Physician–patient interactions and communication with conscious patients during simulated cath lab procedures: an exploratory study

Abstract

Background

This exploratory study investigates the feasibility for observing and evaluating intraoperative communication practices using simulation techniques. Complex procedures are increasingly performed on patients under local anaesthesia, where patients are fully conscious. Interventional cardiac procedures are one such example where patients have reported high levels of anxiety undergoing procedures. Although communication styles can serve to alleviate patient anxiety during interventions, leading to a better patient experience, there has been little observational research on communication, while patient perspectives in intraoperative contexts have been underexplored.

Methods

In this mixed-methods study, observational analysis was conducted on 20 video-recorded simulated scenarios, featuring physician operators (of varied experience levels), communication and interactions with a simulated patient (trained actor), in a controlled and highly realistic catheter laboratory setting. Two independent raters and the simulated patient embedded in scenarios retrospectively rated physician communication styles and interactions with the patient via four key parameters. Patient perspectives of communication were further explored via a quantitative measure of anxiety and semistructured qualitative interviews.

Results

While independent ratings of physician–patient communications demonstrated few discernible differences according to physicians’ experience level, patient ratings were consistently higher for experienced physicians and lower for novice physicians for the four interaction styles. Furthermore, the patient’s anxiety scores were differentiable according to operators’ experience level. Thematic analysis provided further insights into how patient perspectives, including affective dimensions are characterised, and how physician interactions can amplify or attenuate feelings of anxiety through tone of voice, continuity in communication during the procedure, communicating while multitasking and connecting with the patient.

Conclusions

Our findings indicate underlying patient assumptions about physicians’ experience levels, intraoperative communication styles and impact on anxiety. While observational methods can be applied to simulated intraoperative clinical contexts, evaluation techniques such as observational rating tools need to incorporate patient perspectives about undergoing conscious surgery.

Introduction

This paper explores communication practices during interventional cardiac procedures using simulation. In recent decades, pharmaceutical and technological advancements in local anaesthesia, surgical and interventional techniques have led to an increase in the choice of medical techniques and procedures available as day care surgery.¹ Complex procedures are increasingly performed on patients under local anaesthesia, where patients are fully conscious during their procedure.^{2 3} Benefits include shorter hospital stays, reduced complications and increased capacity for hospitals to treat more patients. Negative implications include potential patient anxiety, which may induce physiological responses that serve to hinder clinical performance and outcomes. A recent study of 2604 patients undergoing cardiac catheterisation demonstrated that patients experience the highest level of anxiety just before the procedure, which significantly declines after the procedure, pointing towards a need for caregiver programmes that minimise anxiety.⁴

Although communication style can serve to alleviate patient anxiety during surgery,^{2 5} there has been little research on communication in intraoperative contexts.⁶ In general surgery, previous research derived from surveys administered to patients, preprocedure or postprocedure, highlights the importance of patient anxiety and communication during procedures. Generally, fear of hearing or seeing events has been reported among elective patients.⁷ In terms of physician–patient interaction, the importance of operators instilling patients with a sense of trust via reassuring comments during surgery has been highlighted.⁸ It has also been noted that good communication and information could lead to better patient confidence and satisfaction, less anxiety and pain, all linked with improved operative outcomes.⁹ Significantly, Caddick et al ² reported that careful use of terminology could serve to reduce anxiety levels, while Rufai et al ⁵ concluded that patients feel significantly less anxious when certain approaches are adopted by surgeons and theatre staff, with particular emphasis on verbal reassurance. Effective communication in the operating room is vital for safe surgical performance, where failures in communication have been linked with error rates and adverse events.¹⁰ Team-based interaction has received considerable academic attention, with the development and validation of sophisticated and robust methodological techniques and observational tools to assess how teams work to deliver care safely in various specialities, leading to recommendations for clinical team training.^11–13 As far as we are aware, there are no previous observational studies on intraoperative physician–patient interactions and communication with conscious patients in real clinical settings or simulated environments. This is a neglected area of research, given the current drivers and emphasis towards person/patient-centred care and the exponential rise in the number of surgical procedures on conscious patients. Undergoing invasive procedures can be acutely stressful for patients; indeed, the fact that the patient is conscious during the procedure may increase levels of stress for clinicians also. For patients, contributory stressors include previous experience, pain, anxiety, the unfamiliar environment and fear,¹⁴ with patients often subjected to both direct and indirect forms of communication, listening to technical surgical parlance and overhearing team-based interactions among operating room staff.²

