The American health care system is a constantly changing sea of uncertainty. The passage of the Patient Protection and Affordable Care Act (PPACA) in 2010 was the largest restructuring of the nation’s health laws in nearly 50 years. Since the statute was signed into law by President Barack Obama, it has been disputed and challenged many times in federal and state courts as Americans seek to interpret the new law and abide by its precepts. The purpose of the PPACA, according to Title I of the statute, is to put “individuals, families and small business owners in control of their health care”^[1].

  The genesis of patient autonomy arose from a report published in 2001 by the Institute of Medicine (IOM) entitled, Crossing the Quality Chasm: A New Health System for the 21^st Century. In that manuscript, the IOM theorized that in order for US health care to properly serve its citizens, it must become patient-centered. According to the IOM, health care should be “respectful of and responsive to individual patient preferences, needs, and values, and ensure that patient values guide all clinical decisions”^[2]. Since this recommendation, US health care in general has made a deliberate shift toward providing treatment that is patient-centered and focused on the satisfaction of the recipient.

  Several studies have demonstrated that there is a positive correlation between patient satisfaction and the recovery and well-being of patients after surgery^[3]. Fremont, et al. established that patients who have an acute myocardial infarction experience better outcomes if they report high satisfaction with their patient care while in the hospital^[4,5]. Patients are not the only ones who benefit from patient satisfaction; a study of hospitals in Ohio revealed that institutions who consistently had patient satisfaction in the 10^th percentile had a decrease in volume of 17% while those who consistently had patient satisfaction in the 90^th percentile had an increase in volume of 33%. Also, malpractice rates in the high satisfaction hospitals were significantly lower^[6].

  Many patients who require surgery experience fear and anxiety from the thought of undergoing general anesthesia. Fear of the unknown, fear of nausea and vomiting, fear of pain and suffering, and fear of dying are all commonly expressed apprehensions associated with anesthesia that may contribute to an individual delaying or cancelling a prescribed surgery. If anesthesia providers want to better serve their patients, they need to understand what patients need and want before they arrive for surgery. Likewise, providers need to be aware of patient’s concerns after they emerge from anesthesia and are in the recovery period.

  Focus groups are a powerful method of obtaining qualitative data from a population. First used in the 1920s to analyze people’s reaction to wartime propaganda, focus groups have been used more frequently in recent times to explore people’s feelings about controversial topics like HIV/AIDS and contraception^[7,8]. When led by a trained moderator, focus groups provide a venue for discussion between participants where experiences can be shared and opinions and personal feelings can be expressed. According to David L. Morgan, focus groups are “useful when it comes to investigating what participants think, but they excel at uncovering why participants think as they do”^[8].

  When participants of a focus group interact with each other to express what they think and why they feel the way they do, the motivations that drive opinions about a certain topic can be gleaned by an observing researcher^[9,10]. After data from the focus group is gathered and analyzed, the information can be used by other researchers as a starting point for further qualitative and quantitative work. Lawmakers and industry consultants often find focus group data useful for policy creation and evaluation^[11].

  The objective of this study was to find out through the use of focus groups what kinds of experiences different patients have had with the administration of general anesthesia. Specifically, the research focused on discovering what patients want from their anesthesia provider and what providers can do in the future to fulfill those expectations.

Materials and Methods

  In preparation for this study, we theorized that a focus group could be used to find out what patients want or expect in order to have a positive experience with general anesthesia. The inherent ability of a focus group to encourage patients to talk about their fears and concerns could then be used to help providers tailor the anesthesia experience to meet individual’s needs. By finding out what patients are thinking and why they think as they do, anesthesia providers can give better patient-centered care, resulting in better satisfied patients.

  Before the study commenced, exempt status was obtained from the Institutional Review Board at the University of Pittsburgh (section 45CFR 46.101b2). Focus group participants were obtained by advertising in buildings and hospitals around the University of Pittsburgh and by recruiting former and current patients at the School of Dental Medicine who had previously undergone general anesthesia. All potential participants were offered a free lunch and $25 gift card as compensation for their attendance. Qualifiers for the study included the following criteria: 1) Age of 18 years or more. 2) Previous experience with general anesthesia. 3) Recollection of the anesthesia experience and a willingness to discuss it in a group setting.

