Transcript Communication for Anesthesiologists

The Anaesthesiologist as a
Patient Advocate
Eric Hodgson
Inkosi Albert Luthuli Central Hospital &
Nelson R Mandela Medical School
eThekwini-Durban, KZN, SOUTH AFRICA
www.criticalcare2013.com
Declaration
 Advisory boards
 Bayer, Boehringer-Ingleheim,
Fresenius Kabi, Sanofi-Aventis,
MSD, Pfizer
 Speaker honoraria
 Abbott, Adcock-Ingram, Biopure
SA, Astra-Zeneca, Roche, Pfizer,
Fresenius Kabi, GSK, Janssen-Cilag,
Aspen, Novartis, Nestle, Edwards,
Thebe
 Travel & accommadotion: F K
Lecture Plan
• Patient communication
• Advocacy role
– Preop
– Intraop
– Postop
• Conclusion
Medical Career Selection
Anaesthesiology as a career choice
Andrew F. Smith MRCVFRCA, Make P. Shelly FRCA
CAN J ANESTH 1999 / 46: 11 / pp 1082-1088
• Newly-qualified but unpersonable doctors
• Anesthesiology: no direct patient contact
– BUT: Chronic Pain, ICU, Need for payment
• Serve both surgeons and patients
– What do patients know about anaesthetists?
Anaesthesiologists & Patients
2000
Anaesthesiologists & Patients
Brazil
Braz J Anaesth 2011: 720-7
13
52
9
26
Anaesthesiologists & Patients
Perioperative Communication
How do Anaesthesiologists do?
•Results: Overall dissatisfaction – 3 Paeds 1 Adult
•20x variation between individuals
Perioperative Communication
Challenges for Anaesthesiologists
• Premed visit
– Many patients
Little time
– Easy to appear rushed / uncaring
• Potential solutions
– Pre-Anaesthetic leaflet
• Esp. Billing in Private
– Online Premed (ASA Refresher)
• Pre-anaesthetic clinic
– All comers vs. Screened?
– Cost
• Patient & Anaesthesiologist
YES
Perioperative Communication
How can Anaesthesiologists do better?
• Anesthesiologists need to communicate with:
– Patients / Families
Peers Health Team
• Subconscious assessment
– Thin-slicing
10 000 hours
• Principles
– Reflective listening Observing Accepting
– Utilisation
Suggestion
Perioperative Communication
How can Anaesthesiologists do better?
• Reflective listening / Observing / Accepting
– Patient concerns  Solutions
– Different realities  Accept & Use
• “Obviously you’re scared, but none of us are!”
• Utilisation
– Paeds: “Blow the nasty smell away”
– Adults: “Only necessary people are in OR”
Perioperative Communication
How can Anaesthesiologists do better?
• Establish Rapport
– Words convey <10%
– Sit down
Make contact: Eye & Physical
– Mirror
Encourage
• Obtain information
– Closed questions: “How old are you?”
– Open Questions: “ How do you feel about…?”
– Encourage patient questions
Perioperative Communication
How can Anaesthesiologists do better?
Interview format
• Beginning
– Ideal setting: private room
– Clear your mind for this patient
– Introductions: esp. Specialist Anaesthesiologist!!
• Middle
– Deal with feelings
• Uncertainty
Anger
Anxiety
– Information is better than midazolam et. al.
• Complex  Understandable  What was Understood
Perioperative Communication
How can Anaesthesiologists do better?
Interview format
• End
–
–
–
–
–
Summarise
Patient Satisfied
Reassure: Will meet in OR
Otherwise explain handover
Record
• Benefits
– Satisfaction Anxiety
Perioperative Communication
How can Anaesthesiologists do better?
Suggestion
• Pre-op patients highly suggestible
• Positive
– Direct:
“You”
– Indirect: “Most patients”
• Negative suggestion
– Avoid using emotional terms
– “May be sore, but less than expected”
Perioperative Communication
Conclusion
• Limited time under stressed conditions
– Establish Rapport
Specialist Qualifications
• Provide Reassurance
– Esp. Survival
– Constant presence
– Management of Pain / PONV
• Assess patient comprehension
– “How do you understand what will be happening?”
