One quarter of complaints by hospital patients cite problems with communication as a cause (source: Office of the Health Services Commissioner, Victoria, Annual Report 2010). A significant number of all complaint and litigation cases specifically cite ‘lack of informed consent / failure to warn’, and this figure is significantly higher as a contributory factor. If we consider patient communication and consent lightly, we do so at our own peril.
Increasingly the teaching of communication skills has been included as part of the undergraduate and postgraduate curricula, as the doctor-patient relationship has moved from paternalism to partnership. Effective communication is a two-way process, but how do we know if we or our clinical teams are doing this well?
We may be more aware when our communication is not as good as it might be, when we receive informal or formal feedback. Informal feedback may come directly from the patient, from colleagues or from other members of the healthcare team. Formal feedback from patients is usually through the complaints system, an experience that many surgeons rate as the most aversive they could imagine.
One area where communication is particularly important is in obtaining informed consent. Communicating benefits, risks, alternatives and expected outcomes of surgery is a legal requirement. Best-practice guidelines suggest that we should be sharing this information in an open and honest manner which promotes involvement of the patient in the decision-making process, so called ‘shared decision making’.
The National Health and Medical Research Council 2006 guidelines on what information should be provided (“Making decisions about tests and treatments – principles for better communication between healthcare consumers and healthcare professionals”) state:
- “a consumer cannot make informed decisions if their professional uses medical terms that they do not understand, or provides written information that is beyond their literacy or numeracy skills.”
- “Almost every health decision, including the choice not to have a treatment or test, has some associated benefits and risks. Healthcare consumers need comprehensive information on these risks and benefits, given in a way that they can understand.”
- “Using a decision aid can make weighing up the pros and cons of each option easier. It can also help consumers to prepare for a consultation, so that the professional can spend less time giving facts and more time on discussing things that matter to the consumer.”
Communicating complex aspects of surgery and possible complications in a form that patients can understand is challenging for any clinician, as patients do not readily understand medical terminology and may struggle to retain any information if the clinician has just broken bad news. Enough time must be set aside to gain proper consent prior to surgery as the clinician will be judged to be negligent if he or she fails to provide information that the litigating patient considers would have affected their decision to go ahead with the procedure.
So what help is there for the surgeon? Considerable work has been carried out in Australia by a company called Specialist Management Services developing a set of procedure-specific patient information leaflets to assist the consent process. Each leaflet is written by a specialist in the field and goes through a rigorous development process that includes incorporating consent guidelines from regulatory bodies and specialist colleges. Each leaflet is edited by the Plain English Campaign and involves lay review to ensure the information is readily understood by most people at first read. A local peer expert and an editor of a major Australian medical journal authorise all text. Each leaflet bears the RACS Coat of Arms which acknowledges the quality of the processes that create this material. The leaflets are provided electronically in PDF format and can easily be printed when doctors need to give them to patients.
Written information is a key adjunct to the doctor-patient consultation - and to the process of consent - and should be provided as early as possible in the patient’s journey. High quality written information can inform and remind patients of key points required for decision making and can be given either before they are seen by the surgeon or at the same time. Patients should have time to read and digest the information prior to giving their consent in order to make that consent valid. When this happens, the time the surgeon needs to spend consenting the patient is reduced because the patient is already aware of the important information and the time can be used to clarify, answer questions and emphasise the important points.
Specialist Management Services is the principal supplier of patient education leaflets to the Western Australia Department of Health and one of Victoria’s largest public health networks, Southern Health.
If you would like further information regarding these leaflets you can contact Specialist Management Services on 1800 211 511.
Mr Simon Parsons DM FRCS Mr Keith Rigg DM FRCS
Co-Authors and Editors
Dr Neil McMullin MBBS FRACS (Paed & Gen Surg) F Fin Dr Chris Kimber MBBS FRCS FRACS Prof Steve Trumble MBBS (Monash), MD (Monash), DipRACOG, FRACGP
This article was first published in the May 2008 edition of Surgical News.