Current Understanding of Patients’ Attitudes Toward and Preparation for Anesthesia

Anesthesiology as a medical specialty had its beginnings in the early part of this century when physicians began to manage vital functions during surgery in addition to simply performing the surgical prerequisites of inducing unconsciousness and waking patients at the end of surgery. Complex surgery performed on sicker patients became increasingly possible as physician-anesthetists developed techniques for critical care and active perioperative management of vital functions. The general public understood little of these developments. At the 1939 New York World's Fair, the nascent specialty of anesthesiology announced itself to the nonmedical world 1. A committee of leading physician-anesthetists chaired by Paul M. Wood designed exhibits not only to illustrate anesthetic techniques but also to explain the important role of physician-anesthetists in medicine, thus conveying the message to the general public that anesthesiology was indeed a legitimate specialty. As the health care environment changes and the specialty of anesthesiology evolves, the need and challenges for educating the individual patient and the public at large have never been greater. As discussed later in this review, both the patient and the anesthesiologist are benefactors of this education. The problems of image and status of anesthesiologists in the eyes of the medical and lay communities are not new 2. In the Rovenstine Memorial Lecture in 1979, Leroy Vandam spoke of the history of this problem and offered his views on ways in which individuals can elevate the level of their practice to that of "anesthesiologist-clinicians" 3. Many, if not all, practicing anesthesiologists have struggled at some point with issues relating to the status and image of the specialty. Recent network media exposure citing the lack of presence of anesthesiologists as cause for several patients' demise (ABC News "Day One," 1995) has cast doubt into the hearts of patients by portraying anesthesiologists as vital but inattentive, irresponsible, and uncaring. This article summarizes published data about patients' knowledge and attitudes concerning the specialty and practice of anesthesia, as well as what patients want to know about their own anesthetic. It then reviews the educational efforts that have been made in this area and their effect (if any) on measurable end points such as postoperative pain, length of stay, patient anxiety, or patient satisfaction. Finally, the rationale for improving perioperative teaching and communication is addressed. Patients' Knowledge and Attitudes Concerning Anesthesia and Anesthesiologists In a recent survey of 100 consecutive surgical patients in a British hospital where all anesthesia is provided by physician-anesthesiologists, only 65% thought that the anesthesiologist was a doctor 4. In a similar survey in another British hospital about 15 years earlier, 67% of patients thought their anesthesiologist was a doctor 5. The consistency of findings suggests that the British perception of anesthesiologists has changed little over the past 15 years. Table 1 summarizes the results of similar studies in Britain, Australia, and the United States. The percentage of patients who thought their anesthesiologist was medically qualified ranged from 50% to 88.7%.Table 1: Percentage of Patients Who Thought an Anesthesiologist Is a DoctorIn addition to investigations of patients' knowledge of the physician status of anesthesiologists, patients have been asked about the role of anesthesiologists in perioperative care. When Swinhoe and Groves 4 administered a questionnaire to 100 patients before routine preoperative assessment (see Appendix), 79% of patients believed that the anesthesiologist was primarily responsible for their well-being, suggesting an appreciation for the importance of the role. The duties of an anesthesiologist were less well understood, however, with "monitoring" being mentioned by 54% of the respondents and "keeping the patient asleep" by only 10%. Only 25% of respondents were aware of other hospital responsibilities of anesthesiologists outside of the operating room, such as intensive care, epidural analgesia for labor, pain therapy, or research. While Swinhoe and Groves' study did not control for the patients' knowledge of the health service establishment in general, previous work 5 revealed that although 32% of patients thought that anesthesiologists work in intensive care units an equal number believed that pathologists do so as well! Thus, the public's knowledge of the roles of other specialist physicians besides anesthesiologists is limited. In contrast to British reports, data from the United States suggest better public knowledge of an anesthesiologist's medical training. In a recent survey of 800 patients in New York, the average time spent by an anesthesiologist in medical school was believed to be 4.8 +/- 1.4 years (mean +/- SD) and the average time spent in residency 4.0 +/- 1.9 years 9. Perceptions of the duties of an anesthesiologist included most prominently "putting the patient to sleep" (43%), "relieving pain" (20%), and "administering medications" (17%), with only 5% of patients responding "monitoring vital signs." As the authors observed, the function of the anesthesiologist after completion of the induction of anesthesia is not clear to many patients. This lack of