Easing the Burden on Caregivers- Applications of Artificial Intelligence for Physicians and Caregivers of Children with Cleft Lip and Palate

Abstract

Objective

Many caregivers of children with cleft lip and palate experience a high level of anxiety throughout their child's medical and surgical care. We aim to evaluate artificial intelligence (AI) as a tool to mitigate these feelings and can aid clinicians in the development of robust pediatric educational materials for caregivers and families.

Design

Thirteen of the most common postoperative questions following cleft lip and/or palate repair were developed by an expert panel of senior Pediatric Plastic Surgeons and were posed to ChatGPT. Professional answers from the expert panel were provided and compared to responses from ChatGPT. A literature review was also conducted to generate a new support model for caregivers with children undergoing a surgical procedure.

Setting

Department of Pediatric Plastic Surgery at a metropolitan Children's Hospital.

Participants

Senior Pediatric Plastic Surgeons at a metropolitan Children's Hospital.

Interventions

None.

Main Outcome Measure

The primary outcome was to determine the ability of ChatGPT to respond to common postoperative questions and to develop a model for AI assistance in family-centered perioperative care.

Results

ChatGPT had a postoperative question response accuracy rate of 69% when compared with subject matter expert responses, with its greatest errors being information errors. An extensive literature search revealed that AI can assist in multiple traditional perioperative strategies to reduce caregivers and patient anxiety.

Conclusions

Artificial Intelligence can help to reduce the burden of generating patient education materials as well as support caregivers in multiple aspects and perioperative care.

Keywords

cleft lip and palate artificial intelligence quality improvement

Introduction

Cleft lip and palate (CLP) occurs in 1 out of 700 live births per year globally.^1,2 Primary surgical repair of the cleft lip and/or palate is the most common treatment modality for this congenital difference and on average occurs between 6 to 12 months of age.^3,4 The young age at which this procedure occurs, compounded with caregiver separation anxiety, lack of control over the environment, and the risk of complications can lead to high levels of anxiety in caregivers with children with CLP.^5–8 Furthermore, CLP families often feel a sense of inadequate medical support and low self-esteem in their caregiving capabilities.^2,9 Preoperative anxiety is a common phenomenon surrounding pediatric procedures and affects 74% of caregivers.^10,11 High levels of parental stress or anxiety can drastically impact the child's experience and even lead to higher levels of postoperative pain.^12–14

A critical tool to mitigate caregiver anxiety is through the use of comprehensive patient educational materials. Studies have shown that an increase in written communication provided to caregivers prior to their child's surgery can significantly decrease levels of caregiver anxiety.^15–18 In addition, low caregiver health literacy is associated with higher pediatric emergency department medical visits and may increase medication errors.^19,20 Therefore, it is fundamental to maintain and provide high quality, informative, and easy-to-read patient education materials to caregivers when a child requires medical or surgical care. As a department-wide effort, the Department of Pediatric Plastic Surgery at a metropolitan Children's Hospital launched a quality improvement project in February 2023 to improve postoperative patient education materials for pediatric patients and their families. Improving patient education materials can be labor intensive and this provided an opportunity to apply and evaluate the use of AI in this context.

Chat Generative Pre-Trained Transformer, or better known as ChatGPT (Open AI, San Francisco, CA, USA) is an artificial intelligence (AI) chatbot that can provide multifaceted responses across multiple disciplines.²¹ In the short time since its inception in November 2022, ChatGPT has become a major disrupter in the technology industry. In the medical field, many researchers have sought to determine how extensive ChatGPT's abilities may be. Kung et al. and Gilson et al. have found that ChatGPT possesses the ability to pass the United States Medical Licensing Exam.^22,23 This finding generated a vast interest and spawned many studies in academic medicine which aimed to determine the extent of this powerful technology's abilities and the potential applications of this tool in medicine.

This study aimed to determine if AI can potentially provide appropriate responses to the most commonly asked postoperative questions of parents or guardians of children who underwent cleft lip and/or palate repair. This study also aimed to propose an AI-assisted supportive framework for caregivers with children with cleft lip/palate. Both could serve as potential tools for clinicians to develop patient education materials and mitigate caregiver anxiety with the assistance of AI.

Methods

The need for ethics approval and the need to obtain consent was not required for this non-interventional study.