Given the lack of research on communication and physician–patient interactions during intraoperative conscious procedures, this paper describes how simulation techniques and observational methods can be used to explore and evaluate physician–patient interactions and communication with conscious patients in safe settings. The use of simulated patients in such contexts is highly innovative. Although trained actors have previously been implemented in hybrid simulation and skills training, where embedding a ‘real patient’ in a realistic training environment adds to the demands of clinical performance,^15–18 to date, they have not been used to explore physician–patient interactions in intraoperative settings. In this exploratory study, we incorporate patient-focused simulation training, combining how physicians relate to patients while engaged in complex procedural tasks,¹⁹ and we include observational techniques to explore the ways in which physicians interact with and communicate with their patients and how patients in turn may perceive these interactions.

Conscious surgery and interventional cardiac procedures

Physician–patient communication and interactions are critically connected to interventional cardiac procedures, where patients are conscious during surgery, and physiological and psychological effects of anxiety can negatively impact clinical outcomes.^20–22 Interventional cardiac treatments are rapidly evolving techniques, including elective procedures such as percutaneous coronary interventions (PCIs) or angioplasties. Over 87 000 PCIs are performed in the UK every year, more than three times than a decade ago,²³ while highly complex procedures such as transcatheter aortic valves are now increasingly performed on conscious patients. For emergency cases, prompt treatment significantly reduces the likelihood of death and recurring heart attack via primary PCIs (PPCIs) or primary angioplasties.

Overall, the patient experience will vary according to their individual clinical case—from patients awaiting elective angiograms or angioplasties to emergency angioplasties in the event they are suffering a heart attack requiring urgent, life-saving treatment. Gallagher et al ²⁴ note that coronary angiography and PCI are significant events for patients, while Astin et al ²⁵ found that PPCI patients felt emotionally shocked by their experience. From the patients’ perspective, undergoing invasive cardiac procedures can be acutely stressful, where concerns include the surgery itself, fears about lying flat on a bed, the unfamiliar environment, machines and noise and uncertainty about what to expect.^26–28 The role of negative emotions experienced by patients include preprocedural anxiety reported prior to coronary angiography and PCI.^{25 29–31} Lundén et al ³² noted that patients undergoing cardiac interventions notice and respond to nurse’s conduct in terms of communication style and competence. Positive associations are likely to counter anxiety, while trust in team competence is vital in the patient experience.³³

With regards to procedural anxiety among cardiac patients, pain can cause or potentiate levels of anxiety. Although patients are administered agents to alleviate anxiety during the procedure and local anaesthetic at the point of sheath insertion to lessen pain, patients can experience discomfort, associated with sheath insertion, injection of contrast material and balloon inflation.¹⁴ Despite pharmacological interventions, many patients may still experience procedural anxiety, which might negatively influence their physiological (eg, fluctuations in respiratory rate, heart rate, blood pressure and myocardial oxygen consumption³⁴) and psychological responses, which in turn may adversely affect the procedural outcome. Similarly, a tense or distressed patient may find it difficult to cooperate with the team, thus adding technical difficulties to the procedure.^{35 36} Under such circumstances, effective communication and positive physician–patient interactions are vital, where verbal cues and non-verbal cues serve to amplify or attenuate conditions or perceptions and potentially enhance or impair the patient experience.

In recognition of these issues, and in light of the lack of research in this important area, the aims of this study were twofold: first, to take initial steps towards evaluating physician–patient communication and interactions in intraoperative contexts, exploring the feasibility for employing observational techniques from independent and patient perspectives. Second, to identify areas of focus for further research in this field. In doing so, we measured and compared elements of patient–physicians interactions and explored patient perspectives in more detail. The study involved:

1. Testing a prevalidated modified observational tool for assessment of physician–patient interactions in simulated intraoperative contexts, with a simulated patient.

2. Observing and comparing independent and patient ratings of physicians’ (novice, experience and skilled) interactions (eg, level of empathy, amount of organisation, verbal and non-verbal cues).

