Practice Perfect 690
Surgical Consent: Are You Really Doing It Correctly?

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Jarrod Shapiro, DPM, FACFAS, FACPM, FFPM, RCPS Glasg

Practice Perfect January 21, 2020

Have you ever experienced this situation? You’ve met your patient in the preoperative care unit, about to go into the operating room for their procedure, when you hear the preop nurse ask the patient what surgery they are going to have done. The patient describes something that only vaguely sounds like the procedure you have planned, and you wonder for a moment just how much of what’s about to happen the patient really understands. You might try to re-educate the patient, but more often we just let it go knowing we, the surgeons, know what we’re doing. Unfortunately, this all too common situation – where we’ve completed a consent process, but the patient still doesn’t completely understand – potentially creates many problems.

This is also an underappreciated aspect of surgical care during residency training. How many residents around the country have received specific training on how to properly consent a patient for a procedure? I’ve listened to various trainees at a variety of training levels consent a patient for a surgery and have been unimpressed.

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What is consent? It is “a process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment”.¹

Consent is the process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment

This definition assumes the patient must be competent, adequately informed, and not coerced.² Nowhere in this definition does it say the consent is only a document to be signed. It is really a process that each provider must perform with her patient prior to any interaction.³ In fact, the consent process occurs whether we are performing surgery or nonsurgical treatment. Sitting with a patient, for example, and educating them on the use of a foot orthosis for plantar fasciitis contains the same components of a surgical consent. The only difference is we are not required to document a specific consent discussion with nonsurgical treatment.

At minimum, the consent discussion should include a description of the proposed procedure and its purpose, the material risks (including the risks of doing the surgery as well as the risks of NOT doing the surgery), alternative therapies, and who will be present for the procedure (especially when using trainees or assistants). The bottom line to this discussion is that the patient is educated, empowered to participate in shared decision-making with the surgeon, and can make a well-informed decision.

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The part of this process with which I have the greatest concern is what it means for the patient to be educated. Let’s say, for example, I’m going to perform a Lapidus bunionectomy on a female patient. Should I discuss all the reasons I’ve chosen this procedure over, say a closing base wedge procedure? Do I need to discuss increased intermetatarsal angles, sesamoid positions, hypermobility, and the controversy over correcting frontal plane deformity? Many podiatrists don’t have a full grasp on all this, so how can I expect my patient to understand it? How long would this detailed discussion take? Several hours – totally unrealistic. I tend to boil down this part of the conversation to what I feel are the most significant reasons for my procedure choice. The more challenging aspect is educating a patient if you must perform ancillary procedures such as a flatfoot reconstruction with the bunionectomy.

Surgeons must use their judgement as to how to describe a procedure to each patient.

Best Methods

With this imperfect system in place, what are the best ways to educate and empower our patients? Mulsow and colleagues performed a systematic review to determine how effective various education methods were for consenting patients.⁴ They came to the following conclusions:

• Overall understanding in patients is poor.
• Little evidence supports the use of leaflets.
• Multimedia presentations are effective (especially presenting information in multiple forms).
• Physicians do not use the Internet effectively.
• Patients with lower education levels benefit more from these interventions.

Available Credits: CPME 0

Suggestions

I have a few suggestions to help make the consent process more effective.

First, be willing to take extra time. Consenting a patient for surgery adequately requires at least twice as long as a regular appointment. Fink, et al found the amount of time spent to correlate best with patient understanding.⁵

Second, schedule a separate appointment for elective consent discussions so you can use the encounter time wisely.

Third, use images as much as possible. An image on the consent form that allows the surgeon to draw the procedure is very strong both for patient education and medicolegal protection.

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Fourth, have a medical malpractice attorney review and edit your consent documents. Fifth, make sure your consent document is written at a 12-year-old level, which has been found to be best practice.⁶

Finally, the use of multimedia methods such as interactive presentations and texts have been found to be effective.^7,8 However, these require significant time and effort to develop. I’d love to see a product such as this available for purchase from the American College of Foot and Ankle Surgeons and American Podiatric Medical Association.

If there’s one major take-away from this discussion about informed consent it is that this process is one in which we must take the time to properly educate our patients as much as possible given the limitations of daily practice. Time spent educating your patients will always be time well spent.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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