Comment

What would you like to know?

The recent British case of Montgomery v Lanarkshire Health Board [2015] has focused international attention on one of the most important aspects of providing information to patients before medical procedures: what do patients need to know, and what do doctors need to tell them?

The Montgomery case involved a child born with developmental disabilities following a labour complicated by shoulder dystocia. His mother (who has insulin dependent diabetes mellitus) argued that she would have opted for a caesarean section had she been made aware of the possibility of shoulder dystocia. Her obstetrician is reported as having decided that - although the risk of dystocia was considered to be 9-10% in this woman - the potential for subsequent harm was very small and that mentioning the possibility of dystocia to the mother may have encouraged her to request an elective caesarean section. The obstetrician had judged an elective caesarean as not being in the patient’s best interests. Doctors do have the right to withhold information they genuinely believe would lead the patient to make an inappropriate decision (under the principle of “therapeutic exception”) but it is a restrictive strategy to be used with extreme caution.

The medical profession’s role in judging what an individual patient should know about their procedure has been debated for some time. The 1992 Rogers v Whitaker case in Australia (where an ophthalmologist “failed to warn” a patient who was already blind in one eye that a cosmetic procedure on it carried a tiny risk of complete loss of vision in the other through sympathetic ophthalmia, with that result) joins this recent Montgomery case in challenging the Bolam principle that a doctor need only warn patients of risks that their professional peer group would consider needed to be explained. The correct test is actually whether the doctor has adequately explained the risks to which a reasonable person in the patient’s position would be likely to attach significance. This is not to say that Bolam is out the door - the professional peer group is still the expert arbiter of best clinical practice, but the patient is their own judge of what information satisfies their needs.

Montgomery states that doctors must explain what’s important and what a reasonable patient would want to know. As the UK Supreme Court explained in its judgement:

“The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternatives or variant treatments.

The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.”

The good news is that, in both the British and Australian cases, the courts have pointed doctors in a direction that most want to go. The courts have said that we must use the information we provide to share decision-making with the patient, and that resonates with modern medical practice. While we still need to make our best clinical judgment about a procedure’s risks of which any patient would need to be aware when making a decision, we also need to think about what other information a particular patient would want. And asking them remains the best way to find out.

Good practice involves a structured conversation about any proposed medical procedure, in which the doctor provides the crucial information that their expertise tells them a patient would need to know and then responds to the patient’s questions. Even better if the doctor can anticipate many of the patient’s questions by providing them with information tailored to their individual needs. And, of course, a well-designed patient information sheet - supplemented with individualised comments - is an excellent way of structuring that conversation.

While most doctors would say that any trend towards clinically unnecessary treatments such as elective caesarean sections is an issue for concern, the Montgomery case is a timely reminder that a doctor’s responsibility is not to withhold information but to ensure that patients are properly supported in using it to make appropriate decisions about their health.

 

Professor Steve Trumble

Chair, SMS Editorial Board

(conflict of interest statement: SMS distributes a library of INFOrm4U patient information leaflets to public hospitals and private practitioners throughout Australia)

Comment

Enhanced recovery after surgery (ERAS) leaflets

Enhanced recovery after surgery (ERAS) leaflets

We're pleased to release 17 new information leaflets covering enhanced recovery after surgery (ERAS). The procedures covered are:

  • ER_CR03 Hemicolectomy for Colon Cancer (Enhanced Recovery)
  • ER_CR04 Surgery for Rectal Cancer (Enhanced Recovery)
  • ER_CR05 Closure of Loop Ileostomy (Enhanced Recovery)
  • ER_CR06 Closure of Loop Colostomy (Enhanced Recovery)
  • ER_CR07 Surgery for Diverticular Disease (Enhanced Recovery)
  • ER_CR10 Reversal of Hartmann's Procedure (Enhanced Recovery)
  • ER_CR12 Abdominal Surgery for Crohn's Disease (Enhanced Recovery)
  • ER_OG01 Abdominal Hysterectomy (Enhanced Recovery)
  • ER_OG02 Vaginal Hysterectomy (Enhanced Recovery)
  • ER_OG08 Laparoscopic Hysterectomy (Enhanced Recovery)
  • ER_OS01 Total Hip Replacement (Enhanced Recovery)
  • ER_OS02 Total Knee Replacement (Enhanced Recovery)
  • ER_OS37 Resurfacing Hip Replacement (Enhanced Recovery)
  • ER_UG04 Oesophagectomy (Enhanced Recovery)
  • ER_UG05 Gastrectomy (Enhanced Recovery)
  • ER_UG10 Total Gastrectomy (Enhanced Recovery)
  • ER_UG11 Partial Gastrectomy (Enhanced Recovery)

Please contact us on info@smservices.net.au or 1800 211 511 or on twitter at @s_m_services for more information.

