[Un]Informed Consent?

“Do I need this trigger finger release?” “Should I treat my distal radius fracture in a cast or have plates and screws placed?” “What is the long term risk if I choose not to have my painful TFCC tear repaired?”

The process of obtaining informed consent is an ethical obligation central to the process of counseling a patient about his or her surgical and non-surgical treatment options. However, ask a surgeon about the importance of the rules involved with the process or the consent document itself (how many of us have actually read the surgery consent forms that we use?), and the conversation becomes more nuanced. Many practitioners voice frustration with what they perceive to be a growing divide between the implementation and the intent of regulatory processes such as informed consent documentation. Most of us would agree that the signing of consent documents and the enumeration of surgical risks and benefits to a patient does not mean that said patient has been “informed.”

It is hardly controversial to suggest that the process of obtaining informed consent has become at least as much about hospital compliance and risk management as it is about patient education, with the goal of allowing a patient the autonomy to make a treatment decision that best reflects his or her needs and wishes. As the focus of consenting patients changes from doing it well to “getting it over with,” the quality of the patient-physician informed consent process may deteriorate. Moreover, surgeons are often unaware of the subtle ways in which the manner that they present information to patients biases the conversation and influences how patients choose between treatment options. Why does this happen? The reasons, are many:

• Opportunity cost of time: Physicians continue to see more and more patients in response to decreasing rates of reimbursement. Many of us subconsciously (or sometimes consciously) avoid asking open ended questions to patients for fear of getting caught in a long conversation that slows down his or her busy office day.
• False consensus effect: Physicians overestimate the degree to which patients agree with them and comprehend what they have been told.
• Status quo bias: Patients are reluctant to admit when they don’t understand or don’t agree with the perspective of their physician and therefore become complicit in the process of inadequate informed consent.
• Financial bias: In a fee-for-service health care system, surgeons are compensated to operate, regardless of whether surgery is necessary or appropriate.
  • Frank discussion of surgical risks may lead to fewer patients “choosing” surgery.
• Effort justification: Many patients (and many surgeons) implicitly believe that when the best treatment is unclear, “doing something” (i.e. choosing to operate) is better than “doing nothing” (choosing nonoperative care).
• Paternalism (interviewer bias): Surgeons (and some patients) may believe that his or her expertise makes them better equipped to choose a treatment for a patient, which may undermine the importance of the informed consent process. Patients can be complicit in this bias (“you’re the doctor, you choose”).

Few would question that a physician’s main goal is to help patients. But when one considers the circumstantial evidence – rising rates of elective surgery, widespread variation in treatment patterns, increased cost of care without commensurate improvement in outcomes – it is clear that other competing interests are influencing treatment decision making. These issues are at the heart of why informed consent and support of patient autonomy remain critical to providing excellent patient care. The issues described above are all forms of cognitive dissonance that lead to the “rationally irrational decision making” that has been described and studied in great detail by behavior economists such as Richard Thaler and Dan Ariely. Specific to patient care, these “behavioral biases” interfere with the process of shared decision making and can lead patients to make choices that do not truly reflect their preferences.

So what is a well-meaning surgeon to do? Here are a few suggestions:

• Always take a patient-centric approach. In the US, about 50% of states have adopted the “reasonable patient standard” of informed consent – that is, consent is considered informed if the conversation of risks, benefits and alternatives includes what a “reasonable patient” would consider important. While some states still consider consent to be informed if it covers what a body of responsible physicians deems important, it is only a matter of time before we see widespread adoption of the patient-centric approach. By adopting this approach, a surgeon is now incentivized to understand and consider the patient’s perspective, rather than vice versa. Most of us already adopt this perspective when we answer the commonly posed patient question, “what would you do if you were me” or “what would you advise if I were your mother/father/son/daughter”? As it turns out, these types of questions are far more germane to the process of informed consent than we may realize.
• Ask open ended questions and practice active listening. Patient satisfaction has been strongly linked to empathy [1] and high quality patient surgeon dialogue [2]. Although it is tempting to assume that such techniques will lead to significantly longer patient encounters, there is ample evidence that time spent with patients is not the main driver of patient satisfaction. It truly is about quality, not quantity.
• Learn about behavioral economics? Admittedly, this is an area of personal interest, but with the growing list of books on the topic that have made the NYT best seller list, I’m not alone [3-6]. Even if “leisure reading” is not a hobby for which you currently have time, read the recent article by Bernstein and colleagues who applied some of the more relevant patient care related behavioral economic theories to the process of shared decision making [7].

With these few suggestions, the questions and concerns about the informational value of your patient consent process will decrease and in turn, your patients will benefit.

References:

1. Menendez ME, Chen NC, Mugdal CS, Jupiter JB, Ring D. Physician Empathy as a Driver of Hand Surgery Patient Satistaction. J Hand Surg Am 2015. 40:1860-1865.
2. Parrish RC, Menendez ME, Mugdal CS, Jupiter JB, Chen NC, Ring D. Patient Satisfaction and its Relation to Perceived Visit Duration With a Hand Surgeon. J Hand Surg Am 2016. 41:257-262.
3. Ariely D. Predictably Irrational. New York, NY: Harper Collins; 2008.
4. Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth and Happiness. New York, NY: Penguin Books; 2008.
5. Kahneman D. Thinking, Fast and Slow. New York, NY: Farrar, Straus and Giroux; 2011.
6. Gladwell M. Blink: The Power of Thinking Without Thinking. New York, NY: Little, Brown and Company; 2005.
7. Bernstein J, Kupperman E, Kandel LA, Ahn J. Shared Decision Making, Fast and Slow: Implications for Informed Consent, Resource Utilization, and Patient Satisfaction in Orthopedic Surgery. J Am Acad Orthop Surg 2016; 24:495-502.