Anesthesiology 2009; 111:971– 8 Copyright © 2009, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

Patterns of Communication during the Preanesthesia Visit

Raymond A. Zollo, M.D.,* Stephen J. Lurie, M.D., Ph.D.,† Ronald Epstein, M.D.,‡ Denham S. Ward, M.D., Ph.D.§

Background: Effective communication in the preanesthesia “emotional and relational factors should be considered
clinic is important in patient-centered care. Although patient- as the most significant elements associated with patient
physician communication has been studied by recordings in
other contexts, there have been no observational studies of the
satisfaction with anesthesia.”4 The preoperative visit by
communication patterns of anesthesiologists and patients dur- the anesthesiologist now only rarely takes place in the
ing the preanesthesia interview. hospital the evening before surgery, and it is likely that
Methods: Two experienced standardized patients were the physician performing the preoperative evaluation
trained to portray the same clinical situation by using different will not be part of the anesthesia team providing anes-
coping styles (maximizing information or “monitoring” vs.
minimizing information or “blunting”). Interviews of standard-
thesia on the day of surgery. This may make it doubtful
ized patients by anesthesiologists took place in the preanesthe- that the results of these early studies are applicable to
sia clinic and recorded with the knowledge of the subjects. the practice setting of today. Because of these and other
Audio recordings were analyzed, and the visit was separated facets of today’s anesthesia care, effective patient-cen-
into nine components. Discussion of the risks/informed con- tered communication in the preoperative clinic is par-
sent process was examined, looking for discussion of common
morbidities. The standardized patients completed a survey on
ticularly challanging.5–7
the patient-centeredness of the interview. In a review of the literature discussing patient’s atti-
Results: Twenty-seven subjects participated in this study. tudes toward and preparation for anesthesia, Roizen and
Interviews with the monitor required more time: 17.4 min (con- Klaffta proposed nine components of an appropriate
fidence interval [CI] 15.2–19.6, n ! 24) versus 14.5 min (CI preoperative evaluation: initiating the session, getting
13.1–16.0, n ! 25), P < 0.05. Most interview time was spent in
obtaining the history; 2.4 min (CI 1.8 –3.1) was spent discussing
the patient’s perspective, gathering information in the
risks with the monitor, and only 1.6 min (CI 1.2–2.0) was spent form of a history and physical, describing the anesthetic
with the blunter (P < 0.05). Neither the monitor nor the blunter plan, describing anesthetic risks and obtaining consent,
scored the interview highly for involving the patient in deter- discussing pain control, and closing the interview.8
mining the goals of the anesthetic and recovery. These components are based on a model of patient-
Conclusions: Direct recording of interactions with standard-
ized patients is a feasible method of studying the communica-
centered communication.9 Although patient-physician
tion skills of anesthesiologists. For this study, the anesthesia communication has been studied by direct audio or
providers were able to modify their approach depending on audio/video recordings in numerous contexts, includ-
patient type, but the monitor received more information. ing primary care and surgery,10,11 there have been no
direct observational studies of the communication pat-
IN the 1960s, medical ethicist and noted anesthesiologist terns of anesthesiologists and patients during the pre-
Henry Beecher and colleagues showed that personal operative interview. Differing levels of case-complex-
preoperative communication with patients can result in ity and patient characteristics such as personality can
both physiologic and psychological improvements in make the study of patient-physician communication
patient care.1 In particular, good preanesthetic commu- difficult. Standardized patients have been used to study
nication with patients the evening before surgery was physician-patient communication in a controlled man-
shown to result in less postoperative opioid use and ner12–14; we therefore designed a study that uses standard-
earlier discharge.2 More recently, the Institute of Medi- ized patients of two specific personality types to better
cine’s landmark report titled Bridging the Quality understand the communications taking place during the
Chasm emphasized the need for care that respects and preoperative interview.
responds to patient’s individual needs and preferences This study was designed with two goals in mind: (1) to
(patient-centered care) to prevent medical errors and determine the value of standardized patients in studying
increase patient satisfaction.3 Capuzzo et al. stated that the structure and format of the preoperative interview, and
(2) to observe how anesthesiologists modify interviewing
style and content to match the needs of two patient types
* Associate Professor, Department of Anesthesiology, † Assistant Professor,
‡ Professor, Department of Family Medicine, § Professor and Chair, Depart- commonly encountered in clinical practice.
ments of Anesthesiology and Biomedical Engineering, University of Rochester
School of Medicine and Dentistry, Rochester, New York.
Received from the Department of Anesthesiology, University of Rochester,
Rochester, New York. Submitted for publication March 23, 2009. Accepted for
Materials and Methods
publication June 30, 2009. Funded by grant No. 527463 from the Foundation for
Anesthesia Education and Research, Rochester, Minnesota, and by the Depart- This study was reviewed and approved by the Univer-
ment of Anesthesiology, University of Rochester, Rochester, New York. sity of Rochester research subjects review board (Roch-
Address correspondence to Dr. Zollo: Department of Anesthesiology, 601
Elmwood Avenue, Box 604, Rochester, New York 14642. raymond_zollo@
ester, NY), and informed written consent was obtained
urmc.rochester.edu. Information on purchasing reprints may be found at from all subjects.
www.anesthesiology.org or on the masthead page at the beginning of this
issue. ANESTHESIOLOGY’s articles are made freely accessible to all readers, for
This study was designed by using two standardized
personal use only, 6 months from the cover date of the issue. patients. Both patients portrayed a middle aged man

