BACKGROUND:To train and encourage providers to be more empathic, it is crucial to first understand what behaviors providers consider acts of empathy in clinical practice. Research has asked this important question of patients and certain physician specialties, but has left out a unique physician population-anesthesiologists. Given the link between patients' preoperative anxiety and poorer postoperative outcomes, anesthesiologists' ability to address patients' needs effectively, particularly during shorter interactions with new patients, may impact patient outcomes. The purpose of the current research was to investigate what anesthesiologists consider to be empathic behaviors and to compare these results with past investigations of other physician specialties.METHODS:Practicing anesthesiologists (N = 99) were recruited online to rate 49 physician behaviors on a 0 to 10 scale for the degree to which each behavior was aligned with their own conceptualization of clinical empathy.RESULTS:Three components of empathic behaviors emerged: Conscientious and Reassuring, Relationship Oriented, and Emotionally Involved. In line with past work with other physician specialties, anesthesiologists rated Relationship-Oriented behaviors as those most closely related and Conscientious and Reassuring behaviors as least closely related to what they viewed as empathy. Although not statistically significantly, men anesthesiologists were more likely to view Conscientious and Reassuring behaviors as aligned with their conceptualizations of empathy than women anesthesiologists, and women anesthesiologists were significantly more likely to view Emotionally Involved behaviors as aligned with their conceptualizations of empathy than men anesthesiologists, with medium effect sizes.CONCLUSIONS:Although anesthesiologists interact with patients during some of the most emotionally charged and vulnerable situations when evaluating, monitoring, and supervising patient care, beginning preoperatively and continuing through their postoperative care, they do not view empathy behaviors fundamentally differently than other physician specialties. We discuss how these results can inform medical education communication and relational approaches by capitalizing on the understanding of anesthesiologists' conceptualizations of empathy.

From the Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut. Accepted for publication June 23, 2023. Reprints will not be available from the author. Funding: None. The author declares no conflicts of interest. Address correspondence to David B. Waisel, MD, Department of Anesthesiology, Yale School of Medicine, New Haven, CT. Address e-mail to [email protected].

In 1992, the American Society of Anesthesiologists Committee on Ethics was formed primarily to address the rights of patients with existing Do-Not-Resuscitate orders presenting for anesthesia. Guidelines written for the ethical management of these patients stated that such orders should be reconsidered—not rescinded—thus respecting patient self-determination. The Committee also rewrote the reigning Guidelines for the Ethical Practice of Anesthesiology by expanding its ethical foundations to reflect the evolving climate of ethical opinions. These Guidelines described ethically appropriate conduct and behavior, including anesthesiologists' ethical responsibilities to patients, themselves, colleagues, health-care institutions, and community and society.

Background:Healthcare trainees frequently report facing comments from their patients pertaining to their age. Exposure to ageist comments from patients may be related to greater stress and/or burnout in residents and may impact the quality of the resident-patient relationship. However, little empirical work has examined ageism expressed toward anesthesiology residents in clinical care, and therefore not much is known about how residents respond to these comments in practice. This research sought to determine how anesthesiology residents responded to ageist comments.Methods:Anesthesiology residents (N = 60) engaged in a preoperative interaction with a standardized patient who was instructed to make an ageist comment to the resident. Resident responses were transcribed and coded using qualitative inductive content analysis to identify response themes.Results:The most common resident response to the ageist comment, across gender and resident year, was to state their own experience. Some also described how they were still in training or that they were under supervision. Residents rarely reassured the patient that they would receive good care or identified the patient's anxiety as a cause of the ageist remark.Conclusions:These results provide a first step in understanding how ageism may be navigated by residents in clinical encounters. The authors discuss potential avenues for future research and education for responding to ageist remarks for both patients and clinicians. This study exposed anesthesiology residents to ageist comments by a standardized patient, and systematically examined response patterns, which ranged from no response to refutation, to agreement and reassurance. Analysis of trainees' responses suggested heterogeneity in responses and calls for future research examining the frequency and impact of ageist comments and development of effective responses.

