Year: 2000
Type: review
Abstract: LOOK up communication in a major anesthesiology text, 1a medical dictionary, 2or reference book on legal issues 3and you will not find the word listed, except in the most qualified sense. Yet read these books and you find ample evidence of the importance of communication in anesthesia practice.The word derives from the Latin communicare , meaning to impart, participate. 4Anesthesiologists, other health professionals, and patients communicate on multiple levels every day. Anesthesiologists participate in activities involving complex social transactions with medical, legal, ethical, and personal significance. 5They also impart and receive information that affects their participation in other medical professionals’ actions. 6,7The quality and quantity of anesthesiologists’ communications has a bearing on the values, outcomes, and standards of their professional work. Recognizing the importance of communication, the American Society of Anesthesiologists has charged the Committee on Communication to “improve public education as it relates to anesthesiology.”8‡Good communication is as important to protecting professional integrity as it is to patient safety and satisfaction. For these reasons, it is as important for anesthesiologists to pay attention to the structure and function of professional communication as it is to learn the pharmacokinetics and pharmacodynamics of drugs.Anesthesiologists cannot imagine performing their work without resorting to words or numbers. Humans use language to communicate about consciousness subjectively and objectively. Humans accept language as a reality of their environment, often without reflection. Although exploration of language’s links to consciousness is the work of semioticians and poets, the job of using language is everyone’s. 9Human collective life depends heavily on language. The neurobiological foundations of language are encoded in our genes, yet its structural and symbolic content is predicated on social context. In turn, language structure, content, and context shift continuously. Word meanings drift. The same word has different meanings in different settings. The word inadvertent , for example, means something different in a medical morbidity and mortality conference than it does in a court of law. Language can create, preserve, or destroy relationships of meaning that extend beyond ourself. As a result, language gives humans the power to modify life’s circumstances like no other species.Anesthesiologists face communication challenges that are unique to the circumstances of anesthesia practice. Anesthesiologists’ contact with conscious patients is usually brief. Well-honed communication skills are helpful during such circumstances. Patient anxiety or an atmosphere of rushed care may influence effective preanesthetic communication. Production pressure may cause patients to be treated indifferently or summarily. Diffusion of responsibility within the anesthesia care team can result in confusion about who is the anesthesiologist and who is the nurse anesthetist. Medication-clouded consciousness makes postanesthetic communication challenging. Communication acquires a context-specific meaning and action. Thus, clear, succinct, respectful communication is essential to working in the compressed time frame presented by anesthesia practice.Communication is not all language. 10Manners, habits, appearances, and interpersonal skills affect the impression the anesthesiologist makes on patients or other colleagues. Intentional actions can become nonconscious, automatic, completely learned, and applied to positive ends, with practice. Conversely, unintentional actions can be modified consciously, transformed intentionally, and relearned completely. Indeed, residency training is an exercise in bridging these two varieties of learning. Through repetition, didactic sessions, reading, testing, and mentoring relationships, residency places emphasis on acquiring professional standards and embodying professional norms of behavior and communication.Reflection on communication helps move the anesthesiologist closer to accepted norms. Codes of behavior, ethics, and laws are systematic attempts to induce or redress patterns of action in individuals or groups. The American Society of Anesthesiologists encourages certain actions of its through its ASA Standards, Guidelines and Statements . 11However, these standards and guidelines cannot force members to follow specific recommendations. Reflection on their meaning must first occur. Such documents cannot induce changes in communication patterns rooted in character, personality, or involuntary behaviors. Becoming aware of one’s individual patterns of language and behavior thus becomes a starting point for improved professional communication.Where do opportunities for improved communication exist in the periprocedural period? Anesthesia care and the anesthesiologist–patient relationship are divisible into three distinct phases: preanesthesia evaluation, periprocedural management, and postanesthesia care. Each phase presents unique communication challenges.Anesthesiologists’ (and intensivists’) work differs psychologically and philosophically from that of other physicians. The anesthesiologist cares for the patient in a highly individual and intimate way with minimal knowledge of the patient’s personality. During anesthesia the patient is controlled through interventions that reduce consciousness, eliminate language, alter memory, and limit autonomous actions. Throughout, monitors display physiologic responses. The patient is “known” through raw data display during anesthesia. Paradoxically, the patient becomes better known as a biological preparation but not as a personality. This paradox, how it plays out in the anesthesiologist–patient relationship, and how it influences communication is the focus of the remainder of this article.The preanesthetic evaluation is the first duty of an anesthesiologist to a patient. Ways to provide this important service have received considerable attention. 12–14What should be the content of preanesthesia evaluation? Klafta and Roizen 15identified six interrelated goals. The first is to assess health and ensure physical readiness for anesthesia-requiring procedures. The second is to devise a mutually agreeable anesthetic plan and to educate the patient about it. The third is to reduce the psychological and physiological consequences of anxiety. The fourth is to plan postoperative care and pain therapy. The fifth is to coordinate patient care in a way that decreases total cost and improves outcomes. The sixth is to obtain informed consent for anesthesia. Achieving each goal requires skilled communication.Because biological concerns occasion anesthesia, patient physical status is of great interest to the anesthesiologist, sometimes more so than to the patient. The patient’s perspective is often, but not always, centered around personal concerns. Simply put, the patient seeks reassurance that he or she will be cared for properly and humanely during a procedure. As in any medical encounter, expectations for communication differ on either side from the outset. 