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972 ZOLLO ET AL.

with a smoking history and a lung mass found on a chest Table 1. Segments of the Preoperative Interview
radiograph. After a nondiagnostic bronchoscopy, he is
Opening the interview (open)
scheduled for video-assisted thoracoscopy and possible Gaining the patients perspective (perspective)
thoracotomy. The script was developed after listening to Taking the patient’s history (history)
recordings made of actual preanesthesia interviews ob- Performing the physical examination (physical)
Discussing the plan for the surgery/anesthetic (plan)
tained in a pilot study; details of the script are given in Describing the general anesthetic (general)
appendix 1. Discussing the risks and obtaining informed consent (risks)
The standardized patients were trained to depict one Discussing options for postoperative pain management (pain)
of two different coping mechanisms (called monitoring Closing the interview (close)
and blunting) in response to the stress of significant
Segments of the preoperative interview, based on Klafta and Roizen8 and
medical illness and surgery.15 “Monitors” seek to de- Makoul.9 The transcript of each preanesthesia interview was divided up into
crease their level of anxiety by attempting to exert con- segments that best belonged to one of these types.
trol over everything possible, and “blunters” seek to
decrease their anxiety by ignoring medical detail while Germany). After the interview, the standardized pa-
seeking reassurance that all will be well. It must be tient completed a 10-item questionnaire (appendix 3)
stressed that both “monitors” and “blunters” seek infor- based on a validated communications assessment tool
mation and reassurance, the “monitor” by gaining as used to study patient-physician communication in pri-
much information and control as possible, the “blunter” mary care.16
by limiting too much information and being reassured Audio recordings were coded into nine components of
that all will be well. The skillful interviewer senses these a preoperative interview: opening the interview, gaining
coping styles and modifies his or her communication the patient’s perspective, history, physical examination,
patterns accordingly. Two experienced standardized pa- making a plan, describing the general anesthetic, dis-
tients were selected and trained for their roles by two cussing the risks, planning for postoperative pain man-
experienced standardized patient trainers in consulta- agement, and closing the interview (table 1). In addition,
tion with the authors. A practice session with an expe- interactions with the standardized patient exemplifying
rienced anesthesiologist was video recorded and used to classic personality traits/behaviors associated with the
improve the role portrayal. The standardized patients personality role (monitor/blunter) were marked. Verba-
were given detailed feedback about content, affect, pace tim transcripts for particular areas of interest were ob-
and response to information by the anesthesiologist, to tained. Total interview time as well as time spent in each
make the roles more credible and concordant with the of the nine components (without regard to sequence)
study goals. was obtained from the ATLAS ti software.
Anesthesia residents and junior attending anesthesiol- We looked for and noted whether discussion of several
ogists were recruited by an email advertisement distrib- common morbidities occurred: sore/dry throat/mouth,
uted to the Anesthesiology Department. Participants hoarseness, mouth/dental injury, awareness, injury to
were informed that we were examining the preoperative nerves/blood vessels, eye injury, airway difficulties, aspi-
interview process and that their preoperative interview ration pneumonia, nausea/vomiting, allergic reactions,
with a standardized patient would be audio recorded. cardiac/hemodynamic instability.17 The number of these
One resident refused to participate for an undisclosed areas addressed by the interviewer was recorded for
reason. Participation was primarily determined by sched- each interview.
uling concerns associated with the demands of clinical
practice. Participating providers received a gift card Statistical Analysis
worth $100. Demographic and attitudinal data were col- Summary statistics for the time spent in each part of
lected from the participants after completion of the the preoperative interview were calculated. Repeated
interviews, including years in anesthesia and whether or measures ANOVA was used to determine how interview-
not they recalled having a prior course in patient com- ers differed in their approach to the two different stan-
munication (appendix 2). dardized patients (blunter vs. monitor). If a significant
The interviews of the standardized patients took place difference was found, then ANOVA with standardized
in the preoperative clinic. Each physician interviewed patient type and the sex, country of training, and prior
both monitor and blunter standardized patients with the communication course of the anesthesia provider as
interview sequence randomized and separated by at least independent factors was performed. The total time was
2 weeks. The recordings were made with an Olympus also regressed against the number of years of anesthesia
WS-100 Digital Voice Recorder (Olympus Imaging Amer- experience. Internal consistency of scores on the stan-
ica, Inc., Center Valley, PA) and then transferred to a dardized patient questionnaire was assessed with Cron-
computer for further analysis. The analysis of the audio bach alpha. The questionnaire data were analyzed first
recordings was performed by using ATLAS ti software by repeated measures ANOVA for standardized patient
(Atlas ti Scientific Software Development, GmbH, Berlin, effects and then also by ordered logistic regression with