9 new patient information brochures released

9 new patient information brochures released

We are pleased to announce the release of the following 9 new patient information brochures, bringing the total number of available brochures to 327:

  • CM02 Gynaecomastia Surgery
  • OG25 Laparoscopic Oophorectomy
  • OG26 Laparoscopic Myomectomy
  • OG29 Laparoscopic Subtotal Hysterectomy
  • OS41 Revision Total Knee Replacement
  • OS43 Wrist Fracture Surgery (child)
  • OS44 Elbow Fracture Surgery (child)
  • PS19 Surgery for Hypospadias (child)
  • UR19 Emergency Surgery for Pain in the Scrotum (adult)

Please contact us for further information.

The Consent Conversation

The Consent Conversation

One of the first activities undertaken by all 330 First Year students at the University of Melbourne is to ponder the question: “what is a good doctor?” In fact, this problem is the main focus of their first week in medical school in early February, which culminates in them developing and reporting back their own definitions of ‘the good doctor’. When grouped and analysed, these definitions reveal some interesting trends about what these brand new students think is important in their chosen career.

One word usually stands out. This year, the most frequently used word in defining ‘the good doctor’ was ‘communicator’. It was closely followed by ‘compassionate’ and ‘empathetic’, which are similarly reassuring of the values these students are bringing with them. But the single most important requirement for being a good doctor was seen to be good communication. The challenge for any medical school is to keep those qualities in the forefront of students’ minds throughout their studies.

Those who have been involved in healthcare for much longer than these neophytes will recognise the importance of good communication in ensuring that healthcare is safe, effective and efficient. We are frequently told that poor communication is at the root of many adverse events and that clumsy handling of the interpersonal issues often worsens the consequences of these events. But one area where even very experienced clinicians can fall down as communicators is during the consent process, when they can become ‘locked-on transmitters’. Being barraged with buckets of information is a disempowering experience, unless the clinician is sensitive to the client’s health literacy and specific information needs.

Effective communication is a two way process and this is rarely better demonstrated than when ‘consenting’ patients before a therapeutic or diagnostic intervention. Even the hideous use of the term ‘consenting’ as a transitive verb suggests that it is actively done to the patient, rather than being the outcome of an informative conversation. The decision to proceed with a particular procedure is one undertaken in a partnership, to which the proceduralist brings their expert knowledge of healthcare and the patient brings their expert knowledge of themselves. The responsibility for the decision is shared between the two – the clinician in recommending the most appropriate course of action based on what they know and what they’ve learnt from their client, and the client in deciding how that recommendation fits with their needs and preferences. The client has a variety of different sources of information available to them, and the clinician’s role is to help them assemble that information into a meaningful understanding of the choices they have.

There is no question that the increasing accessibility of health information has made healthcare consumers more informed about their choices, but are they better informed? A recent paper in the British Journal of Medical Ethics created a link between gaining informed consent and the ‘routinisation’ of that process to become largely meaningless1. Although the authors were referring to consent for the exchange of patient information via the Internet, the same principle of loss of patient autonomy due to the reduction of the pre-operative ‘consent conversation’ to an algorithmic routine holds firm. It’s perhaps a little ironic that having a personally tailored conversation with a clinician can be more enabling than independently accessing web-based information without support; the key is in who directs the conversation, and whose agenda is paramount. In a good consent conversation the patient asks a lot of questions, preferably with the clinician’s responses backed up by high quality written material.

This communication partnership is clearly expressed within Standard 2 of the Australian Commission on Safety and Quality in Health Care’s national standards for health services, which talks about making a health service that is responsive to patient, carer and consumer needs2. Apart from high-level issues such as consumer inclusion in governance and policy frameworks, the Standard specifies that consumers should be consulted on patient information distributed by the organisation and their feedback incorporated into revisions of those materials (Standard 2.4, page 24).

It must be recognised that sometimes those who are most expert in a topic are least able to communicate it at a level that a consumer can assimilate, even though it is their responsibility to ensure that their message has been understood; a phone call to an IT helpdesk often reinforces this truism. Consumer partnerships are vital in ensuring that patient information is accessible, meaningful and comprehensible by all those accessing the health service.