clarity may result in the perception that the anesthesiologist is not or need not be physically present during the entire operation. Despite this perception, confidence in the anesthesiologist was high (3.97 +/- 1.07 on a scale of 1-6: mean +/- SD), although it was significantly lower than confidence in the surgeon (4.47 +/- 0.80) 9. Zvara et al. 6 most recently found that 87.9% of patients completing a standard preanesthetic interview were able to correctly identify the anesthesiologist as a physician. This percentage was not significantly different in a similar group of patients randomized to view, as a part of the preanesthetic visit, an educational videotape that described the anesthesiologist as a doctor. Patients' concerns regarding their surgical experience often involve aspects peculiar to anesthetic care 13. Table 2 shows the results of a number of studies looking at what patients fear about an upcoming surgical procedure. Failure to wake up from an anesthetic has consistently been a primary concern of patients who express concerns about the anesthetic 9,14-16. Although none of the patients in these series spontaneously expressed concerns about the qualifications of the anesthesiologist, an alarming 45% of 800 patients interviewed in one study 9 acknowledged this concern when specifically asked about it.Table 2: Summary of What Patients Fear Most About Undergoing a Surgical ProcedureWhile not all of the studies have analyzed the demographics of patients' anesthetic concerns, some trends have been identified. First, a patient's age tends to be inversely related to degree of concern 9,17, that is, older patients tend to have fewer concerns. Second, some studies have demonstrated that women tend to express more fears and concerns about the anesthetic than do men 9,15, but this tendency has not universally been the case 17. The self-reporting of anxiety in men may underrepresent the true degree of anxiety and is perhaps better assessed by way of a personal interview by a trained psychologist 9. This assessment has not been performed in studies to date. Third, neither previous experience with nor type of past anesthesia significantly affected patients' concerns 9,15,17. This lack of correlation of anxiety with prior anesthetic experiences may be surprising to those practitioners who assume that patients' anxiety about an anesthetic necessarily decreases if they have already had a good experience with anesthesia. Fourth, in the only study that specifically looked for this correlation, the patients' level of concern was unrelated to years of education or occupation 9. Previous work has demonstrated that a physician's dress is important to patients 18, and two studies have specifically addressed the question of whether or not anesthesiologists' style of dress affects the patient's perception of them. Patients in Wales expressed a preference for an anesthesiologist in more traditional clothing (suit and tie versus jeans and open-necked shirt), but the style of dress did not affect patient assessment of either the preoperative visit or the anesthesiologist himself 19. Only male physicians were studied, as the traditional standards of dress are more difficult to define for women. More recently, Hennessy et al. 8 also concluded that traditional dress for physicians was preferred by patients specifically asked about dress, but that patients' satisfaction with the anesthesiologist and the preoperative visit was not influenced by dress. In both studies, a name tag and white coat were judged by patients to be highly desirable items of dress, possibly because of their ability to help identify the role of the individual. What Patients Really Want to Know About Their Anesthetic We have focused thus far on what patients know and what patients fear. The relationship between these two entities will now be addressed. There is considerable variation in practice regarding the quantity and nature of information given to patients about their anesthetic care. Some practitioners contend that avoiding explicit discussions of risk is beneficial in reducing patients' fear. Miller and Mangan 20 segregated 40 patients undergoing colposcopy into two groups according to two coping styles, information seekers and information avoiders. All patients were then randomly allocated to receive either "voluminous" preparatory information or the "usual low level" of information. Psychophysiologic variables were measured before and after the information was given and after the procedure was performed. Results showed that voluminous preparatory information did not necessarily decrease arousal (subjective and behavioral measures of distress such as anxiety, tension, hostility, tachycardia, hand clenching, and crying out) and that information avoidance was a less arousing coping style than information seeking. Additionally, the patients in the study were generally less aroused when the amount of preparatory information matched their coping style than when it did not. An information-seeking disposition has also been shown to exist in school-age children requiring surgery 21, but its relationship to the effect of preparatory information has not been studied. When 81 patients (median age, 46 years) having minor surgery were randomly allocated to receive either routine or detailed information before their anxiety was assessed (by Spielberger State-Trait Anxiety Inventory), patients who had had a