Coping Style Affects Quality of Informed Consent Prior to Anesthesia

Oct. 20, 2009
Pushy Patients May Receive Better Information Before “Going Under”

How patients cope with anxiety before undergoing anesthesia, either by demanding information or running from it, may determine whether they are equipped to make vital health decisions, according to a study to be published in the November edition of the journal Anesthesiology. The study has important implications for patients, and for medical schools seeking to teach anesthesiologists how to secure their patients’ informed consent before procedures.

Although patient-physician communication has been studied in other contexts, no study had looked at communication patterns during pre-anesthesia interviews. Past work found that when such discussions are tailored to meet an individual’s needs (patient-centered care), he or she needs fewer painkillers after the procedure and leaves the hospital quicker.

In the current study, 27 anesthesia residents and junior attending anesthesiologists were recruited from the Anesthesiology Department at the University of Rochester School of Medicine & Dentistry to interview patients with one of two personality types. The “monitor” patient type manages his anxiety by exerting control over the conversation to glean every possible detail. The “blunter” ignores detail in the hope that “all will be well.” Skillful interviewers respond to both styles so that all patients get the information they need.

Varying personalities make the study of patient-physician communication complex, and researchers often address the complexity by using “standardized patients.” These are actors trained to deliver information and ask certain questions often seen in the clinic. They follow scripts taken from real patient interviews, but enable researchers to focus on certain facets of the interviews. In the current case, both patients portrayed a middle aged male smoker who has just learned he may have lung cancer. His next step is to “go under” for a more detailed look at his lungs, with open chest surgery a possibility.

Interviews with the controlling monitor patients ran nearly three minutes longer, researchers found. Strikingly, discussions with monitors were also much more likely to cover the issues of most concern to patients – pain control and risks of the procedure. Such concerns were frequently left out of talks with blunters, who were reluctant to ask questions.

“All agree that informed consent represents a crucial part of any pre-procedure discussion, and our study found that patients had to push to ensure that they were truly informed going into a procedure,” said Raymond Zollo, M.D., associate professor within the Department of Anesthesiology within the School of Medicine & Dentistry, and corresponding author of the study. “These findings support recommendations that patients ask questions to challenge their health care providers for complete information.”

Struggle for Control

This current study was designed to determine how well young anesthesiologists change their interviewing style to match the needs of people with various coping patterns. Researchers examined whether a given discussion covered the possible complications of anesthesia: dry mouth, dental injury, nerve or blood vessel damage, eye injury, airway difficulties, pneumonia, vomiting, allergic reactions or cardiac instability.

According to the literature, such interviews should consist of getting the patient's perspective, doing a history, discussing pain control, describing the aforementioned risks and obtaining consent from a properly informed patient. After each interview, the standardized patient judged whether discussion accomplished these tasks using a validated questionnaire.

Overall, the monitor patient type did much better in terms of time spent discussing the anesthetic and its risks, as well as post-operative pain control. The monitor would often ask a specific question that led discussion of key topics, or force the provider to return to a subject when details were scanty. This did not typically occur with blunters.

Two qualities of the providers conducting the interviews also affected how patients rated the interview. First, providers who said they had taken a previous patient communication course received higher scores from patients in terms of providing useful, clear information. Such instruction appeared to make a resident more nimble in terms of shifting conversation to fit the patient. The second provider quality affecting interview success was the level of anesthesia training. Interestingly, the greater the level of anesthesia training, the less satisfied the controlling monitor type was with the interaction. This effect was not seen with blunters, but only where the monitor had to work harder to “steer” a more experienced clinician.

Along with Zollo, the effort was led by Denham Ward, M.D., Ph.D., in the Department of Anesthesiology and Ronald Epstein, M.D. and Stephen Lurie, M.D., Ph.D., in the Department of Family Medicine. Funding for the study was provided departmental funds and by the Foundation for Anesthesia Education and Research, located in Rochester, Minnesota.

“While we acknowledge that the study was preliminary, with limitations that included its small size, the results raise important questions,” said Ward, chair of the Department of Anesthesiology. “Does increased patient satisfaction with an anesthesiologist-patient interaction lead to healthier patients? Can communication training improve satisfaction with their care before and after anesthesia?”