Documents that relate to healthcare can be surprisingly difficult to read. It is widely recommended that patient information sheets be pitched at upper primary school reading age. By contrast, simple analysis by Microsoft Word’s in-built grammar tool (using the Flesch-Kincaid method) shows that the NSQHS Standards themselves have a reading ease score of 33% and that they would probably be understood by a student about to enter Year 10 at secondary school. The ‘EasyRead’ summary of last year’s British publication about involving consumers in decisions about their health: “Liberating the NHS: no decision about me without me”3 scores 77% on readability with an appropriate grade level of 6.2. Shamefully, comprehension of the article you are reading now requires the highest reading grade of 12; unnecessary semicolons and gerund phrases like these not helping.

Health service leaders have long understood the importance of consumer partnerships.  Increased emphasis on involving consumers in the development and improvement of patient information materials is just one more way of ensuring excellence amongst health services.

Author: Professor Stephen Trumble Chair, Editorial Board Specialist Management Services

References 1 Ploug T, Holm S.  Informed consent and routinisation.  J Med Ethics. 2012 Dec 5. Epub ahead of print] 2 Australian Commission on Safety and Quality in Health Care (ACSQHC) (September 2011), National Safety and Quality Health Service Standards, ACSQHC, Sydney 3 http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_134221 (accessed 10 February 2013)

Are you ready for the NSQHS Standards?

Are you ready for the NSQHS Standards?

The National Safety and Quality Health Service Standards developed by the Australian Commission on Safety and Quality in Health Care (ACSQHC) will be implemented nationally from 1 January 2013 and will be compulsory for the majority of public and private healthcare organisations. Standard 2: Partnering with Consumers provides the framework for active partnership with consumers by health service organisations and requires that consumers be consulted on patient information distributed by organisations.

We have taken steps to ensure consumer input in the development of our patient information brochures and have received official endorsement of our library from the Australian Patients Association (APA). The APA logo appears on all of our brochures and our recent media release can be viewed on our website.

It is now widely accepted that healthcare providers, healthcare organisations and consumers are all partners in the healthcare system. A 2010 review of patient engagement strategies (Invest in Engagement web site. Picker Institute Europe, 2010 (www.investinengagement.info)) found that involving consumers in the development of health information and materials was an effective approach for improving patient–provider communication and consequently, partnerships between the health service organisation and consumers.

Evidence is mounting for a connection between effective partnerships, good consumer experience and high quality health care. For example there is evidence that the existence of effective partnerships is associated with:

  • improved clinical outcomes including associations with decreased re-admission rates
  • decreased rates of healthcare acquired infections
  • improved delivery of preventive care services
  • improved adherence to treatment regimens
  • improved functional status.

Studies from the United States have also found that delivering health care based on partnerships can result in reduced hospital costs, lower cost per case and reduced length of stay.

The ACSQHC suggests that "If you do not develop your own information publications – you should try to source and use publications that have been developed in partnership with consumers."

To find out how to access our library of over 300 patient information brochures, call 1800 211 511 or contact us through this website. Contact us today to avoid the high cost and hassle of devloping and maintaining your own patient information brochures.

This text has been adapted from the National Safety and Quality Health Service Standards published by the Australian Commission on Safety and Quality in Health Care. The Standards are available from the ACSQHC website at www.safetyandquality.gov.au

11 new patient information brochures released

11 new patient information brochures released

We have released the following 11 new patient information brochures bringing the total number of available brochures to 318:

  • CR15 Laparoscopic Hemicolectomy for Colon Cancer
  • CR16 Laparoscopic Surgery for Rectal Cancer
  • CR17 Laparoscopic Reversal of Hartmann’s Procedure
  • CR18 Laparoscopic Abdominal Surgery for Crohn’s Disease
  • GS01 Open Inguinal Hernia Repair (male) (Emergency)
  • GS02 Paraumbilical and Umbilical Hernia Repair (Emergency)
  • GS03 Femoral Hernia Repair (Emergency)
  • GS04 Open Incisional Hernia Repair (Emergency)
  • GS11 Open Inguinal Hernia Repair (female) (Emergency)
  • OS39 Arthroscopy of the Hip
  • OP11 Intravitreal Injection for Macular Degeneration

Please contact us for further information.