Content Selection and First Draft of Patient Education Material

As a pilot project, CLP repair was chosen as CLP is the most common craniofacial malformation. The most common postoperative questions were compiled by an expert panel at a metropolitan Children's Hospital. Thirteen of the most asked postoperative questions were selected, and two senior Pediatric Plastic Surgeons drafted their professional answers to generate patient education materials (IG, MSG).

ChatGPT Responses to Postoperative Questions

The same thirteen questions were posed to ChatGPT (ChatGPT 3.5 February 13 Version) and its answers were recorded.

Evaluation of ChatGPT Responses

The answers generated by ChatGPT were evaluated for accuracy by the same two senior Pediatric Plastic Surgeons (IG, MSG). To prevent any bias, the experts were asked to evaluate the answers provided by ChatGPT independently and were blinded to the professional answers written during the expert panel.

Answer generated by ChatGPT that were found to be erroneous were categorized into three groups: information error, statistical error, or multiple errors using previously published methodology.²² Information error was defined as the ChatGPT material not conveying correct information. Statistical error was defined as ChatGPT providing incorrect numbers, with or without calculation. Multiple errors were defined as errors that have a combination of both information and statistical error.

Literature Search to Develop an AI Assisted, Caregiver-Centered Support Model

In parallel to determining the efficacy of an AI chatbot in developing patient education materials, an extensive PubMed and Google Scholar literature search was conducted to identify and incorporate AI into a supportive model for caregivers of children who require surgical treatment. Terms queried included “pediatric surgery”, “cleft palate surgery”, “cleft/lip repair” or/and “caregiver burden”, “parents with cleft/palate children”, or/and “support framework”. AI associated materials were searched using terms “AI” or/and “reduce caregiver burden”, “communication”, “pediatric surgery”, “support framework”. Literature which could help develop the support model was reviewed, incorporated, synthesized, and is presented with our results.

Results

Accuracy and Quality of ChatGPT Responses

The responses generated by ChatGPT were recorded and compared to the professional responses listed in Table 1. Overall, ChatGPT's answers were verbose yet accurate with some notable incongruencies. ChatGPT correctly normalized some common postoperative scenarios such as postoperative bleeding (#1, #7), postoperative halitosis (#2), or changes in postoperative appearance (#8). However, ChatGPT seemed to have limited knowledge of postoperative care such as avoiding using spoons or forks for feeding (#4). In addition, while surgeons recommended caregivers to gently put nasal stents and tubes back in if they fall out, ChatGPT did not recommend doing so (#12). Lastly, ChatGPT seemed to lack knowledge of various specific surgical techniques of cleft lip/palate repair. For example, when ChatGPT was asked about an “open hole” developing after the surgery, it did not realize these could be lateral relaxing incisions rather than surgical dehiscences or postoperative fistulas (#3). ChatGPT also confused cleft lip repair with cleft palate repair (#8).

Table 1.

ChatGPT Responses Compared to Professional Answers.

