By Lola Oladini, MS4, University of Chicago Pritzker School of Medicine

“Awake surgery” is a term that describes procedures performed while the patient is fully alert or minimally/moderately sedated. Previously used primarily for surgical procedures where communication was critical to patient assessment, “awake surgery” has grown to involve several minimally invasive surgical and interventional radiologic procedures. To obtain more insight about this type of surgery, we spoke with Claire Smith, an MS4 at Pritzker School of Medicine, who co-authored a paper on communication and patient/physician perspectives on teaching during awake procedures.

Q: In interventional radiology, moderate sedation is typically utilized for routine procedures, which parallels to what you describe in your research as “awake surgery.” Why did you and your team decide to interview patients and surgeons who operate using moderate sedation?

A: We opted to interview surgeons and patients familiar with awake surgical procedures, defining awake as under no sedation or under conscious sedation, because we were interested in the communication that occurs in the procedure room between the patient and the surgical team. We thought of this setting as one that might cause anxiety for patients, and sure enough, prior studies have shown that it has. We were curious as to how communication could help (or hurt) the patient experience of being awake for their own procedural care, and how awake surgery itself might have larger implications for the surgeon-patient relationship.

Q. When interviewing patients who received moderate sedation for their procedures, what were some salient themes that emerged that would be important for interventional radiologists and surgeons to bear in mind?

A. The most common type of communication that patients mentioned appreciating was having their expectations managed—knowing what was coming, what to expect, and how long things might take (if possible). Many patients appreciated being distracted during their procedure by surgeons or other members of the team. Patients also appreciated emotional comfort—being told that they were doing well and everything was going fine.

A minority of patients had some negative experience with communication during their procedure, and most of these involved the patient feeling excluded from the conversation. Patients had discomfort with hearing whispering, any discussion of technical error, and teaching that suggested a less experienced member of the team was performing the procedure.

Q. Did any of your findings surprise you?

A. One surprising finding was that several patients who had a negative experience during their procedure identified themselves as nurses and said that their comprehension of the surgeons’ conversations made them feel less comfortable—suggesting that educating patients about what is going on during their procedure may not always make them feel better. As we look forward to ways to help alleviate patient anxiety during awake procedures, we’ll have to look for the right balance of information and this might need to be tailored to individual patients.

Q. What do you think is the best teaching approach during moderate sedation procedures? What adjustments, if any, should either the patient or the trainee anticipate during ‘awake’ procedures?

A. Managing expectations is helpful, so introduce residents, explain their role, and warn patients that teaching will be happening, if possible.

As for adjustments, feel free to ask the patient what they prefer—if hearing teaching bothers them, music or a distracting conversation with staff may help.

Last, one strategy for teaching that surgeons mentioned using for awake procedures was reviewing everything with the resident outside the room before the case (and doing the same for questions afterward) in order to minimize any conversation that might be uncomfortable for patients.

Q. From your analysis, do you think physicians would benefit from additional training on how to interact with patients during awake procedures?

A. Absolutely! Surgeons unanimously say that they haven’t received training in this, and have cobbled together their strategies from seeing others do it—many of them were curious about how their peers communicate during awake surgery. Patients, while mostly satisfied with communication during their awake procedures, are still having some specific negative experiences. There is definitely room for improvement.

Q. Considering the concept of “Humanism in medicine”, can you comment on whether there is a space for physicians and trainees to enhance meaningful connection with patients during awake procedures?

A. One of the remarkable things about the surgeon-patient relationship is the trust patients must have for their surgeons while asleep, but with awake surgery that relationship is not so one-sided. Surgeons have to trust patients to be participants in their own procedural care, and have to find ways to be honest and transparent with patients regarding procedural training without increasing patient anxiety unnecessarily. In awake surgery, physicians and patients are all in a vulnerable position and share the opportunity for open communication and trust.