Current understanding of the literate versus illiterate patient's knowledge about anesthesiologists: A comparative study

Abstract

Context:

There is a widespread ignorance among the public about the role of anesthesiologists and their responsibilities inside or outside the operating room both in developed and developing countries.

Aims:

The present study was conducted to assess the knowledge of literate and illiterate patient about the role of anesthesiologists and their concerns regarding anesthesiology.

Setting and Design:

This is a prospective study conducted in a preoperative anesthetic clinic of a large tertiary care hospital. The study consisted of a standard preanesthetic interview and questionnaire.

Materials and Methods:

After obtaining permission from the Ethics committee, patients in the age group 18–75 years of either sex undergoing elective surgery were included. The patients were divided into two groups on the basis of their education: Group A: included patient who are illiterate; Group B: included patients who are literate, completed a questionnaire, which was later evaluated.

Statistical Analysis Used:

Unpaired t test and correlation r test were used.

Results:

There was limited knowledge among both literates and illiterates regarding the perioperative role of anesthesiologists. They wanted to be fully explained about the anesthesiology technique and were keen to meet their anesthesiologist both before and after the surgery.

Conclusion:

To eliminate the ignorance among general public regarding the role of anesthesiologists, efforts must be made to educate and generate awareness among the population.

INTRODUCTION

An anesthesiologist's contribution to patient care intraoperatively has now extended from the operating room to the periphery, intensive care, and pain management. From our experiences, we have observed that the stature of anesthesiologists is low in comparison with other specialists. Studies conducted round the world have revealed that there is a general misconception that anesthesiologists are not physicians but most of the studies were conducted on literate and urbane subjects.[1,2,3,4,5,6] It is believed that education imparts knowledge and increases the curiosity of a person to know more. With the advent of easy access to internet and increasing role of media, it was assumed that the literate patients are more oriented and have more knowledge of anesthesiology and an anesthesiologist.

The aim of this study was to compare and assess the knowledge and attitude of literate and illiterates regarding an anesthesiologist.

MATERIALS AND METHODS

After taking permission from the Institutional Ethics committee, this cross-sectional study was conducted on 510 patients who visited the preanesthetic clinic over a period of 3 months.

A pilot study was under taken in 15 individuals to ensure that the questionnaire could easily be understood and, if required, any modification in the questionnaire could be made before proceeding for the study further these patients were also included in the study.

The study size was ascertained after reviewing the existing data as most of the studies[2,3,4] have taken a sample size of 200 further as the total duration of study was 04 months that include data collection (02 months), compilation, and analysis. The total numbers of patients who filled the questionnaire were 510 but after eliminating the incompletely filled forms, the investigator finally analyzed the sample of 445 patients. The patients were divided into two groups on the basis of their education: Group A (n = 217) included patient who were educated till at least matriculation and could write either in Hindi and English, whereas Group B (n = 228) included patients who were illiterate.

Patients who did not understand Hindi or English, were hard of hearing or had abnormal mental status, and were medical or paramedical staff were excluded from the survey.

Patients were verbally asked whether they would complete the questionnaire and if agreed upon were given the question sheet. The participants were explained that their participation in the study is totally voluntary and their responses will be kept confidential. A questionnaire comprising 16 questions [Annexure 1] prepared in both Hindi and English was given to the patients with each question verbally explained as patients in Group B were illiterate.

The questionnaire had three parts. The first part of the questionnaire was about demographic information. The second part of the questionnaire was designed to assess the knowledge regarding an anesthesiologist. The third part of the study was based on assessment regarding anesthesiology and anesthesiology techniques.

Descriptive statistics (mean, standard deviation, range) were used to summarize patient's demographic data and operative details. The statistical analysis was done using two sample unpaired t test and the correlation r test.

RESULTS

Demographic profile

The study included 445 patients belonging to the age group 18–76 years. Of the 445 respondents, 252 (56.5%) were males and 193 (43.5%) were females. The profession of the subjects ranged from unemployment to the noble profession of teaching. There was no statistical difference in the demographic data between the two groups [Table 1]. The various specialty Outpatient Departments (OPD's) being attended by the subjects are shown in Table 2. On enquiring, only 26.5% (118) patients from above specialities knew why they were referred to the preanaesthetic check-up clinic (PAC clinic).

