A Survey of 800 Patients’ Knowledge, Attitudes, and Concerns Regarding Anesthesia Ketan Shevde, MD, and Georgia Panagopoulos, PhD Department of Anesthesia, Maimonides Medical Center, Brooklyn, New York
The present study was undertaken to assess patients’ knowledge, attitudes, and concerns regarding anesthetic management. A survey of 34 items was developed and administered preoperatively to 800 consecutive patients. Included were 303 men and 497 women with a mean age 52 yr and a mean educational level of 12 yr. Patients were interviewed on their knowledge of the role and training of anesthesiologists and on their preferences regarding anesthetic management. Patients also rated the intensity of their concern on 20 written statements expressing potential anesthetic complications. Results indicated that patients’ perceptions of the anesthesiologist’s training and role were accurate. Most patients preferred (a) general to regional anesthesia and (b) not to select their own anesthesiologist. Most significant preoperative concerns regarding the anesthesiologist focused on experience, qualifications, and presence
A
good anesthesiologist-patient relationship established during the preoperative visit re,duces patient anxiety (1-3). This can be achieved by informing patients about their anesthetic management and addressing their specific concerns regarding anesthesia. Although a personal interview with the patient decreases anesthesia-related anxiety, few efforts have been directed at identifying the patients’ greatest concerns. Only one recent study has assessed, and that only peripherally, patients’ preference for anesthetic procedures and their preoperative fears (4).Results of that survey indicated that the majority (93%) of the patients preferred general anesthesia induced by intravenous injection. A large number (40%))of patients feared either postoperative pain or surgical complications (25%).Anxiety regarding the anesthetic procedure centered primarily on (a) fear of not waking up again, (b) waking Accepted for publication April 10, 1991. Address correspondence to Dr. Shevde, Department of Anesthesia, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219.
190
Anesth Analg 1991;73:1 9 M
or absence during the anesthesia. Patient concerns also included the possibility of not waking up postoperatively, experiencing pain, and becoming paralyzed, Intensity of concern was inversely related to age and unrelated to educational level or occupation. Variables related to type of concern included patient’s sex, type of anesthesia, and proposed surgical procedure. Issues of least concern included disclosure of personal matters during anesthesia, experiencing impaired judgment postoperatively, and being asleep or bedridden for a prolonged period of time. It is suggested that anesthesiologists address significant patient concerns during the preoperative visit to enhance their effectiveness in patient care. Efforts to educate the public on the anesthesiologist’s role in perioperative care should improve patient confidence. (Anesth Analg 1991;73:1904)
up during the operation, (c) being unconscious, and (d) disclosing personal matters. The present study was conducted to assess patients’ knowledge about anesthesiologists and anesthetic management as well as their specific concerns about anesthesia. This information is essential for an effective preoperative visit.
Methods Patient Population The study was approved by the hospital’s human research committee. All patients scheduled for surgery were included in the study. Excluded were patients who refused to participate or were unable to answer questions because of poor medical condition or inability to understand English. The study was based on responses to 34 questions designed to assess the patients‘ perceptions, fears, and concerns relating to anesthesia. The questions, with input from 19 staff anesthesiologists, included ones commonly asked during preoperative visits. The initial section of the survey, oral in nature, was 01991 by the International Anesthesia Research Society 0003-2999/91/$3.50
ANESTH ANALG 1991;731W
SHEVDE AND PANAGOPOULOS PATIENT KNOWLEDGE, AlTITUDE, AND CONCERNS PREOPERATIVELY
administered by interviewers and included openended questions inquiring about patients' objective knowledge of the role and training of the anesthesiologist as well as their preferences regarding anesthetic procedures (i.e., "what is the role of the anesthesiologist?," "how many years of medical and residency training do you think your anesthesiologist has had?," "if you were to choose, what type of anesthesia would you prefer?," "would you like to choose your own anesthesiologist?"). Additionally, patients were questioned about their past surgical history and exposure to anesthetic procedures as well as whether they had been contacted by an anesthesiologist during this hospitalization. Finally, patients were asked the open-ended question "what are you most concerned about?" in an attempt to elicit their primary concerns with minimal prompting. Subsequent to the completion of the oral part of the questionnaire, patients were presented with 20 written statements expressing concerns about potential complications associated with anesthesia. These included survey items 9 through 28 and are presented in the Appendix. Patients were asked to rate, on their own, the intensity of their concerns on a five-point Likert scale. A Likert scale is one in which the patient is asked to respond to written items in terms of degree of reaction. The ratings were as follows: 1= not at all, 2 = somewhat, 3 = moderately, 4 = very much, 5 = extremely. For discretionary reasons, direct questions relating to death were purposely excluded to prevent undue patient anxiety. Finally, patients rated their confidence in the anesthesiologist and surgeon on the same scale and the relative importance of these two speQalists as well as that of their medical doctor in their total perioperative me. The latter was rated on a IO-point scale ranging from 0 = not at all to 10 = extremely important. Patients required approximately 15 min to complete the questionnaire. All patients scheduled for surgery were contacted by one of three trained interviewers within the 24 h before surgery. Ambulatory and hospitalized patients were included in the study. To safeguard against sensitizing the patients to potential anesthetic complications, interviewers remained present throughout the entire administration of the survey to reassure patients as needed.
Stat istical Analyses A coding guide for the survey items was developed to aid in the transcription of the survey data into a computer file. Accuracy of data entry was checked by examining the frequency of out-of-range coded responses on all survey items. This revealed a very low error frequency ranging from 0% to 0.4%.Statistical analyses were performed using BMDP (a biomedical statistical software package). Descriptive statistics
191
(i.e., measures of central tendency, frequency distributions) were obtained on patients' demographics, knowledge of the role and training of the anesthesiologist, patient preferences regarding anesthetic management, and the type and intensity of their concerns. Patients' preferences for anesthetic procedures were coded as 1 = general, 2 = local, and 3 = spinallepidural. We used the term "local anesthesia" to reflect both local infiltration and major peripheral nerve blocks, and "regional anesthesia" to reflect both local and spindepidural anesthesia. Correlational and $-analyses were performed to examine the relationship between patient demographics (i.e., age, sex, educational level) and history variables (i.e., previous experience with anesthesia, having seen the anesthesiologist preoperatively, type of anticipated anesthesia and surgery) and patient concerns. Furthermore, patients' responses on the intensity of preoperative concerns were factor-analyzed using a principal factoring with iteration and orthogonal rotation. The factor analyses were run to determine whether specific factors/dimensions existed describing these Concerns. Finally, independent-samples t-tests were used to evaluate the relative importance of the anesthesiologist compared with other medical specialists, as perceived by patients. A P < 0.05 was accepted as statistically significant.
Results Pa tien t Characteristics Patient population consisted of 800 consecutive consenting adults undergoing elective major and minor surgery in a large metropolitan tertiary care hospital. Ambulatory patients comprised 30% of the total population. Subjects included 303 men and 497 women (mean age, 52 yr) with a mean educational level of 12 yr. Two percent of the patients refused to participate in the study. Although most patients answered all of the survey questions, the number of patients cited in the analyses may vary because of two factors: first, because of the addition of items on demographics and, second, because of missing data from incomplete surveys submitted by a few patients. Twenty-six percent of the patients were scheduled to undergo gynecologic procedures, 18% orthoped~c,15% genitourinary, 8% colorectal, 7%gastrointestinal,3%open heart, and 23% various other procedures. Figures 1 and 2, as well as Table 1, present results on the ethnic and occupational backgrounds of the respondents.
