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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 (accessed 10 February 2013)

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.


Getting the Message

No Australian doctor is fluent in only one language, regardless of their cultural heritage. “Medical English” has been said to have a vocabulary the same size as some European languages and the latest edition of that famous medical dictionary, Dorland’s, runs to 2,175 pages (i), compared to the Macquarie’s 1,940 (ii). Medical English is a language all of its own that is exclusive and difficult to learn. Which is why so many freshly minted doctors look dismayed when they are told they can’t use their brand new language on people who don’t understand it.

Patients generally don’t speak Medical English and will look baffled at the sort of jargon, acronyms and technical terms with which doctors are quite comfortable. We learn to communicate efficiently and effectively in high pressure situations, where describing a patient as “an LOL in NAD after a FOOSH” quickly conveys the message that this particular little old lady is in no apparent distress after falling on her outstretched hand and so treatment can proceed accordingly. Such shorthand communication might be acceptable between members of the health care team but would not be understood by the LOL herself. And, sadly, the acronym “LOL” is now more likely to signify to current medical students that you are either “laughing out loud” or expressing “lots of love”, neither of which would be ideal in the situation.

A recent paper in The Medical Journal of Australia drew attention to the prevalence of jargon and acronyms in surgical consent forms in a public hospital in Adelaide. The authors (Mark Siddins, Elizabeth Klinken and Lee Vocale) found that only 18.5% of forms described the procedure in plain language, with 15.3% using just an acronym to describe a significant component. Admittedly, this was in a urology unit and terms such as TURP have become commonly used by the general population, even if their actual meaning is poorly understood. Simply explaining to a patient that their “turp” is actually a “transurethral resection of the prostate” adds little value, as would pointing out that “laser” actually means “light amplification by stimulated emission of radiation”. The procedure really needs to be explained in plain language with diagrams and time for questions.

The study design didn’t capture what the patients were told verbally, only what was recorded on the consent documentation. But as the authors comment: “... we believe that a consent process is not acceptable unless verbal discussion is augmented by relevant written information.  Specific documentation provides patients and others an opportunity to reconsider key points privately, or share information with “significant others”.  It also ensures consistent and transparent provision of information”. This is especially important when procedures carry a significant degree of risk – only 4.1% of consent forms in the study mentioned relevant risks.

The Adelaide authors state their belief that consent forms for elective procedures should include – at a minimum – a plain language description of the procedure along with its purpose and intended benefit, as well as information regarding material risks and established alternative treatment options. This aligns well with the NHMRC’s 2004 guidelines on providing information to patients (iv) which recommend that the whole communication process (not just the written part) convey:

  • the possible or likely nature of the illness or disease;
  • the proposed approach to investigation, diagnosis and treatment;
  • the expected benefits;
  • common side effects and material risks;
  • whether the intervention is conventional or experimental;
  • who will undertake the intervention;
  • other options for investigation, diagnosis and treatment;
  • the degree of uncertainty of any diagnosis arrived at;
  • the degree of uncertainty about the therapeutic outcome;
  • the likely consequences of not choosing the proposed diagnostic procedure or treatment, or of not having any procedure or treatment at all;
  • any significant long term physical, emotional, mental, social, sexual, or other outcome which may be associated with a proposed intervention;
  • the time involved; and
  • the costs involved, including out of pocket costs.

Although this is a huge amount of information to be successfully conveyed, it is in line with community expectations as to how doctors will perform. Obviously, the completeness and depth of detail will vary depending on the individual case.

Dr Siddins and his colleagues make the valid point: “The primary purpose of consent is not to minimise the risk of subsequent litigation, but to formalise the process by which patients (or those responsible for their care) are empowered to make appropriate decisions regarding treatment options” (iii). Prudent proceduralists would do well to ensure that they are communicating with their patients in easily understood, jargon-free language backed up by printed materials that are similarly useful to the patient.

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


i Dorland's illustrated medical dictionary.  Philadelphia, PA : Elsevier Saunders, 31st ed. 2007

ii Macquarie dictionary.  Sydney : Macquarie Dictionary Publishers, 5th ed. 2009

iii Siddins ST, Klinken EM, Vocale LR. Adequacy of consent documentation in a specialty surgical unit: time for community debate?  MJA 2009; 191(5): 259-262

iv General Guidelines for medical practitioners on providing information to patients. Canberra: National Health and Medical Research Council, 2004



In Other Words

It’s an interesting emotion that goes through us as we read the Medical Board’s regular bulletins of hearings into our colleagues’ conduct, or newspaper reports of medicolegal court cases. A curious mix of disdain that such things should happen, and relief that we are not involved.

