Clinical Case for Discussion: As an anesthesia resident, how does your preoperative interview with a patient differ from that of an anesthesiologist with 20 years of experience?
Discussion: In my second year of residency, I had the pleasure of working with Stanford anesthesia attending C. Philip Larson, M.D., a Past-Chairman of the Department and a Past Editor-In-Chief of our specialty’s leading publication, Anesthesiology. My rotation was neuroanesthesia, and each evening prior to surgery Dr. Larson and I would make rounds on the wards to meet the surgical patients for the next day. (In the 1980’s almost all patients were hospitalized one night prior to surgery.)
I was surprised and taken aback by the experience, and I never forgot what those patient encounters were like. Although Dr. Larson always let me do the anesthesia procedures in the operating room, he presented himself at the pre-op interview as the primary physician in charge of the anesthesia care. When Dr. Larson entered a patient’s room, he sat down on the bed and played a role that was part Santa Claus and part all-knowing, all-loving deity.
Dr. Larson greeted the patient kindly, introduced both of us, and then launched into a comfortable dialogue about any variety of topics, none of them remotely related to the surgery or the anesthesia. I kept waiting to hear him say, “can you walk up two flights of stairs?” or “do you ever have chest pain?”
These questions were never asked or answered at the bedside. They’d already been asked and answered and were present in the patient’s chart. Dr. Larson valued the preoperative interview as a time to connect with his patient, and to establish rapport and comfort between them. After perhaps ten minutes of such banter, he would switch gears and state that we would be doing the anesthesia care the next day, that we would keep him or her asleep and safe, and give a modicum of detail about what to expect. He did not perform any detailed physical exam.
Despite the fact that Dr. Larson was a renowned expert witness in the specialty of anesthesia, he did not recite a litany of informed consent risks. A particular pet peeve of his was the suggestion that an informed consent discussion should include telling a patient of the risk of death. His opinion on this issue always was, “If you tell the patient that they can die, and then you do something negligent and they do die, your informed consent protects you not one bit from the fact that you practiced below the standard of care.”
In his best-selling book, Blink, Malcolm Gladwell writes that the risk of a doctor ever being sued has very little to do with how many errors they make. He explains that there’s an overwhelming number of patients who’ve been harmed by shoddy medical care yet never have filed a malpractice claim. What was the common denominator of the people who do choose to sue? According to Gladwell, they feel they were treated badly by their doctor. That even when injured by clear negligence, most people won’t sue a doctor they like.
Dr. Bruce Halperin, a member of the Associated Anesthesiologists Medical Group in Palo Alto and a member of the Stanford clinical faculty, is renowned for his bedside manner. In the preoperative area, I often hear Dr. Halperin telling joke after joke, and the intermittent bursts of laughter from his patients sometimes make it difficult for me to even hear the conversation with my own patient. One of our busiest cosmetic surgeons often has Dr. Halperin telephone patients early in the consultative process to discuss anesthesia issues. A patient later told this surgeon, “I’m not sure if I want to have the plastic surgery, but I sure do want to have the anesthesia!”
As an anesthesiologist, you have 10-15 minutes to complete your medical interview with your patient, and to get them to respect you, to have confidence in you, and yes . . . to like you.
As a resident-in-training, your preoperative interviews may be thick with questions about active medical problems, particularly cardiac, pulmonary, and neurologic questions. You may perform a rigorous and detailed exam of the airway, lungs, and heart. And you likely spend ample time explaining the anesthetic technique, alternatives, and risks.
You are trained to do all these things. Twenty years from now, your interview may not be as conversational and sparse on medical questions as Dr. Larson’s was, but your technique will evolve.
Most pertinent questions have already been asked and answered in the patient’s medical records. Tailor your interview as appropriate for the patient’s medical co-morbidities and the invasiveness of the surgery. For a 68-year-old with diabetes and hypertension who is about to have a cholecystectomy, it will be relevant to ask them whether they can walk up two flights of stairs and whether they ever have chest pain. For a 24-year-old with a negative history who is about to have a knee arthroscopy, a simple “Are you in excellent health?” may suffice.
What about the physical exam? For experienced anesthesiologists, the assessment of whether the airway may be difficult can usually accomplished in seconds, with examination of the mouth opening and the neck extension. You will listen to the lungs and the heart, but in the absence of symptoms, it is rare to uncover any information with your stethoscope that changes your anesthetic.
Patients are nervous before surgery. They welcome both your expertise in medicine and your skills in making them relax. Experienced anesthesiologists can explain the anesthetic plan and risks in a fashion that will gain the patient’s trust and confidence.
The only procedure most of us do while the patient is awake and unsedated is the insertion of an I.V. catheter. This is a time when you have the luxury of talking about any topic that is calming to the patient. Conversations about the patient’s hobbies, work, hometown, or family are all pleasant diversions to enter the realm of Dr. C. Philip Larson, and connect with the patient without talking any further about anesthesia.
In my previous career, I was an internal medicine doctor. In medicine clinic there are dozens of questions to be asked and answered: “Where is the pain? How long has it been there? What makes it better? What makes it worse? Does it move anywhere? . . .” With a waiting room full of patients, there was little time to ask each patient where they had dinner last night or where their child was going to college.
In contrast, anesthesia practice can provide a wonderful opportunity to relax your patient with well-spun conversation. My advice to you is to be as much like C. Philip Larson, M.D. as your practice allows. Try not to be a walking, talking EPIC-checklist when it’s time to connect with your patients.
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