  Two focus groups were conducted at the University of Pittsburgh School of Dentistry in the Department of Dental Anesthesiology. The focus groups consisted of ten and eleven people respectively. Each group had participants that were of different gender, race, religion and economic status. The only commonality among these extremely diverse participants was that all of them had experienced general anesthesia. Each 90 minute focus group was led by a trained facilitator and each had a recorder present. Digital voice recordings were made of each session and later deleted after transcription. All proper steps were followed in order to ensure the handling of information was HIPPA compliant and to ensure the anonymity of all the participants.

  During the conversational process of each focus group, the facilitator put forth the following questions: 1) Prior to your surgery, what was your greatest concern about getting general anesthesia? 2) What did you do to handle the concerns or fears that you had about getting general anesthesia? 3) What did the doctor, dentist, nurse, anesthesiologist, etc. do to help you with your concerns? 4) After the surgery was over and you came out of general anesthesia, what was your experience? How did that compare with your pre-operative concerns? 5) If you could tell your doctor, nurse, anesthesiologist, etc. anything about your experience, what would it be? What would make it a better experience? What would you change?

  After both of the focus groups were completed, the conversations from each session were transcribed so that data could be properly analyzed. The goal of using the focus group format was to be able to compare the different participant’s experiences and opinions concerning their individual experience with general anesthesia. In order to organize the dialogue of over 180 minutes of conversation, a codebook was used. The codebook contained key words or abbreviations that could be used to identify like themes in the discussions. For instance, when a participant shared a fearful experience, the code word “FEAR” was written in the margin of the transcribed dialogue. Any thought that dealt with the subject of communication was labeled in the margin as “COMMU”. The code word “+EXPER” was used to identify any positive experiences that were shared with the group. A computer program was used to group all of the dialogue that was labeled with similar code words into groups. This provided us two conveniences: 1) It made data that initially appeared disjointed easier to understand. 2) It allowed patient’s opinions and experiences that were centered around a common theme to be contrasted and compared. The codebook permitted us to clear away the insignificant parts of group discussion and focus on the commonalities that existed among the participants.

Results

  As stated previously, the greatest benefit of gathering data in the setting of a focus group is that it allows the participants to freely share their experiences about the topic being addressed. As each of the focus group sessions in this study began to unfold and the participants began expressing their thoughts and feelings concerning their previous anesthesia experiences, three major themes began to emerge. Each of these themes repeatedly appeared as the facilitator’s five questions were presented to the focus group participants.

Theme 1: The importance of a positive relationship with the anesthesia provider
  Nearly all of the participants in the focus groups directly commented on the desire that they had to develop a positive relationship with their anesthesia provider. Many of those who shared experiences expressed concern about the short amount of time that the anesthesiologist spent with them before the surgery. This problem is inherent in the way that modern anesthesia is practiced. For instance, a patient who is scheduled for surgery usually meets with their surgeon one or more times before the surgery actually takes place. These meetings allow the patient and the surgeon to communicate about the patient’s questions and concerns; it is here that the surgeon is able to establish a good rapport or “bedside manner” with the patient. Anesthesia providers, on the other hand, are typically restrained to one brief encounter with the patient before surgery. This brief pre-surgical scenario makes it difficult for the anesthesia provider to “get to know” the patient and often is interpreted negatively by the patient.
The following three statements by the participants in our focus groups illustrate this problem well:
• “You meet with your surgeon if you’re having surgery in an office prior to the actual procedure. You’re not meeting with your anesthesiologist in their office prior to the procedure^[12]
• “This person strolls in, looks at your chart, talks to you for two-and-a-half minutes, and boom. And then maybe you might see them in post-op, but it depends^[12]
• “I think that is especially true of anesthesiologists, that you barely get to talk to them, so you worry, like, do they even care?^[12]