Question	ChatGPT-Generated Answer	Professional Answer
1. Is it normal for there to be bleeding from the nose?	Some bleeding from the nose after cleft palate surgery can be normal, especially during the first few days after the procedure. However, excessive bleeding or bleeding that continues for an extended period can be a cause for concern and should be addressed by a medical professional.	Yes, it is normal to have some bleeding from the nose as the palate repair closes the nose off from the mouth. I would expect some small bleeding for up to a week after surgery.
	It's essential to follow the post-operative instructions provided by the surgeon to reduce the risk of bleeding and promote healing. These instructions may include avoiding strenuous physical activity, not blowing the nose, and avoiding hard or crunchy foods that can irritate the surgical site.
	If you notice excessive bleeding, difficulty breathing, or other concerning symptoms, contact your surgeon or seek medical attention right away.
2. My babies breath smells terrible now, is that normal?	Bad breath or halitosis is not uncommon after cleft palate surgery, particularly during the initial stages of recovery. The surgery can cause changes in the mouth and throat, and there may be some temporary alterations to the normal bacterial flora of the mouth, which can contribute to bad breath.	Yes, since some food particles will get stuck to the stitches, it is normal for baby's breath to smell bad until the sutures are dissolved.
	However, if the bad breath persists or is accompanied by other symptoms such as fever, pain, or bleeding, it may be a sign of an infection or other complication, and you should consult your baby's surgeon or pediatrician as soon as possible.
	To help manage bad breath after cleft palate surgery, it's important to follow the post-operative care instructions provided by your baby's surgeon carefully. This may include gently cleaning the mouth with a soft cloth, encouraging good oral hygiene habits, and avoiding foods or drinks that may exacerbate the problem.
	Your baby's surgeon or pediatrician may also recommend additional measures to help manage bad breath, such as using mouthwash or other oral hygiene products or prescribing antibiotics or other medications if an infection is suspected.
3. Is it normal to have open holes on the side?	It is not normal to have open holes on the side after cleft palate surgery. Cleft palate repair surgery aims to close the gap or opening in the roof of the mouth and create a functioning palate. After the surgery, the surgical site is typically closed with sutures or other materials to promote healing and prevent infection.	Yes, some palatal surgeries create relaxing incisions laterally which mucosalize/fill in over time.
	However, in some cases, complications can occur, and the surgical site may not heal properly. This can result in the formation of open holes or fistulas in the roof of the mouth. Fistulas are openings or channels that can form between two structures, and in the case of cleft palate surgery, may occur between the mouth and nasal cavity.
	If you notice open holes or fistulas after your baby's cleft palate surgery, it's important to consult with their surgeon or pediatrician as soon as possible. The presence of fistulas can cause issues with feeding, speech, and may increase the risk of infection. Your baby's surgeon will be able to assess the situation and recommend appropriate treatment, which may include additional surgery to close the fistula or other interventions to promote healing.
4. Can I feed my baby purees (baby food) with a spoon or a fork after surgery?	Yes, it is generally safe to feed your baby purees or soft baby food with a spoon or fork after cleft palate surgery. However, it is essential to follow the post-operative care instructions provided by your baby's surgeon and pediatrician carefully, as there may be specific guidelines or restrictions on feeding in the immediate aftermath of the surgery.	No, you should not put any hard objects inside the mouth.
	In general, babies who have undergone cleft palate repair surgery may require special feeding techniques or modifications to ensure that they can eat and swallow safely and comfortably. Your baby's healthcare team will be able to provide guidance on appropriate feeding techniques, as well as any modifications that may be necessary to accommodate your baby's specific needs.
	When feeding your baby after cleft palate surgery, it's important to use a soft-tipped spoon or fork and avoid foods that are hard, crunchy, or sticky, as these may irritate the surgical site or be difficult for your baby to eat or swallow. You should also take care to feed your baby slowly and carefully, allowing them to take breaks as needed and monitoring them closely for signs of discomfort or difficulty swallowing.
	If you have any questions or concerns about feeding your baby after cleft palate surgery, it is important to consult with your baby's surgeon or pediatrician for guidance and support.
5. Can my baby have his/her shots after surgery?	The timing of vaccinations after cleft palate surgery may vary depending on the specific surgical procedure and the baby's overall health status. In general, it is usually safe to administer vaccinations following cleft palate surgery, but it is important to consult with your baby's surgeon and pediatrician to determine the appropriate timing and protocol.	Yes, you can have regular vaccines after the procedure.
	Your baby's healthcare team will be able to provide guidance on when it is safe to administer vaccinations after cleft palate surgery and may recommend delaying certain vaccines or modifying the vaccination schedule to accommodate your baby's specific needs.
