Informed Consent: Does that Include Personal Detailing of Your Doctor?
There is still debate in the medical, ethical and legislative
community as to how much information is enough as part of informed consent for
the patient or the patient's surrogate to make a decision as to whether to have
an operation or other procedure or medical treatment. And is there such a thing as "too much
information" for the patient to be told and expected to understand? That
is still debatable. There is no debate as to the legal necessity for a
patient's autonomous decision regarding their treatment but the question is
"how much?" but also "what kind?" For this thread I want to focus on a specific
category of "what kind?" and that is: should the patient be permitted
to ask personal questions about the doctor and followed by detailing by the
doctor to the patient regarding the doctor as a person and as a
professional.
Lance K. Stell PhD, teacher-ethicist, has specified my focus
with the following:
Traditionally,
Informed Consent disclosure duties of the physician were “procedure focused” NOT provider focused.
Some
states (e.g. Pennsylvania and North Carolina) have aggressively restricted statutory Informed Consent disclosures
to the recommended procedure, and its alternatives, including the option of no procedure,
along with a discussion of the risk/benefits of each option.
Other
states have expanded the physician’s disclosure duty to
include
the extent of his/her training and experience with the particular
operation
(and the hospital's) when the outcome disparities between providers
for
the proposed treatment were “material"
This
development and entry of Big Data bids to expand disclosure duties (and
pressure
on physicians to discuss) considerably. For a few examples:
How
many of these procedures have you done, doctor? How many recently? What is
your
Morbidity and Mortality Rate and your (and your hospital’s) 30-day unplanned
readmission rate? Have you ever had a “never event?” You are
proposing to do my operation laparoscopically, but suppose you find it necessary
to “convert” to an open operation. Do your privileges include doing the
procedure open, or must you call in a colleague who has such privileges for back up?
What might be his/her responsibility or role in the setting of such “conversions?”
New rules give me a right to tell you my preferred manner of
receiving health-related
communication. So please, I prefer all information you give me about risk
in statistical terms, not qualitative terms.
Tell me about your Conflicts of
Interest. “I noticed that
you're on the Federal Government’s list for having received payments from
the medical products industry. Does that imply that you’re taking kick-backs or
are under suspicion or something?”
Tell me about the instrumentation you propose to use for
my surgery. How big a profit does you hospital get on it? I support
cost-effective care. Has any of it been implicated
in
Device Problem reports to FDA? If so, have you considered using other
instrumentation? Why not? And how are you compensated for your work?
I strongly disapprove of "fee for service".
And,
this is just the tip of…”By the way, when's the last time you got a good
night’s
sleep?"
So
when you go to the hospital for an appendectomy, about to start chemotherapy
for a diagnosed cancer, are suggested "new" medication rather than
the established drug for your illness, is there more you need to know beyond
the lab tests, your doctors interpretation of your history, physical and labs?
Do you also need to know also more about the personal details about your
doctor? And, if so, should you wait
until you are immediately challenged to make an informed consent or should all
this be part of the first selection of a doctor for your care? ..Maurice.
Graphic: Images from Google Images and modified by me using ArtRage.
posted by Maurice Bernstein, M.D. @ 10:15:00 AM
4 comments
4 Comments:
Dr.B,
At the very least, the doctor should be required to describe to the patient or their authorized representative the recommended treatment or procedure along with any alternatives, including doing nothing, and the relative potential risks/benefits of each. The description should be given in sufficient detail for the patient to understand the potential risks & benefits so they can make a truly informed decision.
The provider should then ask the patient if they have any questions. Any questions the patient has should then be addressed in further detail to whatever degree the patient requests.
Unless otherwise required by law or policy, I don't think going into detail about the provider's qualifications and experience should necessarily be part of the consent. An exception would be if they are a trainee - that should certainly be disclosed, along with to what degree they will be supervised during the procedure and who will be doing the supervision.
That said, any patient/representative with half brain should certainly be asking those questions of the provider, and the answers should be candid and forthcoming. If they weren't, I certainly would not allow them to be performing any procedure on me.
I meant to add...
I believe much of this discussion regarding qualifications and experience should normally be done, if possible, when initially selecting the physician.
In some circumstances, such as emergent or unexpected situations, having the discussion ahead of time may not be possible.
Hex
Choosing a physician is similar to rolling the dice; nothing but chance. There is no reliable method for patients to find out objective details about physicians other than gender and board certification. With respect to informed consent, patients are completely in control, regardless of statue or policy. My informed consent is predicated on the nature and complexity of the procedure, the providers training and proficiency, their success and failure rates, and OR team makeup and "student" participation. There is no consent until my questions and concerns are adequately addressed.
Ed
An interesting study is discussed on a 2005 blog thread titled "The Effect of Physician Self-Disclosure: Surgeons vs Primary Care Physicians"
The study showed a statistical difference regarding how patients accepted self-disclosure of primary care vs surgeons of their own medical or emotional issues that might be relevant to the patient. ..Maurice.
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