Friday, 21 February 2014

Kahneman, Colonoscopy and Goole

The Goole way of improving patient experience of colonoscopy

Colonoscopy and pain

All of us are well aware that despite our collective immense experience, colonoscopy can be a painful procedure for our patients. That is the reason we use analgesics. At this time influencing the experience happens by the sedation (midazolam) we give (influencing the perception, awareness and causing possible amnesia for the duration). Of course, the patient always has a better experience if our technique is good (minimum inflation, not going into loops, undoing loops early, change of position, abdominal pressure, lower total duration of procedure etc). Nevertheless patients can experience pain.

The pain obviously causes immense distress to patients, it also causes complaints. More relevantly pain may cause the patient to decline colonoscopy in the future. For some patients due to the nature of their disease repeat colonoscopy becomes essential and pain or unpleasant experiences puts these patients into distress even at the thought of considering colonoscopy. Patients may also colour the expectations of their family and friends regarding colonoscopy.

Kahneman and clinical psychology

The 2002 Nobel prize winner Daniel Kahneman has done important work on patient experience and its relation to the patients' willingness/readiness for further colonoscopy in the future if required. My understanding of what Kahneman says is that the total duration of the procedure, the highest rating of pain during the procedure or the duration of high levels of pain matters much less than the degree of the pain experienced at or towards the end of the procedure. For instance this means a patient with a 10 minute colonoscopy who was relatively comfortable for 9 minutes but had significant pain the in the 10th minute reports a worse experience than a patient who had a 20 minute colonoscopy with relatively severe pain for the first 17 minutes and no pain in the last 3 minutes. In fact in Kahneman's experiments they deliberately kept the colonoscope in place for extra 2 or 3 minutes so that the patient can have a pain free ending.

The lessons to us are of course self-explanatory - irrespective of the duration of the procedure or the degree of pain we should not take out the scope quickly and allow a pain/discomfort free period before the end of the procedure.

Kahneman explains this as the difference between experience and memory - with the message being what happens in the end is remembered more as the memory (rather than the totality of the duration of the experience even if that was painful/unpleasant).

The Goole Translation

We wanted to translate this into an even more tangible improvement of patient experience than just a slow withdrawal.  We wanted to go forward from the described lack of negative experience to the establishment of a positive experience. If Nobel Laureate Kahneman says the end of procedure experience is counted as memory we wanted to try to deliberately aim for and deliver a positive memorable experience.

At colonoscopy one of the main roles of the nurse who supports the patient is the reassurance role. Till the scope reaches the caecum the nurse has a reassurance role (‘you are doing fine’, ‘its nearly done’, ‘take nice and easy deep breaths’, ‘pass some wind out & you might feel better’ etc) - this is the normal role for the nurse in any endoscopy unit anyway and we do it as well. Once the scope reaches the caecum and completes the examination of caecum/terminal ileum, this reassurance role generally diminishes as the patient feels less pain, less anxiety etc. At this point I declare to the patient and the staff 'we have reached the end we should be getting out soon'. In Goole that statement would be the cue for the nurse to reduce the reassurance role and deliberately start a conversation with a high quotient of humour with the patient. The explicit aim is to try and make the patient laugh.

There seems no obvious downside or specific risks noticed yet. Important to remember that it is the nurse who supports the patient who engages in humour. The endoscopist and the nurse who supports the endoscopist remain extremely focussed and serious on completing the procedure safely.

We find that the patients end up in a really good mood when we are able to make them laugh. The trick is for the nurse-patient conversation to elicit a laugh. On the contrary, nurse-nurse or nurse(s)-endoscopist or even endoscopist-patient conversation eliciting the laugh from the patient is in my view is not as effective. The nurse-patient conversation resulting in a laugh is the crucial element; anyone else laughing may not be liked by some patients especially as the patient could be at the end of an unpleasant procedure.

In my conversations with people in the know, I learn that on the way to the caecum when the patient is experiencing distress/pain it could be okay to distract by attempting a social conversation but not with the intention of humour as that could end up as 'the memory' ('they joked while I was in pain'); the intention to humour is only after reaching the end point while making a slow withdrawal provided the patient does not have pain on withdrawal (if there was pain on withdrawal, then the reassurance role becomes important again)

It seems like common sense. Apart from a potentially great patient experience we find that the atmosphere in the procedure room becomes very enjoyable. It develops a good relationship between staff members. We have only just started doing this. I write my initial impressions and not any definite long term observations. This is not based on research, it is a simple description of what we do and what we feel about what we do on the matter of influencing patient's memory of colonoscopy.  I just wanted to share this simple and in my view, elegant humour based intervention to improve patient experience. You may want to try it with your patients, get your nurses to do this. Not every nurse will agree or be willing to go with this. That is okay, best to work with the willing.

Kahneman has proven the science - I have just added humour to it.


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Anonymous said...

liked it and easy to read

Pitar said...

Awesome post. i hope you will share more articles like this..