Perceptions of the Anesthesiologist's Training and Role Patients' perceptions of the medical school and residency training of anesthesiologists were, for the most part, accurate. Patients indicated that anesthesiologists
192
ANESTH ANALG
SHEVDEAND PANACOPOULOS PATIENT KNOWLEDGE, A‘ITITUDE, AND CONCERNS PREOPERATIVELY
m
--\
1991;73190-8
w1m
1
O3
Figure 3. Perception of the anesthesiologist’s role (n = 800): % patients.
Figure 1. Demographic data (n
=
450): ethnicity (%).
Table 2. Ability to Choose the Anesthesiologist (n = BOO)
Figure 2. Demographic data (n = 450): employment status (a).
Table 1. Demographic Data (n
=
279)”
Occupational level Executive/professional Business manager Administrative personnel Clericdsaledtechnicians Skilled manual Semi-skilled Unskilled Other
Percent 1
3 21 42 14 13 1 5
Patient prefers to make a choice
% Patients
Reasons
%
Yes
23
No
77
Patient should control choice Patient needs recommendation Patient does not know any Patient leaves decision to surgeon It does not matter Patient not qualified to
17 6 40 14 14 9
that ascribed to the surgeon preoperatively (mean, 4.47; SD, 0.80; t-test (617) = -15.49; P < 0.001). When patients were asked about the relative importance of the anesthesiologist, the surgeon, and the medical doctor in the total perioperative care, they rated the significance of the anesthesiologist as being at the same level as that of their medical doctor [t-test (522) = -1.61, P = 0.101. Ratings of both specialists were significantly lower than those assigned to surgeons [t-test (527) = -5.52, P < 0.001 for the comparison between anesthesiologists and surgeons and t-test (527) = -5.62, P < 0.001 for medical doctors and surgeons].
~
“Reflects62%of patients (42%employed and 20%retired).
spend a mean of 4.8 yr in medical school (SD = 1.4). Mean number of years spent in residency training was perceived to be 4.0 (SD = 1.9). Median and mode scores for each variable were 4.0. Figure 3 presents patients’ perceptions of the anesthesiologist‘s role. Overall, patients’ ratings of their confidence in the anesthesiologist preoperatively fell into the “very high” level (mean, 3.97; SD, 1.07; range, 1-5). No sigruficant differences were observed in confidence ratings of patients who had seen an anesthesiologist before providing a rating and those who had not seen one [t-test for independent samples (616) = 1.21, P > 0.101. Confidence ascribed to the anesthesiologist, though very high, was significantly lower than
Patients’ Preferences for Anesthetic Management The vast majority of patients (77%)were reluctant to select their own anesthesiologist primarily because they did not know any (40%), believed they were unqualified to do so (9%),or because it did not matter to them (14%). Fourteen percent of the patients believed that their surgeon would make that decision. Among the 23% of the patients who preferred to choose, 17% expressed a desire to have complete control of such a choice and 6% preferred to choose only if they knew an anesthesiologist or if one was recommended to them. These results are presented in Table 2. Sixty-nine percent of the patients preferred to have general anesthesia so that they would not seelfeel anything (66%)or because they believed spinal anes-
ANESTH ANALG 1991;73:1W
SHEVDE AND PANACOPOULOS PATIENT KNOWLEDGE, ATTITUDE,AND CONCERNS PREOPERATIVELY
193
Table 3. Issues of Concern (n = 8001 % Patients indicating
highest levels of concern m,
WAXC UP
Figure 4. Fearskoncerns expressed spontaneously by patients (n = 612): 9i patients.
Highest concern Anesthesiologist's qualifications Experience of anesthesiologist Being unable to wake-up postop Postop pain Anesthesiologist present in OR Patient becoming paralyzed Pain medications available
45 43
37 34 32 32 28
Moderate concern Fear of the unknown Waking up in the middle of surgery Nervous of hospital environment Postop nausea Anesthesiologist's manners Staying in ICU
25 24 22 22 22 21
thesia to be dangerous (3%).Twenty-two percent of the patients expressed a preference for local anesthesia because they wished to remain awake and aware throughout the procedure (13%)and to avoid side effects of general anesthesia (9%). Only 9% of the Least concern patients preferred either spinal or epidural anesthesia Being unconscious 19 Prolonged sleep postop 18 in order to remain awake and aware. Being bedridden 16 A 3x4 ?-analysis investigating whether type of Fear of needles 13 anesthesia experienced in the past was related to 12 Impaired judgment current preferences revealed that patients tended to 11 Clarity of thought prefer the type of anesthesia they had had in the past. 6 Disclosing personal matters That is, more patients who had received general OR, operating room; ICU, intensive care unit. anesthesia preferred general and more patients who had received spinal anesthesia preferred spinal (2factors was examined further to determine whether test (6) = 92.8, P < 0,001 [n = 5471). The number of patients who had had local anesthesia or combina- the variables loaded highly on the appropriate factor. Most of the variables did load on the appropriate tions of types of anesthesia was too small to yield factor as expected. Table 4 presents the items comvalid results. prising each factor and item loadings. Based on these Among the 254 first-time surgical patients, there was a strong preference for general anesthesia (72%), results the scores from each item were added tofollowed by local (22%) and spinallepidural (6%) gether to form four additional variables describing the above-reported dimensions. anesthesia. This finding mirrored the preferences of the total population. ~~
~~~
~
~~
Correlates of Patients' Preoperative Concerns Patients' Preoperative Concerns Patients' concerns regarding anesthetic management were assessed in two ways: first, patients were asked the open-ended question "what are you most concerned about?' Their responses are presented in Figure 4. Second, patients were asked to rate the degree of their concern on 20 written statements specific to being hospitalized and receiving anesthesia. Table 3 presents in a descending order the percentage of patients who assigned "very much" or "extremely" levels of concern to these areas of anesthetic management. These items were classifted into three categories: issues of highest, moderate, and least concern. Factor analysis of preoperative concerns yielded four factors: (a) specific complications of anesthesia, (b)characteristics of the anesthesiologist, (c) anxiety about being hospitalized, and (d) pain. Each of these
Patient demographics. Pearson product moment and rank order correlation coefficients were computed between the patient's age, educational and occupational level, and degree of concern expressed on the above areas of anesthetic management. Table 5 presents these results. Overall, age showed a statistically significant, but weak inverse relationship with concern. That is, older patients tended to have lower levels of concern. Patients' educational level and occupation were not sigruficantl related to degree of concern. A 2 x 4 AJ -analysiswas performed investigating the effects of sex on patients' responses to the question "what are you most concerned about?" Type of concern was dependent on the patient's sex. More women were concerned about not waking up postoperatively, whereas more men were concerned about experiencing intraoperative and postoperative pain [?-test (3) = 18.98, P < O.OOl]. There was no
194
ANESTH ANALG 1991;73:190-8
SHEVDE AND PANAGOPOULOS PATIENT KNOWLEDGE, ATTITUDE, AND CONCERNS PREOPERATIVELY
Table 5. Correlations Between Patient's Demographics and Intensitv of Concern
Table 4. Factor Analyses of Patients' PreoDerative Concerns
~~
Factor
Item loading
Spedfic anesthesia complications (factor 1) Impairment in judgment Clarity of thought Prolonged sleep postop W i g bedridden Being put unconscious Becoming paralyzed Staying in ICU Being unable to wake up postop Disclosure of personal matters Postop nausea
0.772 0.763 0.756 0.660 0.635 0.613 0.613 0.581 0.471 0.463
Anesthesiologist's characteristics (factor 2) Anesthesiologist's qualifications Anesthesiologist of experience Anesthesiologist present in OR Anesthesiologist's manners
0.875 0.842 0.772 0.634
Anxiety about hospitalization (factor 3) Nervous of hospital environment Fear of unknown Fear of needles
0.831 0.813 0.613
Pain (factor 4) Pain medications available Postop pain Waking in middle of surgery
0.828 0.813 0.436
ICU, intensive care unit; OR, operating room.
