Adding to Our Competitive Advantage: Making the Case for Teaching Communication and Professionalism

To become skilled perioperative physicians, anesthesiologists require not only clinical training but also preparation for leadership roles in patient care teams. Effective leadership entails professional behavior; the ability to address perioperative ethical issues; and clear communication with multidisciplinary health care providers, patients, and families. As the pace and complexity of patient care increase, we believe it is vital that students and residents receive early formal training in these essential skills with deliberate practice and spaced learning of these topics continuing throughout medical school and residency. 1 Focusing dedicated portions of training on improving interpersonal and leadership skills will allow anesthesiologists to provide better patient care as we face changing health care economics, the rise of technologies such as automation and artificial intelligence, the increase in multiprofessional health care practitioners, and an aging and increasingly morbid patient population in the United States. In our opinion, participation in an anesthesiology clerkship should be included in the core curriculum of undergraduate medical education. 2 Anesthesiologists are uniquely positioned to teach students a variety of subjects that will benefit their future practice, including basic and advanced life support, critical care medicine, perioperative patient care, pain management, and palliative care. These clinical experiences typically occur in multidisciplinary and interprofessional care settings. Teaching communication, ethics, leadership, and professionalism in addition to perioperative and critical care clinical topics during anesthesiology clerkships would provide students with universally applicable skills relevant to any medical specialty. Emphasizing these important noncognitive skills as part of the core clinical curriculum will improve students’ learning experience, ensure exposure to the field of anesthesiology, and allow anesthesiology educators to contribute to the planning and innovation of educational goals in medical education and curriculum development. The need for teaching communication and professionalism has been highlighted recently by changes to the assessment of anesthesia residents. New objectives for professionalism have been launched in July 2017 by the Accreditation Council for Graduate Medical Education and include providing patient- and family-centered care, responsiveness to patient needs that supersede self-interest, and providing a professional, respectful, and civil environment. 3 The introduction of the new Objective Structured Clinical Examination (OSCE) by the American Board of Anesthesiology as a component of board certification in anesthesiology presents an opportunity to develop a more structured curriculum and assessment tools for teaching communication and professionalism. 4 The first portion of this new examination focuses on the following: (1) informed consent; (2) presentation of treatment options; (3) discussion of periprocedural complications; (4) ethical issues; and (5) communication with other health care professionals. 5 Physicians who successfully master these skills can improve patient satisfaction, patient outcomes, and decrease health care costs. 6 In this article, we consider strategies and rationales for teaching patient-centered communication, informed consent, perioperative ethics, and professionalism as a core part of an anesthesiology curriculum and suggest ways to incorporate these areas into medical student education and anesthesiology residency training. Many of these topics are included in the OSCE syllabus and are relevant for anesthesiology educators and learners. 4 PATIENT-CENTERED COMMUNICATION In today’s efficiency-driven clinical environment, anesthesiologists have limited time to dedicate to face-to-face patient interaction. Adopting a patient-centered communication style adds value to the time we spend with patients. 7 Patient-centered communication refers to “respecting and responding to patients’ wants, needs and preferences, so that they can directly participate in their care and make choices that best fit their individual circumstances. ”8 Using this approach, anesthesiologists can maximize the impact of direct patient communication to improve patient satisfaction, decrease malpractice complaints, and establish rapport. 9 Spending more time speaking to patients can lead to improved health outcomes and decreased health care spending. 7 In addition, incorporating even a single postoperative visit by the anesthesiologist can significantly improve patient satisfaction with anesthesia care10 and may facilitate timely response to postoperative pain issues and improve future care. 11 Training physicians to communicate in a patient-centered manner can have a positive impact on patients’ quality of life. Currently, medical students undergo standardized training in communication. With the exception of certain primary care training programs, this is not continued in residency education. 6 The new anesthesiology OSCE examination should motivate educators to develop curricula and outcome measures for teaching and assessing patient-centered communication skills. 12 Communication objectives delineated by the American Board of Anesthesiology for the OSCE include clear communication, prioritization of the most important information, the ability to elicit patient questions, responding to patients in lay terms, and demonstration of understanding and concern for the situation of the patient. Practice sessions for the OSCE are an opportunity for residency programs to teach and assess residents’ communication skills and identify struggling residents who may need remediation in these areas. In addition to didactic lectures, avenues to teach patient-centered communication skills include standardized patient encounters, observation, role playing, and role modeling. We suggest 2 methods to teach patient-centered communication to anesthesia trainees: optimizing speech with attention to voice tone and faculty role modeling of effective communication. Optimizing voice tone is one way that physicians can improve how patients perceive our interactions. 13 Voice tone may ultimately be more important than speech content in influencing a patient’s decision to pursue malpractice claims. Surgeons who speak to patients with warmth, concern, and empathy are less likely to have been sued than those who speak quickly in a dominant manner. 