16Anesthesiologists’ approaches to communication have evolved to anticipate and address as many patient concerns as possible. 17Professional competence and readiness to meet patient needs during anesthesia should also be communicated. Verbal and nonverbal practices that communicate caring may reduce stress and medication requirements. Egbert et al. 18concluded that a thorough description of perioperative events serves as a potent anxiolytic when compared with no encounter or barbiturate sedation alone. Leigh et al. 19demonstrated that an information booklet is not as effective as a preanesthetic encounter with an anesthesiologist. Preanesthetic videos may improve the effectiveness of traditional preanesthetic consultation practices. 20Communication tailored to patient need has benefits. Patients with coping styles that are information-avoidant have lower preprocedural arousal levels. Arousal is most reduced when patient coping style and information needs are matched. 21This observation suggests communication choices can have potent effects on the patient’s responses whether matched to patient expectations or not.Anesthesiologist–patient communication notwithstanding, the benefits of pharmacologic intervention are undeniable. Benefits may include anxiolysis, sedation, analgesia, amnesia, control of gastric acid secretion, control of salivation, attenuation of autonomic nervous system effects, reduction of total anesthesia requirements, and protection against specific allergic reactions. That these benefits may be achieved more predictably with drugs than communication contributes to reliance on the former over the latter for these purposes.Contemporary practice patterns demand more ambulatory preparation for procedures than in the past. Current patterns of outpatient preanesthetic preparation cannot always meet the aforementioned goals. Production pressures in preanesthesia clinics and use of telephone or telemedicine techniques can undermine communication as easily as waiting until the preinduction review of the patient’s status to discuss important concerns. Emphasis on rights-based language in the course of preanesthetic communication may leave little room to determine and respond appropriately to individual coping styles, let alone adequately address the patient’s deepest personal concerns. That anesthesiologists self-select to work predominantly in nonclinic settings also compounds communication challenges.Conversely, most patients lack specific knowledge of anesthesia. What questions to ask or basic information to seek is unknown to most patients. Many lack the education required to make sense of technical terms even when translated into plain language. Language barriers may exist. 22Once presented with verbal information supplemented with written and visual information, compliance with instructions remains problematic for significant numbers of patients.Thus, impediments exist that limit anesthesiologist–patient communication effectiveness in both directions. Both parties, in different ways, must cope with a sense of powerlessness and frustration. The advantage—despite consumerist trends and changing healthcare service management structures (e.g. , Health Maintenance Organizations, Preferred Provider Organizations)—still resides predominantly with the physician. Because it is the physician’s services and expertise that are sought, a special obligation resides with the physician.The etiquette governing communication in the professional consultation is at once stringent and delicate. The physician is empowered by virtue of knowledge, while the patient is submissive because of need. … Power may be exercised, but it has to be done with tact and respect. 23In essence, this quote conveys the core sense of the Hippocratic ethic that has dominated medicine. Knowledge confers power, power responsibility. To do no harm also means to speak and act with restraint.As the patient nears induction and maintenance of anesthesia, personal concerns may increase over what is evident during preanesthesia evaluation. These may be unvoiced. The anesthesiologist must be prepared to communicate about issues often not related to the planned procedure the patient is about to undergo.Deep personal concerns—those that relate to the patient’s “state of being” or “ontology”— are not likely to command the attention of most anesthesiologists. However, such concerns exist and may loom large for the patient. Often patients who focus on such concerns out of proportion to the anesthesiologist’s comfort risk being pejoratively labeled as “nuts” or “flakey.” One anecdote relayed to the authors regards a patient, a person with a Ph.D. in pharmacology, who refused general anesthesia because of fear that s/he will “cease to exist” during anesthesia. Indeed, the patient not only fears loss of autonomy but dissolution of sense of being.This concern is not as irrational as it might seem. Our society values consciousness as a marker of individual identity and worth. The definition of brain death is predicated on this connection. Fear of loss of consciousness thus acquires rational meaning. For people who wish to control the “ontologic” facts they believe define them, such a consideration may shape the nature of the anesthesia care plan.The impact of anesthesia on consciousness, autonomous action, and self-defined identity is not a trivial matter. With induction of general anesthesia, the anesthesiologist alters consciousness and suspends the biological possibility of expressive language and intentional action. For a period of time, the patient’s cortical, subcortical, autonomic, and neuromuscular response capacities are manipulated. The patient is treated largely as a biological entity or object of attention. In a sense, two interrelated identities, one psychological and one physiologic, are functionally separated. Metaphorically, it is as if the patient’s psychological “fingerprint” is removed from their physiologic “hand.” The physiologic responses displayed on anesthesia monitors and the body they arise from recall preexisting but suspended ontologic factors. However, the patient is no longer free to express or act on any aspect of their identity. By assuming responsibility for the patient, the anesthesiologist enters a covenant—fashioned during preanesthetic protection of psychological identity through care of physiologic general anesthesia ends, the patient to a of the psychological “fingerprint” the physical “hand.” action becomes possible. the patient a to a self-defined identity that remains by biological factors. 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Source: Anesthesiology
Authors: Vincent J. Kopp, Audrey Shafer
Language: English
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W1995168538