Oops! Surgeons Need to Guard Tongue in 'Awake' Operations

Lara C. Pullen, PhD

August 18, 2016

As "awake" surgical procedures become more common, surgeons increasingly find themselves in the potentially awkward position of being overheard by patients. A new study suggests that surgeons who work with awake patients are very aware that the patients are listening, and are thus careful to limit their communication with trainees and staff. These patient safeguards change the way surgeons communicate with their team and may limit their ability to teach the next generation of surgeons.

Awake surgical procedures occur while the patient is under no sedation, light sedation, or conscious sedation. Although these surgeries benefit the patient through shorter recovery times and decreased hospital stays, they can also cause patients significant anxiety and distress. Surgeons are aware of this risk, and thus try to minimize patient stress during the procedure.

Claire Smith, MFA, from the University of Chicago in Illinois, and colleagues published the results of their interviews with 23 surgeons online June 29 in the American Journal of Surgery. Their study included surgeons who practiced at two related medical centers in the Midwest (a university medical center and a university-affiliated hospital system).

The researchers recruited surgeons from various specialties to answer questions about their experiences operating on awake patients. The surgeries ranged from vasectomy to angiogram to eyelid blepharoplasty. The authors note in their article that surgeons who value communication and consider themselves to be good at communication may have been more likely to respond to the request for an interview.

As expected, most emphasized the importance of managing patients' expectations by preparing them for any anticipated changes in sensation. They also noted that although awake surgeries tend to be more efficient and satisfying for the patients, they also come with challenges; for example, the surgical team must manage the risk that the patient may move during surgery.

"In particular, our findings highlight the tensions that exist between a surgeon's duty to care for the patient, efficiently manage the procedure room, and properly instruct and give experience to trainees," explain the authors.

The researchers found that most surgeons modify their communication and interactions with staff and trainees when in the presence of an awake patient. This includes the creation of code words for use during surgery and using medical jargon the patient is unlikely to understand.

Training Challenges

Surgeons also described the efforts required to balance the necessary training of surgeons with patient comfort. "To our knowledge, this research is the first to broadly examine surgeon-patient communication during awake procedures and to report challenges to this relationship related to teaching during awake procedures," the authors write.

Many patients can be uncomfortable with the idea that a student is operating on them. Surgeons thus tend to obscure trainee involvement in awake procedures. Some surgeons may go even further and be reluctant to let trainees participate in awake surgeries.

The interviews identified challenges in the surgical system and raised several questions the authors described as deserving further investigation. One of these is research into the types of communications that are easiest for the patient to recall during awake surgery. Such recall studies should also include a measure of how the patient responds to those communications (positively or negatively).

The researchers also note that the interviews raised the possibility that surgeons may have a tendency to conceal trainee involvement from unconscious patients, should surgeries be monitored for quality improvement purposes.

The authors have disclosed no relevant financial relationships.

Am J Surg. Published online July 29, 2016. Abstract

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