Australian Patients Association endorses INFOrm4U library of patient information brochures

Australian Patients Association endorses INFOrm4U library of patient information brochures

31st July 2012

APA endorses Specialist Management Services patient information brochures

The Australian Patients Association (APA) has teamed up with Specialist Management Services (SMS) to promote informed patient consent and communication through the endorsement of SMS’s INFOrm4U library of 300 detailed surgical information brochures.

The brochures, which are used by the Western Australia Department of Health, Royal Hobart Hospital and Southern Health (Victoria’s largest health service), are designed to be used alongside a consultation to help patients consider the risks, benefits and alternatives to procedures in order to make informed decisions about their treatment. They can also be taken away and re‐read before an operation, helping to target conversation about concerns and subsequently shortening consultation times and reducing calls to the hospital.

Stephen Mason, Chief Executive Officer of the APA, said, “A primary aim of the APA is to educate patients about the risks involved in operations and procedures, and for them to become more heavily involved in managing their own health and health care decisions. The availability of these excellent information brochures furthers these aims. It is for these reasons we are happy to endorse SMS’s library.”

Brendon Tudor, Business Development Manager at SMS, said, “One of our key objectives has always been to encourage the use of high quality, clear patient information to aid the informed consent process ‐ for the mutual benefit of patients and surgeons. This endorsement indicates the APA’s willingness to work with SMS to improve overall patient care and health outcomes.”

To find out how to access SMS’s INFOrm4U library of 300 detailed surgical information brochures, call 1800 211 511 or contact us through this website.

Notes to Editor:

  • Specialist Management Services is the Australian distributor for EIDO Healthcare, publishers of INFOrm4U patient information brochures.
  • The Australian Patients Association is dedicated to championing and protecting the rights and interests of patients, and improving overall patient care and health outcomes. For more information please visit www.patients.org.auFor further information please contact:Jeanine Purdie | Tel: 03 9867 2526 or Mobile: 0408 944 859 | Email: jpurdie@patients.org.au
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7 new patient information brochures released

We have released 7 new patient information brochures:- MF08 TMJ Arthroscopy - OS38 Surgery for Tennis Elbow - PS23 Surgery for Pilonidal Sinus (child) - UR15 Bladder-Neck Incision - CR14 Laparoscopic Surgery for Diverticular Disease - DT02 Inserting a Dental Implant - DT04 Apicectomy

4 new patient information brochures released

We have released four new patient information brochures: Maxillofacial - MF07 Apicectomy

Obs & Gynae - OG30 Thermal Balloon Endometrial Ablation - OG31 Radio-Frequency Endometrial Ablation

Orthopaedics - OS28 Revision Total Shoulder Replacement

Please contact us for more details.

2 new patient information brochures released

We have released two new patient information brochures:- MF06 Inserting a Dental Implant - CT08 Imaging-Assisted Pleural Biopsy and Drainage Please contact us for more details.

No surprises

45 year old Simone visits a 50 year old plastic surgeon in his private rooms. She is interested in having a naevus removed from the centre of her back. Although it is clearly benign, she has been told by her new partner that it is unsightly. The surgeon is running late for his public list and moves briskly through the consultation before agreeing to perform the simple procedure in a week’s time. Simone leaves his consulting room feeling happy that the blemish will soon be gone. Post-operatively, however, she develops a wound infection that prevents her from swimming with her family on a much-anticipated tropical holiday.

Simone lodges a claim against the surgeon for the cost of the holiday, claiming that he failed to warn her of this possible complication.

Despite the everyday nature of her presentation, Simone and her surgeon have been caught up in a ‘perfect storm’ of medicolegal misadventure. Multiple factors have aligned to create an extremely unpleasant experience for both of them. The surgeon probably performed the excision with all due skill and to a more than satisfactory professional standard; the problem really began during the consent process and was compounded by Simone’s disappointment at the consequences of her unexpected outcome.

A landmark paper in The Medical Journal of Australia last month (Gogos AJ, Clark RB, Bismark MM, Gruen RL, Studdert DM. When informed consent goes poorly: a descriptive study of medical negligence claims and patient complaints. Med J Aust, 2011; 195 (6): 340-344) revealed that Simone personifies the sort of patient more likely to be involved in a complaint or claim against a surgeon for failing to warn of possible complications of operative procedures: a middle-aged woman consulting a similarly-aged male surgeon in his private rooms about a largely cosmetic procedure.