difference between men and women on expressing no concern." Moreover, independent-samples t-test analyses on the four new factors were performed to determine whether there were any differences between men and women on the level of concern they expressed preoperatively. Overall, women tended to express sigruficantly higher levels of concern on all four factors: specific anesthesia complications [t-test (796) = -4.35, P < 0.001]; generalized hospital anxiety [t-test (797) = -8.08, P < 0.001]; the anesthesiologist's characteristics [t-test (795) = -2.12, P < 0.031; and pain [t-test (796) = -3.13, P < 0.011. Table 6 presents the means and standard deviations for these analyses. II
Patient history vuriubZes. $-Analyses were performed to investigate the effects of past experience with anesthesia, type of anesthesia experienced, preoperative contact by an anesthesiologist, and type of anesthesia and surgery expected on the four spontaneously expressed categories of concern. To hold down the increase in error rates due to multiple comparisons, a more stringent a-level of 0.01 was set. Neither previous experience with nor type of past anesthesia appeared to be related to patients' concerns [?-test (3) = 2.59, P= 0.46 and $-test (9) = 8.47, P = 0.48, respectively]. As 61% of patients had seen their anesthesiologist before completing the
Age Education Rank (n = 508) (n = 5-8) (n = 261) Highest concern Anesthesiologist's qualifications Experience of anesthesiologist Being unable to wake-up postop Postop pain Anesthesiologist present in OR Patient becoming paralyzed Pain medications available
-0.02 -0.05 -0.07 -0.08
-0.11
-0.09 -0.21" -0.18" -0.07 -0.21"
-0.07
Moderate concern Fear of the unknown Waking up in middle of surgery Nervous of hospital environment Postop nausea Anesthesiologist's manners Staying in ICU
-0.12" -0.21" -0.14' -0.19" -0.18" -0.19"
Least concern Being unconscious Prolonged sleep postop Being bedridden Fear of needles Impaired judgment Clarity of thought Disclosing personal matters
-0.19" -0.14" -0.12" -0.1Q -0.09 -0.11 -0.21"
-0.01 -0.01 -0.06
-0.04
-0.06 -0.08
-0.10 -0.01
-0.02 -0.02
-0.11
-0.01
-0.09 -0.00
0.01 0.10 -0.02 0.09
-0.03 -0.04 -0.04
0.16" 0.07 0.07 0.04 0.09 0.05 0.09
0.00
-0.12 -0.08 -0.16" -0.07
-0.05 -0.08 -0.06
OR, operating room; ICU, intensive care unit. "P < 0.01.
Table 6. Preoperative Responses on Factors by Patient's Sex Male
Female
Variables
Mean
SD
Mean
SD
t
Specific anesthesia complications Anesthesiologist's characteristics Anxiety about hospitalization Pain
1.95
0.88
2.25
0.99
-4.35'
2.52
1.24
2.72
1.34
-2.12b
1.91
0.88
2.49
1.02
-8.08"
2.37
1.01
2.62
1.14
-3.13'
"P 5 0.001. 'P 5 0.05. L.P
5
0.01.
survey, a 2x4 $-analysis was performed to determine whether frequency of concerns was dependent on having seen an anesthesiologist preoperatively. The result was not statistically significant [?-test (3) = 5.68, P = 0.131, indicating that the frequency of four types of responses (no concerns, unable to wake up, and experiencing pain intraoperatively and postoperatively)was not dependent on such preoperative contact. Patients' responses, however, depended on the type of anesthesia (general, local, spindepidural) and the type of surgery (ambulatory vs inpatient) expected.
ANESTH ANALG 1991;7319C-S
SHEVDE AND PANAGOPOULOS PATIENT KNOWLEDGE, ATTITUDE, AND CONCERNS PREOPERATIVELY
More patients expecting general anesthesia were concerned about not waking up postoperatively and fewer of them were concerned about ex riencing pain intraoperatively and postoperatively [ -test (6) = 39.86, P < 0.0011. The reverse was true for patients expecting local or spindepidural anesthesia; more of them were concerned about intraoperative and postoperative pain. Consistent with this, patients undergoing major/ nonambulatory surgery expressed these concerns more frequently and were less likely to deny any concerns [?-test (3) = 42.7, P < O.OOI~.Ambulatory patients were concerned about postoperative pain more frequently than expected by chance.
F
Discussion This study was conducted to gain insight into patients’ perception of anesthesiologists and anesthetic management. The majority of patients perceived the anesthesiologist’s education and training accurately. Although some of the primary functions of the anesthesiologist were described correctly to include putting the patient to sleep, relieving pain, and administering medication, only 5% of the patients were aware that the anesthesiologist plays an important role in monitoring vital signs and maintaining normal hemodynamics throughout the operation. It appears that some patients are not sure what the anesthesiologist’s functions are once the induction of anesthesia is completed. Hence the perception that the anesthesiologist might not be in attendance throughout the operative procedure is prevalent. It is interesting to note that most of the patients (69%)had a strong preference for general anesthesia instead of regional anesthesia, especially as the latter is on the increase nationally. Patients preferred general anesthesia whether they had received it in the past or not. When questioned about their concerns, most patients spontaneously expressed fears of not waking up postoperatively and experiencing intraoperative or postoperative pain or some type of postoperative disability. Concerns about the anesthesiologist’s qualifications, experience, and continual presence in the operating room were only expressed when patients were specifically asked to comment on them. We would have to assume that these were not of foremost importance to the patients. Direct questions on death were omitted from the questionnaire to avoid undue patient anxiety. Information on this issue was obtained indirectly in two ways. First, in examining the intensity of their concern in the survey item “being unable to wake up postoperatively” and, second, in the frequency of answers relating to inability to wake up provided spontaneously by the patients to the open-ended question “what are you most concerned about?” Finally, our observation of
195
the patients’ preference for general anesthesia and the frequency of concerns such as being unable to wake up postoperatively and experiencing pain were consistent with the results obtained in the study by Elsass et al. (4). Previous experience with anesthesia and having been interviewed by an anesthesiologist preoperatively were not related to patients’ spontaneously expressed concerns. Overall, patients anticipating majorhonambulatory surgery expressed more concerns than expected by chance. Ambulatory patients were primarily Concerned about experiencingpostoperative pain. Consistent with this, patients anticipating general anesthesia were more frequently Concerned about not waking up, whereas patients anticipating regonal anesthesia were more concerned about experiencing intraoperative and postoperative pain. Women were more concerned about not waking up postoperatively, whereas men were more concerned about experiencing pain. Women tended to report significantly higher levels of concern on all variables than men. This difference may be attributed to sex role socializationwhich emphasizes decreased fear expression in males. It may be suggested that the lower concern levels expressed by men could be an artifact of the assessment method used and that the use of a clinical interview with a trained psychologist might have resulted in men ”accurately” reporting more concern. We contend that this is not so. Both questionnaires and clinical interviews are based on patients’ self-report. Therefore, it is likely that the factors that influence men’s self-report operate equally when they answer a questionnaire and during a clinical interview. Such an interview, however, can be designed to yield the “expert’s” rating on the patient’s level of concern, which may more accurately reflect “reality” because it is based on the patient’s self-report as well as the expert’s behavioral observations of the patient (5).Unfortunately, the size of our study made it prohibitive to have such interviews. Regarding our recommendations, as it remains unclear whether men were “truly” less concerned or just reported so, it seems important that the anesthesiologist be aware of this possibility and appropriatelyaddress indications of even low concern levels in men. Despite the significance assigned to the anesthesiologist’s qualifications, an overwhelming number of patients (77%) were reluctant to select their own anesthesiologist primarily because of their unfamiliarity with anesthesiologists and lack of ability to select an anesthesiologist. Fourteen percent of the patients left such a decision to the surgeon because they believed that the surgeon would make the best choice for them. Apparently, patients were unaware that the choice of the anesthesiologist does not always lie with the surgeon. In addition to gaining knowledge by identifying the patient’s fund of information, attitudes, and
196
ANESTH ANALG
SHEVDE AND PANAGOPOULOS PATIENT KNOWLEDGE, ATTITUDE, AND CONCERNS PREOPERATIVELY
concerns regarding anesthetic management, the results of this study idenhfy issues the anesthesiologist ought to focus on during the preoperative visit. We believe that the anesthesiologist should specifically address patients’ concerns regarding waking up and experiencing pain and inform them about the anesthesiologist’s role in monitoring vital signs and maintaining normal hemodynamics. It seems important to inform patients that the anesthesiologist is, in fact, the internist in the operating room.