	It's important to keep in mind that vaccinations are an essential part of your baby's healthcare and help protect them from a range of serious and potentially life-threatening illnesses. Delaying or skipping vaccinations can put your baby at risk of disease, so it's important to work closely with your healthcare team to ensure that your baby receives all necessary vaccinations in a safe and timely manner.
	If you have any questions or concerns about vaccinations after cleft palate surgery, be sure to discuss them with your baby's healthcare provider. They can provide you with the information and guidance you need to make informed decisions about your baby's care.
6. My baby is sticking his/her tongue out of his/her mouth a lot more now, is that normal?	After cleft palate surgery, it is possible that your baby may stick their tongue out of their mouth more frequently than before the surgery. This behavior is generally considered normal and is likely a result of the tongue adjusting to the changes in the mouth and palate following the surgery.	Yes, the palatal repair will change the volume inside the mouth and sometimes the baby needs to “figure out” what to do with the tongue.
	Cleft palate surgery can affect the way the tongue moves and functions in the mouth, particularly in the early stages of recovery. It may take some time for your baby to adjust to the changes and develop new patterns of movement and behavior.
	If you have concerns about your baby's tongue movement or behavior after cleft palate surgery, it's important to discuss them with your baby's surgeon or pediatrician. They can evaluate your baby's tongue function and provide guidance on appropriate care and management.
	In general, it is important to encourage your baby to practice good oral hygiene, including gentle cleaning of the mouth and tongue, as well as promoting healthy eating and drinking habits. This can help reduce the risk of infection and other complications and support optimal healing following cleft palate surgery.
7. Is it normal for there to be bleeding from inside the mouth or the nose after surgery?	It is not uncommon for there to be some bleeding from inside the mouth or the nose after cleft palate surgery, particularly in the first few days after the procedure. Some minor bleeding or oozing from the surgical site is a normal part of the healing process and typically resolves on its own within a few days.	Yes, it is normal to have a small bleeding for about a week after surgery.
	However, if bleeding is excessive or persistent, it is important to seek medical attention immediately. Excessive bleeding can be a sign of a complication, such as infection, and may require further medical intervention.
	After cleft palate surgery, it's important to follow the post-operative care instructions provided by your baby's surgeon and pediatrician carefully, including any guidelines or recommendations for managing bleeding or other potential complications.
	If you have concerns about bleeding or other issues following cleft palate surgery, it is important to consult with your baby's healthcare team for guidance and support. They can evaluate your baby's condition and provide appropriate treatment or management to promote optimal healing and recovery.
8. The lip repair looks different now than it did immediately after surgery, is that normal?	It is normal for the appearance of the lip repair to change in the days and weeks following cleft palate surgery. Immediately after surgery, the repaired area may appear swollen, bruised, and distorted due to the effects of the anesthesia and surgical trauma.	Yes, swelling and changes in the incision as it heals will slightly change the shape of the lip after surgery.
	As the swelling and bruising subside and the tissues begin to heal, the appearance of the lip repair may change. The repaired area may appear more defined and natural-looking over time. However, it's important to keep in mind that every baby's healing process is unique, and the appearance of the repaired area may vary depending on a range of factors, such as the extent of the initial cleft and the specifics of the surgical repair.
	If you have concerns about the appearance of the lip repair after cleft palate surgery, it's important to discuss them with your baby's surgeon or pediatrician. They can evaluate the surgical site and provide guidance on appropriate care and management.
	In general, it is important to follow the post-operative care instructions provided by your baby's healthcare team carefully and to monitor the surgical site closely for signs of infection or other potential complications. With proper care and management, most babies who undergo cleft palate surgery can achieve optimal healing and recovery, with improved appearance and function of the affected area.
9. My baby likes to sleep with his/her face down on the bed, is that ok after surgery?	It is not recommended for babies to sleep with their face down on the bed after cleft palate surgery or any surgery, as this position can increase the risk of complications such as breathing difficulties, especially during the early stages of recovery.	Rubbing the lip on the bed while sleeping should be avoiding. This position will also increase post -operative swelling.
	Babies who have undergone cleft palate surgery may be at an increased risk for airway obstruction and respiratory complications, so it's important to follow safe sleep practices to help minimize these risks. The American Academy of Pediatrics (AAP) recommends that infants be placed on their backs to sleep, on a firm and flat surface, and in a separate sleep area (such as a crib or bassinet) to reduce the risk of Sudden Infant Death Syndrome (SIDS).
	If your baby is used to sleeping on their stomach, you may need to work with them to adjust to a new sleep position. You can try placing your baby on their back for sleep and offering them soothing activities, such as singing or rocking, to help them get used to the new position. It's important to discuss any concerns or challenges with your baby's healthcare team, who can provide guidance and support.
