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The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.

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May 1, 2013 Volume 77, Number 5
Communication in Health Care Myriam P. Garzon, M.D. Committee on Patient Safety and Education


We often speak of the health care “team.” Where would we be without the most important part of the team – the patient?
As anesthesiologists, we are in a unique position to help our patients be part of the equation and be collaborators in their health care instead of passive participants. To be true patient advocates, we need to be able to communicate effectively with our patients. Much of communication is listening; if you listen to your patients, they will tell you what’s wrong and be empowered in their health care choices. Who hasn’t heard the new catch phrase, “patient-centered care?” Achieving patient-centered care requires that we educate our patients so they can articulate their thoughts, concerns and fears.3 Communication is an essential pathway to patient-centered medicine and building the collaborative relationships that we need to incorporate our patients into the “treating team.” If you’ve ever played the childhood game of “telephone,” you can understand what happens when communication is not direct, clear and concise, so taking the time to talk to our patients before and after anesthesia care is critical. Dimensions of patient-centric care according to the Picker Institute3 are:

1. Respect for patients’ values, preferences and expressed needs
2. Information and education
3. Access to care
4. Emotional support to relieve fear and anxiety
5. Involvement of family and friends
6. Continuity and secure transition between health care settings
7. Physical comfort
8. Coordination of care.

We can see from this list that patient-centric care hinges on communication between the provider and the patient or family. Only access to care and physical comfort are not directly impacted by communication, and even they can be influenced by improved communication between physician and patient. These elements also fit into the concept of the anesthesiologist as the leader of the Perioperative Surgical HomeTM concept of care.

We encounter distinctive challenges impeding effective communication. A major challenge is that of time, practicing in an environment where production pressure often strips us of the luxury our surgical and medical colleagues have to develop long-standing relationships with our patients. In spite of production pressure, how do we establish trust? How do we create that positive first impression? During our often brief, hurried “morning of” preanesthetic encounters, we must use all our senses. Keeping in mind that 80 percent of communication is non-verbal, we need to consider these cues when interacting with our patients and their families. Our patients are being asked to rely on and entrust their lives to an individual whom they’ve never met before and who has minimal knowledge of their personality, fears and concerns. Patients often are unaware of our medical training and don’t even recognize that we are physicians!

In the brief amount of time for assessing the patient and developing the anesthesia plan, communication and interpersonal skills are vital. Taking a history is straightforward, but effective communication involves not only spoken but unspoken language: visual, body language, attentiveness and appearance. To be truly effective communicators, we must rely on our interpersonal skills, sensitivity and rapport as well as our emotional intelligence (EI).

Patients feel vulnerable; they seek understanding, reassurance and empathy, as they are surrendering control of themselves to strangers. While some fear “waking up” during their procedure, others may fear never waking up again.1 An anesthesiologist, through his or her communication style, interpersonal skills and EI, should be able to exert an anxiolytic effect rather than relying solely on the use of pharmacological agents. This interaction can hit the pocketbook, as patient satisfaction scores are being brought into “value-based purchasing.”

The establishment of the Perioperative Surgical HomeTM places us in a position to develop relationships and offers a platform to educate our patients. We have the opportunity to teach them why it is so important for them to remain NPO, how smoking cessation improves their healing and outcomes, and how as anesthesiologists we coordinate preoperative evaluations and risk assessments. This is our opportunity to be recognized not only as physician consultants but as partners in their health care team. Imparting increased feelings of satisfaction and trust between physicians and patients may boost patient safety if they feel more comfortable disclosing conditions4 or following instructions. Keeping communication channels open allows for exchange of information, which also is proven to decrease malpractice suits. Poor communication skills may actually increase litigious actions.

As the health care system changes, our role as anesthesiologists is expanding by choice and necessity as a function of the “surgical home” model, to that of “perioperative” physicians. We are in a unique position to be the “hub” of care, providing a necessary role in patient risk assessment, stratification and improved outcomes. Let’s educate our patients; we can teach them what questions to ask us as well as our colleagues. During the preop assessment and visit, we should explain the procedure, what they can expect from the anesthesia perspective and who will be providing care (solo provider or physician-led care team). But more than this, we need to listen to and anticipate their questions in order to allay any fears or misconceptions they may have about anesthesia. Informed patients are truly incorporated into the team.

The art of anesthesia is governed by professionalism. While it is possible to set “putting patients to sleep and waking them up” as our only goals1 and simply evade communication, our commitment to professionalism defines us as persons capable of “speaking forth,” which is the meaning of professionalism.2

We have many tools at our disposal for communication when face-to-face visits are not possible. With technology, communication has exploded; the Internet now allows communication among all the parties regardless of physical location, and the use of electronic health records (EHR) allows for communication among all the participants of the patient’s care team, including the patient (with the federal mandate that patients have access to their EHR), enhancing communication within the health care system.2 This communication forges partnerships providing for convenience, accessibility, accountability, accuracy and providing evidence-based support for decision-making, potentially improving efficiency and quality of care.

In 2012, 81 percent of the U.S. population used the Internet. Many adults report a desire to communicate with their physicians electronically. The growing trend toward digital communication opens up possibilities such as using video calls for preop assessments, email for notifications about appointments or test results and communications. Tertiary centers may use e-consults for guidance as to preparation for anesthesia when coordinating care from rural or distant referral sites. Patient satisfaction or health questionnaires can also be done digitally. The next preop evaluation and satisfaction survey may be done from the patient’s smartphone.

As anesthesiologists, we need to embrace the medical tradition of communication with our patients as well as new technologies in a changing world. We should use the tools at our disposal, both face-to-face and digital, to improve communication and patient education, thereby engaging patients in their health care to improve satisfaction, compliance and outcomes.



Myriam P. Garzon, M.D. is Chief of Anesthesiology at Orlando VA Medical Center; Volunteer Assistant Professor of Anesthesiology, University of Miami; Volunteer Assistant Professor of Anesthesiology, University of Central Florida Medical School, Orlando.

References:
1. Kopp VJ, Shafer A. Anesthesiologists and perioperative communication. Anesthesiology. 2000;93(2):548-555.
2. Mann MY, Lloyd-Puryear MA, Linzer D. Enhancing communication in the 21st century. Pediatrics. 2006;117(5 pt 2):S315-S319.
3. Breen GM, Wan TT, Zhang NJ, Marathe SS, Seblega BK, Paek SC. Improving doctor-patient communication: examining innovative modalities vis-à-vis effective patient-centric care management technology. J Med Sys. 2009;33(2):155-162.
4. Duffy FD, Gordon GH, Whelan G, et al.; Participants in the American Academy on Physician and Patient’s Conference on Education and Evaluation of Competence in Communication and Interpersonal Skills. Assessing competence in communication and interpersonal skills: the Kalamazoo II report. Acad Med. 2004;79(6):495-507.