1991;73:19&8
Moreover, there seems to exist a need to educate the patients and the general public about the role of the anesthesiologist in the perioperative care of the patient. This may narrow the gap in the confidence levels that the patients ascribed to the surgeon relative to the anesthesiologist. Future efforts directed at improving our communication with patients and increasing our exposure in the community via newspaper reports and lectures should achieve higher levels of patient confidence in the anesthesiologist.
Appendix: Patient Survey NAME:
AGE:
TYPE OF OPERATION: TYPE OF ANESTHESIA
SEX: DATE:
REGIONAL
LOCAL
GENERAL
EDUCATION
We are interested in finding out your perceptions of and attitudes toward anesthesia and the role of the anesthesiologist. Please answer the following questions to the best of your ability. 1. What, in your opinion, is the role of the anesthesiologist?
lb) Are they doctors?
Yes
No
2. How many years of medical training do you think your anesthesiologist has had?
Number of years of medical school education
1 2 3 4 5 6
Number of years of residency training
I 2 3 4 5 6
3. Have you had an operation requiring anesthesia in the past?
Yes
No
4. Type of surgery
Date of surgery
5. Under what type of anesthesia did you have your surgery? General
Spinal
Local
6. If you were to choose, what type of anesthesia would you prefer? Spinal Epidural Local General (asleep and completely unconscious). Why?
6b) If the anesthesiologist recommended a different type of anesthesia would you agree or disagree with him? Agree Disagree 7. Would you like to choose your own anesthesiologist?
Yes
No
Please circle one
Why
SHEVDE AND PANAGOPOULOS PATIENT KNOWLEDGE, ATI'ITUDE, AND CONCERNS PREOPERATIVELY
ANESTH ANALG 1991;73190-8
197
8. Have you seen your anesthesiologist yet?
Yes
No
8b) What are you most Concerned about?
2
-
m
3E
Please indicate the extent to which you have thought about the following by circling the number that corresponds to your answer. c)
9c.
z 4-
~~
_____
_ _ _ _ ~
~
8
x
1
2
5
zP
-x
; E
Y
3
G
4 4 4
5 5 5
~
9. Feeling nervous in the hospital environment. 10. Being afraid of the unknown. 11. Being afraid of needles.
2 2
3
1 1 1
2
3 3
1 1
2 2
3 3
4 4
5 5
2 2 2
3 3 3
4 4 4
5 5 5
Are you concerned about: 12. Letting yourself fall into an unconscious state. 13. Disclosing personal matters involuntarily while under
anesthesia. 14. Waking up in the middle of the operation. 15. Feeling pain after the operation. 16. Not having medication in time to relieve your
paiddiscomfort. Anesthesia affecting the clarity of your thoughts. Anesthesia impairing your judgment. Being asleep for a long time after the operation. Being unable to get out of bed for a prolonged period of time as a result of the anesthesia. 1 2 3 4 21. Having to stay in the intensive care unit for a prolonged period of time. 1 2 3 4 22. Being nauseous after the operation. 1 2 3 4 23. Becoming paralyzed because of the anesthesia. 1 2 3 4 24. Being unable to wake up from the anesthesia. 1 2 3 4 25. Whether the anesthesiologist will have good bedside manners. 1 2 3 4 26. Whether the anesthesiologist will stay in the operating room with you throughout the operation. 27. Your anesthesiologist beiig fully qualified to give you 1 2 3 4 anesthesia. 1 2 3 4 28. Your anesthesiologist not being experienced enough to handle your situation. 29. If you have any concerns did you mention them to anyone? -Yes -No I mentioned them to: Anesthesiologist -Surgeon -Other doctor -Family -Other 30. Please rate your confidence in your anesthesiologist. 1 2 3 4 31. Please rate your confidence in your surgeon. 1 2 3 4 32. How important do you think your anesthesioloMst is in your total perioperative care (care before, during, and after the surgical procedure)? Please circle: 0 1 2 3 4 5 6 7 8 9 10 Not at all Extremely 33. How important do you think your surgeon is in your total perioperative care (care before, during, and after the surgical procedure)? Please circle: 0 1 2 3 4 5 6 7 8 9 I0 Not at all Extremely 34. How important do you think your medical doctor is in your total perioperative care (care before, during, and after the surgical procedure)? Please circle: 0 1 2 3 4 5 6 7 8 9 10 Not at all Extremely 17. 18. 19. 20.
5
5 5 5
5 5
198
SHEVDE AND PANAGOPOULOS PATIENT KNOWLEDGE, AlTKUDE, AND CONCEPS PREOPERATIVELY
ANESTH ANALG 1991;73190-8
DEMOGRAPHIC INFORMATION 1. Which of the following best describes you? 1. American Indian 2. CaucasianlWhite 3. Chicano 4. Indian 5. Negrohlack 6. Oriental 7. PuertoRican 8. Other (please describe)
2. Religious background. 1. Jewish 2. Catholic 3. Protestant 4. None 5. Other
3. Occupation. A. What is your occupational status (circle all that apply): 1. Homemaker 2. Student 3. Disabled 4. Unemployed, looking for work 5. Employed B. If you are employed, what is the title of your job and the type of work that you do?
The authors thank Susan Tuchler, MS, Betsy Beeber, RN, and Rashmi Trivedi, MD, for interviewing the patients and collecting the data; James DeVito, BA, for assisting with manuscript preparation; and Pat Celentano for preparing the graphics. We also thank Paul G. Barash, MD, for his review of the manuscript.
References 1. Egbert LD, Battit GE, Turndorf H, Beecher HK. The value of
the preoperative visit by an anesthetist. JAMA 1963;185:553-5.
2. Stoelting RK. Psychological preparation and preoperative medication. In: Miller RD. 2nd ed. Anesthesia. New York Churchill Livingstone, 1986381408. 3. Gaskey NJ. Evaluation of the effect of a pre-operative anesthesia videotape. J Am Assoc Nurse Anesthetists 1987;55: 341-5. 4. Elsass P, Eikard B, Junge J, Lykke J, Staun P, Feldt-Rasmussen M. Psychological effect of detailed preanaesthetic information. Acta Anaesthesiol Scand 1987;31:579-83. 5. Nietzel MT, Bernstein DA. Assessment of anxiety and fear. In: Hersen M, Bellack AS. 2nd ed. Behavioral assessment. New York: Pergamon, 1981:215-45.