As the practice of pediatric anesthesiology grew in the early 20th century, Anesthesia & Analgesia (A & A) became the most important practical resource of pediatric fundamentals for general anesthesiologists. With continued growth in the mid-20th century, focus then shifted to complex cases performed by dedicated pediatric anesthesiologists. To this day, A & A continues to serve as a crucial forum for our subspecialty as it matures. The International Anesthesia Research Society (IARS) also remains pivotal in addressing the crucial questions of modern practice, such as the recent founding of the SmartTots initiative to investigate the potential neurotoxicity of anesthetics in children. While A & A celebrates 100 years of publication, we reflect upon pediatric anesthesiology's evolution and the impact of the IARS and A & A on pediatric anesthesiology's scholarship, clinical practice, and professionalization.

Anesthesiologists must recognize and respond both verbally and nonverbally to their patients’ pain. The current study analyzed 65 videotaped interactions between anesthesiology residents, a standardized registered nurse, and a standardized male patient in pain awaiting urgent repair of a perforated gastric ulcer. Interactions were assessed using a modified version of the Empathic Communication Coding System to code verbal and nonverbal responses to pain cues. Nearly 60% of the time, residents responded with denial or disconfirmation of the pain, either completely ignoring or disconfirming that the patient’s pain was real or needed to be addressed. Only 29% of all responses verbally acknowledged the patient’s pain. Residents responded with more empathic verbal responses to verbal pain cues compared to nonverbal pain cues, and to more intense pain cues compared to less intense pain cues. Residents were more likely to respond when the nurse advocated for the patient’s pain rather than when the patient expressed his own pain. Residents who were more responsive nonverbally and had higher total responsiveness had shorter interactions with the patient. Residents who were more verbally responsive were more likely to prescribe pain medication and prescribe it earlier in the interaction, which was the appropriate clinical action in this scenario to reduce patient suffering. These findings suggest that there may be specific skills and behaviors that physicians can learn to improve recognition, acknowledgment, and treatment of acute pain, enhance patient satisfaction, reduce suffering, and allow for more efficient interactions, especially in the acute care context.

No patient arrives at the hospital to undergo general anesthesia for its own sake. Anesthesiology is a symbiont specialty, with the primary mission of preventing physical and psychological pain, easing anxiety, and shepherding physiologic homeostasis so that other care may safely progress. For most elective surgeries, the patient-anesthesiologist relationship begins shortly before and ends after the immediate perioperative period. While this may tempt anesthesiologists to defer goals of care discussions to our surgical or primary care colleagues, we have both an ethical and a practical imperative to share this responsibility. Since the early 1990s, the American College of Surgeons (ACS), the American Society of Anesthesiologists (ASA), and the Association of Perioperative Registered Nurses (AORN) have mandated a "required reconsideration" of do-not-resuscitate (DNR) orders. Key ethical considerations and guiding principles informing this "required reconsideration" have been extensively discussed in the literature and include respect for patient autonomy, beneficence, and nonmaleficence. In this article, we address how well these principles and guidelines are translated into daily clinical practice and how often anesthesiologists actually discuss goals of care or potential limitations to life-sustaining medical treatments (LSMTs) before administering anesthesia or sedation. Having done so, we review how often providers implement goal-concordant care, that is, care that reflects and adheres to the stated patient wishes. We conclude with describing several key gaps in the literature on goal-concordance of perioperative care for patients with limitations on LSMT and summarize novel strategies and promising efforts described in recent literature to improve goal-concordance of perioperative care.

