Communicating in Specific Contexts is the third of a four-part series that provides more information about ASA’s Enhancing Patient Communications Program.
Although most physicians feel confident that they treat patients equally, preconceived notions bias our interactions, and we may not even be aware of them. Patients may also experience the same unconscious bias in their interactions with us. A review of 42 studies published in BMC Medical Ethics found that health care professionals exhibit the same level of implicit bias as the wider population and that this bias reduces quality of care.
Recognizing that we make assumptions and then challenging those assumptions is difficult, but it is vital to ensuring we are providing high-quality care that leads to good outcomes. The Enhancing Patient Communications Program toolkit was developed to provide anesthesiologists with resources to enhance patients’ experiences, focusing on communicating with them as individuals and giving them the respect they deserve. The section on Communicating in Specific Contexts offers insights for providing patient-centered communications, including culturally competent care. It also addresses communications relating to seniors, children, pregnant women, and those who experience chronic pain, as well as interactions using telehealth and patient encounters during COVID-19.
As part of the ASA Committee on Communications subgroup that helped to develop the toolkit, and as an anesthesiologist and intensivist, I am passionate about acknowledging and mitigating unconscious bias. It is something I strive to improve every day. The following insights and recommendations can help all of us reflect on conversations we’ve had with patients, question our assumptions and approaches, and specifically tailor our communications based on the needs of various patient populations.
Providing culturally competent care
This section of the toolkit delves into the need to focus on being aware of your biases and reflect on them to develop cultural humility. The consequences of not doing so are very real. Research shows, for example, that racial bias in pain management results in Black Americans being systematically undertreated for pain relative to whites due to falsely held beliefs about their biological differences.
Understanding and addressing your biases takes reflection of how a situation might have been managed differently. I can recall one patient who suffered several gunshots to the abdomen and needed surgery. He refused lifesaving surgery despite several health care providers telling him it was necessary. He didn’t want the surgeon “cutting him up.” It wasn’t until a physician went to the patient’s ICU room, pulled up a chair, sat down with him eye to eye, and calmly explained the need for surgery in simple terms that he finally agreed. Did he like to cook? What sort of foods did he like to cook? Did he want to eat again? The physician spoke calmly, was empathetic, got to know him a bit, and was able to garner his trust. No doubt the other physicians wanted what was best for the patient, but by making assumptions about him they failed to garner his trust, reach his level of understanding, and connect with him in a meaningful way, and so were unable to convince him of this necessary care. This is a real consequence of unconscious bias.
It’s important to think about the patient’s needs in terms of cultural, religious, or spiritual beliefs or practices that may influence their care and tailor communications appropriately. Providing this care includes ensuring a translator is present if needed and providing patient education materials in languages that reflect your patient population. It’s also important to advocate for your system to become culturally competent, including ensuring health care providers receive cultural competence training and advocating for the recruitment of providers who reflect your patient population.
Because I am a Veterans Affairs (VA) physician, many of my patients are seniors. Every situation is different – sometimes patients don’t want their caregivers or children to know what’s going on, so maintaining their privacy is important. In other cases, the caregiver is directly involved, so although I speak directly to the patient, I incorporate the caregiver in the conversation, too.
Addressing postoperative delirium is key in this patient population, especially after painful surgeries that require opioids and mind-altering drugs. I’ll tell family members that “postoperative delirium is a very real thing, and it’s important to understand these concerns because your loved one is not going to realize they are confused.” I tell them about the risk of accidental suicide and note that any firearms need to be locked up, especially if the patient is left alone. I let them know post-op delirium can last for a week after surgery, and sometimes longer.
When discussing anesthesia with a child’s family, it helps to break the ice with the child first. I don’t work with children anymore, but when I did, I would incorporate play. For example, when taking their blood pressure, I would say, “I’m going to put a muscle tester on your arm to see how strong you are.” I’d bring out the mask and bag and let them practice “blowing up the balloon.” I’d incorporate the parents, too, having them do it first, which typically makes the child more comfortable doing it themselves.
It’s important to put parents at ease, as well as the child, by explaining what will happen. For older children, including them directly in the discussion helps form a connection.
When discussing labor pain management with pregnant patients, it’s important to offer options, not decisions. When I cared for pregnant patients, I always approached the conversation by recognizing that I was caring for two patients, and I was sure to acknowledge their concerns not just about themselves, but their baby, too.
I often had pre-labor visits with patients, which was particularly important for those who had received limited medical care before they got pregnant. The pre-labor visit offers the opportunity to fully assess their health and provide the comprehensive care they had not previously received. Checking on the patient early in labor – before they are even asking for pain management – gives you the opportunity to demonstrate your compassion.
I work with many Veterans who have chronic pain, and they are a vulnerable population. Because they visit the pain clinic frequently, I develop a rapport with them, which helps ensure they have the best outcomes. I usually start with a nonmedical question. For example, I’ll say, “Have you done any fishing lately? Where did you go?” It takes two minutes and really helps develop trust.
Employing motivational interviewing is important with this group. I ask open-ended questions, ensuring I am talking with them, not at them or down to them. We talk about the risks of opioids. It’s important to avoid assumptions that those who are taking the drugs want to do so. In fact, I’ve found many fear that physicians may be promoting opioids to get them addicted. I assure them that we are very diligent about creating a pain management plan that works best for them, takes into account all of their concerns, and is safe.
Provide telehealth when applicable
Since the pandemic, telehealth has become an important and convenient approach to delivering quality care, even in the anesthesiology department. But it’s important to emphasize that in-person care may be needed to address ongoing questions. It’s vital to understand the technology (for example, knowing where the “mute button” is) and options available so the patient can have a smooth experience.
It’s important to reassure the patient that the conversation is private and that no one is listening to the meeting offscreen. The same communications principles for in-person consultations apply to telehealth as well – make eye contact and acknowledge when they have a question or concern, remembering you’ll need to look at the computer camera, not the person on your screen. I’ll say, “I need to write something in your chart” and then make eye contact with them as soon as possible afterward.
“Although most physicians feel confident that they treat patients equally, preconceived notions bias our interactions, and we may not even be aware of them.”
COVID-19 safety protocols are always evolving, sometimes changing weekly. It’s difficult for health care providers to keep track, so I can’t imagine how hard it is for patients. I try to keep an open mind and be flexible with patients, understanding if they are frustrated. I empathize by telling them I understand how confusing it is, which helps mitigate their frustration. For example, I’ll say, “I completely understand where you are coming from, and this is frustrating to us as well. Unfortunately, we have to follow these guidelines and policies that have been put forth in the best interests of all of us. We all hope it will get better soon.” It’s especially important to acknowledge the challenges of limited visits from family members. That support is so important for well-being.