Surgeon–patient communication during awake procedures

doi:10.1016/j.amjsurg.2016.06.017

The American Journal of Surgery

Volume 213, Issue 6, June 2017, Pages 996-1002.e1

https://doi.org/10.1016/j.amjsurg.2016.06.017 Get rights and content

Highlights

•
Surgeons make use of diverse strategies for communication during awake procedures.
•
The awake patient's presence impacts surgeons' communication with staff and trainees.
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Surgeons describe challenges in balancing teaching and maintaining patient comfort.

Abstract

Background

Surgeons are increasingly performing procedures on awake patients. Communication during such procedures is complex and underexplored in the literature.

Methods

Surgeons were recruited from the faculty of 2 hospitals to participate in an interview regarding their approaches to communication during awake procedures. Three researchers used the constant comparative method to transcribe, code, and review interviews until saturation was reached.

Results

Twenty-three surgeons described the advantages and disadvantages of awake procedures, their communication with the awake patient, their interactions with staff and with trainees, the environment of awake procedures, and how communication in this context is taught and learned.

Conclusions

Surgeons recognized communication during awake procedures as important and reported varied strategies for ensuring patient comfort in this context. However, they also acknowledged challenges with multiparty communication during awake procedures, especially in balancing commitments to teaching with their duty to comfort the patient.

Section snippets

Methods

Surgeons were recruited from the faculty of 2 Midwestern medical institutions—a university medical center and a university-affiliated hospital system. Using anesthesia billing records and recommendations from department administrators, we identified surgeons performing high volumes of awake or semiawake procedures (over 40 per year) in the departments of General Surgery, Orthopedic Surgery, Obstetrics and Gynecology, Plastic Surgery, Dermatology, Ophthalmology, Neurosurgery, Urology, and

Results

Of the 63 surgeons contacted, 33 agreed to participate and 23 were interviewed before conclusion of the study because of saturation. The interviews ranged from 7 to 57 minutes. Awake surgical procedures specifically referred to by surgeons during these interviews include excisional biopsy, vasectomy, first and second trimester abortion, angiogram, Mohs surgery, eyelid blepharoplasty, nipple reconstruction, cataract surgery (phacoemulsification), dialysis access, lumbar puncture and drain

Comments

In our study of surgeons' perceptions regarding awake procedures, we outline surgeons' views on awake procedures and collate their self-reported strategies for communication in this context. This initial, qualitative inquiry offers a broad, descriptive point of entry into surgeon perceptions and highlights areas worthy of further investigation. In particular, our findings highlight the tensions that exist between a surgeon's duty to care for the patient, efficiently manage the procedure room,

Acknowledgments

The authors thank Dr. Peter Angelos for mentorship and support. The authors also thank Colleen Kelly and Aubrey Jordan for technological contributions.

References (18)

M.D. Nijkamp et al.
Factors related to fear in patients undergoing cataract surgery: a qualitative study focusing on factors associated with fear and reassurance among patients who need to undergo cataract surgery
Patient Educ Couns
(2002)
N. Ambady et al.
Surgeons' tone of voice: a clue to malpractice history
Surgery
(2002)
K. Gnanalingham
Day case hernia repair under local versus general anaesthesia: patient preferences
Ambul Surg
(1998)
K. Malterud
Qualitative research: standards, challenges, and guidelines
Lancet
(2001)
E. Knifed et al.
Moral angst for surgical residents: a qualitative study
Am J Surg
(2010)
F.P. Albino et al.
Putting it all together: recommendations for improving pain management in plastic surgical procedures: hand surgery
Plast Reconstr Surg
(2014)
American Society of Anesthesia House of Delegates. Continuum of depth of sedation: definition of general anesthesia and...
M. Mitchell
Conscious surgery: influence of the environment on patient anxiety
J Adv Nurs
(2008)
A. Palese et al.
The experience of patients undergoing awake craniotomy: in the patients' own words. A qualitative study
Cancer Nurs
(2008)

There are more references available in the full text version of this article.

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: There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs.

: The authors declare no conflicts of interest.

: This work was supported by the Bucksbaum Institute for Clinical Excellence at the University of Chicago, the Summer Research Program at the University of Chicago, and the Operative Performance Research Institute at the University of Chicago.

View full text

Surgeon–patient communication during awake procedures

Highlights

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Comments

Acknowledgments

Patient Educ Couns

Surgery

Ambul Surg

Lancet

Am J Surg

Putting it all together: recommendations for improving pain management in plastic surgical procedures: hand surgery

Plast Reconstr Surg

Conscious surgery: influence of the environment on patient anxiety

J Adv Nurs

The experience of patients undergoing awake craniotomy: in the patients' own words. A qualitative study

Cancer Nurs