BACKGROUND:Caudal epidural anesthesia is a frequently performed regional anesthesia block in infants and young children. Traditional landmark-based blind needle insertion remains the norm with no immediate, objective method to determine the presence of local anesthetic in the epidural space. Increasingly, ultrasound-imaging is used in pediatric regional anesthesia with demonstrated improvements in block efficacy and efficiency. The value of ultrasound-imaging in confirming success rate of traditional caudal placement is not well defined.AIM:To assess the success rate of conventional landmark-based caudal technique using ultrasound-imaging.METHODS:Prospective observational study of 30 children ages 1 month to 7 years undergoing surgical procedures with consent for caudal blockade. Provider success rate of caudal blockade placed by landmark technique was measured using ultrasound-imaging of needle tip and local anesthetic flow in the epidural space.RESULTS:Ultrasound-imaging demonstrated 80% success to correct positioning of the needle tip and local anesthetic in the epidural space. Failure was associated with decreasing experience and presence of anatomic variances. All improperly positioned needles were subsequently successfully positioned using real-time ultrasound-imaging. Mean time for confirmatory ultrasound-imaging (SD; range) was 1 minute (0.3; 1-3).CONCLUSION:The use of ultrasound-imaging can be used to identify proper needle placement in the sacral epidural canal and facilitate subsequent corrected placement.

The key to the ethical practice of pediatric anesthesia is: Treat every child and family with the grace and consideration with which a person would want their child and family treated. This chapter discusses several issues concerning pediatric anesthesia such as consent process and forgoing potentially life-sustaining treatment. It also discusses a few aspects of professionalism for the pediatric anesthesiologist such as safety and quality care initiatives, proper disclosure and apology for medical errors, and the obligation to report suspicion of child maltreatment. The doctrine of informed consent centers on the belief that patients have a right to self-determination. The process of pediatric informed consent depends on the age and development of the child. Children, like adults, have the right to limit life-sustaining medical treatment when the likelihood and quality of potential burdens outweigh the likelihood and quality of potential benefits, as defined by the child and family.

Ehlers-Danlos syndrome hypermobility type (EDS-HT) is a hereditary connective tissue disease characterized by joint hypermobility and is associated with joint dislocations and chronic pain often improved by surgery.[1][1] Peripheral nerve blocks (PNBs) in EDS-HT are reported to have potentially

Background: Compassionate behavior in clinicians is described as seeking to understand patients' psychosocial, physical and medical needs, timely attending to these needs, and involving patients as they desire. The goal of our study was to evaluate compassionate behavior in patient interactions, pain management, and the informed consent process of anesthesia residents in a simulated preoperative evaluation of a patient in pain scheduled for urgent surgery. Methods: Forty-nine Clinical Anesthesia residents in year 1 and 16 Clinical Anesthesia residents in year 3 from three residency programs individually obtained informed consent for anesthesia for an urgent laparotomy from a standardized patient complaining of pain. Encounters were assessed for ordering pain medication, for patient-resident interactions by using the Empathic Communication Coding System to code responses to pain and nausea cues, and for the content of the informed consent discussion. Results: Of the 65 residents, 56 (86%) ordered pain medication, at an average of 4.2 min (95% CI, 3.2 to 5.1) into the encounter; 9 (14%) did not order pain medication. Resident responses to the cues averaged between perfunctory recognition and implicit recognition (mean, 1.7 [95% CI, 1.6 to 1.9]) in the 0 (less empathic) to 6 (more empathic) system. Responses were lower for residents who did not order pain medication (mean, 1.2 [95% CI, 0.8 to 1.6]) and similar for those who ordered medication before informed consent signing (mean, 1.9 [95% CI, 1.6 to 2.1]) and after signing (mean, 1.9 [95% CI, 1.6 to 2.0]; F (2, 62) = 4.21; P = 0.019; partial eta(2) = 0.120). There were significant differences between residents who ordered pain medication before informed consent and those who did not order pain medication and between residents who ordered pain medication after informed consent signing and those who did not. Conclusions: In a simulated preoperative evaluation, anesthesia residents have variable and, at times, flawed recognition of patient cues, responsiveness to patient cues, pain management, and patient interactions.

