"Dear Patient." A Second Open Letter to My Preoperative Patients.

Nobody cares anymore.

What a liberating thought. What an alarming reality. It all depends on your stance and philosophy of life.

Should we be worried? Perhaps. But why? By the time this post goes live, the 2016 US election will be history. And it will be hard for any person alive today, (born after 1914), to recall a campaign where contempt and narcissism by two future leaders have been on a more public and global display. A campaign where ethics and integrity have become so depleted of actual meaning. And yet we blindly follow them—vote for them. Why is that?

Is it because we have lost our moral compass? Are we choosing to be blatantly ignorant? Or is it as simple as “we really don’t care anymore?”

Is it, therefore, any news to realize that not your doctor, nor your patient, care anymore? Oh, on the surface we do. We perform all kinds of PR-tomfoolery—creating the illusion of compassion and integrity and effectiveness. But deeper down where it matters, where it asks from us—we don’t. Because caring is hard work. It demands much. It requires commitment, ethics, it requires doing uncomfortable, unpopular, sometimes even painful things—and, on a daily basis.

When you go for elective surgery it is crucial to understand and realize how much you can do to enhance your experience. Yes, you can have a good experience! (See the concept of medicine’s Triple Aim.) One of the biggest favors you can do for yourself (and your loved ones), is to realize and appreciate how your health and welfare is a shared responsibility between you and your doctor(s) and healthcare providers. It is a two-way street. It is not a drive-through fast food scenario, where you phone in, rush through, grab your items in a brown paper bag and off you go. Life, and especially your health, doesn’t work that way. Sorry.

We can empower you, inform you, guide you—but you make the ultimate choice. You decide yes or no. You can read more about this in a previous post, “an open letter to my preoperative patient.”

Rest assured—medicine (and more specifically surgery and anesthesia) in 2016, can pull most anybody through alive—irrespective of your age or health status. (We have the expertise, technology, and pharmaceuticals. But at what cost? And I am not only referring to the dollar value. Don’t forget personal and societal cost as well as the decimation of the quality of life of individuals.) The good news is you will not die—very unlikely. But how well you will do, that is an entirely different matter. (And this is where the escalating healthcare costs come in—rehabilitation AFTER surgery is ten times more expensive than prehabilitation BEFORE surgery.)

Prehabilitation and preoperative optimization are unpopular and slow to catch on. Why?

There are many reasons:

• Many feel it is unnecessary. (We’ve always been doing things the old way.)
• We are caught up in ‘conveyer-belt’ medicine
• Physicians are remunerated to perform procedures (operations), to prescribe medications, and not necessarily to get you healthier. Fortunately – there is an overlap.
• As physicians, it is difficult to distance ourselves from medical tradition and dogma. Even evidence-based medicine has its limitations—it is more biased than we would like to acknowledge.
• We live and thrive in a society of “instant gratification.” Prehab is a bit of hard work.
• Going for surgery is viewed and promoted by many as the equivalent of going for a hamburger and soft drink at a drive-through restaurant. No big deal. This is a false picture.
• We fail to grasp this unique opportunity to get our lives and health in order.
• We cling to the outdated belief, “my health is only my doctor’s responsibility.”
• We (physicians and patients) are reluctant to realize prehab is inexpensive but effective. It is a fraction of the costs entailed when we have to play catch-up after surgery when patients don’t do well.

Yes, we have come a long way with modern 21st-century medicine—with minimal-invasive surgeries and interventions and newer medications, enabling us to operate on the extremes of ages and severely ill individuals and pull them through.

Yet, illness, the development of chronic diseases, and going for elective surgery is a time for reflection. Often not by choice. We are all living our lives—busy lives. Lifestyle-related disease make up 60-80% plus of the illnesses we encounter in our adult population. The good news about this is that through inexpensive, but effective “optimization” we can shift the needle out of the red zone, the danger zone. It isn’t all bad news.

A growing proportion of our population is deconditioned and continue to become so, whether we are 25, 55, 85 or 95. (We are becoming more and more functionally unfit, have a poor nutritional status and are emotionally fragile, and not bolstered.)

What does triple-intervention optimization (prehab) involve? (During the 3 – 4-week preoperative period):

• Improve functional fitness (The aim is not weight loss. Irrespective of age—improve aerobic capacity and build and strengthen muscle. Learn the basics of aerobic and resistance exercises.) An elastic resistance band costs < $ 10.00
• Improve nutritional status. Decrease or quit alcohol and smoking. A Mediterranean-type diet recommended. A container of whey protein will go a long way. (< $45.00)
• Emotional bolstering. Toughening up emotionally prior to surgery and neo-adjuvant chemotherapy has a direct impact on morbidity and mortality. Antidepressant and anxiolytic medications are not the only options. Physical fitness, especially group classes, and psychotherapy can have great benefit.

Why should we bother utilizing this time between the day you saw the surgeon and the actual date of your elective surgery?

• It makes medical sense. (Forget the drive-through lane, think, preparing like a soldier for battle – even a small battle.)
• It empowers – you become involved in your own care – it gives a sense of control in your own care.
• It will prepare you physically and physiologically for the trauma of surgery
• It will decrease your complications during and after surgery
• You will recover faster and heal better
• It will help you establish a lifelong healthier lifestyle
• If you continue with the principles of the triple intervention, (for the remainder of your life), you will also be able to beat Dementia

Dear Patient, (or dear reader), the bottom line is this: we don’t want you to merely settle for surviving the surgery, but to go beyond and thrive! (Keep following these principles for the rest of your life.)

Remember, the triple intervention optimization is merely the beginning. It is to get you started on a road to better health. You do not have to suffer from lifestyle associated chronic disease! Don’t stop with this basic program. Go on. Learn more. Get stronger. Get fitter – irrespective of your age. You can excel at age 25, 55, 85 and 95!

You will find, if you prepare better, you will also do better. And the biggest side effect of all—you will feel better. Everyday.

Dear patient, we care.

Thank you for reading!

References:

1. Post: How worried should you be? Your doctor doesn’t care (anymore.) March 29, 2016 
2. Chong SW et al. The relationship between study findings and publication outcomes in anesthesia research. CJA; 2016 Jun; 63(6):682-90.
3. Carli F, Scheede-Bergdahl C. Prehabilitation to Enhance Perioperative Care. Anesthesiology Clin 33 (2015) 17 -33

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