3. Further exploring patient perspectives of communication during conscious surgery via a mixed-methods approach (quantitative measure of anxiety and in-depth qualitative exploration of affective dimensions).

4. Consider implications for further research and training using innovative simulation and observational methods, and additional cross-specialty clinical applications.

Methods

Simulation setting, scenarios and physicians

Observational analysis was conducted on a subset of 20 video-recorded crisis-orientated simulated scenarios of individual physicians’ performance constituting part of a broader simulation training programme purposely designed for cardiology physicians to practice skills in a realistic, safe, simulated cath lab environment (figure 1). The 20 physicians were classified according to Lipner et al’s³⁷ three levels of interventional expertise. Novices reported limited experience (<10) of performing elective cases as primary operators (n=8); skilled, had performed >90 elective cases as primary operators (n=6); and experienced reported >1000 elective cases as primary operators (n=6).

Figure 1.

The simulated cath lab.

All simulated scenarios featured an embedded simulated patient (figure 2), supplied with an earpiece to provide verbal and non-verbal cues from the outset of the scenarios, with a trajectory from initial entrance of the physician, introduction to the patient, two-way physician–patient interaction and discussion including case history, requiring the physician to decide on the appropriate course of action and instruct the cath lab team, leading to commencement of the interventional procedure, onset of crisis, patient deterioration and loss of patient consciousness, the duration of which ranged between 5 min and 10 min. The trained actor exhibited anxiety and concerns about the procedure, providing realistic cues as to their physiological status and symptomology as the procedure evolved into complications and loss of consciousness. The cath lab team remained passive throughout the scenarios.

Figure 2.

Embedded simulated patient (trained actor) in the simulated cath lab.

Evaluation techniques

Observations

A modified version of the prevalidated revised Physician–Patient Interaction Global Rating Scale (PP-GIS)^{38 39} was used (online supplementary appendix 1). PP-GIS aims to capture the quality of physician interaction with a patient via the assessment of four key behaviours and was deemed as relevant for the intraoperative context:

1. Response to patient’s feeling and needs (empathy)

2. Degree of coherence in the interaction/conversation with patient (amount of organisation)

3. Verbal expression

4. Von-verbal expression.

Each behaviour is rated on a five-point scale (1=very poor performance, 3=adequate performance, 5=very good performance). PP-GIS also provides an overall assessment of knowledge and skill demonstrated in the scenario, recorded as ‘incompetent,’ ‘borderline’ or ‘competent’.

Independent ratings

Two raters, a research psychologist (TK) with experience in simulation and communication research and a clinician (EA) with experience in cardiac procedures and simulation, independently observed and rated the 20 simulated scenario clips retrospectively using the PP-GIS.

The patient perspective

The simulated patient (trained actor) embedded in the scenarios observed and rated the 20 simulation clips retrospectively using the PP-GIS. The simulated patient had prior experience as an actual patient undergoing a cardiac procedure (coronary angiography) and was therefore familiar with the real and simulated clinical context.

Patient anxiety was measured using a one-item visual analogue scale (VAS) for anxiety,^{4 27 28} ranging from 0 (no anxiety) to 10 (worst possible anxiety). Anxiety was assessed retrospectively, after the simulated patient observed the clips.

In order to capture more detailed qualitative feedback about communication, physician–patient interactions and affective responses and feelings evoked from viewing the clips, a semistructured interview was conducted after the rating of each clip. All clips were presented to the simulated patient randomly according to physician’s experience level and were rated by the simulated patient in the presence of a research psychologist (TK), who also conducted the semistructured interviews following each clip.

Statistical analyses

All data analyses were performed using the IBM Statistical Package for the Social Sciences (SPSS) V.24.

Thematic qualitative analysis

The qualitative patient perspective data were coded according to emergent themes.⁴⁰ Alignment of the coding with the themes was independently checked by a second researcher experienced in qualitative research methods, with perfect agreement of 100%.