Most medical practitioners will be familiar with the general principles of the Rogers v Whitaker 1992 High Court case that established our obligation to ensure that patients are warned not only of the general risks of a medical intervention but also of any risks that have specific importance to them individually. Less well known is a case that came before the New South Wales Supreme Court in 2002 (Knight v Stocker [2002] NSWSC 1161). The judgement of Justice Simpson makes fascinating reading, not least because of the caning she hands out to an expert witness she describes as “aggressive” and “combative”. Never anger a judge – the role of the expert witness is to assist the Court.

But judicial fury is not the focus of this article; it’s all about whose responsibility it is to decide what the patient should be told. The details of the case are complex but – in a nutshell – it relates to inguinofemoral pain experienced by a patient for many years following a routine D & C and laparoscopic sterilisation. The patient was unsuccessful in her complaint of “failure to warn” as she was unable to prove that the pain was caused by the procedure – negligently performed or not - and the Court found in favour of the doctor. The case has been used by at least one Australian medical indemnity company to illustrate the risks of failing to warn patients of a procedure’s material risks.

The most instructive aspects of this case lie within the judge’s comments relating to the adequacy of information given to the patient by the doctor. It appears that a fairly standard hospital consent form was signed by the patient before she underwent the procedure in 1991. The form included the words:

“I have received all information sought by me concerning care and all questions asked by me concerning the proposed operation and other procedures and all questions asked have been satisfactorily answered.”

The patient’s signature was witnessed by an intern, who was also described on the form as the person who had explained the effect and nature of the procedure. This raises a whole set of separate issues about whether it is appropriate to delegate the authority for gaining informed consent to somebody who might not be competent to perform it. Despite being common practice, it’s not.

Although there were RANZCOG information brochures available within the hospital that described the procedure and its risks, the patient was not given one as the surgeon apparently relied “… on his practice of asking patients if they required further information. He did not believe there was a need to hand out a pamphlet if a patient expressed herself satisfied with his explanation”. Mind you, just handing out a brochure does very little to reduce your medicolegal risk. You need to be confident that the material within has been read and understood.

Many doctors have participated in the very popular seminars by the Cognitive Institute – which I have presented - that encourage doctors to use words such as: “Now, is there anything I’ve told you today that you didn’t understand? Is there any more information you need to make this decision?”. These are very useful words in practice; a patient who says “no” to both of those questions must be pretty satisfied with the information they’ve received. But the answers to a patient’s questions should really be the icing on the cake of the consent process. The prudent practitioner will ascertain their patient’s individual information needs at the beginning of the process, give them general and specific information tailored to these needs (but not limited just to what the patient wants to hear), and then finish off with those two questions once he or she is satisfied that they have imparted the critical core. So while it is good practice to invite and respond to questions, it is not the patient’s responsibility to know what to ask; they can only query things that are worrying them. It is the doctor’s responsibility to decide what the patient needs to know and to inform them in a way that they can understand.

That’s an awful lot of information that needs to be transmitted from the doctor to the patient and Justice Simpson had this to say about not supporting the patient with a written document to assist their decision: “Again, it seems to me that this is an unwise approach and one which does not meet the obligation the law places upon a medical practitioner. The obligation is not only to give relevant information, but to do so in language, and in a manner, that the patient can understand. A patient in a consultation may be under stress or pressure, and may frequently not be able to absorb all that she is told. Giving a patient information in written form gives her an opportunity to consider it at leisure, outside the tension, and sometimes pressure, of a medical consultation; and to discuss it with friends or relatives. Further, the use of such a pamphlet constitutes a protection, not only for the patient, but also for the doctor. I found the defendant’s explanation for what was obviously a considered decision not to make use of the pamphlet rather puzzling. I am satisfied that the information provided by the defendant to the plaintiff was deficient”.

Many of us have long recognised the benefits of well written patient information sheets in making both the doctor’s and the patient’s jobs easier. A previous SMS newsletter has outlined some of the elements that make an information sheet effective; a key factor is how well the sheet complements and supports the doctor’s own explanation. It’s important to remember that patients are not as fascinated by the technical details of how a procedure is performed as you are. A sheet that goes into the technical detail of a surgical text book is not going to be effective; it needs to be a patient education resource rather than a “how to” manual. The level of detail has to be just enough that an uninformed patient can glean an understanding of the basics of how the job is done. Their main interest is going to be in what can go wrong and how likely that is to happen to them.

Justice Simpson concludes her judgement by acknowledging that a medical practitioner is not obliged to advise a patient of “bizarre or unforeseeable consequences” of operative procedures, but that a patient information brochure is a useful starting point in deciding what material risks a reasonable practitioner should inform the patient about. It is still up to the patient to decide whether they have enough information to make a decision; a good brochure helps both doctor and patient get to that point.