• Allow / Encourage questions
– Medical / Non-medical (Fees in Private)
Intraoperative Communication
• Show respect for patient as sensate being
• Communication of respect builds trust
• Always speak as if the patient will remember
• Limited time to make a good impression
Preoperative Patient Advocacy
• Anesthesiologists & HCWs communicate
– Multiple levels
Whole work day
• Complex social transactions
– Medical, legal, ethical & personal significance
• Different priorities
– State
– Surgeon
vs. Private
vs. Patient
vs. Anaesthesiologist
Preop Patient Advocacy
State Sector
• Hierarchical structure
– Student Intern Registrar Consultant HoD
• Concerns at one level referred up
– Extent of proposed surgery
– Patient’s physiological reserve
– Timing
- Will delay improve outcome?
- Placement on list
• Appropriate management by consensus
– Conveyed to patient by surgical team
– Beware assuming “Gatekeeper” role
• “No operation – Anaesthetist says you’re too sick”
Preop Patient Advocacy
Private Sector
• NO Hierarchy
– Each specialist = Every other specialist
– Limited (if any) Peer review
• Decision made by surgeon alone
– Alternatives presented to patients:
• Surgery with full recovery
• No surgery with progressive discomfort / death
• Anaesthesiologist
– Can’t operate but understands operations
– Able to provide alternative perspective
Preoperative Patient Advocacy
The Hippocratic Ethic
• Patient submissive & in need
• Physician empowered by knowledge
– Anaesthesiologist & Surgeon
• With this power comes responsibility
• Exercise power with tact and respect
• Do no harm = speak and act with restraint
– Preventing harm means discussion with surgeon
Preop Patient Advocacy
Private Sector
• Training to specialist level
– School + University + Internship + Registrarship
– 25+ years of experience
• Informed consent
– 25+ years impossible in consult / premed
– Surgical alternatives part of Premed
• Based on likelihood of survival: ASA Grade
• Advocacy
– Raise alternative options with surgeon first
– Unreasonable refusal to consider = conflict
Preop Patient Advocacy
Conflict Resolution
• Discuss options with surgeon first
– Ideal vs. Possible
• Whipple’s
• Operation
vs. Bypass
vs. Palliation
• Unreasonable refusal to consider options
– Senior anaesthetic colleague opinion
– Senior surgical opinion
• Patient advice
– Second opinion for elective cases
• Or withdraw
– Emergency??????
• Proceed but clearly document concerns
Intraoperative Advocacy
The “Captain Effect”
“It is probable that the tendency of some
anesthesiologists not to bother or
contradict surgeons, or the reluctance of
some nurse anesthetists or residents to
call their supervisors, has led to
catastrophe…” Gaba DM 1989 IAC
Intra-op Patient Advocacy
Error Prevention
• Foster equality
– Empower team members
– Korean Airlines vs. Toyota
• Anaesthesia vs. Commercial Flying
– Anaesthesia error = >100 fatal crashes/day
• WHO surgical checklist
– Pioneered by Atul Gawande
– Adopted worldwide
– Major impact on safety
• Wrong operation / site / side
Intra-op Patient Advocacy
WHO Checklist
Intra-op Patient Advocacy
Damage control surgery
• Severely injured / septic patients
– Operative time ≈ Mortality
• Damage control
– Control bleeding
– Exclude GI Injuries
– Immobilise fractures
– 2o resuscitation
• Anaesthetic role
– Simplify & Shorten
Intra-op Patient Advocacy
Infection control
• Personal hygiene
– Hand Washing
– PPE: Hats Masks Gloves
• Injection technique
– 3-way taps Ports
– Multi-dose vials
• Appropriate antibiotic prophylaxis
– Adequate dose within 30min of incision
– 2nd dose: Long operation
>50% blood loss
OR Infection control
New
Anaesthesia
Role?
• Particles diminished by:
– Endoscopic surgery if possible
– Procedure not unnecessarily prolonged
– Reduced staff in / circulating in&out of OR
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Post-op Patient Advocacy
• Handovers (Recovery / ICU)
– SBAR:
– Situation
Background
Assessment Recommendation
– Provide information
– Repeat to assess transfer
• Pain Management
– Multimodal
– Special techniques for
Special patients
Benefits of Communication & Advocacy
Patients
Satisfaction
Recovery
Staff
Enhanced self esteem
Improved work satisfaction
Personal & Professional Growth
Healthcare organizations
Enhanced reputation
Decreased litigation
Facility with a variety of
communication skills signifies
highly developed professionalism.
Literal meaning of “profession” =
“speaking forth”
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