The present study was undertaken to assess patients’ knowledge, attitudes, and concerns regarding anesthetic management. A survey of 34 items was developed and administered preoperatively to 800 consecutive patients. Included were 303 men and 497 women with a mean age 52 yr and a mean educational level of 12 yr. Patients were interviewed on their knowledge of the role and training of anesthesiologists and on their preferences regarding anesthetic management. Patients also rated the intensity of their concern on 20 written statements expressing potential anesthetic complications. Results indicated that patients’ perceptions of the anesthesiologist’s training and role were accurate. Most patients preferred (a) general to regional anesthesia and (b) not to select their own anesthesiologist. Most significant preoperative concerns regarding the anesthesiologist focused on experience, qualifications, and presence
A
good anesthesiologist-patient relationship established during the preoperative visit re,duces patient anxiety (1-3). This can be achieved by informing patients about their anesthetic management and addressing their specific concerns regarding anesthesia. Although a personal interview with the patient decreases anesthesia-related anxiety, few efforts have been directed at identifying the patients’ greatest concerns. Only one recent study has assessed, and that only peripherally, patients’ preference for anesthetic procedures and their preoperative fears (4).Results of that survey indicated that the majority (93%) of the patients preferred general anesthesia induced by intravenous injection. A large number (40%))of patients feared either postoperative pain or surgical complications (25%).Anxiety regarding the anesthetic procedure centered primarily on (a) fear of not waking up again, (b) waking Accepted for publication April 10, 1991. Address correspondence to Dr. Shevde, Department of Anesthesia, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219.
190
Anesth Analg 1991;73:1 9 M
or absence during the anesthesia. Patient concerns also included the possibility of not waking up postoperatively, experiencing pain, and becoming paralyzed, Intensity of concern was inversely related to age and unrelated to educational level or occupation. Variables related to type of concern included patient’s sex, type of anesthesia, and proposed surgical procedure. Issues of least concern included disclosure of personal matters during anesthesia, experiencing impaired judgment postoperatively, and being asleep or bedridden for a prolonged period of time. It is suggested that anesthesiologists address significant patient concerns during the preoperative visit to enhance their effectiveness in patient care. Efforts to educate the public on the anesthesiologist’s role in perioperative care should improve patient confidence. (Anesth Analg 1991;73:1904)
up during the operation, (c) being unconscious, and (d) disclosing personal matters. The present study was conducted to assess patients’ knowledge about anesthesiologists and anesthetic management as well as their specific concerns about anesthesia. This information is essential for an effective preoperative visit.
Methods Patient Population The study was approved by the hospital’s human research committee. All patients scheduled for surgery were included in the study. Excluded were patients who refused to participate or were unable to answer questions because of poor medical condition or inability to understand English. The study was based on responses to 34 questions designed to assess the patients‘ perceptions, fears, and concerns relating to anesthesia. The questions, with input from 19 staff anesthesiologists, included ones commonly asked during preoperative visits. The initial section of the survey, oral in nature, was 01991 by the International Anesthesia Research Society 0003-2999/91/$3.50
ANESTH ANALG 1991;731W
SHEVDE AND PANAGOPOULOS PATIENT KNOWLEDGE, AlTITUDE, AND CONCERNS PREOPERATIVELY
administered by interviewers and included openended questions inquiring about patients' objective knowledge of the role and training of the anesthesiologist as well as their preferences regarding anesthetic procedures (i.e., "what is the role of the anesthesiologist?," "how many years of medical and residency training do you think your anesthesiologist has had?," "if you were to choose, what type of anesthesia would you prefer?," "would you like to choose your own anesthesiologist?"). Additionally, patients were questioned about their past surgical history and exposure to anesthetic procedures as well as whether they had been contacted by an anesthesiologist during this hospitalization. Finally, patients were asked the open-ended question "what are you most concerned about?" in an attempt to elicit their primary concerns with minimal prompting. Subsequent to the completion of the oral part of the questionnaire, patients were presented with 20 written statements expressing concerns about potential complications associated with anesthesia. These included survey items 9 through 28 and are presented in the Appendix. Patients were asked to rate, on their own, the intensity of their concerns on a five-point Likert scale. A Likert scale is one in which the patient is asked to respond to written items in terms of degree of reaction. The ratings were as follows: 1= not at all, 2 = somewhat, 3 = moderately, 4 = very much, 5 = extremely. For discretionary reasons, direct questions relating to death were purposely excluded to prevent undue patient anxiety. Finally, patients rated their confidence in the anesthesiologist and surgeon on the same scale and the relative importance of these two speQalists as well as that of their medical doctor in their total perioperative me. The latter was rated on a IO-point scale ranging from 0 = not at all to 10 = extremely important. Patients required approximately 15 min to complete the questionnaire. All patients scheduled for surgery were contacted by one of three trained interviewers within the 24 h before surgery. Ambulatory and hospitalized patients were included in the study. To safeguard against sensitizing the patients to potential anesthetic complications, interviewers remained present throughout the entire administration of the survey to reassure patients as needed.
Stat istical Analyses A coding guide for the survey items was developed to aid in the transcription of the survey data into a computer file. Accuracy of data entry was checked by examining the frequency of out-of-range coded responses on all survey items. This revealed a very low error frequency ranging from 0% to 0.4%.Statistical analyses were performed using BMDP (a biomedical statistical software package). Descriptive statistics
191
(i.e., measures of central tendency, frequency distributions) were obtained on patients' demographics, knowledge of the role and training of the anesthesiologist, patient preferences regarding anesthetic management, and the type and intensity of their concerns. Patients' preferences for anesthetic procedures were coded as 1 = general, 2 = local, and 3 = spinallepidural. We used the term "local anesthesia" to reflect both local infiltration and major peripheral nerve blocks, and "regional anesthesia" to reflect both local and spindepidural anesthesia. Correlational and $-analyses were performed to examine the relationship between patient demographics (i.e., age, sex, educational level) and history variables (i.e., previous experience with anesthesia, having seen the anesthesiologist preoperatively, type of anticipated anesthesia and surgery) and patient concerns. Furthermore, patients' responses on the intensity of preoperative concerns were factor-analyzed using a principal factoring with iteration and orthogonal rotation. The factor analyses were run to determine whether specific factors/dimensions existed describing these Concerns. Finally, independent-samples t-tests were used to evaluate the relative importance of the anesthesiologist compared with other medical specialists, as perceived by patients. A P < 0.05 was accepted as statistically significant.
Results Pa tien t Characteristics Patient population consisted of 800 consecutive consenting adults undergoing elective major and minor surgery in a large metropolitan tertiary care hospital. Ambulatory patients comprised 30% of the total population. Subjects included 303 men and 497 women (mean age, 52 yr) with a mean educational level of 12 yr. Two percent of the patients refused to participate in the study. Although most patients answered all of the survey questions, the number of patients cited in the analyses may vary because of two factors: first, because of the addition of items on demographics and, second, because of missing data from incomplete surveys submitted by a few patients. Twenty-six percent of the patients were scheduled to undergo gynecologic procedures, 18% orthoped~c,15% genitourinary, 8% colorectal, 7%gastrointestinal,3%open heart, and 23% various other procedures. Figures 1 and 2, as well as Table 1, present results on the ethnic and occupational backgrounds of the respondents.