Incorrect, inappropriate, and misleading citations propagate untruths. The resultant inappropriate illusion of authority gives unwarranted confidence in the cited statement. In this issue of Anesthesia & Analgesia, Benzon et al’s1 eye-opening report on a survey of pediatric anesthesiology fellows’ perceptions of medical error and faculty supervision is ripe for misunderstanding, despite the authors’ praiseworthy attempts to forestall distortion. Although there are other opportunities, misunderstandings from this article will likely be from insufficient appreciation that these data are based on the perception of fellows. Consider the following statements, all of which could be drawn from the study by the hurried reader or inexact author. Misleading: Pediatric anesthesiology fellows make a high rate of medication errors. Better: In an article published in 2017, 22% of pediatric anesthesiology fellows reported making more than 1 medication error in the past year. “Medication error” was not defined by the survey. The words “high rate” is an imprecise value judgment open to interpretation. Data collection through fellows self-reporting errors colors the results. The extent to which a term is defined in the survey, in this case “medication error,” informs the reader about what the results actually mean. Misleading: Anesthesia residents reported performing more procedures for which they were not properly trained than did pediatric anesthesiologist fellows. Better: In a 2013 article,2 29% of anesthesiology residents reported performing more than 1 procedure for which they perceived they were not properly trained. In a 2017 article using the same methodology, 9% of pediatric anesthesiology fellows reported performing more than 1 procedure for which they perceived they were not properly trained. Including specific data, methodology and year of publication improves the reader’s understanding of the statement. Quantitative reporting usually trumps qualitative reporting. The percentages offer context about the extent of risk, and the need to address this problem. Misleading: Twenty-five percent of pediatric anesthesiology fellowship attendings were not interested in teaching and that impaired supervision of trainees. Misleading: Less supervision of pediatric anesthesiology fellows did not lead to more errors. Better: Twenty-five percent of pediatric anesthesiology fellows perceived that lack of interest in teaching by the faculty were barriers to faculty supervision, but that this barrier did not affect frequency of reported errors. A slight misunderstanding by a dull-eyed reader perverts the data. The first sentence has changed the “25% of” from pediatric anesthesiology fellows to pediatric anesthesiology attendings. The first sentence also substitutes the loaded term “impaired supervision” for the term the authors used, “barriers to faculty supervision.” The term “perceived” is particularly critical here because it goes to declaring another individual’s intent (unless, of course, an attending said to the fellow “I have no interest in teaching”). Even though the authors state that this should not be used to alter staffing patterns, one can also imagine this being turned around—“quality of supervision does not affect the frequency of reported errors”—to decrease the extent of attending supervision. ARE CITATION ERRORS A PROBLEM? Citation errors are often classified as either major or minor. Major errors are those considered “not at all in accordance with the claim of the authors.”3 These would include citations that do not support, that misrepresent, that contradict or are irrelevant to the cited statement. Minor errors “are often defined as inconsistencies and factual errors not severe enough to contradict”3 the cited statement. Minor errors may include indirect or secondary citation errors, which refer to citing a review article rather than the article that directly supports the cited statement. These definitions do not include errors such as wrong data (eg, page numbers) in a citation. A 2015 meta-analysis3 of 28 articles that analyzed citation errors (ranging from 1985 to 2011, 10 from 1985 to 1994; 9 from 1995 to 2004; 9 from 2005 to 2013) out of 559 screened found a total citation error rate of 25.4% (95% CI, 19.5–32.4, n = 28) and, of those, a major error rate of 11.9% (95% CI, 8.4–16.6, n = 27) and a minor error rate (including indirect citations) of 11.5% (95% CI, 8.3–15.7, n = 27). When indirect citations were removed from the analysis, the minor error rate was 8.5% (95% CI, 6.8–10.7, n = 27). These results were not due to few sloppy articles; 79% (22 of 28) of the articles reported 10% or higher total citation errors, and the lowest reported rate of citation errors was 6.7%. STRATEGIES TO IMPROVE MINDFULNESS ABOUT CITATION ERRORS Greater awareness about the etiologies and situations that lead to citation errors (particularly indirect citations) should improve this situation. These suggestions are mundane, yet we need to be mindful of them when we run into situations that may lead to unintentional citation error. To be fair, I have made each of these errors and more, mostly because I had a narrow view of citation errors. Seek needed citations cautiously: This pressure is perhaps most acute when an editor asks you to provide a citation or to “improve citations” during the peer-review process. In the end, remember that the editor is asking for useful, accurate, and directly supporting citations. If you are unable to find one, you may want to (1) inform the editor and/or (2) rewrite the sentence to permit appropriate citation by another reference. Notify the reader if you write a statement for which there is no suitable citation. Banish review articles from your citations: If the review article has a citation error, using it perpetuates the error. Read the primary article to verify that it supports the statement. Citing the primary article directs the reader to the most useful source and gives intellectual credit to the authors.4 Avoid citing review articles that do not have citations for the fact or concept you want to cite. Review articles are acceptable if being used to direct the reader to a useful review (eg, “Jones provides an excellent review of this topic”) or if you are citing the opinion or overall thrust of the review article (“Jones argues that …”). Be cognizant of timing: Do not use a 10-year-old article to suggest that the rates of events then are the same now unless you have positive evidence (as compared to an absence of evidence) that the rates have not changed. Resist the catnip of using abstracts as valid citations: The ubiquity of electronic access to abstracts taunts us. Demand of yourself to read the complete article before judging whether it is a supporting reference. Trust but verify: Seeking an article to support a desirable point tempts unconscious bias. Be suspicious of what you think you know. Do not rely on memory as to the appropriateness of a citation. Production pressure leads to shortcuts: Actively assess whether pressure from projects, deadlines, insufficient assistance, or too many projects leads you to skirt best practices. CONCLUSIONS Authors and readers have the responsibility to be aware of the extent and harm of citation errors. Relevant education, particularly in how to combat the risk factors for citation errors, will likely improve the actions of authors and readers, who, in the end, use this information for patient care. DISCLOSURES Name: David B. Waisel, MD. Contribution: This author was solely responsible for the manuscript. This manuscript was handled by: Edward C. Nemergut, MD.

