March 1, 2013
Volume 77, Number 3
Observations: Spreading the Word
N. Martin Giesecke, M.D. Editor, ASA NEWSLETTER
There are scores, if not hundreds, of aphorisms about communication. “It’s not what is said, it’s what is heard.” “It’s not what is said, it’s how one says it.” “The most important part of a conversation is hearing what is not said.” “The root of all problems is a problem with communication.” Each of these adages rings a bit true. It is interesting that, as much as we and our anesthesia care team members communicate, we aren’t so much better at it.
To illustrate this issue, let’s look at just a couple of ways we communicate with our patients. Everything we discuss hopefully takes place during a routine preoperative anesthetic evaluation. We’ll mention the use of a computer during this visit. Then we’ll discuss obtaining informed consent. In each area, some pitfalls of the manner in which we articulate information to the patient will be presented. For those of you who have been around the block a few times, nothing said here will be new. For some of the newer physicians, maybe something that follows will strike a chord.
There are a couple of reasons we perform preanesthetic evaluations. Obviously, we are there to gain historical and physical information that will
allow us to prescribe the best, safest anesthetic for any given patient. A second, equally important aspect of the preoperative visit is to allay the patient’s anxiety about receiving anesthesia. Several studies have documented the positive benefit on anxiolysis that results from a good preanesthetic visit.1-4
Consider the following situation, typical of those sites where an electronic medical record is in use. The anesthesiologist enters the patient’s room, identifies him or herself, then immediately turns their back to the patient while asking questions and typing responses into a computer terminal. Some younger patients, who are used to the relative lack of face-to-face contact brought about by electronic communication, will not blink an eye at this behavior. However, many older patients are likely to wonder what happened to this physician’s interpersonal skills. They will think, “who comes to talk to me and does not sit, facing me, while paying attention to how I am reacting?” It is still in my value system that at that moment in time, the patient is the most important person in the room. If there is a chair in the room, I will sit in it, facing the patient. It is my intention that patients realize I have plenty of time to talk to them, even if I am rushed. Often, while listening to their answers, I will take their hand in mine, providing a calming touch even while palpating the pulse. If I need to jot something down, I will do so, but only for the length of time it takes to write that note. A computer would only be utilized in my preanesthetic visit if it was small enough to be obscure to the patient, and was arranged in such a way that it would not interfere with my face-to-face attitude with the patient. These are some of the things I hope to impart to residents, medical students and even nurse anesthetists who are in the room with me during the preop visit.
What about gaining informed consent? For some, it seems this part of the process is merely showing the patient a piece of paper and telling them to sign by the X, if they want an anesthetic. This act, and that of not fully explaining the course of the anesthetic, is an example of poor communication. Of course, many states, and The Joint Commission, now have regulations pertaining to the process of informed consent. In a nutshell, informed consent should contain a presentation of the patient’s anesthetic options, a discussion of how each of those anesthetics would proceed, mention of the risks of the anesthetic procedures, and then a discussion about what is achieved by having the patient sign the consent form.
Though some patients may be concerned that they are “signing their life away” by placing their signature on the consent form, that is far from the case. It is true that in the 14th century, doctors in Italy, France and the Middle East requested that patients sign a document that would hold them harmless from any future adverse occurrence following a procedure.5-7 Modern-day consent forms began as a way to provide the patient with some autonomy in the process of medical care. The form was designed to give them information about the risks of their procedure, whether surgical or anesthetic, allowing them to make the conscious choice of whether or not to proceed. Essentially, this is where we still stand. The actual form is a written documentation that we provided the patient with the information they required to make the decision to proceed (or not). Thus, informed consent is not just the document to which the patient affixes his or her signature. Rather, it is the entire process described in the previous paragraph.
We need to remember that each of us still likely practices in a manner that relies on the patient-physician relationship. We need to realize that – while in the greater sense of communication, ASA will follow a communications plan in speaking to the public, legislators and regulators of medical care – we still need to provide appropriate one-on-one communication with each of our patients. Our integrity depends on this.
1. Magalhães Filho LL, Segurado A, Marcolino JA, Mathias LA. Impact of preanesthetic evaluation on anxiety and depression in cancer patients undergoing surgery. Rev Bras Anestesiol. 2006;56(2):126-136.
2. Kopp VJ, Shafer A. Anesthesiologists and perioperative communications. Anesthesiology. 2000;93(2):548-555.
3. Egbert LD, Battit G, Turndorf H, Beecher HK. The value of the preoperative visit by an anesthetist. A study of doctor-patient rapport. JAMA. 1963;185(7):553-555.
4. Leigh JM, Walker J, Janaganathan P. Effect of preoperative anaesthetic visit on anxiety. Br Med J. 1977;2(6093):987-989.
5. Ajlouni KM. History of informed medical consent. Lancet. 1995;346(8980):980.
6. Rothman DJ. History of informed medical consent. Lancet. 1995;346(8990):1633.
7. Baron JH. History of informed medical consent. Lancet. 1996;347(8998):410.