Perceptions of the Anesthesiologist's Training and Role Patients' perceptions of the medical school and residency training of anesthesiologists were, for the most part, accurate. Patients indicated that anesthesiologists
192
ANESTH ANALG
SHEVDEAND PANACOPOULOS PATIENT KNOWLEDGE, A‘ITITUDE, AND CONCERNS PREOPERATIVELY
m
--\
1991;73190-8
w1m
1
O3
Figure 3. Perception of the anesthesiologist’s role (n = 800): % patients.
Figure 1. Demographic data (n
=
450): ethnicity (%).
Table 2. Ability to Choose the Anesthesiologist (n = BOO)
Figure 2. Demographic data (n = 450): employment status (a).
Table 1. Demographic Data (n
=
279)”
Occupational level Executive/professional Business manager Administrative personnel Clericdsaledtechnicians Skilled manual Semi-skilled Unskilled Other
Percent 1
3 21 42 14 13 1 5
Patient prefers to make a choice
% Patients
Reasons
%
Yes
23
No
77
Patient should control choice Patient needs recommendation Patient does not know any Patient leaves decision to surgeon It does not matter Patient not qualified to
17 6 40 14 14 9
that ascribed to the surgeon preoperatively (mean, 4.47; SD, 0.80; t-test (617) = -15.49; P < 0.001). When patients were asked about the relative importance of the anesthesiologist, the surgeon, and the medical doctor in the total perioperative care, they rated the significance of the anesthesiologist as being at the same level as that of their medical doctor [t-test (522) = -1.61, P = 0.101. Ratings of both specialists were significantly lower than those assigned to surgeons [t-test (527) = -5.52, P < 0.001 for the comparison between anesthesiologists and surgeons and t-test (527) = -5.62, P < 0.001 for medical doctors and surgeons].
~
“Reflects62%of patients (42%employed and 20%retired).
spend a mean of 4.8 yr in medical school (SD = 1.4). Mean number of years spent in residency training was perceived to be 4.0 (SD = 1.9). Median and mode scores for each variable were 4.0. Figure 3 presents patients’ perceptions of the anesthesiologist‘s role. Overall, patients’ ratings of their confidence in the anesthesiologist preoperatively fell into the “very high” level (mean, 3.97; SD, 1.07; range, 1-5). No sigruficant differences were observed in confidence ratings of patients who had seen an anesthesiologist before providing a rating and those who had not seen one [t-test for independent samples (616) = 1.21, P > 0.101. Confidence ascribed to the anesthesiologist, though very high, was significantly lower than
Patients’ Preferences for Anesthetic Management The vast majority of patients (77%)were reluctant to select their own anesthesiologist primarily because they did not know any (40%), believed they were unqualified to do so (9%),or because it did not matter to them (14%). Fourteen percent of the patients believed that their surgeon would make that decision. Among the 23% of the patients who preferred to choose, 17% expressed a desire to have complete control of such a choice and 6% preferred to choose only if they knew an anesthesiologist or if one was recommended to them. These results are presented in Table 2. Sixty-nine percent of the patients preferred to have general anesthesia so that they would not seelfeel anything (66%)or because they believed spinal anes-
ANESTH ANALG 1991;73:1W
SHEVDE AND PANACOPOULOS PATIENT KNOWLEDGE, ATTITUDE,AND CONCERNS PREOPERATIVELY
193
Table 3. Issues of Concern (n = 8001 % Patients indicating
highest levels of concern m,
WAXC UP
Figure 4. Fearskoncerns expressed spontaneously by patients (n = 612): 9i patients.
Highest concern Anesthesiologist's qualifications Experience of anesthesiologist Being unable to wake-up postop Postop pain Anesthesiologist present in OR Patient becoming paralyzed Pain medications available
45 43
37 34 32 32 28
Moderate concern Fear of the unknown Waking up in the middle of surgery Nervous of hospital environment Postop nausea Anesthesiologist's manners Staying in ICU
25 24 22 22 22 21
thesia to be dangerous (3%).Twenty-two percent of the patients expressed a preference for local anesthesia because they wished to remain awake and aware throughout the procedure (13%)and to avoid side effects of general anesthesia (9%). Only 9% of the Least concern patients preferred either spinal or epidural anesthesia Being unconscious 19 Prolonged sleep postop 18 in order to remain awake and aware. Being bedridden 16 A 3x4 ?-analysis investigating whether type of Fear of needles 13 anesthesia experienced in the past was related to 12 Impaired judgment current preferences revealed that patients tended to 11 Clarity of thought prefer the type of anesthesia they had had in the past. 6 Disclosing personal matters That is, more patients who had received general OR, operating room; ICU, intensive care unit. anesthesia preferred general and more patients who had received spinal anesthesia preferred spinal (2factors was examined further to determine whether test (6) = 92.8, P < 0,001 [n = 5471). The number of patients who had had local anesthesia or combina- the variables loaded highly on the appropriate factor. Most of the variables did load on the appropriate tions of types of anesthesia was too small to yield factor as expected. Table 4 presents the items comvalid results. prising each factor and item loadings. Based on these Among the 254 first-time surgical patients, there was a strong preference for general anesthesia (72%), results the scores from each item were added tofollowed by local (22%) and spinallepidural (6%) gether to form four additional variables describing the above-reported dimensions. anesthesia. This finding mirrored the preferences of the total population. ~~
~~~
~
~~
Correlates of Patients' Preoperative Concerns Patients' Preoperative Concerns Patients' concerns regarding anesthetic management were assessed in two ways: first, patients were asked the open-ended question "what are you most concerned about?' Their responses are presented in Figure 4. Second, patients were asked to rate the degree of their concern on 20 written statements specific to being hospitalized and receiving anesthesia. Table 3 presents in a descending order the percentage of patients who assigned "very much" or "extremely" levels of concern to these areas of anesthetic management. These items were classifted into three categories: issues of highest, moderate, and least concern. Factor analysis of preoperative concerns yielded four factors: (a) specific complications of anesthesia, (b)characteristics of the anesthesiologist, (c) anxiety about being hospitalized, and (d) pain. Each of these
Patient demographics. Pearson product moment and rank order correlation coefficients were computed between the patient's age, educational and occupational level, and degree of concern expressed on the above areas of anesthetic management. Table 5 presents these results. Overall, age showed a statistically significant, but weak inverse relationship with concern. That is, older patients tended to have lower levels of concern. Patients' educational level and occupation were not sigruficantl related to degree of concern. A 2 x 4 AJ -analysiswas performed investigating the effects of sex on patients' responses to the question "what are you most concerned about?" Type of concern was dependent on the patient's sex. More women were concerned about not waking up postoperatively, whereas more men were concerned about experiencing intraoperative and postoperative pain [?-test (3) = 18.98, P < O.OOl]. There was no
194
ANESTH ANALG 1991;73:190-8
SHEVDE AND PANAGOPOULOS PATIENT KNOWLEDGE, ATTITUDE, AND CONCERNS PREOPERATIVELY
Table 5. Correlations Between Patient's Demographics and Intensitv of Concern
Table 4. Factor Analyses of Patients' PreoDerative Concerns
~~
Factor
Item loading
Spedfic anesthesia complications (factor 1) Impairment in judgment Clarity of thought Prolonged sleep postop W i g bedridden Being put unconscious Becoming paralyzed Staying in ICU Being unable to wake up postop Disclosure of personal matters Postop nausea
0.772 0.763 0.756 0.660 0.635 0.613 0.613 0.581 0.471 0.463
Anesthesiologist's characteristics (factor 2) Anesthesiologist's qualifications Anesthesiologist of experience Anesthesiologist present in OR Anesthesiologist's manners
0.875 0.842 0.772 0.634
Anxiety about hospitalization (factor 3) Nervous of hospital environment Fear of unknown Fear of needles
0.831 0.813 0.613
Pain (factor 4) Pain medications available Postop pain Waking in middle of surgery
0.828 0.813 0.436
ICU, intensive care unit; OR, operating room.