Point-of-care ultrasound imaging is increasingly used by anesthesiologists to facilitate rapid clinical diagnosis and treatment in the perioperative period. With its growing popularity, inevitably, unfamiliar structures will be observed. We present a case of cystic liver lesions in a healthy model during a point-of-care workshop. We address the clinical, ethical, and legal implications of incidental findings in anesthesiology. We offer recommendations and an algorithmic approach to these occurrences.

Pediatric AnesthesiaVolume 28, Issue 1 p. 6-7 EDITORIAL We need personalized assessments for implicit bias in higher risk situations David B. Waisel, David B. Waisel david.waisel@childrens.harvard.edu orcid.org/0000-0002-5307-4092 Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USASearch for more papers by this author David B. Waisel, David B. Waisel david.waisel@childrens.harvard.edu orcid.org/0000-0002-5307-4092 Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USASearch for more papers by this author First published: 11 December 2017 https://doi.org/10.1111/pan.13289Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume28, Issue1January 2018Pages 6-7 RelatedInformation

Background: The endotracheal tube is an amalgam of the ideas and innovations of physicians across multiple centuries, having gone through multiple iterations before arriving at its current form. This abstract presents the changes in endotracheal tube design from before the advent of ether anesthesia through the modern era.

Purpose of review This review describes advances in rising and continuing ethical issues in research in patients in pain. Although some of the issues focus directly on pain research, such as research in neonatal pain management, others focus on widespread ethical issues that are relevant to pain research, such as scientific misconduct, deception, placebo use and genomics. Recent findings Scientific misconduct is more widespread than realized and requires greater awareness of the markers of misconduct like irreproducibility. More education about what qualifies as misconduct, such as consent violations, plagiarism and inappropriate patient recruitment along with data falsification needs to be implemented. Wayward researchers may attend a rehabilitation conference to improve their practices. Studies in neonatal pain management do not require comparing an intervention with the inadequate analgesia of a placebo; comparing with a standard approach is sufficient. Deception of research patients may be acceptable under narrow circumstances. The legitimacy of using broad informed consent for biobanking and genomic studies are being challenged as changes to the Common Rule are being considered. Summary Increasing complexity and the desire to further medical knowledge complicates research methods and informed consent. The ethical issues surrounding these and offshoot areas will continue to develop.