A new standard of care: Why this Texas practice evaluates mental health ahead of surgery

The post-surgery process often involves some physical pain, but the related mental effects tend to be treated as an afterthought, if not overlooked entirely.

The PREOP Center, based in San Antonio, is aiming to change that. Clinicians at PREOP, which stands for Patient Risk Evaluation and Optimization Program, evaluate patients before surgery, identify factors that may impact recovery, and create a post-op pain plan for each patient.

Preventing tragedy

On June 1 a Tulsa, Okla., spine patient who had complained of postoperative pain shot and killed two orthopedic surgeons, including the one who operated on his back less than two weeks prior. Two others were killed in the attack.

"It sounds like he didn't get the answers he wanted, or he didn't feel like he was being heard for the pain he was in," PREOP Center founder and spine surgeon Adam Bruggeman, MD, told Becker's. "Undoubtedly, he probably had some significant coexisting depression or anxiety, or something underlying all of this."

Depression and physical pain are connected and feed into each other. A 2005 study published in Psychiatry found those with major depression were four times more likely to report chronic pain than others, and those with chronic pain were four times more likely to have depression or anxiety.

"If your brain is busy dealing with marriage issues, children issues, financial issues, anxiety, depression, you don't have the capacity to say, 'I'm getting pain from my knee, but I'm going to get better,'" Dr. Bruggeman said.

Surgery can both address and cause pain, but patients are often left by themselves to figure out what mental healthcare they need and where to get it.

"This definitely fills that gap," PREOP Center supervising physician and retired anesthesiologist Bryan Clifton, MD, told Becker's.

Before surgery, clinicians at the center walk patients through their expectations of pain, whether their living situation presents unique obstacles, and what their support system at home looks like. They also screen patients for mental health issues that could affect the recovery process.

Heading off those potential issues ahead of time can pay dividends later, Dr. Bruggeman said. It could even save lives.

"If we can even prevent one of those [shootings], then it's paid off," Dr. Clifton said.

Tackling the opioid problem

Prescribing and monitoring pain medication is a big part of the PREOP Center's scope of practice. The presurgical screening process includes a patient's history with opioids, and when approved, patients are given a prescription before surgery. That way, they don't have to worry about going without relief during the most painful period of recovery: the first 48 hours.

"Our goal is to get patients to whatever their baseline was before surgery, and if they were already on narcotics before surgery, to get them off of narcotics," Dr. Clifton said.

To do that, the PREOP Center will follow a patient for up to three months after surgery.

The center's clinicians only prescribe postoperative pain medication one week at a time. That strategy hits two aims: it keeps patients from being flooded with opioids they don't need, and it plays a benevolent psychological trick.

"It signals to the patient that this isn't going to be that bad of a procedure," Dr. Bruggeman said. "We're preparing the patient subconsciously to go, 'This really isn't going to be too bad. I'm expected to get better in a short period of time.'"

Taking the burden off of surgeons

Most ASCs don't have a preadmission testing department, which means surgeons are forced to find resources in the community and cobble together what's needed. When done for every patient, that adds up to a lot of extra work.

"As a surgeon, I like things to be consistent," Dr. Bruggeman said. "I like it done the same way every time, so when you say, 'Hey, you have to do preoperative clearances with 50 different primary care doctors in town, and each one uses different labs, and some of them send the labs to the surgery center, some send them to us and some don't send them to anybody,' all those inconsistencies slow the system down."

It's not the only bottleneck, either. Surgeons are frequently relied on to write their patients' pain prescriptions — usually an unwanted responsibility, and one that takes time away from the operating room. Often, surgeons end up writing prescriptions the day of the procedure, which can make for a stressful postoperative time crunch for patients trying to get them filled.

"What if the pharmacy is closed?" Dr. Clifton said. "What if they don't have that particular medication in stock that day? What, we're supposed to send the patient home with no pain medicine?"

Drs. Bruggeman and Clifton said they think the PREOP Center's model offers a better way: They take all the narcotics out of the surgeon's hands.

"[Surgeons] love it, because they don't want to have to write the narcotics," Dr. Clifton said. "They don't want the phone call at two in the morning when they're on call. We take care of all of that."

'This needs to be the standard of care'

Healthcare in the U.S. in some ways is in a state of growth and transition, especially with mental health. There is a broad push to increase funding and bolster services generally, but the industry is still figuring out how and where it fits clinically and economically.

The PREOP Center may have figured out an important piece of the puzzle.

"A lot of insurance companies now are strongly suggesting mental health clearances [before surgery]," Dr. Clifton said.

The center has made believers out of at least some of its patients. Markay Garcia, one of the practice's clinicians, told Becker's not only has she seen dramatic results, but that patients are seeing the value too.

In one example, she had what some might call a breakthrough with a recent PREOP Center patient who was embarrassed to talk about his depression.

"I always make an effort for those patients to tell them, 'It's okay, you're not alone. We have counseling here, I'm here, we're here to help you,'" Ms. Garcia said. "When I told him that he wasn't alone, he looked at me, he's like, 'No one's ever said those words to me.'" 

For the practice's clinicians, the clearest argument in support of their model is the benefit it provides to a wide range of industry stakeholders. 

"I think it really needs to be replicated throughout the healthcare system, and it needs to be covered by health insurance," Dr. Bruggeman said. "It's the right thing to do."

"This needs to be the standard of care," Dr. Clifton said.

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