Results

Reliability of the PP-GIS

Since the modified PP-GIS had not been previously implemented in intraoperative communication contexts, it was subjected to initial reliability testing. The overall internal consistency and reliability of the rating scale was established by calculating a Cronbach’s alpha score (α=0.95), confirming excellent internal consistency of the PP-GIS. Interclass correlation coefficients (ICCs) were used to establish the level of interassessor agreement in scoring the PP-GIS. ICCs were high (>0.89), demonstrating that the subscales were reliable, that is, scored consistently between assessors (table 1). Overall assessment of physicians’ competency demonstrated absolute agreement between the independent assessors.

Table 1.

Interclass correlation coefficient (ICC) scores for level of interassessor agreement in scoring the PP-GIS

Rating scale item	ICC*
Response to patient’s feelings and needs (empathy)	0.93
Degree of coherence in the interaction/conversation with patient (amount of organisation)	0.91
Verbal expression	0.92
Non-verbal expression	0.89
Overall assessment of the knowledge and skills demonstrated in the scenario	1.00

*ICC >0.70 denotes adequate level of agreement between raters.

PP-GIS, Physician–Patient Interaction Global Rating Scale.

Comparisons between patient and independent ratings of physician–patient interactions

Independent mean scores were combined and calculated for independent raters for the three physician groups according to their experience level and were compared against patient ratings (figure 3). Although there were few discernible differences between the independent rating scores, the patient consistently rated the interactions—levels of empathy, amount of organisation, verbal and non-verbal cues—as higher; experienced physicians were rated highest, followed by skilled physicians. The patient scored novices as lower for all interactions. No statistically significant findings were found in the range of scores.

Figure 3.

Overview of comparisons between patient and independent ratings of physician–patient interactions.

Comparisons between patient and independent assessments of physicians’ overall knowledge and skills

The overall global assessments of physicians’ knowledge and skills are presented in figure 4. While the independent raters did not deem any of the physicians as incompetent, the patient rated half of the novice physicians (4 out of 8) and 1 out of 6 skilled physicians as incompetent. Experienced physicians were largely rated as competent by the patient. Borderline cases were identified across all physicians’ experience levels.

Figure 4.

Patient and independent ratings for overall assessments of physicians’ knowledge and skills to physicians.

The patient perspective

Patient anxiety

Mean scores for patient anxiety according to physician’s experience level are shown in figure 5. Novice (5.25), skilled (5.00), experienced (4.00) scores reflected that the patient felt moderately anxious throughout procedures with all operators, though experienced marginally lower levels of anxiety while undergoing procedures with experienced physicians.

Figure 5.

VAS patient anxiety scores.

Qualitative analysis of physician–patient interactions

The qualitative data was subjected to thematic analysis in order to explore the patient perspective about communication, physician–patient interactions and affective responses in more detail. Four emergent themes, with exemplar dialogue extracts and patient reflections are presented in table 2.

Table 2.

The patient perspective: themes elicited from qualitative analysis and exemplar extracts

Theme 1: Tone of Voice	Theme 3: Continuity and Not Being Spoken to During the Procedure
Physician–Patient Interaction Excerpt	Physician–Patient Interaction Excerpt
Patient: Doctor, I’ve never quite felt this bad… Physician: Your blood pressure’s a wee bit low…so we’re going to get on and see what’s been causing that for you… Patient: … I’m so scared Physician: [to patient] What we’re going to do is see if we can get the problem sorted as quickly as we can for you… [to team] Let’s get this catheter to behave….	Patient: I’m feeling a bit uncomfortable… Physician: [no response] Patient: Uhhh. Doctor…. that feels uncomfortable… Physician: Where? Patient: … just in the umm groin thing… where they made that cut thing… they said I shouldn’t feel a thing… but… Physician: Where is your pain? Is it in the groin? Patient: yeah…and I was told I wouldn’t feel a thing… Physician: [to patient] ok. [to team] shall we take a picture of the screen now? [no further response to patient].
Patient Reflection	Patient Reflection
‘His voice is very calm. In the scenario things aren’t going well, but he remains calm. I’ve had an angiogram in real life… there were a lot of people in the room… being awake you’re so aware of everything…. you can really sense when [operators] are nervous and aren’t really coping… This one, he’s more experienced, his voice is very calm, his tone is calm, it helped so much…’ (Experienced physician, 1)	‘It’s almost like some of them see you as a bunch of symptoms, not a human being… she asked me if I was in any pain at the beginning and didn’t interact with me at all after that! Then I start to wonder if they’re listening to me at all. Some of the younger [operators] hardly talk to you at all once they’ve started the procedure. They’re obviously focusing on what they’re doing but it can make you feel really nervous if they don’t talk to you at all’ (Novice operator physician, 3)

