The old adage “You never get a second chance to make a first impression” applies daily in the practice of anesthesiology. The field is marked by brief encounters with patients during some of their most stressful life events: before the birth of a child, before a major surgery, or in the face of critical illness. Imagine the same interactions from the patient’s perspective occurring in a foreign land. Global health encompasses medical care, education, research, and policy with the goal of promoting health equity for all. As a field, global health transcends geographical borders to apply to diverse patients of various cultural, ethnic, religious, and socioeconomic backgrounds at home and abroad. Engagement in global health can facilitate culturally sensitive communication and help anesthesiologists quickly establish rapport during the preoperative evaluation and consent process, especially since the approach to informed consent and medical decision-making varies greatly across cultures. Since communication and rapport-building skills are critical for anesthesiologists, having experience with global health outreach can guide interactions with patients from birth to end of life and enhance awareness of differences in language, culture, and belief systems that profoundly impact their medical care. The following examples highlight how important these skills are to all aspects of anesthesiology practice.
Anesthesiologists guard patient safety from the very beginning of life, starting during labor and delivery. Eliminating maternal and early neonatal mortality is one of the UN’s Sustainable Development Goals for 2030 (asamonitor.pub/3IgnzRn). Cesarean sections are conducted in 5%-15% of pregnancies worldwide, according to the World Health Organization (Monitoring emergency obstetric care: a handbook. 2009). The skills gained from global health engagement are readily applicable in obstetric care, where taking the time to understand a patient’s expectations and goals for delivery in the context of their cultural beliefs is paramount. For instance, many cultures embrace the strength of a woman and “heroism” through labor pain and may discourage any form of labor analgesia, especially invasive procedures like epidurals (Pain Manag Nurs 2003;4:145-54). The individual patient’s desires for labor analgesia may be overshadowed by family members in certain patriarchal or matriarchal societies, often due to a limited understanding of what treatment options entail or associated risks and benefits. To prepare patients to navigate these obstetric decisions, anesthesiologists can collaborate with obstetricians to develop inclusive and culturally sensitive pre-delivery educational programs. By investing in the time to understand family dynamics and educating obstetric patients and their families about anesthetic and analgesic options, anesthesiologists can establish rapport to improve health outcomes and the overall patient experience.
In many practice settings, anesthesiologists encounter patients who speak different languages or dialects, whether that is a Spanish-speaking patient in Texas or a Maasai-speaking patient in Tanzania. This is particularly relevant in obstetrics, where most patients are awake for the entire clinical experience. Parturients who do not speak the local language often struggle to communicate their needs and therefore lose the ability to advocate for themselves, impacting their safety and well-being. Language barriers with patients can be improved by using resources available through the hospital, such as language interpretive services or assistance of providers who speak the patient’s native language. In-person, phone, or video interpretive services can facilitate the discussion of options for labor analgesia or neuraxial anesthesia during a Cesarean delivery. In our practice, patients are given the option to continue the phone call with the interpreter during the Cesarean section as it creates a real-time channel of communication throughout the procedure and empowers both patients and anesthesiologists to work together toward better health outcomes. Anesthesiologists can gain competency with diverse cultural, racial, ethnic, and geographic groups through cultural humility and encouraging patients to express their values in a safe and nonjudgmental space using their native language (J Contin Educ Health Prof 2013;33:164-73). Indeed, experience with global health education can assist anesthesiologists in navigating these common obstetric interactions to enhance patient comfort and safety during this memorable – yet critical – period of their lives.
