Tales From VA Anesthesiology

Patient-First Approach

A core competency of the Accreditation Council for Graduate Medical Education for an anesthesia residency is the Interpersonal and Communication Skills program. A comprehensive discussion of communication is far beyond the scope here. But not surprisingly, deficient communication between physicians and patients can cause emotional distress, significant dissatisfaction among family members, and negative patient judgment of how well we communicate.^4-6 These observations are particularly true in our increasingly elderly surgical population, in which both surgeons and anesthesiologists often feel unequal to the task of discussing concepts such as code status.^7,8

In our practice and in residency training, the preoperative clinic often is the location where patient/provider communication occurs. Here we consider the latest American College of Cardiology/American Heart Association guidelines, examine airways, review electrocardiograms, and formulate plans agreeable to and understood by our anxious patients and their families. The potent anxiolytic effect of a preoperative visit by an anesthesiologist is well established.⁹ Anxiety about surgery is a risk factor for impaired decision making before surgery.¹⁰ And surgery is traumatic—as many as 7.6% of postoperative patients experience symptoms consistent with PTSD attributable to the surgery, placing it on a par with being mugged (8.0%).^11,12

The patient in this case presented several communication challenges even absent his revelation of prior traumatic experience with anesthesia. He was elderly, anxious, and had multiple comorbidities. He had mild cognitive impairment and required a code status discussion. There also were the clinical challenges—navigating a 99-year-old with severe aortic stenosis and a right ventricular systolic pressure > 90 mm Hg through a general anesthetic gave me a sinking feeling.

He was fortunate that the procedure could be done with local anesthesia, mitigating his risk of cognitive dysfunction, including delirium. He also was fortunate in that his anesthesiologist and surgeon had created a collaborative, patient-first approach and that his US Department of Veterans Affairs (VA) clinic had the time, space, and staffing to accommodate an unexpected 90-minute visit. A big investment in communication, mainly my keeping quiet, made the intraoperative management simple. Such is life in an integrated health care system without financial incentives for high-volume care—and another reminder that VA physicians are blessed to guide patients through some of the most vulnerable and distressing moments of their lives.

Postscript

During the preparation of this manuscript, the patient passed away at the age of 100. His obituary was consistent with what I had learned about him and his family during our 2 encounters: a long successful career in local industry; extensive involvement in his community; an avid sportsman; and nearly 30 grandchildren, great-grandchildren, and great-great grandchildren. But there was one more detail that never came up during my extensive discussion with him and his daughters: He was awarded the Purple Heart for his service in World War II.