Theme 2: Communicating While Multitasking	Theme 4: Connecting With the Patient
Physician–Patient Interaction Excerpt	Physician–Patient Interaction Excerpt
Patient: You’re just doing this under local anesthetic and I’ll be able to walk out after this, will I? Physician: [to patient] It depends what we see, really, [to team] can we flush please?, [to patient it really depends on…. [to team] and aspirate please, [to patient] yes, it depends on what we see…let me take the pictures, and I’ll keep you informed ok? Let me know if you have any issues too…	Patient: Will this take a while? Physician: It depends what we find… it could take 20 min or it could take longer, it depends what we find, ok? That’s why you’re here, you’re in the right place and we’ll do our best to get it sorted, ok? Patient: Sorry to disturb you again… but uhhh… the chest pain is getting quite bad Physician: The chest pain is getting quite bad? Ok, what we’re going to do is get you some medication to try and help with that, to help with the pain and try and relax you. [To team] can we get 2.5 of morphine, 2.5 of midazolam, and…
Patient Reflection	Patient Reflection
‘He’s keeping one eye on me, and addressing my questions, while also never losing sight that he needed to be on top of what he’s doing and giving instructions. And I think having a different voice is important because he distinguishes,. now I’m talking to you [patient], now I’m talking to you [team]. I think its very appropriate to do that… it’s a good signal to the patient, its shows that he’s getting on with his job while listening to me’. (Novice operator physician, 8)	‘He’s warm and conversational while starting the procedure, he’s holding the conversation throughout the procedure, and connecting with me very well’. (Skilled operator physician, 4)

Tone of voice

The patient associated good examples of communication with operators’ tone of voice. More experienced operators were often described as calmer than their less experienced counterparts. Maintenance of a calm tone of voice was implicitly linked with reassurance; the patient indicated she would give them ‘the benefit of the doubt’ and would be less worried as a result. The patient indicated that any anxiety perceived in the physician’s tone of voice would in turn give rise to patient anxiety.

Communicating while multitasking

The patient noted variability among operators in terms of adeptness in their ability to multitask, for example, performing the procedure while interpreting images on the operating monitors, instructing the team and concurrently talking to the patient. One notable example of positive multitasking was in relation to a novice physician using different vocal pitches while talking to the patient and instructing the team, which was interpreted as a ‘good signal’ for reassuring the patient.

Continuity and not being spoken to during the procedure

A salient theme was that of not being spoken to by the operator during the procedure, and the tendency for operators to ‘switch off’ and focus entirely on the technical component of the procedure and the operating screens, after initial introductions once the procedure had started. In one case, the patient was specifically asked not to talk by an experienced operator, which gave rise to a feeling of being a ‘nuisance’, being spoken down to and only being spoken to on the operator’s terms. In other cases, novice operators simply failed to respond to the patient’s dialogue during the procedure, resulting in feelings of nervousness and uncertainty about how the procedure was progressing. Furthermore, being spoken to solely in terms of symptoms ‘e.g. where is your pain’ led to feelings of being dehumanised.

Connecting with the patient

Operator’s ability to ‘connect’ with patients through communication was regularly observed. ‘Brusque’ styles of communication by some experienced operators were linked with a ‘get the job done’ attitude, although with an implicit sense of trust that all was going well in the procedure due to the operator’s experience, while more fluid conversational styles during the operating experience were linked with having a good connection, which served as a form of reassurance in alleviating anxiety.