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PREANESTHESIA COMMUNICATION 973

the sex, country of training, and prior communication

course of the anesthesia provider as independent fac-
tors. All statistical data analysis was performed with the
STATA software package (College Station, TX). Data are
given as mean ! SE or 95% confidence interval (CI)
unless noted. Significance level is at the P " 0.05 level.

Results
Nineteen male and eight female anesthesiologists or
residents participated in the study. Completed question-
naire and audio recording sets for both standardized
patients were available for 20 participants. For five ad-
ditional participants, complete data were available for Fig. 1. Amount of time spent in each part of the preoperative
the blunter interview, but were incomplete for the mon- interview. * P < 0.05 difference between the time spent in each
task between the blunter and monitor standardized patients.
itor interview (three with no data and two with partial Abbreviations shown on abscissa are from table 1. Blunter de-
data); in two additional participants, complete monitor picted with the black bars, and monitor depicted in gray. Error
data were available, but the blunter interview data were bars represent SEM. hx ! history; open ! opening the inter-
view; pers ! gaining the patient’s perspective; pe ! physical
incomplete. Several residents graduated from the pro- examination; plan ! making a plan; ga ! describing the general
gram and moved away from the Rochester area during anesthetic; risks ! discussing the risks; pain ! planning for
the study and were unable to conduct the second inter- postoperative pain management; close ! closing the interview.
view. All available data were used in the analysis.
Twenty-three participants were trained in the United
States, and four had received their medical education in were discussed with the blunter and 6.3 ! 2.6 (mean !
another country. Fourteen (52%) stated that they had SD) with the monitor. However, many risks were not
previously had a specific course in patient-physician discussed with either patient type, e.g., airway difficul-
communication. The years in anesthesia (including resi- ties were discussed with only 56% of the blunter inter-
dency/fellowship training) were 2.4 ! 1.0 (mean ! SD). views and 78% of the monitor interviews.
The average response of the participants to the question- Examples of transcribed text for the monitor and blunter
naire ranged from 4.0 for questions 4, 5, and 6 to 4.3 for roles are shown in table 2. Examples of patient-centered
questions 2 and 3 (appendix 2), indicating that all the and nonpatient-centered communications occurring with
participants felt it was important to conduct a patient- the monitor and blunter are shown in table 3.
centered preoperative interview. These results did not The total (sum) score (a total score of 10 would be the
differ by sex, country of medical training, or prior com- best score, and 40 the worst) on the standardized pa-
munication course. tients questionnaire (appendix 3) was 25.7 (CI 24.6 –
Interviews with the monitor lasted 17.4 min (95% CI 27.2) for the blunter and 21.8 (CI 19.7–23.9) for the
15.2–19.6, n # 24) versus 14.5 min (95% CI 13.1–16.0, monitor (P " 0.01) The Cronbach’s alpha for the blunter
n # 25) for the blunter (P # 0.02). Most interview time was 0.76 and 0.77 for the monitor. The total score was
was spent in obtaining the history: 6.8 min (95% CI significantly affected by standardized patient type (P "
5.9 –7.1) for the blunter, 6.1 min (95% CI 5.2–7.0) for the 0.01) and whether or not the anesthesia provider had
monitor (P # 0.03). Figure 1 shows the times for all taken a communication course (P # 0.03). The effect on
components of the interview. the prior communication course was more pronounced
A greater amount of time was spent in discussing risks for the monitor (fig. 2), but it did not reach statistical
with the monitor than with the blunter, 2.4 min (95% CI significance (P # 0.06). Sex and country of medical
1.8 –3.1) versus 1.6 min (95% CI 1.2–2.0), P # 0.03. In school training did not have a significant effect. Years of
each case, discussion of risk comprised less than 15% of anesthesia training showed a significant negative corre-
the interview. The time spent in discussion of postoper- lation with the total score for the monitor standardized
ative pain control options was 1.2 ! 0.9 min (mean ! patient but not for the blunter (fig. 3).
SD). Maximum time spent was 3.9 min; in 11 interviews Figure 4 gives the scores for each question on the
(10 blunter, 1 monitor, 22% of interviews), no discussion standardized patient questionnaire (appendix 3). Note
of postoperative pain control options occurred at all. that the monitor standardized patient gave the same
Examination of the discussion of the risks of anesthesia response to the “goals” question (question 6); this ques-
revealed no statistical differences in the types of risks tion was dropped from the statistical analysis because of
discussed between the monitor and the blunter. Of the lack of variation in the ratings. Except for satisfaction
11 risks that were tabulated, on average 5.6 ! 2.2 risks with the discussion of the anesthetic options (question

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974 ZOLLO ET AL.