13 Anesthesiology residents can learn to adopt appropriately warm and reassuring voice tones to convey sincere concern for patients. For medical students and residents, this skill can be enhanced by practicing conversations with real or standardized patients and reviewing the recorded encounters. Learners and educators can observe the filmed encounters together and reflect on the learner’s performance in a concrete way. This would provide the learner with feedback supported by specific examples. Voice tone effectiveness could also be incorporated into resident and student feedback evaluation during observed patient encounters or using 360 evaluation tools14, 15 that allow effective multidisciplinary and patient-based feedback. The importance of having residents and students participate in a care team with attending physicians who role-model desired professional habits and behaviors cannot be overemphasized. Surgical faculty and residents have reported that “learning by example” was the most common way they learned professionalism. 16 As anesthesiology residents become more independent during their training, they may no longer have the benefit of observing attending faculty complete a full preoperative history and physical discussion and perioperative risk conversation with a patient. Reviewing video recordings with trainees of exemplary and intentionally poor physician–patient interactions may be a convenient way to demonstrate ideal physician behaviors when faculty are unavailable. 17, 18 Third year medical students on an anesthesiology rotation noted positive and exemplary behavior when anesthesiologists spoke to patients using calm and comforting demeanor and prioritized addressing the patient’s concerns. 19 Health care organizations that provided training in patient-centered communication to attending physicians improved physician’s self-confidence, self-assessed communication skills and patient satisfaction. 20 Additionally, investing in faculty development to promote and encourage patient-centered communication styles could lead to significant downstream improvement in the communication skills of learners at all levels. INFORMED CONSENT The process of obtaining informed consent is fundamental to perioperative care and an area of opportunity for new curriculum development. Poorly performed informed consent can lead to compromised patient autonomy, reduced patient safety, and negligent care. 21 Learners from all medical specialties would benefit from training in the informed consent process. Many medical schools teach the concepts of informed consent as a part of a formal communication curriculum. Unfortunately, this subject is not uniformly included in resident education at all institutions. 22 The key components of informed consent include a discussion of the risks, benefits, and alternatives of a procedure or research protocol. In a study of 1057 recorded informed consent discussions led by either surgeons or primary care physicians, only 9% included all components of informed decision-making. 23 Interventions to deliver informed consent such as the use of written material, audiovisuals, testing, and feedback have been explored with varying degrees of success, and best practices remain to been identified. 21 Time constraints for learners and attending physicians limit the amount of structured education time dedicated to teaching this topic; however, opportunities exist during clinical practice. The preoperative clinic and the obstetric ward are 2 patient care areas where informed consent could be taught within anesthesiology and evaluated in a rigorous and convenient manner. For example, structured teaching on the standards of the informed consent process and methods of providing informed consent could be incorporated into the curriculum when learners participated in these clinical rotations or clerkships. Faculty could observe and provide feedback to residents while they see and evaluate patients together. This would facilitate workflow and save time by avoiding the need to have separate large group didactic sessions and pulling residents from their clinical responsibilities. Teaching informed consent as a specific part of the perioperative curriculum during observed clinical encounters with a written rubric of key components, using either checklists or recorded standardized encounters, allows educators to provide pointed structured feedback and improves the resident or student’s ability to discuss and document informed consent. 24, 25 PERIOPERATIVE ETHICAL ISSUES The growing geriatric population undergoing procedures and requiring critical care necessitates that providers be facile in understanding and managing the ethical issues surrounding aging and end-of-life care. We present 2 educational opportunities: conducting end-of-life discussions in the critical care unit and managing code status during the perioperative period. Improving end-of-life discussions is greatly beneficial to patient care and an area where anesthesiologists can enhance quality and value of care. While these discussions are often led by intensivists, palliative care physicians, and primary care physicians, anesthesiologists are frequently members of critical care or resuscitation teams and need to discuss code status and end-of-life care with patients and their families. Carefully managing a patient’s code status during the perioperative period is an important skill as every patient arrives with his or her unique preferences and circumstances regarding resuscitation in a dynamic environment where a patient’s condition can rapidly change. Proactive-structured end-of-life discussions led by physicians decrease the cost of medical care during the last weeks of life and improve the quality of life for dying patients and their caregivers. 6 After engaging in end-of-life discussions, patients are more likely to decline invasive procedures, focus on symptom management, enroll in hospice, and report a higher quality of life in their final weeks of life than patients who do not participate in proactive end-of-life conversations. 26 In a 2009 multi-institutional study of 627 patients with advanced cancer, aggregate care costs during the final weeks of life for patients engaged in end-of-life discussions were 35. 7% lower than those who did not, a difference of 1041 per patient. 27 Caregivers also benefit from end-of-life conversations after the patient’s death. They report fewer symptoms of posttraumatic stress disorder, anxiety, and depression after the patient’s death when they participated in early end-of-life discussions. 