Gabriel M. Gurman, MD
Many years ago, during my residency in anaesthesia I heard one of my pals saying that he chose this speciality because he was “not supposed to waste his time having a conversation with his patients:” we keep them asleep, we wake them up and leave them when they are still under the influence of our drugs and they do not talk and do not ask questions…..”.
Needless to say, he was wrong, but this thinking about us was (and still is) shared by many of our peers, surgeons and internal medicine specialists, for instance.
This opinion is, as simple as that, a product of ignorance.
We do communicate with the patient, during the various stages of our involvement in his/her treatment.
This is a duty, a proven way to create a fruitful situation in which both sides gain, one confidence, the other one precious information.
Paget et al (1) wrote some 10 years ago: “professional ethics in health care stress the intrinsic importance of respectful and effective communication as a core aspect of informed consent and a trusting relationship”.
Let’s start with the preoperative stage.
Klafka and Roizen (2) wrote: “the main communication activity of the anesthesiologist takes place in the pre-anaesthesia period”, and specified the list of anaesthesiologist’s tasks: assess health, devise a mutually accepted anaesthesia plan, reduce patient’s anxiety, plan postoperative care and pain treatment, and finally obtain the informed consent.
So, we meet the surgical patient in the outpatient anaesthesia clinic. Such clinics exist and function in most of our hospitals. Patients are invited to meet an anaesthesiologist weeks or days before elective surgery, and this is the proper time to obtain the most pertinent data regarding the patient’s clinical condition. We draw conclusions, decide upon further investigations and discuss with the patient the details of the anaesthetic procedure she/he is supposed to have in the near future.
Yentis (3)wrote: “Information about anaesthesia and its associated risks should be provided to patients as early as possible, preferably in the form of an evidence‐based online resource or leaflet that the patient can keep for future reference. Those undergoing elective surgery should be provided with information before admission, preferably at pre‐assessment or at the time of booking, but the duty remains on the anaesthetist to ensure that the information is understood”.
Some years ago we wrote (4) about the obligation of the anaesthesiologist to discuss with his/her patient a possibility of accidental awareness during general anaesthesia (AGA):” It is the authors belief that a preoperative discussion on AGA might substantially reduce the magnitude of repercussions of AGA among high-risk patients to develop this anesthetic complication”.
Apparently, this is an easy task, but the reality shows not only once that sometimes it would be difficult to fulfil it. The patient today is completely different from that one I used to meet during my residency, some 60 years ago. He/she knows a lot of things since pertinent information could be easily achieved by looking into the internet sources, so sometimes it can be difficult to answer his/her questions on the spot.
But more than this, there are some obstacles in the way of performing this duty.
Let me be clear: not all of us are born with the gift of communication with another human being, especially with a patient. The approach could be cold and hard, too distant to create an atmosphere of mutual trust.
Unfortunately, the art of conversation or of communication with the patient is only very seldom taught in our medical schools and during the years of residency in anaesthesia. Too often we forget that each patient is different from the next and that we do not simply prepare an anaesthetised part of the body that has to have an operation, we have in front of us a patient.
Today, in a reality strongly influenced by the “production pressure” we do not have enough time for each patient. We spent too many minutes in front of the computer, looking for data and filling out paperwork, and the next patient is already waiting in the reception room.
Sometimes it creates an impossible situation.
Wright (5) published the story of a successful primary care doctor who decided to close her practice. Her explanation: “The electronic health record took time away from my patients, added hours of clerical work to each day and supplanted my clinical judgment with technology in health care”.
Next comes the end of the anaesthetic and surgical procedure. Much too often we forget that it is our duty to inform the family in the waiting room about the outcome of the anaesthesia technique and also answer the patient’s questions in the recovery room.
But much more important is the postoperative visit. I have bad news in this direction: some unpublished data show that almost 90% of our patients do not benefit from his/her anaesthesiologist’s visit in the first 24 hours after surgery.
This reality does contribute to the fact that the anaesthesiologist remains too often an anonymous member of the surgical team, so one cannot be too surprised by the fact that most of our patients remember well the name of their surgeon and have no idea who anaesthetised them!
And what about the patient treated in an intensive care unit (ICU)?
He/she is most of the time unconscious, surrounded by tubes and machines, in a clinical condition that might change suddenly, and the family outside the unit is confused and in permanent stress due to the fact that their relative is obviously at risk of clinical deterioration.
We are supposed to find the time to discuss the situation with the family.
Lamas (6) described it: “We examine him every day-the elderly patient, intubated, sedated, with a bewildered wife at his side. We should sit down with his wife before we ask her to make hard decisions about her husband’s care, but the unit is so busy that we find ourselves scurrying by, pausing only to offer rushed updates that do not allow for the exchange of meaningful information”.
So, how could we reduce the magnitude of panic and stress?
I do hope that I am not surprising our readers telling them that in the units I used to work until my retirement the rule was that the physician in charge of the patients met every single day with the families, reporting the patients’ situation and answering their questions.
This kind of meeting creates an important role for the social worker, who is supposed to get data about the family’s problems in relation to the patient’s condition and try to assist them anytime is possible.
One of the most important questions refers to the obligation, to tell the truth, and not to hide any item which could influence the patient’s decision or dissipate the family’s confusion.
In the mid-19th century, the American Medical Association’s code of ethics stated that physicians had a “sacred duty” to “avoid all things which have a tendency to discourage the patient and depress his spirits”.
Things are not completely different these days. Yasgur (7) dealt with this important aspect of communication with the patient. More than 24,000 physicians answered this question in Medscape’s 2012 Ethics Report. Many were adamant about maintaining honesty at all costs; others felt that opening up about insignificant oversights would cause patient distress for no useful reason. Some asked, “Why to open a can of worms?” Almost two-thirds of the respondents (63%) said that it was never acceptable to cover up or avoid revealing a mistake, but 16% said that it was, and 21% said that it depends on the situation.
But Smith (8) wrote: “Patients need truthful information in order to make good choices. If patients are offered truthful information-repeatedly- on what is going to happen to them, they can choose wisely.” The same applies to the family of a patient treated in an ICU.
It seems that the obligation of efficiently communicating with the patient is not only a moral and ethical one but also helps the patient overcome a situation that could jeopardise his/her life. Moira and Stewart (9) reported that many studies demonstrated a correlation between effective physician-patient communication and improved patient health outcome.
It also improves the physician’s self-esteem and strengthens his/her commitment toward the profession.
In her book, “The human side of medicine” (10), Sawett wrote:” Of all the letters of appreciation I received from patients during my years of practice, not one thanked me for ‘that great CT scan, ‘that great blood test,’ or ‘that great surgical referral.’ Rather, they expressed gratitude for my listening, being present, helping them through difficult times, providing emotional support, and enabling them to understand what was going on and how to deal with it”.
During my long professional career, I learned a lot from others, with whom I used to work, and from those who put in writing their thoughts and experience related to the process of communication with the patient.
Here is how I summarise the main lessons “to take home”:
- Know your patient clinical and background data
- Express empathy
- Find a common language
- Maintain eye contact
- Introduce yourself and everybody who accompanies you
- Have a friendly and open expression
- Respond briefly and clearly
- Listen, listen, but stop futile explanations
- Ask only pertinent questions
- Avoid confrontation
And, please, do not forget the definition of a stethoscope: an instrument that has a human being on each side.
- Paget L, Han P, Nedza S et al. Institute of Medicine of the National Academies June 2011
- Klfta JM, Roizen MF Anesth Analg 1996;83:1314
- Yentis SM. Anaesthesia 2017;72:93
- Gurman G. M., Weksler N., Schily M. Minerva Anestesiologica 2002 ;68:90
- Wright AA, Katz IT. New Engl J Med 2018;378,309
- Lamas D. New engl J Med 2018;378:2431
- Yasgur BS, www.medscape.com December 6 2012
- Smith TJ, New Engl J Med 2012;367:17
- Moira A. Stewart, Can Med Assoc J 1995; 152:1423
- Savett LA. The human side of Medicine, 2002, Westport