  Anesthesia providers who recognize that they have a short time to establish a relationship of trust with their patient and make a concerted effort to do so obviously have a profound effect on them. Consider the following accounts by three different patients:
• “They knew that I was there for that procedure. It made me feel like, ‘[Name], now I’m concentrating on you^[12]
• “They did a very good job of making me feel comfortable. The anesthesiologist…was very calm and explained exactly what was going on^[12]
• “I will never forget that woman. I am still singing her praises twenty years later, because she took the time to realize that this was a very unique case and she made that connection^[12] Other revealing quotes from the focus sessions included the following:
• “I think sometimes they’re not quite warm and fuzzy^[12]
• “I wondered whether or not he even realized what had happened”^[12]
. • “I’d like to know that they’ve taken enough time to get to know that I’m a person”^[12]
. • “You [would] feel better if you feel like you’ve made a connection^[12]
. • “I would say that they [the anesthesiologist] probably need to have better bedside manner than your physician…because you may have only seen them once. Your life is depending more on them than the doctor^[12].

Theme 2: The importance of establishing good communication with the anesthesia provider
  The second theme that emerged as participants described their anesthesia experiences centered around the concept of effective communication with the anesthesia provider. Two interesting yet opposite trends were observed in conjunction with provider communication. The first trend was characterized by patients who were very fearful of having specific risks or side effects associated with general anesthesia described to them in explicit detail. These patients did not necessarily want to know the minutia of the anesthetic procedure. In other words, these patients did not want to know about all of the bad things that could possibly happen to them, nor did they want to know all of the normal things that were going to happen to them. For these patients, less information was better.
• “I’m okay with not knowing everything. Just give me the basics and I can go from there…that would scare me if I knewevery little thing that someone’s doing”^[12].
• “I think my comfort level with more knowledge or less knowledge directly would be corresponded to what I was having done”^[12].
• “If the risk is high, you almost don’t want to know that it’s high”^[12]. Patients characterized in the second trend were very fearful of not knowing all of the details of anesthesia. In other words, for these patients, more information was better.
• “Explain everything in detail. Just explain every step, the process, in a non-arrogant [way]…just talk me through it completely”^[12].
• “I thing knowing minimized uncertainty. The more information that people get, I think that it does minimize the uncertainty”^[12].
  Analyzing these two polar opinions about pre-operative communication revealed a great opportunity for anesthesia providers. If providers want to establish effective communication with their patients, they can take the necessary time to determine which trend each patient follows; do they require a brief summary of the planned anesthesia procedure, or do they need an indepth description? The anesthesia provider that makes the effort to adequately communicate with their patient will discover what kind of information they need and then tailor their pre-operative information appropriately. Learning from the examples shared in the focus groups, it is apparent that patients crave individual attention and a message tailored specifically for their needs. Admittedly, modern anesthesia practice is fraught with deadlines, start times, and busy schedules; most of these demands are difficult, at best, to alter or change. However, as providers look for ways to truly help their patients, taking the time to establish effective communication will pay untold dividends.

Theme 3: The importance of knowing that the anesthesia provider cares
  Theme three that emerged from the focus group sessions was an extension of the other two themes already stated. Because many participants felt that there was a lack of a positive relationship with their anesthesia provider and because many felt that effective communication was lacking, it is easy to understand why several participants wondered if their anesthesia provider cared about them as an individual.
  In the following quote from a participant, it is easy to see that she was concerned about the perceived lack of caring or “emotional support” from her anesthesiologist.
• “I know they’re not my mother, my father, my husband, but I just [want] someone to care, just for that little while before I [go] under, just show me that somebody’s [there] with me through this. It’s the emotional part. There [isn’t] emotional support in the midst of it”^[12].

  Patients know when they matter to the provider. Contrast the former quote with the experience shared by the participant in the following quote:
• “The anesthesiologist who tried very quickly to get me anesthetized so they could get my son out was wonderful. A wonderful lady. Calming, and literally took my hand in her face and was like, ‘Just look at me. You don’t want to look at anything else.’ They knew it was a critical situation, so she was right there”^[12]. This woman was so deeply touched by the compassion displayed by her anesthesia provider that she added:
• “I will never forget that woman. I am still singing her praises twenty years later, because she took the time to realize that this was a very unique case and she made that connection”^[12].

