This Information Statement was developed as an educational tool based on the consensus opinion of the authors. It is not a product of a systematic review process. Readers are encouraged to consider the information presented and reach their own conclusions.
Successful medical encounters require effective communication between the patient and the physician. "Success" implies that the patient and physician have developed a "partnership" and the patient has been fully educated in the nature of his or her condition and the different methods to address the problem. This allows the patient to be actively involved in the decision-making process and establishes agreed upon expectations and goals.1 Many models have been developed to assist healthcare providers in developing approaches to improve their ability to communicate with their patients. These models focus on improvement in the quality of the encounter and do not necessarily require any significant increased investment in the length of the encounter. These approaches have been demonstrated to improve patient satisfaction and also allow the provider to demonstrate empathy, concern and humanism.2,3,4 Learning communication skills allows the orthopaedist to build trust, promote healing, and ultimately improve outcomes. Interestingly, not only do successful encounters improve patient outcomes they have also been shown to improve professional satisfaction. These skills lead to professional respect among the physician's peers and result in patients seeking care from these providers. Finally, interviews with patients who have filed malpractice suits against their physicians often site poor communication and lack of empathy as a factor in pursuing legal action.5,6
The American Academy of Orthopaedic Surgeons (AAOS) urges orthopaedic surgeons to use patient-focused communication skills during their direct patient encounters. These include:
- Sitting down during patient encounters
- Developing an understanding of the patient as an individual, not as a disease or a musculoskeletal condition
- Showing empathy and respect
- Listening attentively and creating a partnership
- Eliciting concerns and calming fears
- Answering questions honestly
- Informing and educating patients about treatment options and the course of care
- Involving patients in decisions concerning their medical care
- Demonstrating sensitivity to patients' cultural and ethnic diversity
When time counts, it is the quality and not necessarily the quantity of physician-patient communication that is vital. The patient often measures quality by how well the physician listens, validates his or her musculoskeletal complaint, and acknowledges concerns. Quality is also measured by how thoroughly the physician explains the diagnosis and treatment options, and how well the physician involves the patient in decisions concerning his or her care. These factors play an important part in the way patients perceive, recall, and evaluate their visits with the physician.2,3,4
AAOS believes that orthopaedic surgeons must place an emphasis on good communication with patients and the quality of the interaction, especially when time is limited.
Components of Informed Consent
Obtaining consent to perform a medical intervention is a mainstay in the current practice of medicine. It allows the physician to subscribe to and follow the three basic tenants of medical ethics: respecting patient autonomy, beneficence (doing good), and non-maleficence (not causing harm). The process needs to be "informed" and the physician should spend time with each patient to insure that the patient (or legal guardian) understands the proposed treatment and has had an opportunity to have any questions addressed. Even if the patient is given written materials to explain the proposed treatment, the physician should review the explanation with the patient. It is important that the discussion utilize words which the patient is able to understand. Specifically, the consent process should include the following elements:
- Nature of the problem
- Proposed treatment to address the condition (if the surgeon has a specific recommendation)
- Alternative treatments
- Anticipated benefits of each treatment option
- Risks and side effects of each treatment option
- Consequences of no treatment
- Assessment of the patient's understanding of the proposed treatment
The surgeon is bound to disclose any information which the patient needs to know to make an informed decision about a recommended course of treatment. Generally, this would include the framework listed above and include the commonly reported complications of a procedure and less frequent complications which have significant long term implications for the individual. Any adult patient with decision-making capacity has the legal right to refuse care, even if this refusal may ultimately result in the loss of a limb or death.
Documentation of the consent process is critically important. Institutional consent forms are designed to allow patients to verify with their witnessed signature that they have been fully informed and agree to the proposed procedure. These forms are very general in their wording and do not include the specifics of each informed consent discussion. The surgeon should document the complete informed consent process with a comprehensive note in the patient's medical record. This entry should report the nature of the discussion and include all of the specific information outlined above. It is recommended that this note document that the patient or guardian understands the explanation and has had an opportunity to have any questions answered. Finally, the note should report that the patient (guardian) wishes to proceed with the recommended treatment.
The World Health Organization (WHO) and the AAOS recommend that the surgeon verify the correct surgical site with the patient. This site should be "signed" (usually with the surgeon's initials) and witnessed by the patient prior to the patient being brought into the operating room.
In some states and institutions, the physician is required to obtain pre-operative consent from the patient for the operating room attendance of people who are not members of the health care team.
This may include representatives of biomaterial or implant device manufacturers or other observers. The surgeon should be familiar with state and institutional regulations requiring permission for observers in the operating room. Surgeons should also obtain specific consent for intra-operative medical photography for the purpose of documenting the patient's condition.
Minors (ages 18-21, state dependant) are not legally permitted to consent to surgery. Despite this, it is well recognized that children should actively participate in the discussions related to their health care. The degree of involvement will depend on the age of the child and his or her individual capacity to understand the discussion. In 1994 the American Academy of Pediatrics, Committee on Bioethics, released a position statement entitled "Informed Consent, Parental Permission and Assent in Pediatric Practice. (This position was reaffirmed in October 2006).7,8
The position statement outlines the benefits and limitations in the participation of a minor in health care decisions. By obtaining "assent" we allow the child to "achieve a developmentally appropriate awareness of his or her condition". Care must be taken to insure that the discussion is age and capacity appropriate and not deceiving. A nine-year-old child with an open fracture needs to be treated in the operating room. This process should include an explanation to the child as to what happened and what has to be done to help. Seeking permission (assent) and receiving a refusal would lead the child to mistrust the healthcare providers. A sixteen-year-old with normal capacity scheduled for surgery for idiopathic scoliosis should actively participate in the discussion and assent to the procedure. Many physicians actually have the adolescent child and the guardian both sign the informed consent form.
One of the additional protections provided by the law to minors is their right to receive limb- or life-saving treatment even when this treatment is refused by the guardian. Thus the surgeon may provide, for example, a blood transfusion to the child of parents who refuse this treatment, if he or she believes that the child's life is at risk without the transfusion. The surgeon should be familiar with the institutional and legal processes to be followed when providing limb- or life-saving treatment to a child against the wishes of the child's parent.
Under certain circumstances, minors are legally allowed to provide informed consent for their own treatment. The most common circumstance encountered by physicians is when minors have a condition for which they might fail to seek treatment if parental consent was required, such as pregnancy, sexually transmitted disease, substance or alcohol abuse, or a psychiatric condition. Minors with these conditions may have concomitant orthopaedic problems, complicating the issue of their capacity to provide consent. Because the conditions for which minors are emancipated vary from state to state, orthopaedic surgeons should familiarize themselves with the specific requirements of the states and institutions in which they practice.
AAOS urges orthopaedic surgeons to provide information and education to their patients about treatment alternatives and the course of care, especially expectations for surgical outcomes. Discussing the risks of surgery and possible complications, in a kind and compassionate manner, can create realistic expectations on the part of the patient, increase patient satisfaction, and minimize the risk of malpractice claims.5,6
- D'Ambrosia R: Orthopaedics in the New Millennium, A new patient-physician partnership. J Bone Joint Surg AM 1999; 81: 447-451.
- Schattner A: The silent dimension: expressing humanism in each medical encounter. Arch Intern Med 2009; 169:1095-99.
- Tongue J, Epps H, Forese L: Communication skills for patient-centered care; research-based, easily learned techniques for medical interviews that benefit orthopaedic surgeons and their patients. J Bone Joint Surg Am 2005; 87:652-8.
- Press Ganey Associates. "Friendliness/courtesy of physician", 2009.
- Bhattacharyya T, Yeon H, Harris MB. The medical-legal aspects of informed consent in orthopaedic surgery.
- Bone Joint Surg AM 2005:87:652-8.
- Levinson W, Roter D, Mullooly J, Dull V, Frankel R: Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997; 277: 553-9.
- Committee on Bioethics, American Academy of Pediatrics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics, 1995; 95: 314-17.
- Committee on Bioethics, American Academy of Pediatrics. Informed consent, parental permission, and assent in pediatric practice. Pediatr Rev, 2008; 29: e2-e3.
Copyright December 2000 American Academy of Orthopaedic Surgeons.
Revised September 2005, December 2011.
This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons.
Information Statement 1017
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