Table 1.

Demographic profile of the patients

Table 2.

Distribution of patients according to the specialty OPDs they attended

Knowledge of anesthesiologists

A total of 32.3% patients had a previous surgical and anesthetic exposure, of which 126 (87.5%) could recall the name of the operating surgeon while a meager 32 (22.2%) could remember the name of the anesthesiologist. There was significant a difference: Patients in Group A could recall the name of the anesthesiologist of the last surgery, while very few patients in Group B could recollect the name of the anesthesiologist [Table 3].

Table 3.

Previous anesthetic exposure

Only 93 (20.8%) knew that anesthesiologists were medically qualified doctors, 91 (20.4%) subjects thought anesthesiologist was nursing staff, while 87 (19.5%) believed that anesthesiologists were actually assistant to surgeon, whereas 133 (29.8%) had no clue regarding the identity of the anesthesiologist [Table 4]. No statistically significant correlation was found between education and the knowledge regarding anesthesiologists. Regarding the knowledge of the working area of the anesthesiologist, 211 (47.5%) responded correctly stating that they work in operating room. There was no significant difference between the two groups (P > 0.05) with concern to their knowledge regarding the role of anesthesiologist outside the operating room [Table 4].

Table 4.

Identity and work profile of the anesthesiologist

Knowledge about type of anesthesiology

On asking what are the various methods by which a patient is anaesthetized, most of the people knew about commonly used methods of administering anesthesiology like general anesthesiology (287 (64.5%)) and regional anesthesiology (133 (29.8%)). More subjects in Group A were aware of regional anesthesiology than subjects in Group B [Table 5].

Table 5.

Knowledge regarding type of anesthesiology techniques in practice

Patient's concerns regarding anesthesiology and its management had multiple responses. A majority of the subjects (284 (63.8%)) were more concerned about the complications and outcomes of surgery as opposed to 29 (0.06%) who were worried about anesthesiology. There was a significant difference (P < 0.05) among the two groups regarding the outcome of anesthesiology; subjects in Group A were more concerned about awareness during surgery while respondents in Group B were more worried about not waking up. There was no significant difference (P < 0.05) in voicing their concern about pain during operative period (64.4%) [Table 6].

Table 6.

Major concern regarding anesthesiology and its outcomes

There was a unanimous decision among both the group in that they wanted to know about all the complications associated with the anesthesiology technique. The majority (63.51%) felt that a surgeon is responsible for the outcome of surgery [Table 7].

Table 7.

Responses on whether who is responsible for outcome of surgery and should anesthesiology complications be discussed

An overwhelming 41.3% responded that the anesthesiology technique, its advantages, and disadvantages have been explained clearly to them. But it was disheartening to observe that given a chance a meager of 13.2% would like to choose their anesthesiologist as they trusted the surgeon more [Table 8]. 40% (Group A) and 22% (Group B) believed that co-morbid conditions could be a risk for surgery (overall 31%).

Table 8.

Response on whether they would like to choose anesthesiology in future and how procedure has been explained

DISCUSSION

The lack of data co-relating the level of literacy and awareness of the population about anesthesiologist and their contribution encouraged us to conduct this study. Several studies conducted both internationally[2,3,7,8,9,10,11,12,13,14] and in India[4,5,6,15] have showed varying results regarding the knowledge of general public about anesthesiologists and their role in surgery. In developed countries, the percentage of subjects who knew about anesthesiologist ranged from 70% to 90% and those in developing countries ranged from 18% to 89%. But our study showed that only 34% of the population knew that an anesthesiologist is a trained doctor [Table 9].

Table 9.

International and national studies depicting the percentage of patients who knew anesthesiologist was a doctor

In previous studies, the survey was conducted in advanced hospitals in metropolitan cities which cater to the people from higher socio-economic group, people living in urban environment, having exposure to media that may have influenced their responses. Our survey was conducted on people from both high and low socio-economic groups and coming from urban and rural backgrounds.