Table 2. Examples of Conversations from the Interview Table 3. Examples of Interview Exchanges that Showed
Transcripts Different Degrees of Patient-centeredness

Monitor Monitor, patient-centered

D: A very uncommon reaction would be, you know patients P: I’ve read about all the bad stuff, I mean on the Internet, the
can have an anaphylactic reaction to the anesthetic. people that don’t wake up, the reactions, people who are
P: Now what is that? never in their right mind when they’re all done, and things
D: Your body goes into a state, simply put, a state of shock like that so.
and you can, it’s a life threatening. D: And these are things that you are obviously concerned
P: Can you fix that? about or?
D: It is life-threatening, we can give you medication to try and P: Yes, very concerned.
prevent, to try and help the reaction once it happens, but D: Um, so generally speaking, those would be, well, what we
that’s one of those situations that I was saying maybe one call, well more of a severe side effect. For the most part,
in 10,000. they are pretty rare. There is a possibility, would you like me
D: You could possibly get an eye injury, and it’s a, it’s painful. to go into all of the risks? No matter how remote? Some of
It does usually resolve, but we’re going to tape your eyes, the risks are extremely rare.
we’re going to be careful and put lubricant on them. Monitor, not patient-centered
P: How do you hurt my eyes? D: Anybody in your family have any problems with surgery or
D: Because the scope that were putting in, you can actually anesthesia?
rub, either with the scope or the mask. P: No, not really. I mean I have read on the Internet about all of
Blunter the problems, but there doesn’t seem to be anything in my
D: Any questions about any of that? family.
P: No, I just you know, I just want to know that it I’m going to D: Okay, I see the you have a reaction to penicillin.
come through it all right, I’ll wake up, I don’t want to wake Blunter, patient-centered
up too soon. D: Would you like me to go into more of the theoretical risks?
D: Right, right. P: Not really (laughs nervously).
P: But I want to wake up. D: Okay, that’s what I see.
D: Right, and that’s our goal too. P: You know, in a way the more I know the more I. I.
P: I just want to go to sleep and wake up, that’s it. D: I understand. Most of these risks are very rare, so it’s the
D: Okay, and you’re to do that, you’re to do that too, this is kind of thing that I kind of feel out the situation and decide if
just kind of an added thing that you don’t have to make a you want to hear it or not.
decision today about it, but I just want you to know that it’s Blunter, not patient-centered
an option and that somebody will probably offer it to you D: Um, he would kind of be in a sitting position, and umm feel
[epidural]. a little bee sting, we give you some numbing medicine.
D: Did your doctor have any explanation why you might have P: Oh whatever, I’d rather not know too much.
got that [blood clot]. D: Oh, okay. And they’ll talk about it, more about that.
P: No, nothing I really wanted to hear. You know, no I. P: Oh yeah, okay.
D: Had you been on a long airline trip? Or in the car for a long D: For the actual procedure, you go back to the operating
period of time? room, we put a bunch of monitors on you, EKG leads, pulse
P: No, no. oximeter on your finger, breathe some oxygen, through a
D: Do they think that you had some kind of problem with your mask, and then drift you off to sleep through your IV.
blood at all?
P: No. D # anesthesiologist; EKG # electrocardiogram; P # standardized patient.
D: That would make you have a clot?

imental paradigm. We find that a difference in coping

D # anesthesiologist; P # standardized patient.
styles portrayed by the standardized patients results in
different responses from interviewers. A larger, more de-
3) and the anesthetic goals (question 6), the monitor was
tailed study will need to confirm our preliminary observa-
generally more satisfied with the preanesthesia discus-
tions that a prior communications course improves the
sion. The logistic regression analysis showed the same
quality of the interview and that, for a monitoring coping
questions as having a significant difference between the
style, anesthesiologists’ prior experience (e.g., years in
blunter and monitor standardized patients. Interestingly,
practice) may not result in a more patient-centered in-
question 4, although not showing a significant standard-
terview. Our preliminary qualitative analysis provides a
ized patient effect, did show a significant effect from
rich paradigm to test further controlled interventions to
having a previous communication lecture as did ques-
improve patient-anesthesiologist interactions.
tion 5. There were no other significant effects for the
The presence of many potentially confounding vari-
other independent variables.
ables in any communication study, some of which are
difficult or impossible to remove, can make any conclu-
Discussion sions reached provisional at best, but our study design
attempted to limit these problems. We used preliminary
This study was designed to provide an empirical de- observations gleaned from actual patient interviews col-
scription of the contents of the anesthesiologist provider lected during their preoperative clinic visit to help de-
preoperative patient interview and to investigate the use sign the standardized patient training protocol. This was
of standardized patients in providing a controlled exper- done to determine the tasks where the least and the most