	Overall, it's important to prioritize safe sleep practices and follow the recommendations of your baby's healthcare team to promote optimal healing and recovery after cleft palate surgery.
10. I want to start feeding my baby real food, can I do this after surgery?	It's important to follow the recommendations of your baby's healthcare team regarding when to start feeding your baby real food after cleft palate surgery. In general, the timing for introducing solid foods can vary depending on the specifics of the surgery and the individual needs of your baby.	It is recommended to not feed young babies solid hard foods (bread, pretzels, etc). If you want to start on mushy baby food, wait until about 3 weeks after surgery.
	In most cases, babies who have undergone cleft palate surgery will start with pureed or mashed foods, which can be easier to swallow and digest. Your baby's healthcare team may recommend a specific timeline for gradually introducing solid foods, and may provide guidance on appropriate foods and feeding techniques.
	It's important to keep in mind that babies who have undergone cleft palate surgery may have specific feeding challenges or requirements, such as difficulty with sucking, swallowing, or oral control. Your baby's healthcare team can provide guidance and support to help you navigate these challenges and ensure that your baby is receiving adequate nutrition.
	Overall, it's important to work closely with your baby's healthcare team to develop an appropriate feeding plan that meets your baby's unique needs and promotes optimal healing and recovery after cleft palate surgery.
11. My baby's nose has a lot of boogers in it, can I use anything to take the snot/buggers out?	After cleft palate surgery, it's important to be gentle when cleaning your baby's nose to avoid causing any irritation or damage to the surgical site. If your baby has a lot of mucus or boogers in their nose, you can use a saline nasal spray or drops to help loosen and clear the mucus.	You should avoid placing anything in the nose for at least 3 weeks after surgery.
	To use saline nasal spray or drops, first wash your hands and then tilt your baby's head back slightly. Squeeze the recommended number of saline drops or spray into each nostril, then gently wipe away any excess mucus with a clean, soft tissue or cotton ball.
	It's important not to use any objects, such as cotton swabs or suction devices, to remove mucus or boogers from your baby's nose after cleft palate surgery, as these can cause injury or irritation to the surgical site.
	If you have concerns about your baby's nasal congestion or if you notice any signs of infection, such as fever or increased redness or swelling around the surgical site, it's important to contact your baby's healthcare team right away. They can provide guidance on appropriate care and management to ensure optimal healing and recovery.
12. My baby had nasal stents or tubes in the nose after cleft lip repair and they fell out, should I put them back in?	If your baby's nasal stents or tubes have fallen out after cleft lip repair, it's important to contact your baby's healthcare team for guidance on what to do next. Depending on the specifics of the surgery and the timing of the stent removal, your baby may or may not need to have the stents or tubes replaced.	Yes, if you can safely and gently put them back in, I would recommend doing that.
	In general, nasal stents or tubes are placed after cleft lip repair to help maintain the shape and position of the nasal tissues as they heal. If the stents or tubes fall out before they are supposed to, it's possible that they have already served their intended purpose and may not need to be replaced.
	However, if the stents or tubes fell out prematurely or if your baby is experiencing any symptoms such as nasal congestion or difficulty breathing, your baby's healthcare team may recommend that the stents be replaced or that additional treatment be pursued.
	Overall, it's important to follow the guidance of your baby's healthcare team and to communicate any concerns or questions you may have about your baby's recovery after cleft lip repair. They can provide you with the information and support you need to ensure the best possible outcomes for your baby.
13. When can I start scar cream and or scar massage on the cleft lip scar?	The timing for starting scar cream and massage on a cleft lip scar can vary depending on the specifics of the surgery and the individual needs of your baby. In general, it's best to follow the recommendations of your baby's healthcare team regarding when to start scar management.	After cleft lip repair, normally it is ok to start scar cream and massage about 3 weeks after surgery.
	After cleft lip repair surgery, it's common for the incision site to be sensitive and tender, and it may take several weeks or months for the scar to fully heal. Your baby's healthcare team may recommend waiting until the incision site has fully closed and any sutures or staples have been removed before starting scar management.
	Once your baby's healthcare team has given the go-ahead to start scar management, they may recommend using a scar cream or ointment to help moisturize and protect the scar tissue. Scar massage may also be recommended to help improve circulation and promote healing.
	It's important to use gentle pressure and techniques when performing scar massage, and to avoid causing any pain or discomfort to the incision site. Your baby's healthcare team can provide guidance on appropriate scar management techniques and products, and can help you develop a plan for ongoing scar management as your baby continues to heal and grow.

