Eric Hodgson Inkosi Albert Luthuli Central Hospital & Nelson R Mandela Medical School eThekwini-Durban, KZN, SOUTH A

1. The Anaesthesiologist as a Patient Advocate Eric Hodgson Inkosi Albert Luthuli Central Hospital & Nelson R Mandela Medical School eThekwini-Durban, KZN, SOUTH AFRICA

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3. 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

4. Lecture Plan • Patient communication • Advocacy role • Preop • Intraop • Postop • Conclusion

5. Medical Career Selection

6. Anaesthesiology as a career choiceAndrew F. Smith MRCVFRCA, Make P. Shelly FRCACAN 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?

7. Anaesthesiologists & Patients 2000

8. Anaesthesiologists & Patients Brazil Braz J Anaesth 2011: 720-7 13 52 9 26

9. Anaesthesiologists & Patients

10. Perioperative CommunicationHow do Anaesthesiologists do? • Results: Overall dissatisfaction – 3 Paeds 1 Adult • 20x variation between individuals

11. 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 Perioperative CommunicationChallenges for Anaesthesiologists YES

12. Perioperative CommunicationHow 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

13. Perioperative CommunicationHow 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”

14. Perioperative CommunicationHow 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

15. Perioperative CommunicationHow 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

16. Perioperative CommunicationHow can Anaesthesiologists do better? Interview format • End • Summarise • Patient Satisfied • Reassure: Will meet in OR • Otherwise explain handover • Record • Benefits • Satisfaction Anxiety

17. Perioperative CommunicationHow 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”

18. Perioperative CommunicationConclusion • 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)

19. 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

20. Preoperative Patient Advocacy • Anesthesiologists & HCWs communicate • Multiple levels Whole work day • Complex social transactions • Medical, legal, ethical & personal significance • Different priorities • State vs. Private • Surgeon vs. Patient vs. Anaesthesiologist

21. Preop Patient AdvocacyState 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”

22. Preop Patient AdvocacyPrivate 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

23. Preoperative Patient AdvocacyThe 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

24. Preop Patient AdvocacyPrivate 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

25. Preop Patient AdvocacyConflict Resolution • Discuss options with surgeon first • Ideal vs. Possible • Whipple’s vs. Bypass • Operation 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

26. Intraoperative AdvocacyThe “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

27. Intra-op Patient AdvocacyError 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

28. Intra-op Patient AdvocacyWHO Checklist

29. Intra-op Patient AdvocacyDamage control surgery • Severely injured / septic patients • Operative time ≈ Mortality • Damage control • Control bleeding • Exclude GI Injuries • Immobilise fractures • 2o resuscitation • Anaesthetic role • Simplify & Shorten

30. Intra-op Patient AdvocacyInfection 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

31. Particles diminished by: Endoscopic surgery if possible Procedure not unnecessarily prolonged Reduced staff in / circulating in&out of OR OR Infection control New Anaesthesia Role?

32. 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

33. Benefits of Communication & Advocacy Patients Satisfaction Recovery Staff Enhanced self esteem Improved work satisfaction Personal & Professional Growth Healthcare organizations Enhanced reputation Decreased litigation

34. Facility with a variety of communication skills signifies highly developed professionalism. Literal meaning of “profession” = “speaking forth”

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