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PREANESTHESIA COMMUNICATION 975

pain may show significant variability and may not require

the same degree of discussion in each case, but some
discussion should always occur. This variability was re-
moved in our standardized patient study design, which
used a clinical scenario (possible thoracotomy) for which
significant postoperative pain is likely, and there are a
variety of treatment options.
Another patient factor that is difficult to control in a
study using actual patients is patient coping style. It is
likely that the two archetypal styles (blunter and moni-
tor) that were used in this study represent opposite
poles of a spectrum and that most actual patients fall
somewhere between. We designed the standardized pa-
tient study by using these two extremes. Both of these
coping styles were noted by anesthesiology trainees in
obtaining informed consents.19
In addition to the potential for postoperative pain and
patient coping mechanisms, many other illness as well as
Fig. 2. Comparison of the total score on the postinterview ques- patient and contextual factors can affect patient-anesthe-
tionnaire shown in appendix 3 (median and quartiles). Partic- siologist communication—such as complexity and sever-
ipants who recalled having a doctor-patient communication
course had a greater effect for the monitor (P ! 0.06) than for ity of the illness, patient cognitive ability, and whether
the blunter (P ! 0.23). For combined blunter and monitor the patient comes alone or accompanied. The advantage
standardized patients, effect of the communication course was
significant, P ! 0.03.
of the standardized patient methodology is that these
variables can be controlled, allowing a focus on provider
amount of time was spent, and the overall pattern and pace rather than patient factors.
of the preoperative interview. Further, we wanted to de- Mean interview times as well as times spent in each
termine if major areas were omitted or were not covered interview component for the standardized patients
completely during the interview. We found that the aver- closely resembled those for actual patients in the clinic,
age interview time for actual patients was approximately observed during our preliminary pilot data collection in
20 min, and that generally, most of the important tasks preparation for this study (Analysis of actual patient
were completed. However, it was striking that for some recordings, Raymond A. Zollo, M.D. Rochester, NY,
patients, there was no discussion of postoperative pain 2005 unpublished observation), suggesting that our stan-
control, and that the discussion was minimal for others. dardized patient portrayal evinced similar anesthesiolo-
This finding is important because numerous studies have gist behavior as actual patients. Most of the interview
shown that surgical patients are very concerned with post- time was spent in obtaining the patient’s history. This is
operative pain and expect that this issue will be ad- consistent with data obtained in other specialties, and
dressed.18 It can be argued that for actual patients having a very consistent with the expected pattern in a preoper-
variety of surgical procedures the level of postoperative ative evaluation interview, where most effort is spent

Fig. 3. Relationship between the experi-

ence level (including residency) of the
anesthesia provider/participant and the
total satisfaction score (appendix 3) of
the standardized patients. The slope was
significant (P ! 0.02) for the monitor,
but the correlation was relatively weak
with r2 ! 0.23 for monitor (B) and 0.04
for blunter (A).

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976 ZOLLO ET AL.

