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April 3, 2017

How surgeons can prepare for the latest trend: Awake patients

Daily Briefing

More patients are opting to stay awake during surgery, and while some surgeons are uncomfortable with the trend, others are trying to get ahead of the curve by fine-tuning their patient communication strategies in the OR, Jan Hoffman reports for the New York Times.

Going under, with eyes open

Mark Siegler, a medical ethicist at the University of Chicago and a co-author of a recent study on surgeon-patient communication during awake procedures, said, "For a thousand years, we talked about the operating theater. And for the first time in recent years, the patient has joined the cast."

While some procedures, such as deep brain simulation, require the patient to be awake for critical communication, advances in anesthetics are enabling patients to stay awake for a wider variety of surgeries. Orthopedics, Hoffman reports, "is the chief specialty for such procedures," though other surgical specialties, ranging from colorectal to cosmetic, are "also moving in this direction."

Whether a patient has the option to stay awake during surgery depends on several factors—patient safety is paramount, but the surgeon's willingness, whether the procedure is suited for a patient being awake, and the hospital's ability to schedule such a procedure also influence the decision. And, of course, it also comes down to the patient. 

According to Hoffman, some patients opt to stay awake simply because they don't want to use general anesthesia, while others are curious about the surgical process. Alexander Langerman, an author of the communication study and a head and neck surgeon at Vanderbilt University Medical Center, added that the trend could reflect a growing suspicion of authority figures. "The occasional scandals that emerge while patients are sedated continue to erode [patients'] trust in [surgeons]," he said.

TV shows and social media might also be a factor, Langerman added, with some physicians posting their procedures online. But Langerman cautioned that some patients—used to watching surgical procedures on popular TV shows—might experience a bit of a letdown. "It's not as orchestrated and symphonic as on TV," Langerman said. "It's people at work, doing their job."

Surgeon strategies

Yet while more patients are opting to stay awake, "doctor-patient protocol has not kept pace," Hoffman reports. For instance, patients who are awake during surgery can become unnerved at the silence or take offense at what doctors might consider "office humor."

And a patient's concerns can unnerve surgeons as well, Hoffman writes. Many doctors are apprehensive about offering to do the procedure while the patient is awake, since they might get anxious or distract the surgeons. Doctors also might fear litigation or "disappointing the patient," Langerman said.

Physicians have several strategies at hand to help cope with potentially anxious patients, Hoffman writes. For instance, Stavros Memtsoudis, a researcher and professor of anesthesiology at Weill Cornell Medical College, said he keeps headphones, music selections, and video glasses on hand to help soothe patients who become anxious.

And Michael Marin, a professor and chair of the surgery department at Mount Sinai Medical Center, said he adjusts how he speaks to a resident scrubbing in on the surgery if the patient is awake. Instead of using an ordinary instruction that could unnerve a patient, such as "See if you can find your way through it," Marin will tell the resident, "We need to adjust this piece over there."

Marin added that when he feels that a nervous patient is listening closely to the surgeons, he'll sometimes "go overboard and say, 'That's perfect!' or 'It came together exactly the way we wanted" just to reassure the patient. Marin explained, "That makes patients feel much better ... They want to know you are confident, focused, and in control."


Patient and provider concerns aside, Hoffman reports that patient satisfaction with awake procedures "tends to be high." Recalling her own experience staying awake for a knee procedure, Hoffman writes, "I left the hospital a better-informed patient, with new respect for the operating room staff members."

Proponents of awake surgery also say it makes the process more transparent, Hoffman writes. Asif Ilyas, a hand and wrist surgeon who operates at the Rothman Orthopaedic Specialty Hospital, said, "It's all about communication, comfort and experience." He added, "It is definitely catching on and creating a different kind of surgeon-patient relationship" (Hoffman [1] New York Times, 3/25; Hoffman [2], New York Times, 3/25).

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