, walking, swimming, going to a gym or fitness center like Curves, working with physical therapist or a knowledgeable trainer are all helpful.

Sixth, practice eating healthy foods and following healthy eating habits. Follow a Mediterranean diet. Read Food Rules by Michael Pollan, and take the message seriously. Say goodbye to fast food, all you can eat buffet, an endless string of "last suppers", and the world of snacking and comfort feeding. This stuff is all part of the addiction to maladaptive a maladaptive lifestyle. Learning the eat in a healthy fashion before surgery removes some of the fear of flopping after surgery.

Seventh, "better living through pharmacology"? If you are taking psychotropic medications, make sure the doses are optimized. If you have significant "situational anxiety", meaning that you are squared away about surgery, but are just scared to death about it and are waking up at nights worrying, ask your PCP or psychiatrist for some Xanex and/or a sleeping pill. We all function better on a good night's sleep. And if you are tossing and turning, you are not doing yourself or anyone else a favor. Do not turn to alcohol or street drugs to relieve anxiety. They too are part of the problem, not part of the solution.

Debbie, this is a long answer to a short question. I hope it gives you some guidance on the process of coming to terms with anxiety about your upcoming surgery and making the best out of a very positive opportunity for your future. Good luck, and best wishes.

Dr. Callery

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