Most medical students don’t take classes on how to discuss informed consent, that is, talking about the risks and benefits of a medical procedure with a patient.
Pauline Chen remembers such conversations, where she “bumbled through each consent on [her] own, picking up certain phrases and dropping others through a sometimes painful and often awkward process of trial and error.”
That’s often the case, as “young doctors rarely have formal mentorship or the opportunity to observe more experienced physicians doing the process well before they begin to obtain consents on their own.”
And it doesn’t have to take much effort on the part of medical schools to improve the skill. A study that Dr. Chen cited found that a single day-long session was all that was needed to improve a doctor’s ability to navigate through the informed consent discussion.
Every medical school should find time for that.
Related posts:
- Psychiatrists and informed consent
- Informed consent is central to the doctor-patient relationship
- Does a physician’s bias color the informed consent discussion?
- He said, she said: Does informed consent discussions need to be videotaped?
- Informed consent gone wrong
- Can bedside manner be taught, or is it something you’re born with?
- Getting consent . . .
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I think that informed consent is often wrongly reduced to patients signing lengthy forms that they have not read or may not understand. Have these patients participated in an informed consent discussion before signing away their gallbladders? It would be enlightening if the informed consent process of physicians, including me, were surreptitiously recorded and viewed later.
As a medical malpractice lawyer I can tell you first hand that even the witnessed informed consent discussions are never recalled by the Plaintiffs in informed consent cases. Despite the fact that they sign a document acknowledging informed consent. It is always a he said/she said and area of contention in litigation. However, I do believe that spending time while physicians are training to tailor a discussion that is applicable to the physician’s practice is a very good idea because if that discussion is uniform and custom of the physician it becomes admissible evidence even if it was unwitnessed; i.e. the physician always does it that way and never varies. These discussions are usually backed up with the typical informed consent documents and are documented in the pre-operative History and Physical – all these things, done by virtue of custom and practice by the physician, is much more convincing evidence than a Plaintiff’s memory selective – “he never mentioned that to me”! So I am a proponent of some formal training covering informed consent.
As a third year medical student who just completed 2 months of inpatient adult medicine, I was asked several times to go to a patient and get a consent form signed for a procedure. In general, as someone who is very unfamiliar with MOST of these procedures, I felt like it was really inappropriate to ask the naive to explain a procedure to the naive!
Thankfully an intern took the time to let me observe him doing a few, and taught me how to explain risks and benefits and especially to talk about the option to do NOTHING! Not saying that I am in any way an expert at this point, but that short educational session made me feel so much better about being able to talk to patients about informed consent. A whole day of class would be ideal, and I think there is definitely time for it during orientation for 3rd year.
I realize some of informed consent is just CYA. However, is not the goal also to try to get the patient to understand the proposed procedure and possible alternatives so they are active participants in their health care decsionmaking?
I understand this may be difficult with many patients who may range anywhere form frightened to not intellectually capable (I”ll catch hell for that) of understanding the proposed course of treatment.
I recently lost my 86 year old grandmother to a cardiac death. Six weeks prior to her death she was given the recomendation to undrego agressive cardiac surgery. She refused (she had dementia and I was her POA so it was touchy but her wishes prior to the onset of dementia were well known) She died at home and peacfulluy. And cheaply form a beancounter perspective.
I would guess informed consent is one of the most important skills a MD (Or DO)can have. Explaining something very complex in a way a patient with very little ability to comprehend can get it.
I would hope it is more than lawsuit prevention in a six page single spaced binder. Also, it seems to me a physician who can effectively communicate treatment choices (I know this is easier said than done) would be less likely to end up on the other end of a lawsuit.
Joe the Patient
I went to obtain an informed consent,
And explain to the patient what that meant,
I spent the next several moments explaining
Concepts I’d learned over eight years of training.
The patient said: “Fine,
I am ready to sign,
Just inform me what this procedure will cost”.
And I had to admit I was lost.
I can lecture on stents
‘til my face turns cyanotic,
Diagram how we treat flat lines
Like they’re merely asymptotic,
But billing codes for DRGs
Are a topic Gordian-knot-ic…
I told this patient, let’s call him ‘Joe’,
That his particular price I didn’t know,
But if I knew, I couldn’t say,
If Medicare or insurance was to pay.
He could try looking up reimbursement rates
On Medicare.dot.gov,
And if stymied at their portal gates
Joe really ought to love
The government rationale for why
In Medicare’s case, the Freedom of Information Act
Simply does not apply.
Now, Patient Joe was frugal, didn’t buy beyond his means,
And was dead-set on keeping his own body free of liens.
Said Joe: “I can’t sign an informed consent
If I’ve not been informed of price!”
I sighed, “Then you’ll have to sign this other form,
Entitled ‘Against Medical Advice’.”
Joe huffs and says: “…well, ok, but what about my stent?
I may just have to sue you for abandonment!”
Then he laughs and says “Just kidding doc, this system really sucks.
Howzabout just you and me, say, cash, three hundred bucks?”
I mustered all my dignity and drew myself erect,
And…and…
(“meet me in the alley out back at nine. Here’s a razor, and some Betadine.”)
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