Overall, ChatGPT's responses provided excessive and unnecessary information leading to much lengthier responses than a professional answers. The accuracy of ChatGPT generated responses was 69%, with most errors being information errors (Table 2).

Table 2.

Analysis of ChatGPT-Generated Responses.

Question	Accuracy	Error Type	Expert #1 Comment on ChatGPT Answer	Expert #2 Comment on ChatGPT Answer
1. After cleft palate surgery, is it normal for there to be bleeding from the nose?	Yes	-	“Accurate”	“This is a lot of information. The middle paragraph is not necessary.”
2. After cleft palate surgery, my babies breath smells terrible now, is that normal?	Yes	-	“Accurate, verbose”	“Very verbose. Do not need the last 2 paragraphs.”
3. After cleft palate surgery, is it normal to have open holes on the side?	No	Information error	“Inaccurate, and doesn’t distinguish between relaxing incision’ i.e., on the side ‘and holes in the middle of the palate, i.e., hard- soft junction. Also, holes fistula can result largely from increased tension on the repair, and in and of itself will not harm the baby, it's important to consult with a surgeon for specific instructions if a hole in the middle of palate is noticed that was not there before”	“This response is incorrect. Though fistulas are described correctly, chatGPT fails to account for relaxing incision side ports which can be used in certain repair types. Usually, I tell my patients’ families to expect these side ports to alleviate concern.”
4. Can I feed my baby purees (baby food) with a spoon or a fork after cleft palate surgery?	No	Information error	“Inaccurate 1^st paragraph: not recommended. 3^rd paragraph: would not recommend any spoon nor fork”	“The gist of the end of the 1^st paragraph and 2^nd paragraph are correct. I would be careful with the use of a spoon or fork as though these can be offered to the baby, they are supposed to tongue or bite the food off and these should not be inserted in the mouth.”
5. Can my baby have his/her shots after cleft palate surgery?	Yes	-	“Accurate yet verbose.”	“First 2 paragraphs are correct. Don’t really need the next 2 paragraphs.”
6. After cleft palate surgery, my baby is sticking his/her tongue out of his/her mouth a lot more now, is that normal?	Yes	-	“Accurate but 4^th paragraph could likely be deleted.”	“First paragraph is correct. 3rd paragraph is ok. 4th paragraph is entirely unnecessary.”
7. Is it normal for there to be bleeding from inside the mouth or the nose after cleft palate surgery?	Yes	-	“Accurate and verbose”	“Correct but very wordy.”
8. The lip repair looks different now than it did immediately after cleft palate surgery, is that normal?	Yes	-	“First sentence confused lip and palate surgery…Otherwise, verbose but somewhat accurate.”	“The response confused lip and palate repairs. Overall accurate and helpful though the term “Surgical trauma” is a bit more drastic than necessary.”
9. My baby likes to sleep with his/her face down on the bed, is that ok after cleft palate surgery?	Yes	-	“Accurate”	“Correct answer though the “after any surgery” part may not be correct.”
10. I want to start feeding my baby real food, can I do this after cleft palate surgery?	Yes	-	“Accurate”	“First paragraph is correct. 2^nd paragraph, though technically correct, is not necessary to answer this question.”
11. My baby's nose has a lot of buggers in it, can I use anything to take the snot/buggers out?	No	Information error	“Not quite accurate as to timing of introducing nasal sprays or cleansers- this also applies to lip repair which ChatGPT does not mention.”	“1^st paragraph is technically correct though the idea of “Gentle cleaning” may be misleading and make parents think they can clean inside the nose. 2–3^rd paragraphs correct.”
12. My baby had nasal stents or tubes in the nose after cleft lip repair and they fell out, should I put them back in?	No	Information error	“If the medical team had instructed and/or counseled you on how to replace them, then follow those instructions. (which may involve lubricating the stents with antibiotic ointment) but otherwise would contact the surgical team for further guidance.”	“2nd paragraph is not really correct. 1st paragraph is safe and correct.”
13. When can I start scar cream and or scar massage on the cleft lip scar?	Yes	-	“Always defer to the surgeons’ preferences. We recommend starting silicone-based scar gels around 3–4 weeks after surgery, and massage about 6 weeks post operatively.”	“1^st paragraph is a safe answer. 2^nd paragraph is technically correct except that I don’t know of anyone who uses staples in a cleft lip repair. 3^rd and 4^th are correct but overly informative.”