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

This article was first published as an insert in the June 2009 edition of Surgical News.



Family Affairs

One of the aspects that attracts many of us to medical practice is the uniqueness of the doctor-patient relationship; just you and your patient working together in the privacy of your consulting room.

In reality, however, the consulting room is pretty crowded. Although it might just be the two of you sitting in there, you both have a whole lot of other people virtually present who influence the consultation.

Through your medical knowledge and surgical training, you bring into the room a host of experts, teachers and mentors all of whom continue to influence your practice. On the patient’s side of the desk sit their family and friends, each of whom have some level of interest in the patient’s health and in your management of it. There are also dozens of neighbours and acquaintances who will not let their complete absence of medical training stand in the way of providing a critical post-fact appraisal of your skills. And, inevitably, there’s a small flock of lawyers and regulators circling lazily above your desk.

Most of the patient’s team will have his or her best interests firmly at heart and will support and assist your endeavours to do the best job you can. Emotions run hot within families, however, and the full gamut from guilt to greed can impact upon your work in the consulting room, the wards and theatre.

It’s wrong to paint family members who accompany patients to their appointments with you solely as a threat. They are stakeholders in your healthcare interaction and so their needs must be considered. Family members can be an invaluable source of information about their relative’s medical history, family history, symptoms and so on. In return, they can be wonderful adjuncts to your consultations, ensuring that the patient understands your explanations and reinforcing key messages at home. The patient remains the centre of the interaction, however, and your explanations must be directed at them no matter how tempting it might be to communicate directly with a more capable accompanying person. This is especially true when you do not share a language with the patient and a family member offers to assist. Many family members find it difficult to act purely as a translator rather than as an interpreter.

Giving the patient written information to take away and discuss with their family and friends is a useful strategy to help improve their understanding outside your consulting room. Inevitably, however, the authority consulted will be their son’s girlfriend who is a second year osteopathy student and so the information must be clear and robust. It is never enough to hand a brochure or information sheet to a departing patient and suggest that they get someone at home to explain it to them. Rather, the sheet needs to be discussed in some detail by you with frequent checks that the patient is following your explanation. Underline the key bits and annotate the sheet with facts that are specifically important to that patient. By all means encourage the patient to share the contents of the sheet with a family member or friend. I still recall doing a home visit on an elderly couple only to find my information sheet on erectile dysfunction prominently displayed on the fridge.

The Internet is another source of opinion against which your information will be measured. Professor Google from the University of Wikipedia seems to be the ultimate authority on most things medical. As frustrating as this is, it’s important to imbue your information sheets with your own authority so that incorrect or inaccurate internet postings do not confuse the patient. Having said that, there are some high quality websites available that may well reinforce your message if you check them out before recommending them.

Many patients have a tendency to give socially desirable responses when talking to doctors. The question: “Now, you understood all that, didn’t you?” really invites an affirmative response. Asking which bits of the explanation the patient did not understand, or – even better – asking them how they will explain it to their family members when they get home is much more appropriate. This gives the patient a chance to rehearse what they will say while you have the opportunity to correct any misunderstandings.

Some family members will play quite a prominent role in a patient’s medical decision making, and not just at the extremes of life. While it might seem inappropriate or even a waste of time to delve into a patient’s family constellation, the prudent clinician is aware of whom else needs to be brought on board before the patient can front up for an operative procedure with confidence and equanimity. Taking a preoperative phone call from a concerned family member is a wise investment of time for all concerned.

Building trust, rapport and understanding with patients and their families is an essential part of the consent process; this requires clear, effective communication. It is also an important aspect of minimising the fall-out when something inevitably goes wrong. It’s well known that families and significant others play an important role in influencing the decision to litigate after adverse events (1,2). After all, where there’s a will there’s a relative…

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


1 Liebman CB, Hyman CS. A mediation skills model to manage disclosure of errors and adverse events to patients. Health Affairs 2004 Jul-Aug;23(4):22-32.

2 Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted families to file medical malpractice claims following perinatal injuries. Journal of the American Medical Association 1992; 267 (10): 1359–1363.

This article was first published as an insert in the March 2009 edition of Surgical News.



Just Read This...