26 Anesthesiology trainees should learn evidence-based best practices for leading end-of-life conversations. Incorporating existing guidelines into the curriculum and clinical practice will optimize our impact on patients and families. One approach proposed by Lautrette et al28 is the VALUE method. In it, the end-of-life conversation is structured with specific objectives, and families receive a written brochure summarizing information at the conclusion of the discussion. VALUE is a mnemonic for caregivers to Value and appreciate what the family members said, Acknowledge the family members’ emotions, Listen, ask open-ended questions that allow an Understanding of who the patient was as a person, and to Elicit questions from family members. The authors demonstrated a significant improvement in the bereavement symptoms experienced by family members using this approach. The VALUE method could be taught to trainees during critical care rotations as they progress from observing family conversations to leading them with faculty support by the end of the rotation. Outstanding communication intervention skills are relevant to the practice of anesthesia in general and are greatly needed because providers periodically are required to address issues such as intraoperative death or perioperative cardiac arrest with patients’ families and caregivers. When these devastating events occur, the anesthesiologist is often the code leader and primarily responsible for discussing outcomes with patients and their loved ones. Anesthesia-related mortality in the United States has become increasingly rare with a rate of approximately 8. 2 anesthesia-related patient deaths per million hospital surgical discharges based on data from 1999 to 2005. 29 Similarly, perioperative cardiac arrest (defined as cardiac arrest occurring intraoperatively or in the postanesthesia care unit) is also rare, occurring at a rate of only 5. 6 deaths in the perioperative period per 10, 000 surgical cases with an associated mortality from the arrest of 58. 4%. 30 Thus, medical students and learners would benefit from simulation training to practice delivering bad news and engaging in goals-of-care and end-of-life discussions in the setting of perioperative death and cardiac arrest due to the low likelihood of clinical exposure during training. Simulated scenarios with standardized patients and caregivers would also be ideal to enhance learners’ communication training to prepare for these infrequent yet devastating events. The management of code status for patients undergoing surgery is another important perioperative ethical concern that warrants improved education for providers. Code status terminology has undergone revision in recent years because the phrase “Do Not Resuscitate (DNR) ” has been problematic for many patients and physicians. 31 In its place, new phrases such as “Do Not Attempt Resuscitation” and “Allow Natural Death” have been promoted by institutions such as the American Heart Association. These new terms are less confusing, particularly regarding whether resuscitation is successful, and emphasize continuing support for patients regardless of their code status. 32 Because the 2013 American Society of Anesthesiologists guideline on ethics uses DNR and anesthesiology practitioners may not be familiar with the new terminology, we continue to use the term DNR. 28 The American Society of Anesthesiologists currently recommends collaborative decision-making with patients and families instead of automatic suspension of DNR status at the time of surgery. 33 Survival after perioperative cardiac arrest with favorable neurologic outcome has been estimated at 25%, higher than survival in other settings. 34 This statistic may affect whether patients decide to keep or rescind their DNR statuses. Providers should educate patients and families, and support and honor the patient’s self-determined decision whether to maintain or temporarily suspend DNR status during the periprocedural period. 34 In order to best honor the patient’s goals and values, options for patients can include a full attempt at resuscitation, limited attempt at resuscitation with specific procedures permitted, or a significantly limited attempt at resuscitation. The desires of many patients may conflict with their documented DNR status, emphasizing the importance of meaningful health care provider–patient discussion surrounding their end-of-life wishes. 35 Patients with palliative care issues highlight the often perplexing issues that arise when these patients require operative procedures to improve their quality of life. 36 Medical students and anesthesia residents need to learn the skills that allow effective elicitation of patient preferences when conducting preoperative DNR status discussions. Education on these important perioperative ethical issues could take place during critical care or general anesthesia rotations and be incorporated into existing didactic material covering cardiopulmonary resuscitation. Three methods of instruction valued by Canadian internal medicine residents when learning palliative and end-of-life topics include direct observation of family meetings with feedback, small group discussion, and video-recorded consultations. 37 Time spent teaching these topics would likely improve trainees’ satisfaction with education and increase their confidence in leading end-of-life and perioperative ethical discussions. 37 Ultimately, this would help promote a culture of patient-centered and empathetic care at the end of life. PROFESSIONALISM In a recent essay entitled, “On the Road to Professionalism, ” author David Chestnut, MD, noted “we have a crisis of professionalism in the practice of medicine. ” Rude, dismissive, and aggressive behavior is common among many physicians. 38 Consequences of poor professionalism are dire. Internal medicine residents who demonstrated unprofessional behavior had a negative impact on their working environment and relationships with other colleagues. 39 Patients are more likely to litigate unprofessional physician behavior can lead to poor working and decrease satisfaction and Unfortunately, residency training focuses more on addressing of professionalism than and professional attention as educators should be on and role modeling desired professional to the Accreditation Council for Graduate Medical Education Anesthesiology these behaviors include (1) to patients, and (2) and ethical behavior; (3) to and (4) and and (5) to maintain and key of an for professional behavior with and faculty educators for positive downstream on medical students and residents could be of these exemplary faculty educators providing opportunities for and with are methods of faculty educators who professional Medical students are required to have structured formal teaching on professionalism and would anesthesiology attending physicians in a favorable as they behaviors of and in clinical practice. 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