Most of the subjects believed that anesthesiologist were assistants to surgeon (24.5%) and worked in operating rooms (61%); this may be because in our country the surgeons enjoy an unparallel status of demigod. Applying simple mathematics that surgery is performed in operating rooms and anesthesiology is given before surgery, the respondents may have assumed that an anesthesiologist works in operating rooms and is thus an assistant to surgeon. As observed in other studies,[4,5] the female anesthesiologists are often mistaken for nursing staff; this study too confirms the belief that general public thinks that anesthesiologists are nursing staff, as 22.5% of the respondents believed that anesthesiologists were nurses. A high percentage of participants (17%) were not sure who an anesthesiologist is and 23% did not know about their place of work.

Generally, a previous experience should increase the knowledge of a person but to our disappointment, we observed that 32.3% subjects had undergone previous surgery and anesthetic exposure out of which 87.5% remembered the name of their surgeon but only 32% remembered the name of the anesthesiologist. This can be explained due to the lack of good interaction between the anesthesiologist and the patient. This lack of interaction could be because of time constraints mostly in relation to operating theatre overload that the preoperative visits are rushed.

In some countries, a small booklet describing the role of anesthesiologists is given at the time of admission. Again giving handouts and brochure to illiterate patients does not serve the purpose and patients always prefer personal touch.[16] There are recommendations that the patient can be shown a video about perioperative care.[9] These methods may be extremely helpful but cannot substitute the direct patient contact or the personal touch the patients prefer. On some occasions, the anesthesiologist and the patient meet for the first time in the theatre as the person doing PAC and the one giving anesthesiologists are different and at times in a busy hospital like ours, the patient rush is extreme in the preanesthetic clinic that giving personal attention to the patient becomes difficult. In our institute, we have set a time aside a day prior to surgery where we interact with the patient to explain the details of anesthetic procedure, discuss their preference of anesthesiology, and allay their anxiety.

It was astonishing to see how much the patients entrusted their surgeons, as 63.5% believed that surgeons were responsible for the outcome of surgery and only 6% believed that the anesthesiologist were in-charge of their well-being in a perioperative period.

The majority of subjects in both the groups (66% in Group A and 75% in Group B) preferred general anesthesiology over regional anesthesiology as in other studies.[6,15] Even though the fear of intraoperative pain and not waking up was rampant among illiterates, the fear of backache and long-term weakness and disability due to regional anesthesiology was profound. These fears about regional anesthesiology were mainly due to misinformation the subject had from his own experience or from hearing tales of a friend or relative. This finding highlights the misconceptions the general population has about anesthesiology and an anesthesiologist and also makes us aware of their source of information and beliefs.

We observed that the major preoperative concern was different among the two groups; illiterate were more concerned about not waking up after surgery (41%) and having pain 51%, but among the literates the main concerns were pain (67%), both during and after surgery, and intraoperative awareness (39%) which is similar to studies previously done in both developing and developed countries. As the aforementioned concerns of the subjects are due to lack of knowledge about the anesthesiologist and the work they do, proper education and communication will reduce the unnecessary fears and increase the cooperation of the patients’ perioperatively. In both the groups, the patients who had undergone previous surgeries were as concerned about perioperative complication as subjects undergoing surgery for the first time. This is in contrast to the study by Gurunathan et al.,[4] who observed that patients with previous anesthetic/surgical exposure had decreased anxiety. There was no statistically significant difference among the sexes in expressing their fear like in other studies.[4]

Another disturbing fact which was revealed in this study was that on asking whether the participants would like to choose their anesthesiologist in future or had any preference for any particular anesthesiologist, the responses were discouraging.

Every culture has their own set of beliefs, but in this study we observed the misconception about the concerned branch was the same among people from different cultures and socio-economic backgrounds. Education of either health care personnel who enjoy enviable creditability with patients may improve the present scenario.