I cursed a medical colleague last week when a notoriously anxious staff member burst into my office brandishing a sheaf of information sheets. Her surgeon had referred her to a haematologist to investigate an unexpectedly low platelet count. In the process, a low titre of antinuclear antibodies had also shown up. The haematologist had muttered something vague about ‘lupus’, printed off a whole lot of information from a website, and steered her towards the door. He invited her to return when she knew what she wanted to do about it. The haematologist probably thought he was doing the right thing: empowering the patient with enough information to make her own decisions. Where he had failed, unfortunately, was in not considering the impact that such an indigestible bolus of data would have on this particular woman. Rather than helping her, his ill-considered patient information sheets had added significantly to her problems.

Much has been written in the Australian literature about our obligations as clinicians to provide enough information so that any reasonable patient could make an informed decision about a procedure, as well as considering the particular information needs of the individual patient. Most Australasian surgeons are familiar with the ophthalmological case (i) that ended up in the High Court and gave rise to our understanding of the need to tailor our informed consent processes to the individual. There seems to be a growing trend, however, for clinicians to seek to abdicate their responsibilities to provide this information onto pre-printed patient information sheets. This is not on. A well constructed patient information sheet can be an invaluable aid to the process but it can’t do all the heavy lifting on its own.

When choosing a patient information sheet, there are several key points to consider:

Is it authoritative?

The sheet should be written by clinical experts and reviewed by peers who understand both the procedure being described and the clinical context in which we all work. Significant statements (such as the risk of adverse outcomes) need to be clearly stated and backed by the best available evidence. Your sheets will be shown to your patients’ families.

Is it complementary?

As the sheet is primarily an aid to the surgeon’s explanation of the procedure (with its risks and benefits), it should be written in a style that complements your own voice rather than clashing with it. Personalise the sheet by circling important information or crossing out treatment options that are not relevant to that patient. A great deal of efficiency can be gained in consultations when the sheet works with you rather than against.

Is it up to date?

Surgery is a rapidly advancing discipline and a patient information sheet is virtually out of date the moment it leaves the author. It is important to keep an eye on the revision dates of individual sheets and throw out any that are out of date. Better still, keep your sheets filed electronically so that they are easy to find when you need them and wastage is minimised when an updated version arrives. Storing your sheets electronically also allows them to be customised to your practice, increasing the link between your authority and theirs.

Is it comprehensible?

It seems blindingly obvious but a good information sheet needs to be written in language that can be understood. Surgeons working in multicultural areas might consider getting their sheets professionally translated. Even if your patient reads English, it is recommended that written information be pitched at the level of a primary school student (ii). A number of readability indexes are available and most are based on the structure of sentences rather than the use of technical jargon. This article, for example, only has a Flesch reading ease score of 43.3% and the reader would have to be a senior secondary school student to handle it. The INFOrm4U patient information sheets with which I am associated score around 60% (readable by junior secondary school students). Lincoln’s Gettysburg address scores 79.1%; Mr Rudd’s “Sorry” address scores 48.8%. The average score of articles in the ANZ Journal of Surgery was recently found to be 18.6% (iii).

Diagrams are equally important in assisting health literacy. A complex, multicoloured and too anatomically correct picture may confuse a patient who has no frame of reference. Any surgeons who have taught anatomy to medical students in theatre will be familiar with the befuddlement of a person being confronted with too much complexity too early.

Is it comprehensive?

This is a difficult balance to strike – including enough pertinent information without overwhelming the patient. Piloting, peer reviewing and revising the text several times may be necessary. A good medical editor can help to ensure that the writing is accurate and concise but only experienced surgeons can really be sure that the content is appropriately inclusive.

Is it free of bias*?

Patient information can be biased in very subtle ways. Some patients will produce printouts from websites that are clearly promotional and can be dismissed as such. At other times, authors can unconsciously coerce patients into one particular course of action by writing their information sheets so that one management approach is favoured over others. Of course, it is the surgeon’s role to indicate which course of action is in the patient’s best interests where appropriate, but a sheet cannot make that clinical judgement on your behalf.

In summary, a good patient information sheet makes the surgeon’s job easier and more effective in enabling patients to make the decision that is in their best interests. The fact that it may also help build stronger doctor-patient relationships, reduce medico legal risk and contribute to the satisfaction of both patient and doctor is a benefit we can all enjoy.

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


i Rogers v Whitaker (1992) 175 CLR 479

ii Paasche-Orlow MK, Taylor HA, Brancati FL. Readability standards for informed-consent forms a compared with actual readability. The New England Journal of Medicine. 2003. Vol. 348, Iss. 8; pg. 721

iii Hall JC. The readability of original articles in surgical journals. ANZ Journal of Surgery, 76 (1-2), January 2006 , 68-70(3)

* Steve Trumble is Chair of Specialist Management Services’ Editorial Board.

This article was first published as an insert in the November 2008 edition of Surgical News.



Patient Communication and Consent

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.