previous anesthetic before hospitalization were less influenced by the amount of information given than those patients who had never been previously anesthetized. In fact, there were no significant differences between the routine information/experienced group and the detailed information/no-previous-anesthesia-experience patients. The most significant effects of giving detailed information before the procedure were found in a small number of side effects such as slow cerebration (a self-reported complaint), nausea, and a general feeling of discomfort. Length of stay was not different between groups, and use of analgesics was not evaluated 22. The effects of providing preoperative statistical risk information relating specifically to the anesthetic have also been investigated 23. Forty adults who had had at least five previous anesthetics and were giving consent for their own or their child's surgery were randomly assigned to receive either routine preoperative information (anticipated sequence of events and possibility of postoperative nausea, vomiting, and sore throat) or detailed information (the same information as the control group but numerical incidences of nausea and vomiting, sore throat, dental injury, awareness, brain damage, and death). The group given detailed information gained more accurate knowledge of the likelihood of two of the rare occurrences, but more importantly, this knowledge did not increase state anxiety as assessed by an established instrument (Spielberger State-Trait Anxiety Inventory). The results of this study may not be applicable to the general patient population in that these patients had considerable experience with anesthesia. The question of whether to educate patients regarding the risk of rare complications was investigated in a study of the parents of healthy children undergoing outpatient procedures 24. Of 115 parents surveyed, 87% wanted to know the chances of death as a result of anesthesia (19% believed the risk to be "once in a while"; 68%, "extremely rare"; and 13%, "no chance"). When the preanesthetic discussion mentioned or implied the risk of death, 88% of parents questioned later wanted this information. When the preanesthetic discussion did not mention or imply the risk of death, 47% of parents wished it had been included and 38% did not want it discussed. Thus, while most parents were already aware of the relative risk of death, many wanted to discuss it further in the setting of a preanesthetic interview. Lonsdale and Hutchison 25 administered a preoperative questionnaire in Scotland and Canada to discover the information patients wanted from an anesthesiologist about the perioperative period. The questionnaire contained 13 items relating to the experience of anesthesia about which patients might want information, such as alternative methods of anesthesia and their risks and benefits, details about lines or catheters, and expected postoperative milestones. For each item, patients indicated "would like to know," "feel I have the right to know," or "prefer not to know." In both countries, patients less than 50 years old desired more information than patients older than 50 years of age. In Canada, women desired more information than men, as measured by the number of patients who responded to each question with one or both of the options "have a right to know" and "would like to know." Patients' overall strong desire for information was not significantly affected by the number of previous operations. Patients placed the highest priority on meeting their anesthesiologist before the procedure. details of complications of anesthesia and surgery was consistently given low from a similar study in were with the however, more patients had a desire to know about all possible complications patients results that imply that want to know more about anesthetic risks have been found in a In a survey of patients from the United 45% men, there was no correlation between the level of information provided and patient correlation between patients' satisfaction with the amount of information provided and anxiety as by a scale of anxiety was high Thus, the level of knowledge was not as important as the patients' degree of satisfaction with that knowledge or information. results to identify of patients who either from or be by further information and level of preoperative teaching Patients About Anesthesia has to and the of the patient for anesthesia and to an anesthetic and educate the patient regarding the anesthetic to the patient and to discuss postoperative care and pain to decrease by improving reducing length of stay, and communication the patient care and to The of preanesthetic in operating and has been demonstrated The preoperative visit as a for patient and its in improving measurable end points can be More than years et al. the of a preanesthetic visit in patient patients over the age of years were randomly allocated to receive either with a preoperative visit, or a to the preoperative judged the patients' anxiety The group both was judged the most by the group the preoperative by the group findings from the patients' about their own degree of and The of postoperative pain preoperative has been et al. found in a of patients that preoperative about postoperative pain and its with intensive postoperative and significantly on postoperative 2 after a of operations. 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