We often blame the surgeon that they do not explain the patient about our role and contribution in the surgery but isn’t it true that we are satisfied living in the shadow of the surgeons. Maybe because of excessive workload we do not bother about improving our status, but the authors feel that we should now try to carve a niche for ourselves. We need to specifically address the patients concern regarding anesthesiology technique, course, role of anesthesiologist intra- and post-operatively. As suggested by Mittal et al., educating in hospital patients who form an important group of public can improve the image of the anesthesiologist.[5] In Indian scenario, personal experiences of the patients tend to influence the thinking of their friends and relatives. Educational efforts during the pre-anesthetic examination can be supplemented with other modalities like newspaper, magazine, television, radio, and internet.

CONCLUSION

This survey has identified a number of deficiencies in public knowledge about the role of anesthesiologists. We are involved in increasing numbers of areas of anesthesia care and should be proud of different roles we have. Therefore, we advocate better communication with the patient.

QUESTIONAIRE (Tick the best response) (TO BE FILLED BY THE PATIENT WITHOUT ANY ASSISTANCE FROM ANY MEDICAL STAFF) THERE COULD BE MORE THAN 1 ANSWER

Section I: Demographic data

• Name (Optional): Age: Sex: M ◻/F ◻ IPD No:

• Occupation:

• Qualification: Not Educated ◻/Primary ◻/High School ◻/Intermediate ◻/Graduation ◻/Post Graduation ◻/Other ◻

• Language: Hindi ◻/English ◻ Diagnosis:

• Religion: Hindu ◻/Muslim ◻/Christian ◻/Sikh ◻/Any Other ◻

• Address:

Section II

• Have You ever undergone any surgical procedure? Yes ◻/No ◻

• If yes, it was done under:

• 1. LA (Local Anaesthesia) 2. GA (General Anaesthesia)

• 3. No Anaesthesia 4. Don’t Know

• Do you remember the name of the anesthetist of your last surgery? Yes ◻/No ◻

• Do You Remember the name of the surgeon of your last surgery?

• Anesthetist: Is a Doctor ◻/Nurse ◻/Student ◻/Paramedical Staff ◻/Assistant to Surgeon ◻

• Where does an anesthetist work:

  • In OT ◻/ICU ◻/Don’t Know ◻/Emergency ◻/Pain Clinic/Labour room ◻/Pharmacy ◻/Laboratary/Others ◻

• During the surgery the anesthetist are responsible for:

  1. Putting the patient to sleep/monitoring heart rate, blood pressure, breathing
  2. Keeping patient alive /helping surgeon with actual surgery
  3. Treating an medical problem during surgery
  4. Making sure patient wakes up /making sure patient is apin free
  5. Giving any necessary drug
  6. Supervising patient in recovery room

• What are you more worried about: Surgery ◻/Anesthesia ◻

• A good operation is a teamwork of both surgeon and anesthetist Yes ◻/No ◻

• Should anesthetist tell ablout all the complications Yes ◻/No ◻

• Who is responsible for the well being of the patient during surgery: Surgeon ◻/anesthetist ◻/ both/none ◻

• Has the anesthetic procedure being explained to you: Very clearly ◻/clearly ◻/little clear ◻/not clear at all ◻

• What are you afraid of in anesthesia: Not waking up ◻/awareness ◻/pain /nausea & vomiting ◻/any other ◻

Section III

• Type of anesthesia you would prefer: Regional ◻/ general ◻

• If the patient suffers from any other disease (like diabetes, hypertension, asthma, epilepsy, liver dysfunction), is old, is smoker or an alcoholic then risks during anaesthesia increase? Yes ◻/No ◻/Don’t know ◻

• What is your source of information? Or how do you know all what you have told?

  1. Any past experience
  2. Friends and relatives
  3. Any other way (books, newspaper, TV, radio etc.)

• Would you like to know more about the work of an anaesthetist if given a chance? Yes ◻/No ◻

• Do you have any knowledge regarding the techniques of regional anesthesia? Yes ◻/No ◻

• If yes then do you have any idea about local/spinal/epidural anaesthesia? Yes ◻/No ◻

• Do you have any knowledge regarding complications related to regional anaesthesia? Yes ◻/No ◻

• If yes then what: Causes headache after procedure ◻/causes backache ◻/causes lifelong weakness ◻/any other ◻

• Do you have any knowledge regarding the advantages of regional anaesthesia on other types of anaesthesia? Yes ◻/No ◻