of the patient’s coping style. However, it was striking how

often important risks were not discussed.
Next, standardized patient evaluations of the interview
process were examined against provider demographic
data to look for provider characteristics that may have
played an important role in the perception of interview
quality by the (standardized) patient. Two provider char-
acteristics seem to play an important role in this percep-
tion. First, the provider self-report that they had received
instruction in communication at some point during their
training significantly improved the perception of the
provider by the standardized patient. It is important to
note that we did not obtain any detail regarding the kind
of communication instruction that may have occurred.
However, the fact that this is reported by providers them-
selves would seem to indicate that it must have some
Fig. 4. Response to the postinterview questions for the Blunter
and Monitor standardized patients. The question numbers refer significance in their training and clinical practice. Perhaps
to table 2. * P < 0.05 for a comparison between monitor versus this instruction in communication improved their ability to
blunter. Blunter depicted with the black bars, and the monitor recognize patient coping mechanisms and allowed them to
in the gray. Error bars represent SEM.
alter their communication styles accordingly.
gathering information and only a directed physical exam A second provider characteristic that played a signifi-
is typically performed. cant role was the level of anesthesia training. Interest-
Of particular interest are the differences apparent be- ingly, the greater the level of anesthesia training, the less
tween the monitor and blunter interviews. The monitor satisfied the monitor was with the interaction. This ef-
received a significantly greater amount of provider time fect was not seen with the blunter. Perhaps this illus-
in the description of the anesthetic, the description of trates the other side of the spectrum; the monitor has to
the risks of anesthesia, and in the discussion of postop- work harder to steer the more experienced clinical pro-
erative pain control. Again, most patients tend to be vider, causing a decrease in the monitor’s satisfaction
most anxious about these topics, and they may expect to with the clinical interaction. The recent emphasis on
discuss them at some time during the preoperative pro- effective doctor-patient communication in medical
cess. Further, qualitative analysis of these recordings school curricula may make the more recent graduates
indicated that often the monitor asked a specific ques- more adept at recognizing patient coping styles and at
tion resulting in discussion of these topics, or forced the altering their communication approach accordingly.
provider to return to these topics when the discussion We acknowledge many limitations with this study. First,
was insufficient. This did not typically occur in the the anesthesiologists knew that their interactions were be-
blunter interviews, where the blunter is reluctant to ask ing audio recorded. Such knowledge may lead them to
questions. This finding supports recommendations that exhibit “good” behaviors that they would not do other-
patients be encouraged to ask questions of their health wise. However, if they are able to exhibit such behaviors
care providers to get complete information and to pre- under any circumstances, they are at least capable of such
vent medical errors.!! behaviors, which they may have learned at some point in
While there is little consensus about the exact compo- their education. Furthermore, many subjects did not ex-
sition of a valid informed consent, there is universal hibit optimal patient-centered behaviors despite being ob-
agreement that the informed consent represents a cru- served, and exhibited differences in their interactions with
cial part of any preprocedure evaluation and discus- patients with different coping mechanisms. It is likely that
sion.17 The apparent differences in provider effort ob- such differences would be apparent in their clinical prac-
tained by the monitor and the blunter prompted us to tice. For future studies, it would be possible to use unan-
examine the informed consent process and the discus- nounced standardized patients.20
sion of anesthetic risk in a qualitative fashion. Indeed, Another limitation is having the standardized patient
the monitor tended to fare better in this area as well. grade the interaction with the provider while in role—in
Although the monitor was scripted to ask questions during neutral, where the standardized patient remains in role
the informed consent process, differences in the risks dis- but does not stay in the emotion at the end of the
cussed were not significantly different. This may indicate interaction. That is, the evaluation is given as the patient
that the anesthesiologists discuss a set of risks independent being portrayed, but “looks back on what happened
from a slight distance.”12,13 This is a common technique
!! Available at: http://www.ahrq.gov/questionsaretheanswer/. Accessed June
for evaluation by standardized patients. Although there is
11, 2009. a certain objectivity that comes with the use of experi-

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PREANESTHESIA COMMUNICATION 977

