Pre-Surgery Anxiety? The Anesthesiologist Can Help
BY KATHY KATELLA November 7, 2017
Anesthesiologists think of themselves as the patient’s best advocate—the doctor who is focused on keeping you safe by administering drugs and monitoring levels of consciousness and functions of vital organs, while minimizing pain during and after surgery. That is in stark contrast to their portrayal on the TV show Gray’s Anatomy, which treats anesthesiologists as if they were a step down from surgeons. Donna-Ann Thomas, MD, doesn’t like that.
Dr. Thomas is an anesthesiologist, as well as division chief of Regional Anesthesiology & Pain Medicine for Yale Medicine. She says anesthesiologists have the ultra-important role of keeping the patient safe. Earlier in her career, Dr. Thomas herself once insisted that a surgeon stop what he was doing when she suspected a safety issue needed to be addressed. And she is keenly focused on making sure the patient is comfortable and feeling minimal pain before, during and after surgery.
Dr. Thomas urges patients who are anticipating surgery to talk to their anesthesiologist, who is a specially trained physician and can discuss any concerns. Drawing upon vast experience and research, and a surprisingly comprehensive toolbox of treatments, they welcome conversations with patients. “Nobody should have to be afraid. In the vast majority of cases, we can do something,” Dr. Thomas says.
We caught up with Dr. Thomas to discuss her work as an anesthesiologist and pain medicine specialist.
So, there is actually a name for fear of surgery — tomophobia?
That’s right. But I think the patients who have this type of intense fear of surgery are a minority. There are many patients who have a psychological phobia—fear of spiders, fear of flying, fear of lizards. These are real pathologies. There are some patients who are afraid they won’t wake up from surgery—or they worry they will wake up during surgery, which is an extremely rare phenomenon. I certainly wouldn’t belittle any patient who has these fears.
But, in general, patients going into surgery often have a generalized fear of the unknown. You are about to lose control where you previously had control. In my experience, there are many patients who undergo surgery whose generalized anxiety goes unrecognized and can sometimes be exhibited as pain. Women have so many stressors: We have a family, we have to make sure our children are going to get to the school bus on time. Men have this too, but women especially feel they have to make sure that everything is in order before they go into surgery.
What can you do about this anxiety?
I look for it in patients—before the surgery. As a pain physician, I am more aware of it than anybody else, because psychology and psychiatry are part of a pain physician’s training. I’ve seen a patient’s anxiety after surgery (symptoms of anxiety can resemble pain symptoms in this setting) treated with pain medications because anxiety was not immediately obvious.
We need to remove the stigma that is associated with anxiety or depression—or any psychological issues. I tell patients, “If it were your heart you wouldn’t think twice about going to a cardiologist. The brain is just another organ.” It would be ideal if we could screen all of our patients for these issues before an operation. That would also help us better care for them after their surgery.
What else can anesthesiologists do to help with anxiety?
It might help people to know that anesthesiology is one of the safest fields in medicine. Anesthesiologists have helped to increase the safety of surgery. We monitor patients closely, we take the necessary precautions, and we have data and scientific evidence to show that the risk to patients in the hands of a physician anesthesiologist is low. We have developed policies and protocols that are evidence-based for patients with heart disease, diabetes, difficult airway and other problems. We have studied and continue to study all of these things to make surgery a better and safer experience.
At Yale Medicine, the fact that we have physician anesthesiologists is key. Many people are not even aware that we have gone through four years of medical school and internships, and completed a residency in anesthesiology. And many of us specialize even further, in such areas as cardiac anesthesiology, neurology anesthesiology, regional anesthesiology, critical care, anesthesiology for obstetrics, thoracic anesthesiology, pain management and pediatric anesthesiology. All of these specialists work at Yale Medicine. If you are a patient, having a specialized anesthesiologist increases your safety during the surgery significantly.
Many people are also terrified of pain. As a pain specialist, how can you help with that?
There are so many things we can do for pain today. It’s important to remember that the physician anesthesiologist is really a perioperative physician, which means we provide care before, during and after surgery. We start working with you before the surgery to determine how we will treat your pain throughout all of these phases.
Many people are familiar with spinals and epidurals. We still use those techniques when necessary, but we have so many other tools in our toolbox now. For example, a nerve block (a local anesthesia that blocks the transition of pain messages to the central nervous system), can profoundly reduce pain in the area being worked on, but not the rest of your body. And there are many varieties of blocks we can do now—even in breast surgery. This is an exploding field.
Do you make a conscious effort to avoid prescribing opioids?
Yes. Opioids are a national concern and addiction can start following an injury or surgery. My primary concern is the effect the opioids have on breathing. We can reduce the number of opioids that a patient needs after surgery without affecting their pain control. One thing we do is take a multimodal approach (instead of using opioids alone, the doctor supplements them with medications for such problems as inflammation and muscle spasms that may be contributing to the pain). Each patient and surgery is different. Some will even do well with over-the-counter pain relief.
In many cases, doctors can prescribe fewer opioids. A study at Dartmouth last year tracked the opioids prescribed for a number of surgeries. From that, the researchers estimated that patients actually need far fewer opioid medications than are generally prescribed. The thing is, when we as physicians prescribe a particular quantity of a medication, many patients continue to take those medications even after the incision has healed, and that can cause problems.
We get patients who are still requesting opioids from a surgery they had several years prior or because they have had multiple surgeries or injuries. I am not saying this is never the case, just that it is very infrequent. We need to be telling patients that if they find they need to take opioid medications weeks after surgery, they need to have a conversation with their health care provider.
What about mind/body approaches? Do they help?
This is an important strategy. There are many studies that show that when you have chronic pain, there is a reprocessing in the brain that leads to negative feelings. This can be changed with daily meditation, and techniques such as biofeedback therapy and cognitive behavior therapy, which can reprocess the brain toward positive feelings and help to reduce pain. So, the mind/body connection is really strong. I personally speak to my patients about daily meditation, about guided imagery and about biofeedback. Those things play an important and solid role in decreasing anxiety and managing pain.
How did you choose this field in the first place?
It was expected of me, in a sense. I started in general surgery and when I switched over to anesthesiology, the vice chair and head of pain medicine was a doctor named Sebastian Thomas. I sort of became the heir apparent because my last name was Thomas! I resisted at first, then I realized that pain medicine worked well with the same things that attracted me to surgery.
On a more personal note, my sister has sickle cell anemia. I’m a first-generation physician, and I didn’t know about pain medicine at that time. Now taking care of patients with sickle cell is one of my passions. But I’ve also treated many other types of patients. One profound story involved a postpartum woman who came to the ER with painful “sciatica.” She said an obstetrician told her that this kind of pain is common when you have a baby and she’d have to live with it. That broke my heart. She had sacroiliac joint inflammation due to hormonal and physical changes that happen during pregnancy, and we treated it with an injection to the area, which relieved her pain. I’ve had many patients like this who cry when their pain goes away. It really humbles me. It’s what drives me.
Are you able to help patients with stress in every case?
We can almost always do something for you. If you are going to have surgery, you should never be afraid to talk to the anesthesiologist about anxiety and pain. At Yale Medicine, we are available to you at any time before your procedure. We have reviewed your chart, we have examined you, we know the potential areas of concerns, and we have a plan to prevent or to treat you and address any issues. You just need to have confidence in knowing we are here to help and protect you, and that we strive daily to maintain a high level of quality and safety. You are in the very best hands.