My recent experience as a cancer patient has illuminated many things. It has shown me how our health care system is not standardized and how it sometimes makes patient care decisions based on financial incentives or convenience rather than patient preferences or best clinical practice. Take, for example, the topic of sedation.

The question of whether to sedate is common in pain management, which often involves invasive intraspinal procedures such as epidural steroid injections, radiofrequency ablations, and spinal cord stimulators.

On one hand, in these procedures, you do not want the patient to move. Squirming or flinching can result in permanent damage when sharp needles are used in or around the spine or principal nerve bundles. On the other hand, sometimes the best way to avoid damage is to have the patient awake and alert so that we can ask questions and receive feedback about sensation and function to ensure we target the correct area.

For this reason, the choice between conscious sedation and local anesthetic alone is often made on a case-by-case basis. How nervous and uncomfortable is the patient about the procedure? Do they want sedation? Do they have complicating medical conditions that increase sedation risk or require active feedback during the procedure?

When I was preparing for my first prostate biopsy, I was surprised by my own anxiety. Although I have spent three decades performing invasive treatments on patients, I hated the thought of someone else probing my insides while I was awake. I knew I had better find a doctor who would offer me sedation; otherwise, my anxiety could be bad for both of us.

This reminded me that logistics too often determine which options patients are offered.

My first urologist did not offer sedation. Many private clinics do not employ anesthesia-trained staff and are not certified to administer sedation. When a procedure does not strictly require sedation, these clinics may not see this as a problem. In fact, treating patients in-clinic is often more profitable than referring them to a sedation-capable surgical center.

Hospitals and surgical centers generally offer sedation, which is why I chose one for my biopsy. But what if I did not know to ask? Many patients tell me they are unaware of such options.

Financial incentives also exist in hospitals and surgical centers. A facility can often charge thousands of additional dollars for the same procedure performed with sedation compared to local anesthetic alone. For example, in hand surgery such as carpal tunnel release, local anesthesia instead of IV sedation can save between $1,320 and $1,613 per case, including anesthesia, operating room, and recovery costs.

Where does this leave patients and doctors? Patients should be aware of their options. If you are having an invasive procedure, you can often find a provider who offers sedation. However, consider whether you need it, since sedation has risks. These risks can include allergic reactions, respiratory depression, and interactions with other medications. Doctors may avoid offering it for valid medical reasons, as unnecessary sedation is best avoided.

If you believe your anxiety could be a problem, tell your physician. If they do not listen, consider a second opinion. Movement or flinching can increase the risk of complications, and high anxiety can raise blood pressure and heart rate, creating additional risks.

Your comfort also matters. If fear leads you to delay necessary care, that is a medical risk. Avoiding medical trauma and PTSD are also valid concerns. For example, even localized procedures like wisdom tooth extraction under local anesthetic can cause PTSD in about eight percent of patients. Those with preoperative anxiety or prior traumatic experiences face an even higher risk.

Physicians should clearly explain procedure risks and consider patients’ comfort. The potential risks of not receiving sedation, especially for anxiety or trauma responses, should be part of the conversation. By fostering clear dialogue, providers can improve the patient experience and empower patients to voice concerns.

Sedating medications must be prescribed carefully. We are counseled to avoid unnecessary medications, especially those that are potentially habit-forming, which is one reason opioids are rarely used for sedation or anxiolysis today.

At the same time, we must minimize complications and take patient concerns seriously. If a patient fears they cannot tolerate a procedure without extreme stress, they are probably right. Medical trauma in such cases can result in long-term health consequences by discouraging future medical care.

The question of sedation will always be decided individually, based on the patient’s medical history, the procedure’s risks, and the patient’s anxiety level. This personalized approach should reassure patients that their providers are considering their needs. By assessing emotional state and communicating clearly before invasive procedures, we can improve both outcomes and experiences.

Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness. 

Dr. Torres was born in Spain and grew up in Puerto Rico. He graduated from the University of Puerto Rico School of Medicine. Dr. Torres performed his physical medicine and rehabilitation residency at the Veterans Administration Hospital in San Juan before completing a musculoskeletal fellowship at Louisiana State University Medical Center in New Orleans. He served three years as a clinical instructor of medicine and assistant professor at LSU before joining Florida Spine Institute in Clearwater, Florida, where he is the medical director of the Wellness Program.

Dr. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine. He is a prolific writer and primarily interested in preventative medicine. He works with all of his patients to promote overall wellness.

Simon Wahba is a medical student.