Major surgeries throughout life
Major surgeries are another important time point in a patient’s life where anesthesiologist engagement in global health can enhance patient-centered care. The physician-patient relationship is established during the initial evaluation and consent process prior to surgery. Medicine in the United States has transitioned from paternalistic to shared decision-making; however, globally there are different models of the physician-patient relationship. The ethical and legal emphasis in the U.S. celebrates patient autonomy and informed consent, which requires the full disclosure of information regarding patients’ diagnosis and prognosis, risks and benefits of all treatment options, and the ability to choose or opt out of any treatment without coercion. This ethical ideal requires physicians to be detailed and forthcoming about fatal illnesses and poor prognosis. However, emerging evidence has shown that the focus on autonomy might be overly narrow and that patients of certain cultures may prefer a broader rather than detailed approach to informed consent (JAMA 1995;274:820-5). In a recent case at our institution, an elderly patient with cardiac comorbidities was scheduled for a procedure under monitored anesthesia care. She had long been cared for by her proceduralist, had previously declined to be informed regarding the details of her prognosis and procedures, and had designated her son as the durable power of attorney. The well-meaning anesthesiologist attempted to consent the patient directly, leading to conflict with the family and a request for a different anesthesiologist. This could have been avoided with clearer documentation and understanding of the patient’s wishes. For example, the anesthesiologist may have asked, “Some of my patients prefer a more detailed explanation of the risks and benefits of the procedure, while others prefer to have a more general overview. Which would you prefer?” While physicians are encouraged to respect patient autonomy in all cultures, autonomy can extend to the patient’s right to refuse to know the details of a diagnosis or procedure directly and may prefer the information be discussed with their family instead. Therefore, asking individuals within these cultures open-ended questions about their understanding of the disease process, such as Arthur Kleinman’s Eight Questions, and about their preference for medical details can help anesthesiologists navigate these situations (Ann Intern Med 1978;88:251-8).
“Since communication and rapport-building skills are critical for anesthesiologists, having experience with global health outreach can guide interactions with patients from birth to end of life and enhance awareness of differences in language, culture, and belief systems that profoundly impact their medical care.”
Critical care and end of life
Anesthesiologists support patients throughout the course of their lives, including in the critical care and palliative settings at the end of life. Global health experiences can highlight the diverse cultural, religious, and ethical beliefs that inform patient and family approaches to life-threatening illness. Studies have shown that some cultures, such as Korean American, Mexican American, and Haitian, prefer a family-centered approach where details about diagnosis and prognosis are only given to family members and not directly to patients (JAMA 1995;274:820-5). This is believed to cause less anxiety and emotional suffering for the already ill patient. In these cultures, physicians who share a poor prognosis only to a trusted family member may be seen as compassionate, whereas physicians who deliver news of terminal illness directly to the patient may be seen as unempathetic and detached. Developing early rapport, encouraging patients to express their medical decision-making preferences in the context of their values, and understanding family relationships can lead to mutual respect between anesthesiologists and their diverse patients. Ultimately, the normalization of these considerations can improve health equity for all patients at all life stages.
Global health encompasses caring for patients of diverse cultural, religious, ethnic, and linguistic backgrounds and promoting equitable access to safe and effective health care. Engagement in global health helps anesthesiologists understand and work with these differences and develop skills that can be applied to providing anesthetic care for diverse populations in our local communities and when engaged medically abroad. Place of origin and upbringing can dramatically impact patients’ experience of pain, perspectives on birth and death, and willingness to be guided by or to question their physicians. Taking the time to communicate using interpreters, to learn how patients perceive medical information in the context of their background, and to understand their approach to decision-making for anesthetic and surgical care are critical to establishing trust. This trust allows patients to share symptoms, advocate for themselves, and overall receive more equitable health care. Breaking down the traditional hierarchy of the physician-patient relationship allows anesthesiologists to position themselves as patient allies. Whether in a low- or high-resource setting, cultural competency plays a vital role in anesthesiologists’ ability to engage patients and deliver a positive experience. While global health is not a requirement in anesthesiology residency training in the United States, it may be available as an elective to help in gaining cultural competency in patient care. Anesthesiologists interested in enhancing cultural competency can also use resources such as the Tool for Assessing Cultural Competence Training (“TACCT”) from the Association of American Medical Colleges and the e-learning program A Physician’s Practical Guide to Culturally Competent Care from the U.S. Department of Health & Human Services (asamonitor.pub/3jJJG9H; asamonitor.pub/3IhuQRd). Citizenship in the global medical community and advocacy of health equity can reduce health care disparities for low-resource populations abroad and for patients at home.