difference between men and women on expressing no concern." Moreover, independent-samples t-test analyses on the four new factors were performed to determine whether there were any differences between men and women on the level of concern they expressed preoperatively. Overall, women tended to express sigruficantly higher levels of concern on all four factors: specific anesthesia complications [t-test (796) = -4.35, P < 0.001]; generalized hospital anxiety [t-test (797) = -8.08, P < 0.001]; the anesthesiologist's characteristics [t-test (795) = -2.12, P < 0.031; and pain [t-test (796) = -3.13, P < 0.011. Table 6 presents the means and standard deviations for these analyses. II
Patient history vuriubZes. $-Analyses were performed to investigate the effects of past experience with anesthesia, type of anesthesia experienced, preoperative contact by an anesthesiologist, and type of anesthesia and surgery expected on the four spontaneously expressed categories of concern. To hold down the increase in error rates due to multiple comparisons, a more stringent a-level of 0.01 was set. Neither previous experience with nor type of past anesthesia appeared to be related to patients' concerns [?-test (3) = 2.59, P= 0.46 and $-test (9) = 8.47, P = 0.48, respectively]. As 61% of patients had seen their anesthesiologist before completing the
Age Education Rank (n = 508) (n = 5-8) (n = 261) Highest concern Anesthesiologist's qualifications Experience of anesthesiologist Being unable to wake-up postop Postop pain Anesthesiologist present in OR Patient becoming paralyzed Pain medications available
-0.02 -0.05 -0.07 -0.08
-0.11
-0.09 -0.21" -0.18" -0.07 -0.21"
-0.07
Moderate concern Fear of the unknown Waking up in middle of surgery Nervous of hospital environment Postop nausea Anesthesiologist's manners Staying in ICU
-0.12" -0.21" -0.14' -0.19" -0.18" -0.19"
Least concern Being unconscious Prolonged sleep postop Being bedridden Fear of needles Impaired judgment Clarity of thought Disclosing personal matters
-0.19" -0.14" -0.12" -0.1Q -0.09 -0.11 -0.21"
-0.01 -0.01 -0.06
-0.04
-0.06 -0.08
-0.10 -0.01
-0.02 -0.02
-0.11
-0.01
-0.09 -0.00
0.01 0.10 -0.02 0.09
-0.03 -0.04 -0.04
0.16" 0.07 0.07 0.04 0.09 0.05 0.09
0.00
-0.12 -0.08 -0.16" -0.07
-0.05 -0.08 -0.06
OR, operating room; ICU, intensive care unit. "P < 0.01.
Table 6. Preoperative Responses on Factors by Patient's Sex Male
Female
Variables
Mean
SD
Mean
SD
t
Specific anesthesia complications Anesthesiologist's characteristics Anxiety about hospitalization Pain
1.95
0.88
2.25
0.99
-4.35'
2.52
1.24
2.72
1.34
-2.12b
1.91
0.88
2.49
1.02
-8.08"
2.37
1.01
2.62
1.14
-3.13'
"P 5 0.001. 'P 5 0.05. L.P
5
0.01.
survey, a 2x4 $-analysis was performed to determine whether frequency of concerns was dependent on having seen an anesthesiologist preoperatively. The result was not statistically significant [?-test (3) = 5.68, P = 0.131, indicating that the frequency of four types of responses (no concerns, unable to wake up, and experiencing pain intraoperatively and postoperatively)was not dependent on such preoperative contact. Patients' responses, however, depended on the type of anesthesia (general, local, spindepidural) and the type of surgery (ambulatory vs inpatient) expected.
ANESTH ANALG 1991;7319C-S
SHEVDE AND PANAGOPOULOS PATIENT KNOWLEDGE, ATTITUDE, AND CONCERNS PREOPERATIVELY
More patients expecting general anesthesia were concerned about not waking up postoperatively and fewer of them were concerned about ex riencing pain intraoperatively and postoperatively [ -test (6) = 39.86, P < 0.0011. The reverse was true for patients expecting local or spindepidural anesthesia; more of them were concerned about intraoperative and postoperative pain. Consistent with this, patients undergoing major/ nonambulatory surgery expressed these concerns more frequently and were less likely to deny any concerns [?-test (3) = 42.7, P < O.OOI~.Ambulatory patients were concerned about postoperative pain more frequently than expected by chance.
F
Discussion This study was conducted to gain insight into patients’ perception of anesthesiologists and anesthetic management. The majority of patients perceived the anesthesiologist’s education and training accurately. Although some of the primary functions of the anesthesiologist were described correctly to include putting the patient to sleep, relieving pain, and administering medication, only 5% of the patients were aware that the anesthesiologist plays an important role in monitoring vital signs and maintaining normal hemodynamics throughout the operation. It appears that some patients are not sure what the anesthesiologist’s functions are once the induction of anesthesia is completed. Hence the perception that the anesthesiologist might not be in attendance throughout the operative procedure is prevalent. It is interesting to note that most of the patients (69%)had a strong preference for general anesthesia instead of regional anesthesia, especially as the latter is on the increase nationally. Patients preferred general anesthesia whether they had received it in the past or not. When questioned about their concerns, most patients spontaneously expressed fears of not waking up postoperatively and experiencing intraoperative or postoperative pain or some type of postoperative disability. Concerns about the anesthesiologist’s qualifications, experience, and continual presence in the operating room were only expressed when patients were specifically asked to comment on them. We would have to assume that these were not of foremost importance to the patients. Direct questions on death were omitted from the questionnaire to avoid undue patient anxiety. Information on this issue was obtained indirectly in two ways. First, in examining the intensity of their concern in the survey item “being unable to wake up postoperatively” and, second, in the frequency of answers relating to inability to wake up provided spontaneously by the patients to the open-ended question “what are you most concerned about?” Finally, our observation of
195
the patients’ preference for general anesthesia and the frequency of concerns such as being unable to wake up postoperatively and experiencing pain were consistent with the results obtained in the study by Elsass et al. (4). Previous experience with anesthesia and having been interviewed by an anesthesiologist preoperatively were not related to patients’ spontaneously expressed concerns. Overall, patients anticipating majorhonambulatory surgery expressed more concerns than expected by chance. Ambulatory patients were primarily Concerned about experiencingpostoperative pain. Consistent with this, patients anticipating general anesthesia were more frequently Concerned about not waking up, whereas patients anticipating regonal anesthesia were more concerned about experiencing intraoperative and postoperative pain. Women were more concerned about not waking up postoperatively, whereas men were more concerned about experiencing pain. Women tended to report significantly higher levels of concern on all variables than men. This difference may be attributed to sex role socializationwhich emphasizes decreased fear expression in males. It may be suggested that the lower concern levels expressed by men could be an artifact of the assessment method used and that the use of a clinical interview with a trained psychologist might have resulted in men ”accurately” reporting more concern. We contend that this is not so. Both questionnaires and clinical interviews are based on patients’ self-report. Therefore, it is likely that the factors that influence men’s self-report operate equally when they answer a questionnaire and during a clinical interview. Such an interview, however, can be designed to yield the “expert’s” rating on the patient’s level of concern, which may more accurately reflect “reality” because it is based on the patient’s self-report as well as the expert’s behavioral observations of the patient (5).Unfortunately, the size of our study made it prohibitive to have such interviews. Regarding our recommendations, as it remains unclear whether men were “truly” less concerned or just reported so, it seems important that the anesthesiologist be aware of this possibility and appropriatelyaddress indications of even low concern levels in men. Despite the significance assigned to the anesthesiologist’s qualifications, an overwhelming number of patients (77%) were reluctant to select their own anesthesiologist primarily because of their unfamiliarity with anesthesiologists and lack of ability to select an anesthesiologist. Fourteen percent of the patients left such a decision to the surgeon because they believed that the surgeon would make the best choice for them. Apparently, patients were unaware that the choice of the anesthesiologist does not always lie with the surgeon. In addition to gaining knowledge by identifying the patient’s fund of information, attitudes, and
196
ANESTH ANALG
SHEVDE AND PANAGOPOULOS PATIENT KNOWLEDGE, ATTITUDE, AND CONCERNS PREOPERATIVELY
concerns regarding anesthetic management, the results of this study idenhfy issues the anesthesiologist ought to focus on during the preoperative visit. We believe that the anesthesiologist should specifically address patients’ concerns regarding waking up and experiencing pain and inform them about the anesthesiologist’s role in monitoring vital signs and maintaining normal hemodynamics. It seems important to inform patients that the anesthesiologist is, in fact, the internist in the operating room.
