Perioperative communication practices of anesthesiologists: A need to introspect and change.

BACKGROUND: We conducted an audit of various communication practices during perioperative care among anesthesiology resident (R), faculties (F), and private practitioners (PP) in South India. We also documented the level of psycho-social support given to the patient and patient relatives and communication with the surgical colleagues during perioperative care.
METHODOLOGY: A 15-point questionnaire based on communication practices was distributed in three major anesthesiology conferences requesting anesthesiologists to answer and drop the forms in the drop box provided. Resident and consultant level anesthesiologists of various Medical Schools in South India and private practitioners were involved in the study. The answers were analyzed to find out the various communication practices in perioperative care.
RESULTS: The freelancing private practitioners (PP) were more communicative to patient and relatives especially in complicated cases (Q1 - 45.6%, Q2 - 97.8%, Q4 - 94.4%, Q8 - 98.9%, respectively) in comparison with institutionalized practitioners. The choice of anesthesia and discussion related to the advantages of one mode of anesthesia over other was the most neglected part of communication (R - 14.2%, F - 17.6%, and PP - 5.6%). The PP's (95.6%) are more concerned about intraoperative communication (R - 27.6%, F - 39.2%). The discussion of postoperative pain management plan with the surgeon is not given priority in the communication by postgraduates (7.9%) and teaching faculties (8.8%).
CONCLUSION: There is an urgent need to introspect and change the communication practices. We strongly recommend that communications skills should be introduced in anesthesiology resident curriculum.

INTRODUCTION

The patient safety and communication to provide psychological support are the prerequisites of a good perioperative care. Though patient safety is taken care properly, psychological support is the most neglected entity among anesthesiologists due to their busy work schedule. This has led to the lack of awareness of anesthesiology specialty among patients and their relatives.[1] The anesthesiologists are unfortunately considered as behind the screen physicians. The anesthesiologists' perioperative contact with the patient is for a brief period only. A good communication practice during this brief period increases trustworthy relationship with the patient. It is as important as we learn and apply the pharmacokinetics and pharmacodynamics of drugs perioperatively. Communication is not just a language. Anesthesiologists' interpersonal communication skills create an impression on surgical colleagues. Epstein and Hundert emphasized the basic communication skills as a standard of professional cognitive competences in clinical practice.[2]

Anesthesia care is divisible into three distinct phases: Preanesthesia evaluation, periprocedural management, and postanesthesia care. Each phase represents unique communication challenges. The anesthesiologists' dependability on the monitors during anesthesia administration make them to know their patients through raw data displayed on the monitor screen rather than considering them as human personality.[34] Are we really worried about patient comfort? Are we really providing total patient care to call ourselves as perioperative physicians? With this regard, we conducted an audit of various communication practices in perioperative care among anesthesiology residents, faculties, and private practitioners in different Medical Schools in South India. We also looked at the communication practices toward giving psycho-social support to the patient, their relatives, and the surgeon perioperatively.

METHODOLOGY

After obtaining Institutional Ethics Committee approval, resident, and consultant level anesthesiologists of various Medical Schools in South India and private practitioners were involved in the study. A 15-point questionnaire was devised based on common communications made among anesthesiologist, patient, patients' family, and surgeon. The preoperative communication was more focused on patients' self-perceptions and anxiety related to perioperative course and their family interacting with the anesthesiologists at the same time. The intra-operative period questionnaire was framed to focus on anesthesiologists' effort to make the patient comfortable in an unknown environment of operation theater, during induction and recovery from anesthesia. The postoperative period questions focus mainly on the communication of major perioperative concerns with the surgeon.

A total of 500 questionnaire forms were distributed in three major anesthesiology conferences requesting anesthesiologists to answer and drop the filled forms in a drop box at the conference venue. The anonymity of the study participants was maintained by not asking for personal details on the questionnaire. The answers were filled as “yes or no.” The answers to the questionnaire were analyzed to find out the various communication practices in perioperative care. The questionnaire is given in Table 1.

Table 1

Response to the questionnaire

RESULTS

A total of 500 questionnaire forms were distributed. Three hundred and nineteen participants responded to the survey (response rate 64%) which includes 127 postgraduate students (40%), 102 teaching institute faculty members (32%), and 90 free lancing private anesthesia practitioners (28%) [Figure 1]. The responses to the questionnaire are given in Table 1.

Figure 1

Distribution of anesthesiologists participated in the study

DISCUSSION

A professional communication among an anesthesiologist, patient, patients' family, and surgeon essentially contribute to patient safety, improved standard of perioperative care and satisfaction.[567] The perioperative period includes three distinct phases – Pre-, intra-, and post-operative periods. Each phase demands a specific communication practice unique to the patient satisfaction and safety.

Preoperative communication

The six goals of preanesthesia assessment are reduction of patient and family anxiety, assessment of physical and mental readiness for surgery, discussion and education with patient about anesthetic plan, likely complications, cost, and consent for procedure.[8] Our questionnaire looked into various aspects of preoperative patient anxiety and communication made by different anesthesiologist fraternity for the same. The presurgical procedure discussion with the surgeon regarding patient optimization, perioperative plan and likely perioperative complications, and the importance of communicating with patient relatives about surgical time is also emphasized.