enced standardized patients, is it really possible for the 13. Srinivasan M, Franks P, Meredith LS, Fiscella K, Epstein RM, Kravitz RL:
Connoisseurs of care? Unannounced standardized patients’ ratings of physicians.
standardized patient to completely separate their role Med Care 2006; 44:1092–8
from their personality? In an attempt to limit the effect of 14. Fiscella K, Franks P, Srinivasan M, Kravitz RL, Epstein R: Ratings of
physician communication by real and standardized patients. Ann Fam Med 2007;
this potential problem, standardized patients were se- 5:151–8
lected who have a tendency to exhibit such coping 15. Miller SM, Mangan CE: Interacting effects of information and coping style
in adapting to gynecologic stress: Should the doctor tell all? J Pers Soc Psychol
mechanisms in real life (type-casting). 1983; 45:223–36
Finally, our study is limited by the relatively small 16. Schirmer JM, Mauksch L, Lang F, Marvel MK, Zoppi K, Epstein RM, Brock
D, Pryzbylski M: Assessing communication competence: A review of current
number of participants, all with relatively little experi- tools. Fam Med 2005; 37:184–92
ence in anesthesiology (residents and junior attending 17. Jenkins K, Baker AB: Consent and anaesthetic risk. Anaesth 2003; 58:
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physicians). Firmer conclusions, particularly about the 18. Brennan F, Carr DB, Cousins M: Pain management: A fundamental human
role of anesthesiology experience and a prior communi- right. Anesth Analg 2007; 105:205–21
19. Waisel DB, Lamiani G, Sandrock NJ, Pascucci R, Truog RD, Meyer EC:
cation course, will require a larger study. Anesthesiology trainees face ethical, practical, and relational challenges in ob-
The outcome of this study raises several questions for taining informed consent. ANESTHESIOLOGY 2009; 110:480–6
20. Epstein RM, Levenkron JC, Frarey L, Thompson J, Anderson K, Franks P:
future investigations. Does increased patient satisfaction Improving physicians’ HIV risk-assessment skills using announced and unan-
with an anesthesiologist–patient interaction in the periop- nounced standardized patients. J Gen Intern Med 2001; 16:176–80
erative period lead to better outcomes? Can instruction in
anesthesiologist-patient communication improve patient Appendix 1: Detailed Training Script
satisfaction in the perioperative period prospectively? Can
Name/Age/Sex: John Smith/48/Male
instruction in anesthesiologist-patient communication off- Ethnicity/Race: Caucasian
set the possible “negative” effects of increased clinical ex- Presenting Situation: Comes to the Preadmission Evaluation Center
perience level? Is there a training window in which instruc- in preparation for his lung surgery. He is having a thorascopic wedge
tion in communication is most effective? Are there resection for lung tissue biopsy to rule out cancer. If cancer is present,
a lobe of the lung or the entire lung may be removed.
differences in the techniques used by junior and senior
Opening Statement: I’m here because I need to have lung surgery.
anesthesiologists to obtain needed information, and which In response to silence or open-ended questions, will spontaneously
techniques are more effective? Should anesthesia programs disclose:
devote more time during residency to teaching effective I guess I am here to discuss the anesthesia for my surgery. Other than
communication with patients? Studies specifically designed that, I am not sure why I need to be here. (Blunter)
I want to discuss the details regarding the anesthesia for my wedge
to address these questions could yield results that would
biopsy. What kind of anesthetic, what drugs are you going to use.
improve patient-centered anesthesia care. When do I have to come in the morning? I know I have to not eat
anything after midnight the night before, but I usually take my antacid
The authors thank Ashwani Chhibber, M.D., Professor of Anesthesiology and and my supplements with food. (I get sick if I don’t). Exactly who will
Pediatrics, and Barry Zimmerman, M.D., Associate Professor of Anesthesiology
be in the room with me? (Monitor)
(both Department of Anesthesiology, University of Rochester Medical Center,
Rochester, New York), for their invaluable assistance and guidance for the Patient Symptoms:
conduct of this study. None right now. I had some pain and swelling in my right leg, so I
went to the doctor. He told me I had a blood clot there. He put me in
the hospital so I could go on blood thinners to dissolve the clot. When
References they took a chest x-ray, they saw something in my lung. Now I am here.
I did have a cough which was worse in the morning. It’s been there
1. Egbert LD, Battit GE, Turndorf H, Beecher HK: The value of the preopera-
for a couple of months. When asked about weight loss, Mr. Smith
tive visit by an anesthetist. JAMA 1963; 185:553–5
2. Egbert LD, Battit GE, Welch CE, Bartlett MK: Reduction of postoperative reports that he has lost a few pounds, but that he has been trying to
pain by encouragement and instruction of patients. N Engl J Med 1964; 270: stay on a diet.
825–7 Onset Of Symptoms (Cough): Cough first noticed it getting worse a
3. Institute of Medicine: Crossing the Quality Chasm: A New Health System for
couple of months ago. Although I think I have always had a little
the 21st Century. Washington, DC, National Academies Press, 2001
4. Capuzzo M, Landi F, Bassani A, Grassi L, Volta CA, Alvisi R: Emotional and smokers cough.
interpersonal factors are most important for patient satisfaction with anaesthesia. Pattern: Worse in the morning. I do not notice it during the day
Acta Anaesthesiol Scand 2005; 49:735–42 much.
5. Fischer SP: Development and effectiveness of an anesthesia preoperative
Location: NA
evaluation clinic in a teaching hospital. ANESTHESIOLOGY 1996; 85:196–206
6. Task Force on Preanesthesia Evaluation: Practice advisory for preanesthesia Radiation: NA
evaluation: A report by the American Society of Anesthesiologists Task Force on Quality: Seems to usually be pretty dry, occasionally I bring up some
Preanesthesia Evaluation. ANESTHESIOLOGY 2002; 96:485–96 stuff.
7. Kopp VJ, Shafer A: Anesthesiologists and perioperative communication.
Intensity: Bad in the morning. I often sit on the edge of the bed first
ANESTHESIOLOGY 2000; 93:548–55
8. Klafta JM, Roizen MF: Current understanding of patients’ attitudes toward thing in the morning and cough for 10 min before I get up.
and preparation for anesthesia: A review. Anesth Analg 1996; 83:1314–21 Onset of Symptoms (Leg Swelling, Clot): Oh I noticed that about 2
9. Makoul G: Essential elements of communication in medical encounters: The weeks ago, woke up with my leg pretty sore and swollen. It hurt to
Kalamazoo consensus statement. Acad Med 2001; 76:390–3
walk on it, and it was pretty warm that’s when I went to the doctor.
10. Levinson W, Chaumeton N: Communication between surgeons and pa-
tients in routine office visits. Surgery 1999; 125:127–34 Pattern: It was just there.
11. Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, Ferrier K, Location: My right leg, hurts worse in the back of the leg.
Payne S: Observational study of effect of patient centredness and positive ap- Radiation: Usually doesn’t go anywhere, hurts in the same places.
proach on outcomes of general practice consultations. BMJ 2001; 323:908–11
Quality: A mixture of a dull ache and a burn.
12. Epstein RM, Franks P, Shields CG, Meldrum SC, Miller KN, Campbell TL,
Fiscella K: Patient-centered communication and diagnostic testing. Ann Fam Med Intensity: Oh it was sore. I had trouble moving it. Had to take the day
2005; 3:415–21 off of work and go see the doctor.

