Tuesday, June 12, 2012

Telluride Day 2 -- Informing consent

#TPSER8  The picture above shows the nearly unanimous positive response to a question I posed near the end of day 2 at the Telluride Patient Safety Camp. Hang on for a few paragraphs to learn what I asked.

The emotional aspects of health care have come forth during this conference in several ways.  Today, it was the presentation of a video entitled, The Faces of Medical Errors...From Tears to Transparency:  The Story of Michael Skolnik.  This powerful story is described as follows by the producers:

Viewers are compelled to rethink the critical role that shared decision-making and informed consent play in patient safety and transparency. This emotionally engaging program tells the story of Michael Skolnik, an intelligent, compassionate young man who died at age 25 after a three-year ordeal following brain surgery. Michael’s parents, Patty and David Skolnik, are joined by industry visionaries who together challenge viewers to consider how fully informed consent, true shared decision-making, and open and honest communication can change outcomes, how it could have changed the outcome for Michael, can change outcomes for countless others, and in the process reduce risk for institutions and the dedicated providers who care so deeply.

For our session today, the residents were asked to reflect on the training they had received with regard to obtaining informed consent from patients and/or family members, recognizing that all procedures have inherent risks and possible benefits.  The responses were clear and virtually uniform:

"In medical school, we never got training in informed consent."

"In my training, there was none.  We would always say there was a risk of infection and bleeding because we figured that was safe."

"I remember as an intern getting consents for central lines.  I was so excited [to be doing the procedure], but I didn't really understand the risks."

"Sometimes the surgeon orders the nurse to get the informed consent and send it to the OR, where he will see the patient for the first time."

From this, we migrated into a discussion of shared decision-making, how to give the patient sufficient information to know about the potential risks and benefits of a procedure, the alternative to it, and the like.  The idea is to create a true partnership between the physician and the patient to reach a decision that is acceptable and understood by all.

But some of these items are quite technical and are delivered under stressful circumstances.  People talked about the idea of "teach-back method."  Should we have in place system that allows us to get to the point that the patient can explain back to the doctor the risks and benefits and alternatives in a cogent fashion?  Is it better to have the informed consent form in hand when talking with the patient, or does that interfere with communication?  How do we deal with the fact that administration of certain medications can have risks as great as procedures but often do not require informed consent?  How does one actually quantify risks and benefits, especially if one is a doctor in training and does not have a full knowledge of those matters?

Between the movie and the discussion, we devoted about 2.5 hours of excellent thought and commentary to this topic.  The question I then asked the residents was, "Hold your hand up if this discussion was the most extensive or intensive conversation about informed consent in your entire medical education."  Virtually every hand in the room went up.

What an indictment of the medical education system.  The most basic of interactions between a physician and a patient get virtually no attention in the undergraduate medical curriculum and in the graduate medical education training program.  And, yet, as illustrated in the case of Michael Skolnik, a conversation can change a clinical outcome.  Indeed, a conversation can save a life.


Anonymous said...

At the very first you have to get past the entrenched idea that informed consent is nothing more than an unimportant piece of paperwork. There is almost no forethought that goes into this process in most hospitals.

nonlocal MD

e-Patient Dave said...

Quick first note:

As I think you know, there's at least 30 years of work in this field, and the fact that med school curricula largely ignore it is (I suspect) a symptom of an honest delusion that it's POSSIBLE for a doctor to know everything.

And I think that delusion is at the core of almost every dysfunction in medicine today, except for financial ones.

Remove that delusion and a whole lot of other things make much more sense, and the path to improvement opens up.

WITH that delusion, it becomes the clinician's job TO know everything, and any suggestion to the contrary is an insult to his/her professionalism.

Anonymous said...

Not sure exactly what you're saying, Dave, but I think any physician at any level personally obtaining informed consent for a procedure in which s/he will participate or watch should know what the risks and complications of that procedure are before s/he obtains the consent. If the job has been delegated to someone who doesn't know, that in itself is a problem. Am I thinking wrongly here?


Bart Windrum said...

Another crucial aspect of informed consent is its timeliness. Related to that is a question I hope all providers ask: why are you here / considering this procedure / voicing this concern/stipulation? Asking why the patient-family have showed up at a particular juncture—rather than merely accepting their presence—can be *the* key factor in opening up a conversation leading to joint decision making and informed consent. I know because the lack of this likely resulted in my dad's earlier-than-necessary demise.

Anonymous said...

As a retired RN (from Levy's previous "post") I want to emphasize that it it illegal for a nurse to obtain informed consent -- nurse may only witness the signing (to the occasional consternation of residents)