We looked at the communication practices regarding patient related anxiety and providing psychological support to the family. The free lancing private practitioners (PP) were more communicative (Q1 - 45.6%, Q2 - 97.8%, Q4 - 94.4%, Q8 - 98.9%) in comparison with institutionalized practitioners (postgraduates and teaching faculties). The responsibility of a freelancer practitioner as a sole person to deal with the patient is much more than an institutionalized anesthesiologist such as faculties and postgraduates. The minimal interaction of a teaching faculty with the patient may be attributed to their busy working schedule and a shortage of man power. The solution could be practicing communication skills even in the busy schedule which comes automatically based on their training. Steinert et al. emphasized the importance of faculty development program designed to teach professionalism to academic anesthesiologists to bring out changes in their teaching practice of communication.[9] The majority of anesthesiologists in India are inclined to communication skill courses in medical education as suggested by Kumar et al.[10]

The preoperative questionnaire also looked at communication related the receptive and affective behavior of an anesthesiologist to inform and make a shared decision among the patient, patients' family, and the surgeon. The communication about offering choice of anesthesia to the patient and discussion related to the advantages of one mode of anesthesia over other was limited (P - 14.2%, F - 17.6%, and PP - 5.6%). We attribute this lack of communication by all types of practitioners due to lack of knowledge and power of communication skills. Understanding and applying the concept of “patient centered care” for a perioperative period should be the focus of today's medical practitioner. The Picker/Commonwealth Program for Patient-Centered Care (1988) highlighted the importance of understanding the disease, communicating the same to the patient according to the respective specialty.[11] Kopp and Shafer quoted the core sense of Hippocratic ethic on knowledge of communication as “knowledge confers power and power responsibility” with respect to a perioperative communication by anesthesiologists. The same principle should be applied in todays' anesthesiology teaching practice by the faculties.[12] Kindler et al. expressed the concerns about technical nature of preoperative visit not providing scope for patients to express psychological issues leading to increased anxiety.[13]

Intraoperative communication

The sudden change in the surrounding environment and the departure of loved ones before the surgery in preoperative waiting area and operation theater is an extremely distressing situation for a patient while waiting for his or her turn for surgery. Intraoperative communication involves perception and action of the anesthesiologist in understanding the requirement of comfort level needed to be offered to the patient at the time of induction. This includes even a simple communication of informing and seeking permission from the patient about attaching an electrocardiographic leads or blood pressure cuff. The private practitioners (PP - 95.6%) are appearing to be more concerned about doing this simple communicative measure with respect to academic institute practitioners (P - 27.6%, F - 39.2%). A small talk by an anesthesiologist describing the sensation or unfamiliar sights of the operation theater can provide emotional support. A communication done with empathy can act as a vocal anxiolytic.[7] The private practitioners (PP - 100%) provide better communication regarding the end of surgery with the patients' family in comparison with the teaching faculties (8.8%). This could be attributed to the teaching institute anesthesiologists involved in anesthetizing cases in succession.

Postoperative communication

The questionnaire exclusively involved assessment of four simple but essential communications among anesthesiologist and surgeon about postoperative fluid management, analgesia, glycemic control and hemodynamic management. This technical communication exposes the necessity of a “professional behavior” to be established between an anesthesiologist and a surgeon. A statement by one care taker may make sense to him or her but can be misinterpreted as nonsense by the other and can create harmful environment and worst perioperative outcome, where the best patient care is the end point. The nonverbal communication practice also plays an equal share as verbal communication with surgeons.[14] Kumar et al. in their questionnaire based study state that 95.5% anesthesiologists felt that good communication practices between surgeon and anesthesiologist can improve perioperative care.[10]

The private practitioners were more readily available to agree to communicate with surgeons on these four perioperative issues (Q13 - 100%, Q14 - 97.8%, and Q15 - 94.4%). We attribute this to the exclusive practice by private anesthesiologists in India working in a surgical set up run by surgeons. The communication with the surgeon about postoperative analgesia is still not a priority by postgraduates (7.9%) and teaching faculties (8.8%). This can be attributed due to the conflict in choices of postoperative pain management modalities and the individual preferences by the surgeons and anesthesiologists in a teaching institute.

CONCLUSION

Anesthesiologists communicate with technical language, and their actions remained mysterious and frightening to the patient. Since the interaction of an anesthesiologist with conscious patients is for a brief period, communication should be clear and respectful. The anesthesiology fraternity despite knowing the poorly practiced communication in perioperative care, efforts are not taken to teach communication skills and empathy to anesthesia residents. The same practice is translated when they become independent anesthesiologists. There is urgent need to introspect and change the communication practices. Our study results should embark a perioperative communication strategy in teaching hospitals and related research in the same field in future. We strongly recommend that communications skills should be introduced in anesthesiology resident curriculum.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest