Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Judith F. Baumhauer, MD*,
Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York
Posted September 2008
This prospective cross-sectional descriptive study examines
the quality of the informed decision-making process in orthopaedic practices. It
was performed by evaluating 141 audiotaped patient-physician discussions regarding
the option of surgery, and it was scored with use of a modification of a
previously published informed-consent model1. The prior consent-model
elements were defined as the nature of the decision, the patient's role,
alternatives, risks and benefits, uncertainties, the patient's understanding,
receiving input from others, and exploring the patient's preferences. In
addition to total quality score, the inclusion frequency of each of these
elements and the relationship between visit duration and a quality score were explored.
The authors concluded that the major deficiency for
orthopaedic surgeons in the informed decision-making process was the patient's
involvement—more specifically termed the patient's role and understanding. Only
14% of the discussions included the topic of the patient's role, and only 12%
of the discussions included an assessment of the patient's understanding. The
amount of time spent with the patient did not correlate with an improved
quality score.
Informed consent is defined by dictionary.com as a "patient's
consent to a medical or surgical procedure or to participation in a clinical
study after being properly advised of the relevant medical facts and the risks
involved." As Braddock et al. discussed in their prior paper in JAMA, "Many
clinician-authors have called for a shift toward a view of informed
consent in which the emphasis is on a meaningful dialogue between
physician and patient instead of a unidirectional, dutiful
disclosure of alternatives, risks, and benefits by the physician. This expanded view is termed informed
decision making."1 This is an extremely important topic. In a
MEDLINE search with use of "Informed Decision Making" as a title, only seventy-eight
articles were found to be published on this topic, and none had reference to
orthopaedics. This study attempts to measure the ability of the surgeon to
communicate with the patient with use of a validated tool. This has
implications to the training of our residents and the 360-degree feedback evaluations of our peers and other health providers.
A related but different type of decision-making is shared
decision-making, in which patients are given the current best evidence on a
topic and in which patients can decide on the best treatment options2.
This process has a somewhat different agenda. Shared decision-making has
focused on influencing the rates of surgeries through communication of the
evidence-based outcomes and has been shown to influence the procedure rates of
prostate and spinal surgery through video education of patients. The limitation
on our current advancement in educating our patients is the paucity in the
orthopaedic literature of evidence-based outcomes and high-level research
publications.
The limitations of the current study include the narrowly focused
patient population—74% were women of sixty years of age or older. It is unclear
if the same findings would be present irrespective of age and gender. The
physician practice was 40% academic and 56% community based. The other 4% were
not defined in the paper. It was unclear how many visits the patient had with
the surgeon prior to these audiotaped conversations and what had been
previously discussed. The amount of patient understanding based on this
informed decision-making discussion was not assessed. Previous studies have
reported that the amount of information a patient retains during the informed consent
process is quite limited3. Finally, the prior published validated
model was modified for use with this paper, and this brings into question the
ongoing validity of the instrument and subsequent results.
In summary, this paper attempts to quantify a pivotal
communication between the surgeon and the patient and provide examples of high-quality
conversations. It appears that this may be a "first step" toward objectively
assessing this process of informed decision-making for surgery.
*The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of her immediate family, is affiliated or associated.
References
1. Braddock CH 3rd, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282:2313-20.
2. Weinstein JN, Clay K, Morgan TS. Informed patient choice: patient-centered valuing of surgical risks and benefits. Health Aff (Millwood). 2007;26:726-30.
3. Turner P, Williams C. Informed consent: patients listen and read, but what information do they retain? N Z Med J. 2002;115:U218.
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