Information Statement

The Importance of Good Communication in the Physician-Patient Relationship

This Information Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

Good communication with patients has always been essential in orthopaedic practice. It is the “cornerstone” of the physician-patient relationship. Open, honest communication builds trust and promotes healing. It favorably impacts patient behavior, health outcomes, patient satisfaction, and often reduces the incidence of malpractice actions. For physicians, good communication with patients can also increase professional satisfaction, enhance community image, and provide a competitive economic advantage for the medical practice.

Increasing demands on orthopaedic surgeons in today’s healthcare environment often leave less time to provide care to a greater number of patients. While time constraints can make it difficult to communicate as effectively as one would like, the quality of time spent with the patient remains very important. For this reason, effective patient-focused communication skills are essential. They can be applied quickly and effectively within the normal patient encounter.¹

The American Academy of Orthopaedic Surgeons (AAOS) urges orthopaedic surgeons to use patient-focused communication skills during their direct patient encounters. These include:

• Showing empathy and respect
• Listening attentively
• 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. To the patient, quality is often measured by how well the physician listens and acknowledges patient concerns. It is 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

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.

Good communication between the orthopaedic surgeon and patient can be an effective risk management tool. While poor treatment outcome is one of the primary causes of malpractice actions, poor communication is also a factor in a majority of cases. Patients who sue often cite the failure of physicians to listen or the physician’s unwillingness to answer questions. Patients who are well informed about treatment options, the course of care, expected outcomes, and possible complications are more satisfied patients, and are less likely to file malpractice claims.

Informed Consent

Components of Informed Consent

The orthopaedic surgeon should follow the process of obtaining informed consent when he/she communicates with patients regarding treatment alternatives and receives permission to proceed with treatment. Informed consent is the autonomous authorization obtained from the patient after the surgeon explains and describes the:

• Nature of the problem
• Alternative treatments
• Anticipated benefits of treatments
• Risks and side effects of treatments
• Consequences of no treatment

The surgeon is legally bound to disclose any information which the patient needs to know to make an informed decision about a recommended course of treatment. As long as the adult patient has the capacity to understand the information provided by the surgeon, he/she also has the right to refuse treatment (even if it will save life or limb).

Documentation

Documentation of consent is critically important. In addition to the consent form, which is signed by the patient or guardian and a witness, the surgeon should document in the chart that he/she has obtained consent according to the guidelines listed above, that the patient or guardian understands the explanation and all of their questions have been answered, and that they wish to proceed with the recommended treatment. The AAOS recommends that the surgeon and patient “sign the site”, or agree upon and mark the planned surgical site together prior to surgery.

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

Minors have greater legal protections than adults, and cannot legally provide consent for treatment until they have reached the age of majority (18 to 21 years of age, depending on the state of residence). Instead, consent for minors is provided by their legal guardian, usually the parent(s)

This does not, however, mean that minors are ignored during the process of obtaining informed consent for elective surgery. According to the guidelines of the Midwest Bioethics Center (MBC),³ minors fall into three categories regarding their capacity to participate in the informed consent process:

1. No capacity to participate (infants, toddlers, children with severe developmental delay)
2. Developing capacity (school age children)
3. Capable decision-makers (older adolescents)

The MBC Guidelines suggest that the surgeon obtain written assent, or permission, from older adolescents before proceeding with elective surgery. This assent is not binding, and is not valid without the guardian’s consent, but obtaining it shows that the surgeon supports and respects the adolescent’s decision-making abilities, thereby fostering their participation and cooperation with the treatment plan. Children with developing capacity should be involved in the process of informed consent to the extent of their desires and capabilities; for instance, they may be allowed to choose the color of their cast.

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/she believes that the child’s life is at risk without the transfusion. The surgeon should be familiar with the institutional and legal processes they should follow 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, the orthopaedic surgeon should familiarize him/her self with the specific requirements of the state and institution 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.⁴

1. Stein, T., MD, Tong Nagy, V., Ph.D., Jacobs, L., MD; Caring for Patients One Conversation at a Time: Musings from the Interregional Clinician-Patient Communication Leadership Group http://www.kp.org/medicine/permjournal/fall98pj/fall98pjcaring.html
2. D’Ambrosia, RD, MD, AAOS Past President; Physicians must put patients first in partnership to rebuild trust, American Academy of Orthopaedic Surgeons Bulletin; Volume 47, Number 2, April 1999
3. Midwest Bioethics Center Task Force on Health Care Rights for Minors. Health care treatment decision-making guidelines for minors. Bioethics Forum, 11(4); A1-A16, 1995
4. Patients need more information, American Academy of Orthopedic Surgeons Bulletin; Volume 44, Number 1, January 1996

© December 2000, September 2005, American Academy of Orthopaedic Surgeons

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons.^®

Document Number: 1017

For additional information, contact the Public and Media Relations Department, (847)384-4031.