Anesthesiology, V 111, No 5, Nov 2009

978 ZOLLO ET AL.

Treatments Tried: I took some Tylenol and just let my leg rest, but and lose a little weight. I know I need to stop smoking. Other than that,
that did not help. So I went to the doctor. I have been very healthy, never been in the hospital until I got the
What Makes It Better?: Not moving it. blood clot.
What Makes It Worse?: Moving it. Surgeries: None.
Pertinent Negatives: As far as you remember, you did nothing to Injuries: Oh, I pull a muscle now and then but that’s about it. No
injure your leg, it just seemed to happen. broken bones. No serious injuries, not even stitches allergies. I remem-
Prescribed Medications: None. ber someone telling me that I am allergic to penicillin. I guess I had a
Over-the-Counter Medication: Vitamins (with food); Antacid (for reaction to it when I was a kid, but I don’t remember.
upset stomach) which I seem to have all the time. Family Health History:
Herbal Remedies: Oh, I take some supplements now and then. Mother: Living at age 80 yr; has some arthritis and seems to get a bit
Past Medical History: confused lately but is able to live alone.
Illnesses, Prior Episodes: I know my blood pressure has been high; Father: Died of massive heart attack a year and a half ago, when he
it’s the stress at work I am sure. I have been trying to watch my diet was 75 yrs old.

Appendix 2. Anesthesiologist Questionnaire

ID # Age Male e Female e

Attending e Resident e CRNA* e Years of anesthesia (including training years):
Country of Medical School / Nursing School: USA e Other e
1. Have you ever had a specific course in Provider / Patient communications?
Yes e No e If yes, when: Post-grad e
Residency e
CRNA training e
Nursing School e
Medical School e
Other e
2. How important do you feel the medical component of the preanesthesia evaluation is?
Not at all e (1) A little bit e (2) Moderately e (3) Quite a bit e (4) Extremely e (5)
3. How important is the explanation of the anesthetic plan to the patient?
Not at all e (1) A little bit e (2) Moderately e (3) Quite a bit e (4) Extremely e (5)
4. How important is the explanation of the postoperative pain management plan to the patient?
Not at all e (1) A little bit e (2) Moderately e (3) Quite a bit e (4) Extremely e (5)
5. How important is it to elicit and follow the patient’s desires for the anesthetic and pain management plans?
Not at all e (1) A little bit e (2) Moderately e (3) Quite a bit e (4) Extremely e (5)
6. How much can a good preoperative discussion with the patient affect clinical outcomes?
Not at all e (1) A little bit e (2) Moderately e (3) Quite a bit e (4) Extremely e (5)
7. How much do you think patients worry about their anesthetic (as distinct from anxiety about the procedure)?
Not at all e (1) A little bit e (2) Moderately e (3) Quite a bit e (4) Extremely e (5)

Each participant in the study completed this questionnaire after completing both interviews. For questions 2–7, the numbers in parenthesis were used to average
the scores. See Results.
CRNA # Certified Registered Nurse Anesthetist.

Appendix 3. Standardized Patient Post-interview Questionnaire

1. To what extent were your concerns about your anesthetic discussed?

e (1) Completely e (2) Mostly e (3) A little e (4) Not at all
2. How well do you think the anesthetist understood you today?
e (1) Very well e (2) Well e (3) Somewhat e (4) Not at all
3. How satisfied were you with the discussion of your anesthetic options?
e (1) Very satisfied e (2) Satisfied e (3) Somewhat e (4) Not satisfied
4. How satisfied were you with the discussion of your pain management options?
e (1) Very satisfied e (2) Satisfied e (3) Somewhat e (4) Not satisfied
5. How much opportunity did you have to ask your questions?
e (1) Very much e (2) A fair amount e (3) A little e (4) Not at all
6. To what extent did the anesthetist ask about your goals for the anesthetic and recovery?
e (1) Completely e (2) Mostly e (3) A little e (4) Not at all
7. To what extent did the anesthetist explain the anesthetic and possible side effects?
e (1) Very well e (2) Well e (3) Somewhat e (4) Not at all
8. To what extent did the anesthetist explain the postoperative pain management and possible side effects?
e (1) Very well e (2) Well e (3) Somewhat e (4) Not at all
9. To what extent did the anesthetist encourage you to take the role you wanted in your own care?
e (1) Completely e (2) Mostly e (3) A little e (4) Not at all
10. How much would you say that this anesthetist cares about you as a person?
e (1) Very much e (2) A fair amount e (3) A little e (4) Not at all

After each interview, the standardized patient completed this questionnaire relating to the interview, keeping the role played (i.e., a blunter or monitor patient).
The numbers in parenthesis were used to average the scores. See Results.

Anesthesiology, V 111, No 5, Nov 2009