AI-assisted Perioperative Support Model

A proposed model of AI-assisted pediatric perioperative care to reduce the burden on caregivers was generated and is represented in Figure 1. The traditional model was adapted from previous work by Chorney et al. and Santapuram et al.^8,24 In Chorney et al., to support caregivers of pediatric patients who required surgical treatment, the family-centered pediatric perioperative care system can be categorized into (1) family factors, (2) preoperative factors, (3) intraoperative factors, (4) postoperative factors, and (5) provider/system factors.

Figure 1.

Schematic of the traditional perioperative support model versus our proposed AI-assisted model.

Adapting from Santapuram et al., which provided strategies to reduce caregiver anxiety in preparation for pediatric surgeries, we identified that AI could assist in multiple categories of family-centered pediatric perioperative care. Under family factors, AI-run chatbots can provide additional emotional support. Within preoperative factors educational materials, audiovisual intervention, and therapeutic play could be supported by AI. Under postoperative factors, communication between healthcare professionals, communication style, training, and organization policy could be strengthened by AI. The details of the components of the traditional perioperative support model and the AI-assisted model are listed in Table 3.

Table 3.

Details of the Components of the Traditional Perioperative Support Model and the AI-Assisted Model.

	Traditional Model	AI-Assisted Model
Family Factors	Parent's level of health literacy: familiarity with the healthcare system and vernacular can promote better outcomes in postoperative care and lessen anxiety in parents. Support system: a strong support system can reduce parental anxiety. Financial support: healthcare finances can be a major stressor on a family and can contribute to the level of anxiety a parent experiences during pediatric operative care. Anxiety management: coping skills for stress and anxiety are critical in managing the stress in both the child and parent.	Parent's level of health literacy: AI can generate education materials at different education levels, which can tailor the needs of parents. Support system: AI generative chatbots can provide tailored emotional support to caregivers and patients 24/7.^31,32 Anxiety management: AI chatbots can provide coping skills and supportive conversations to manage anxiety and stress.^31,32
Preoperative	Preoperative education: educational materials given prior to surgery has been shown to reduce parental anxiety.^{7,15,16,17,18} Audiovisual intervention: educational videos shown prior to surgery may be more effective than written communication.^7,36 Therapeutic play: play-based interventions significantly reduce parental anxiety.^7,34,35 Integrative preparation program: These programs integrate parent and child preparation to lower preoperative anxiety of both the child and parent.²⁴	Preoperative education: AI can facilitate the creation of educational materials. Audiovisual intervention: Web-based apps or educational videos potentially run by AI programs can provide on-demand support to reduce preoperative anxiety.⁷ Therapeutic play: Robot-assisted therapy based in AI has been shown as a potential new mechanism and application for reducing anxiety in parents and pediatric patients.³⁷
Intraoperative	Parental presence at anesthetic induction: parental presences is preferred by parents and increases parent satisfaction, reduces separation anxiety, and decreases the need for premedication.²⁴
Postoperative	Communication between healthcare professionals: studies have shown that parents often note that discharge information can be improved. Reiteration of communication with healthcare professionals can improve self-efficiency in caregiving postoperatively.²⁴ Organizational support: administrative policies and support for families can reduce parental anxiety and the burden felt on caregivers often experience at discharge.²⁴	Communication between healthcare professionals: AI can supplement communication through chatbots to answer simple questions or improve postoperative education materials.
Provider/System Factors	Communication style: an effective communication style can affect the level of acceptance of the strategies by parents and children.²⁴ Training: training in managing parental anxiety and working with children and families can benefit providers when dealing with anxious parents or children.²⁴ Organizational policy: policies that support family-centered care is key to successfully implementing anxiety-reducing strategies.²⁴	Communication style: AI has the potential to provide materials with a communication style that is receptive to caregivers. Training: AI can aid in the development training policies and materials. Organizational policy: AI can ease the development of materials that surround policies that support family-centered care.