Of course, the situation is much more complex than any stereotype can represent, but ‘failure to warn’ is a key issue leading to complaint or litigation and surgeon’s should be alert to the risk. 481 cases alleging failure of the informed consent process were culled by the researchers from the files of Australia’s largest medical insurer (Avant) and Victoria’s Health Services Commissioner (HSC) in the seven years until December 2008. 92% of these cases involved a surgical procedure and 71% had the doctor’s supposed failure to mention or properly explain treatment risks as their primary allegation. These cases of dissatisfaction with the consent process were commonly accompanied by claims against the insured doctor (65%) or complaints to the HSC (54%) for other quality of care issues.

The researchers found that 69% of cases involved female patients and that – collectively – plastic surgeons, general surgeons, orthopaedic surgeons and ophthalmologists accounted for 81% of all cases that involved surgeons, which in turn made up 57% of the 481 cases identified. Obstetrician-gynaecologists were considered separately (14%) and general practitoners (with the largest number of practising doctors) were involved in 11% of cases. Adding it all together, that only leaves 18% of cases for the other medical specialists such as physicians, psychiatrists, anaesthetists and so on to be involved in.

There are some important lessons that emerge from this review of informed consent failure cases. One is that patients expect their doctor to display the same level of thoroughness and skill in the informed consent process as in the actual operative procedure. If patients are well-informed about the procedure, its possible risks and expected benefits, then they should turn up on the day with reasonable expectations about what is going to happen during and after the actual procedure. A policy of ‘no surprises’ is an excellent one to pursue, even though it is extremely difficult to anticipate all of the information needs that an individual patient might have. Asking them what they need to know in order to go ahead with the procedure is a good place to start, while true mastery of a procedural craft must include knowing what issues are likely to be in patients’ minds and anticipating their questions where appropriate.

Another important message from the paper is that these cases of ‘failure-to-warn’ have a propensity to flock with other issues of dissatisfaction, possibly by influencing the patient’s perception of the rest of the surgeon’s performance. The skillset required to explain risks in the consulting room might seem far removed from prowess in the operating theatre, but to the patient they are all part of the same experience and dissatisfaction with one can bleed into the other.

It is an inescapable fact that only one person can decide whether a doctor’s informed consent performance was satisfactory: the patient. Of course, if a case moves to investigation or litigation, others will be called upon to pass judgment based on the evidence uncovered. But every time an operative procedure is carried out, the patient involved will include the doctor’s information-sharing ability in their assessment of how satisfied they are with the whole surgical experience. The best way to make sure that the patient has no grounds for complaint is to tell them what they need to know and to ensure that their individual knowledge needs have been met. While adverse events are an unavoidable part of surgical practice, knowing that they might occur lessens the surprise and the disappointment.

Author: Professor Stephen Trumble Chair, Editorial Board Specialist Management Services This article was first published as an insert in the October 2011 edition of Surgical News.

2 new patient information brochures released

We have released two new patient information brochures:- ENT12 Turbinectomy - UR03 Localised Prostate Cancer (Treatment Options) Please contact us for more details.

10 new patient information brochures released

We have released 10 new patient information brochures including:- General Anaesthetic (child) - Day Case - Thyroidectomy (for Nodule) - Day Case - Thyroidectomy (for Goitre) - Day Case - Sub-Total Thyroidectomy (for Thyrotoxicosis) - Day Case - Parathyroidectomy - Day Case - Total Thyroidectomy (for Thyrotoxicosis) - Day Case - Laparoscopic Incisional Hernia Repair - Day Case - Laparoscopic Gastric Banding - Day Case - Lumbar Microdiscectomy - Day Case - Laparoscopic Nissen Fundoplication Please contact us for further information.

6 new patient information brochures released

We have released the following new patient information brochures:

  • CM05 Liposuction
  • DT01 Removing Wisdom Teeth
  • DT03 Removing Teeth
  • OS30 Revision Total Elbow Replacement
  • OS33 De Quervain's Disease
  • V13 Toe and Forefoot Amputation

Please contact us for more information.

8 new patient information brochures released

We are pleased to announce that we have released 8 new brochures. The new brochures we have released are as follows:

  • B12 Breast Reconstruction with an Implant or Tissue Expander
  • DP01 Reducing your risk of developing a blood clot
  • GS23 Laparoscopic Incisional Hernia Repair
  • MF05 Mandibular Sagittal Split Osteotomy
  • NS03 Cervical Laminectomy
  • OS32 Trapeziectomy
  • OS36 Trigger Finger Release
  • R12 Prostate Biopsy

Please contact us for further information.