Discussion

  Anesthesia providers today face immense pressures; in addition to the vigilance required to keep patients safe during each procedure, anesthesiologists must also juggle heavy schedules and attend to a multitude of other responsibilities on a daily basis. They are constantly challenged to communicate with multiple patients and patient’s families from all walks of life; they must educate, answer questions, and resolve concerns. In a word, anesthesia providers are busy.

  At the beginning of this project, it was assumed that most of the concerns that patients had with general anesthesia revolved around side effects inherent to the process. It was anticipated that most of the participants in the focus group would share fears about complications that are well known in the field of anesthesia, namely, post-operative pain, post-operative nausea and vomiting (PONV), death, heart attack, stroke and nerve injury^[13]. When the data from the focus groups was analyzed, these common fears were appreciated along with a multitude of others. With such a wide variety of concerns expressed about general anesthesia by such a relatively small group of people, it was initially tempting to assume that there were no similarities; that each person’s fear was individual to their own experience. However, it soon becomes clear that most participants’ concerns, whatever they were, had a few commonalities. It was apparent that most concerns either were, or could have been, sufficiently resolved by their anesthesia provider if the provider took the opportunity to do so. For instance, many of the previous quotes from patients, if examined closely, center around concerns that could be resolved by better communication. In other words, it seemed as though what the participants really wanted was someone who could compassionately listen and show concern, someone who could answer their questions and reassure them in spite of their uneasiness.

  One commonality that we found among most of the focus group participants is that they were very grateful for their anesthesia provider. The participants expressed confidence in their anesthesia provider’s clinical knowledge and skills and many commented that they trusted their anesthesiologist implicitly. However, when asked what they would change about their experience with anesthesia, nearly all of the participants said that they would like to receive more personalized attention from their anesthesiologist. Overwhelmingly, the focus group participants felt like their anesthesia provider needed to give more priority to the “human side” of anesthesia.

  Patients crave individualized attention. They want anesthesia providers to approach their case as if it were the first and only case of the day. This desire became evident in the discussion about how each participant preferred to have the information concerning general anesthesia presented to them. Recall that there were two camps of thought concerning the dissemination of pre-operative information and instruction: The first group of patients desired to have the specifics of anesthesia described to them in detail. The second group, fearing that too much information would cause them undue stress, preferred only to be told of the procedure in generalities.

  It is important to most patients that they develop a relationship with their healthcare providers. This is as essential for anesthesiologists as it is for any other doctor. Even though anesthesia providers have a relatively short interaction with the patient, they can have a profound positive or negative effect upon that person. An anesthesiologist’s bedside manner is important, because it the means by which he or she can develop that coveted physician-patient relationship.

  Anesthesia providers who make the effort to get to know their patients and learn about them are same providers who are better able to avoid negative post-operative problems. Patients’ concerns of feeling rushed after emerging from anesthesia coincide closely with many of their pre-operative concerns, namely, the concern of lack of communication with their anesthesia provider. Providers that take the time to help their patients understand the timing of post-operative discharge beforehand will most certainly avoid having patients who feel rushed or pushed to leave after waking up.

Conclusion

  As the manner in which twenty-first century medicine is practiced shifts from a production-based model to a patient- centered model, and as the emphasis on quality and patient satisfaction increases, anesthesiologists will need to pay special attention to the needs and concerns of the patients they serve. Anesthesia providers who take the necessary steps to establish a meaningful relationship with their patients that is centered on effective communication and who clearly demonstrate a caring attitude will have better satisfied patients. As stated earlier in this paper, satisfied patients will have a better recovery record, and providers who make having satisfied patients a priority will see higher patient volumes and lower malpractice rates. There is no long-term downside to focusing on patient’s individual needs and wants; its what patients really expect from their anesthesiologist.

Disclosure:
  The contents of this paper are based upon the author’s masters essay entitled: “What Patients Want: Using Focus Groups to Discover Concerns about General Anesthesia” submitted to the University of Pittsburgh Graduate School of Public Health on December 1^st, 2014. The quotations from focus group participants are taken directly from that manuscript. The author has no conflicts of interest to report.

References