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Letter to the Editor: Medicolegal Sidebar: Who Should Obtain Informed Consent?

Rickert, James MD; Levin, Paul E. MD; Piasio, Mark MD, MBA; Boniface, Tom MD; Grogan, Tom MD; Rutherford, Rob MD

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Clinical Orthopaedics and Related Research: November 2018 - Volume 476 - Issue 11 - p 2282-2283
doi: 10.1097/CORR.0000000000000529
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To the Editor,

Teo and colleagues [4] join much of the medical establishment in reacting negatively to Pennsylvania’s (PA) recent Supreme Court decision requiring surgeons to personally conduct consent discussions [2]. We disagree and applaud the court’s decision. We argue that the PA Supreme Court has affirmed that surgeons are not just mere technicians—that through our intense and focused education, our continuing medical education, and our lived experiences as surgeons, we have a nuanced view of surgical risks, benefits, and alternative therapies that cannot be replicated by videos, printed booklets, physician assistants, nurse practitioners, or nurses. While this may lead to some short-term inconvenience for surgeons required to obtain their own consents, the court’s affirmation of this fact bodes well for the long-term health of our profession.

We believe that surgeons should personally spend the time necessary to obtain consent and answer patient questions for the benefit of our patients. Informed consent is an important, interactive process, not a signed piece of paper. Following an initial decision between the surgeon and the patient to proceed with surgery, it is appropriate for other members of the surgeon’s team to be involved in educational efforts, distributing materials that support shared decision-making along with performing any other tasks to assist the patient and their involved family members in gaining a comprehensive understanding of what is planned. But ultimately, the final, comprehensive informed-consent discussion should take place between the responsible surgeon and his or her patient. That discussion should cover the patient’s pathology, why the operation is recommended, what other approaches might be considered, and what will happen if no intervention is performed. The surgeon then should answer all of the patient’s questions and address his or her concerns. Successful patient-physician communication is one of the primary contributors to patient satisfaction and adherence [1, 3]. A thoughtful, unhurried consent conversation will not just improve satisfaction, it will help ensure a good fit between each patient and his/her surgical choice. Importantly, a proposed surgery that does not accurately reflect a patient’s goals, values, and risk tolerance—as the PA Supreme Court decided in this unfortunate case—could have as devastating an effect on a patient as a surgery poorly performed in the operating room.

We acknowledge that some surgeons will find their clinical flows interrupted by consent requirements, and that this may cause some inconvenience, but many of us around the country who personally consent our patients for surgery have overcome such obstacles. We strongly support the concept that the responsible surgeon is the individual who best understands the risks and benefits of the proposed surgery. A bioethically sound informed-consent process requires a comprehensive discussion about a treatment plan that has been thoughtfully designed to be consistent with the patient’s personal values. We believe that only the responsible surgeon—and no one else—has the requisite knowledge both to craft such a plan and explain it in light of the available alternatives. For that reason, we do not believe informed consent should be delegated.

References

1. Alston C, Paget L, Halvorson G, Novelli B, Guest J, McCabe P, Hoffman K, Koepke C, Simon M, Sutton S, Okun S, Wicks P, Undem T, Rohrbach V, Von Kohorn I. Communicating with patients on health care evidence. Available at: https://nam.edu/wp-content/uploads/2015/06/VSRT-Evidence.pdf. Accessed August 28, 2018.
2. Fernandez Lynch H, Joffe S, Feldman EA. Informed consent and the role of the treating physician. N Engl J Med. 2018;378:2433–2438
3. Grocott A, McSherry W. Identification of meaningful communication from the patient’s perspective. Available at: http://www.mdpi.com/2227-9032/6/1/26/htm#B7-healthcare-06-00026. Accessed August 28, 2018.
4. Teo WZW, Brenner LH, Bal BS. Medicolegal sidebar: Who should obtain informed consent? Clin Orthop Relat Res. 2018;476:1566–1568.
© 2018 by the Association of Bone and Joint Surgeons