Discussion

In light of the lack of research focusing specifically on physician–patient interactions and communication with conscious patients in intraoperative contexts, the findings of this exploratory study demonstrate the importance of evaluation techniques that incorporate patient perspectives and highlight avenues for further research. Although our findings demonstrated feasibility for use of the PP-GIS as evidenced by high scores for interassessor agreement and reliability in terms of internal consistency, independent ratings of patient–physician interactions showed little differentiation and no discernible differences between the performance of novice, skilled or experienced practitioners; yet, patient ratings were consistently higher for experienced physicians and lower for novice physicians for each interaction style—empathy, organisation, verbal expression and non-verbal expression. Furthermore, from the patient perspective, physicians’ overall knowledge and skills were more differentiated, with indications of incompetence demonstrated by novice practitioners, while patient anxiety scores were higher for novice practitioners and lower for experienced operators. Although there were no statistically significant differences, the differentiable patient ratings between interaction and communication styles and anxiety experienced at the hands of novice, skilled and experienced operators, point towards underlying patient assumptions about physicians, their experience level and communication styles, which may not be fully captured in observational rating scales such as PP-GIS.

The themes that emerged from the qualitative component of our study serve as a first step towards highlighting how patient perspectives while awake and conscious during procedures are characterised, and how physician communication styles can evoke affective responses that impact levels of anxiety. The patient perceived variations in operators’ tones and pitches of voice, and how this may serve to amplify or attenuate feelings of anxiety, while a calm communication style served as reassurance for the patient even if the procedure was not perceived to be going well, an anxious tone of voice in turn gave rise to feelings of nervousness and anxiety, as did examples of not being spoken to, or being ignored during the procedure. Another consistent theme for the patient was lack of continuity and how novices in particular ‘switched off’ from the patient during the procedure. Fluid conversational styles were contrasted with abrupt dialogue that was solely linked with clinical indicators, leading the patient to feel like ‘a bunch of symptoms’ and dehumanised. However, the patient demonstrated an appreciation for the complex tasks required of the practitioner and their need to multitask: perform the procedure, instruct the team and talk to the patient, and provided insights about what merits ‘good’ signals for the patient (vocal pitch and tone), which interestingly contrast with Smith et al’s⁶ findings on surgeons’ propensity to use non-verbal communication strategies when interacting with staff in order to avoid upsetting the patient. Indeed, in our study, interactions with staff were deemed as part of the process, but vocal tones provided reassurance or conversely a sense of alarm, giving rise to anxiety. We suggest that patient insights such as these offer considerable value in the development of evaluation techniques to measure patient–physician interaction. Incorporating the patient perspective into any evaluation, for example, observational tool, requires more detailed attention. The qualitative patient feedback in our exploratory study was restricted to that of our simulated patient (trained actor) only. Although the actor has experienced a real coronary procedure and therefore drew insights from that experience, further research is required on patient perspectives to inform the development of observational tools that can be tested in safe simulated settings, as in the case of this study.

Implications

Our findings provide an initial indication that improved communication and patient–physician interaction in conscious procedures is likely to lead to reduced patient anxiety and an enhanced patient experience. In cardiac contexts, alleviating patient anxiety during procedures has several implications including short-term and longer term benefits since cardiac patients often undergo repeat procedures. Thus, a positive patient experience is likely to be linked with less anxiety in follow-up procedures. Although cardiac procedures are becoming increasingly safe, assessment of outcomes should include the quality of the patient experience, which needs to be established through patient perspectives of undergoing procedures. Training in this aspect of care is neglected, and better tools to assess communication styles, regardless of experience level, need to be developed and integrated into educational training. Intraoperative communication, though recognised as a very challenging skill, currently does not feature in pregraduate and postgraduate trainings. High-fidelity simulation can play a significant role in training of simultaneous procedural and patient interaction skills. This could be expanded beyond the cardiovascular field to other local anaesthetic procedures.

Conclusion

This exploratory study provides a unique insight into a neglected area of research. Using patient-focused simulation techniques, we have explored approaches to evaluate patient–physician interaction during simulated procedures with conscious ‘patients’ in intraoperative settings. As far as we are aware, no previous research has explored patient perspectives of physician–patient communication and interactions in intraoperative contexts. Our initial findings show that, while observational tools can be applied to these settings, they do not currently sufficiently incorporate patient perspectives. Further research is needed to develop tools that serve to capture the experience of conscious patients undergoing procedures in order to improve the communication-based skillset of physicians. Translated to clinical settings, such improvements would serve to alleviate patient anxiety during conscious procedures, potentially contributing to improved clinical outcomes and enhancing the overall experience of patients undergoing conscious and awake surgery.