Discussion

This study explored ChatGPT's ability to produce patient education materials and an AI-assisted perioperative support model for cleft lip/palate patients. Though ChatGPT struggled to compute and understand granular differences in surgical techniques and its answers were lengthy and provided unnecessary, and sometimes irrelevant, information, its answers to the postoperative questions were overall accurate. This aligns with the current literature which ascribes some level of medical knowledge to ChatGPT.^22,23,25 As suggested by our model, there is an increase in utility (or at least the consideration of the utility) of AI in the medical field. This posits that AI might be able to decrease caregivers’ emotional burden through multiple avenues including AI-assisted patient education material generation, audiovisual interpretation, therapeutic play, emotional support and coping skills (via a chatbot that provides tailored supportive conversations to manage anxiety and stress for caregivers 24/7), and communication between providers and caregivers.^8,24 AI also has the capability in language translation for patients and caregivers and translation of complex medical information into varying reading levels.^26,27

Ensuring a high level of accessibility and quality of educational materials distributed to patients and caregivers by providers or healthcare systems requires an extensive amount of time from experts to develop and maintain these materials. Additionally, given the nature of AI models constantly updating its algorithm, more advanced versions of ChatGPT will be able to provide more accurate medical knowledge across more fields, with some studies already investigating the use of ChatGPT to provide quality and empathic patient messages.^28–30 Furthermore, with ChatGPT 4 providing the capability to analyze images, this unlocks a substantial number of possibilities for ChatGPT to aid surgeons in postoperative surgical concerns for patients with limited access to healthcare.

This pilot study contains several strengths. The ChatGPT-generated answers were evaluated in terms of information accuracy, statistical accuracy, and a combination of both, allowing for an improved ability to identify any erroneous elements. This study also offered a unique caregiver-centered model which incorporates AI to reduce caregiver experienced anxiety and postoperative burden of care. Additionally, the postoperative questions generated by our expert panel align closely with previously published literature, offering a general application for all healthcare providers in CLP management.³¹ Moreover, answers provided by our expert panel align with the general consensus of other published patient education resources.^32,33 The senior craniofacial surgeons included in the expert panel also have standardized postoperative practices as a part of their cleft team consensus practices. Therefore, inaccuracies in the answers provided by ChatGPT can be accredited to its lack of medical knowledge rather than discourse in the literature.

Despite these strengths, there are some limitations to consider regarding the use of AI in patient education materials. To begin, ChatGPT's algorithm is constantly evolving. Our study did not use the newest version of ChatGPT (ChatGPT 4) as it is currently a paid service and ChatGPT4 was published after inception of this study.³⁴ As the authors do not have access to change the algorithm of ChatGPT (to increase the accuracy of the answers), we realized that pursing a high accuracy rate of ChatGPT generated materials was not the goal of this study, but rather it was a proof of concept. In addition, it is important to note that the purpose of using ChatGPT is not to replace healthcare providers in generating educational materials, but rather to supplement and reduce the burden of this often time-consuming process. Tone, body language, and other nonverbal communication also contributes to quality communication between a provider and patient/caregiver and subsequently, the lowering of caregiver and child perioperative anxiety.³⁵ Given that AI cannot currently match this level of communication, this limitation should be considered when using AI in caregiver-centered perioperative care. Further validation methods are needed to truly determine the effect of this interventional method.

As the field of AI continues to grow, it is important for medical researchers to elucidate how this technology can be applied to different facets of healthcare. With virtual capabilities becoming more popular in healthcare, more companies are exploring the application of AI in patient care to provide immediate support to caregivers and patients, ultimately increasing the accessibility.^36,37 A large language AI model such as ChatGPT can be a critical tool for clinicians to efficiently provide high quality care for patients and their caregivers. With consideration to its limitations, we believe this tool could unlock a sizable number of new applications for surgeons to explore and provide much needed support to both physicians and caregivers.

Conclusion

With the substantial incidence of CLP and the high levels of stress and anxiety caregivers can experience when their child undergoes surgical repair, it is important for clinicians to seek ways to reduce this anxiety in caregivers. Educational materials and multifaceted support models have shown to improve caregiver anxiety and improve outcomes in pediatric procedures. AI could supplement the current traditional methods for caregiver-centered perioperative care and support clinicians in multiple aspects for pediatric surgical procedures.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Sara C Chaker

Ya-Ching Hung

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