Dr. David B. Adams – Psychological Blog

Psychology of Illness, Pain, Anxiety and Depression


Unmet Expectations:  “He feels that surgery did not go as planned, that the outcome was poor, yet we have the surgical notes which indicate that it was a successful lumbar fusion. Why the discrepancy?”

“There can be a vast difference between OBJECTIVE surgical outcome and the patient’s SUBJECTIVE (emotional) response to that outcome.

From an objective standpoint, a surgery may be quite successful. The problem, perhaps a herniated disc, was effectively addressed, and the spine is now fused and stable.  The patient’s needs for relief from all pain may well be unmet.

From a subjective standpoint, however, the patient may not have been prepared to see surgery as successful unless there was a complete resolution of all complaints including pain.

Despite the number of forms completed prior to surgery (interestingly, while the authorization and other forms may contain important information, patients do not read the forms, blindly sign them, and assume whoever is treating them will tell them what they truly need to know).

Very trusting. In order to relinquish control of our lives, we must invest trust in s/he to whom we are assigning that control. That clinician, in turn, may have assigned patient education to a health care extender who may, or may not, have an abundance of training and information about treatment and/or complications. There is a break in the pipeline of information that should reach the patient and patient’s needs are unmet.

In reality, in many cases, the extent of what needs to be done, what can be done, and the highest probable outcome is not completely know until after treatment begins or a procedure is completed.

(Incidentally, this is no more true than in the case of psychological care. Insurers will ask “what needs to be done, and how long will it take?” Very difficult questions since patients reveal information and plans very cautiously. Psychological care can be ever changing sets of data as the patient, released as the patient becomes more comfortable).

Regardless if the concern is surgery or psychotherapy, a consenting patient is not always a well-informed, appropriately educated, patient.

It may be argued that telling patients the whole true merely creates anxiety and will cause them to focus upon the negative outcome components. That argument states that a patient with high positive expectancies is a more motivated, enthusiastic and positive individual. The belief is that if the patient is optimistic, outcome measures will be improved.

However, the true risk is the patient who has unmet expectancies. The resultant disappointed, frustrated, angry and fearful individual then represents our greatest management concern.

Psychological care should come into play when the patient believes that surgical outcome is disappointing and even frightening. If that alarm is not addressed psychologically when it emerges, recovery is impeded.

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