The Retrievals S02 Episode 4: The Solutions

Summary of The Retrievals S02 Episode 4: The Solutions

by Serial Productions & The New York Times

45m•August 7, 2025
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Summary — The Retrievals S02 Episode 4: "The Solutions"

Author/Host: Serial Productions & The New York Times
Episode focus: How one hospital changed care for awake C‑section patients by shifting culture, training clinicians, and building pain measurement into the electronic medical record.

Overview

This episode follows efforts at a Boston hospital (UIC / Mass General Brigham context) to reduce untreated pain during cesarean sections. After harmful incidents (explored earlier in the season), clinicians—led by an OB anesthesiologist named Heather—implemented educational and systems‑level changes: targeted resident training about communication and consent, new analgesic practices, and an EMR‑integrated pain‑scoring workflow that compels repeated pain checks and documentation during C‑sections.

Key points & main takeaways

  • Culture matters: Historically, patients in awake C‑sections who experienced pain were often ignored, minimized, or labeled "difficult." Changing clinician attitudes is central.
  • Training targets the next generation: Heather focuses on residents to normalize better behavior for years to come—teaching language, tone, and how to ask about fear and pain.
  • Concrete system change: The hospital added an EMR prompt that requires pain scores every 15 minutes during C‑sections. Scores ≥ 3 trigger structured follow‑ups (type/location of pain, interventions).
  • System + people = better compliance: Education and role‑modeling help, but integrating pain checks into routine workflows produces consistent behavior change.
  • Patient voice and data: The system captures not just numbers but patient quotes, making pain visible in the medical record and available to patients reviewing their files.
  • Communication strategy is debated: Some clinicians favor softening language to avoid suggesting pain; Heather argues for honest expectations to build trust.
  • Real cases illustrate approach: An anesthesiologist (Corey) calmed a resisting patient with informal, empathetic language and IV drugs when she refused general anesthesia; another observed patient reported pain 8/10 and received nitrous and prompt escalation because of the EMR workflow.

Notable quotes & insights

  • One-word empowerment: “Stop.” — reflects a cultural change allowing patients and team members to halt surgery when pain is reported.
  • “What's measured matters.” — Heather’s rationale for adding pain scoring to the workflow.
  • Teaching script: “I can't promise you a pain‑free surgery… But what I can promise you is if you tell me you're having pain, I will give you more medicines. I will work with you. I will be present with you.” — an example of honest, trust‑building communication.
  • On labeling patients: Residents often described assertive, informed patients as "difficult," exposing a bias that training seeks to correct.
  • Patient-as-hostage metaphor: People may not raise pain because they fear upsetting providers who control their care.

Topics discussed

  • Awake C‑section pain management and failures of regional anesthesia
  • Team dynamics and hierarchies in the OR (surgeon vs anesthesia, junior vs senior clinicians)
  • Communication skills: tone, phrasing, and bedside approach to fearful/resistant patients
  • Behavior change strategies: education, modeling, and systems/EMR interventions
  • Pain measurement: practical implementation, controversies over pain scores, and capturing qualitative data (patient quotes)
  • Examples of analgesic options referenced (e.g., clonidine, nitrous, IV meds) and that research on drug efficacy exists, but research on communication does not
  • Ongoing larger studies (SONAR in UK/Australia) looking at pain reporting during cesarean

Action items & recommendations (for clinicians and hospitals)

  • Implement routine intraoperative pain assessments for awake C‑sections (e.g., every 15 minutes) and make them part of the EMR workflow so they are not optional.
  • Require structured follow‑ups for moderate pain scores (≥3): ask location, type, and consider appropriate interventions.
  • Train all staff—especially residents—in specific communication skills: ask why a patient refuses options (e.g., general anesthesia), explore fears, use authentic tone, and explain realistic expectations.
  • Model and normalize speaking up: empower nurses, junior OBs, and anesthesiologists to pause surgery if a patient is in significant pain.
  • Document qualitative patient feedback (quotes) along with numerical pain scores to preserve context.
  • Collect and analyze data locally to inform best practices and contribute to broader research (there’s a knowledge gap on communication interventions).
  • Avoid labeling patients as “difficult”; instead see assertive questions as advocacy and respond with clarity and respect.

Conclusion

The episode shows that reducing intraoperative pain during C‑sections requires both cultural and system change. Teaching clinicians how to communicate and adding mandatory, EMR‑linked pain checks created measurable shifts: patients’ pain was attended to more consistently, clinicians were held accountable by data, and the medical record began to reflect patient experience. While questions remain (evidence about the "best" pain‑measurement tool and communication scripts), the combination of training, role modeling, and built‑in reminders makes it easier for teams to do the right thing for patients.