1991;73:19&8
Moreover, there seems to exist a need to educate the patients and the general public about the role of the anesthesiologist in the perioperative care of the patient. This may narrow the gap in the confidence levels that the patients ascribed to the surgeon relative to the anesthesiologist. Future efforts directed at improving our communication with patients and increasing our exposure in the community via newspaper reports and lectures should achieve higher levels of patient confidence in the anesthesiologist.
Appendix: Patient Survey NAME:
AGE:
TYPE OF OPERATION: TYPE OF ANESTHESIA
SEX: DATE:
REGIONAL
LOCAL
GENERAL
EDUCATION
We are interested in finding out your perceptions of and attitudes toward anesthesia and the role of the anesthesiologist. Please answer the following questions to the best of your ability. 1. What, in your opinion, is the role of the anesthesiologist?
lb) Are they doctors?
Yes
No
2. How many years of medical training do you think your anesthesiologist has had?
Number of years of medical school education
1 2 3 4 5 6
Number of years of residency training
I 2 3 4 5 6
3. Have you had an operation requiring anesthesia in the past?
Yes
No
4. Type of surgery
Date of surgery
5. Under what type of anesthesia did you have your surgery? General
Spinal
Local
6. If you were to choose, what type of anesthesia would you prefer? Spinal Epidural Local General (asleep and completely unconscious). Why?
6b) If the anesthesiologist recommended a different type of anesthesia would you agree or disagree with him? Agree Disagree 7. Would you like to choose your own anesthesiologist?
Yes
No
Please circle one
Why
SHEVDE AND PANAGOPOULOS PATIENT KNOWLEDGE, ATI'ITUDE, AND CONCERNS PREOPERATIVELY
ANESTH ANALG 1991;73190-8
197
8. Have you seen your anesthesiologist yet?
Yes
No
8b) What are you most Concerned about?
2
-
m
3E
Please indicate the extent to which you have thought about the following by circling the number that corresponds to your answer. c)
9c.
z 4-
~~
_____
_ _ _ _ ~
~
8
x
1
2
5
zP
-x
; E
Y
3
G
4 4 4
5 5 5
~
9. Feeling nervous in the hospital environment. 10. Being afraid of the unknown. 11. Being afraid of needles.
2 2
3
1 1 1
2
3 3
1 1
2 2
3 3
4 4
5 5
2 2 2
3 3 3
4 4 4
5 5 5
Are you concerned about: 12. Letting yourself fall into an unconscious state. 13. Disclosing personal matters involuntarily while under
anesthesia. 14. Waking up in the middle of the operation. 15. Feeling pain after the operation. 16. Not having medication in time to relieve your
paiddiscomfort. Anesthesia affecting the clarity of your thoughts. Anesthesia impairing your judgment. Being asleep for a long time after the operation. Being unable to get out of bed for a prolonged period of time as a result of the anesthesia. 1 2 3 4 21. Having to stay in the intensive care unit for a prolonged period of time. 1 2 3 4 22. Being nauseous after the operation. 1 2 3 4 23. Becoming paralyzed because of the anesthesia. 1 2 3 4 24. Being unable to wake up from the anesthesia. 1 2 3 4 25. Whether the anesthesiologist will have good bedside manners. 1 2 3 4 26. Whether the anesthesiologist will stay in the operating room with you throughout the operation. 27. Your anesthesiologist beiig fully qualified to give you 1 2 3 4 anesthesia. 1 2 3 4 28. Your anesthesiologist not being experienced enough to handle your situation. 29. If you have any concerns did you mention them to anyone? -Yes -No I mentioned them to: Anesthesiologist -Surgeon -Other doctor -Family -Other 30. Please rate your confidence in your anesthesiologist. 1 2 3 4 31. Please rate your confidence in your surgeon. 1 2 3 4 32. How important do you think your anesthesioloMst is in your total perioperative care (care before, during, and after the surgical procedure)? Please circle: 0 1 2 3 4 5 6 7 8 9 10 Not at all Extremely 33. How important do you think your surgeon is in your total perioperative care (care before, during, and after the surgical procedure)? Please circle: 0 1 2 3 4 5 6 7 8 9 I0 Not at all Extremely 34. How important do you think your medical doctor is in your total perioperative care (care before, during, and after the surgical procedure)? Please circle: 0 1 2 3 4 5 6 7 8 9 10 Not at all Extremely 17. 18. 19. 20.
5
5 5 5
5 5
198
SHEVDE AND PANAGOPOULOS PATIENT KNOWLEDGE, AlTKUDE, AND CONCEPS PREOPERATIVELY
ANESTH ANALG 1991;73190-8
DEMOGRAPHIC INFORMATION 1. Which of the following best describes you? 1. American Indian 2. CaucasianlWhite 3. Chicano 4. Indian 5. Negrohlack 6. Oriental 7. PuertoRican 8. Other (please describe)
2. Religious background. 1. Jewish 2. Catholic 3. Protestant 4. None 5. Other
3. Occupation. A. What is your occupational status (circle all that apply): 1. Homemaker 2. Student 3. Disabled 4. Unemployed, looking for work 5. Employed B. If you are employed, what is the title of your job and the type of work that you do?
The authors thank Susan Tuchler, MS, Betsy Beeber, RN, and Rashmi Trivedi, MD, for interviewing the patients and collecting the data; James DeVito, BA, for assisting with manuscript preparation; and Pat Celentano for preparing the graphics. We also thank Paul G. Barash, MD, for his review of the manuscript.
References 1. Egbert LD, Battit GE, Turndorf H, Beecher HK. The value of
the preoperative visit by an anesthetist. JAMA 1963;185:553-5.
2. Stoelting RK. Psychological preparation and preoperative medication. In: Miller RD. 2nd ed. Anesthesia. New York Churchill Livingstone, 1986381408. 3. Gaskey NJ. Evaluation of the effect of a pre-operative anesthesia videotape. J Am Assoc Nurse Anesthetists 1987;55: 341-5. 4. Elsass P, Eikard B, Junge J, Lykke J, Staun P, Feldt-Rasmussen M. Psychological effect of detailed preanaesthetic information. Acta Anaesthesiol Scand 1987;31:579-83. 5. Nietzel MT, Bernstein DA. Assessment of anxiety and fear. In: Hersen M, Bellack AS. 2nd ed. Behavioral assessment. New York: Pergamon, 1981:215-45.
