PureInsight | October 1, 2006
"What's the worst thing that can happen if I agree to surgery?" a
patient recently asked me. Unfortunately, the only honest answer was:
"Some patients die." It's hardly the positive way to discuss surgical
complications, but it does get quickly to the heart of the issue.
Today, patients have every right to be informed about risk, but to do
so effectively is easier said than done.
For instance, it could be cynically said that the only truly informed
patient would be a brain surgeon being informed by another brain
surgeon about potential complications. There are no ifs, ands, or buts
in this case.
In a similar vein, I could talk to a nuclear physicist for days without
ever understanding the complexities of his subject. But if he told me
that by mixing A with B I'd blow myself up, I'd quickly get the message.
So in 2006, what are the powder-keg issues of consent that doctors
should stress to patients and that leave no room for doubt? The first
is that surgical risks should never be swept under the rug. It's
impossible for surgeons or any medical practitioner to guarantee the
outcome of any procedure.
One patient may survive a complicated heart operation. Another may die
from an unexpected anesthetic problem during removal of an ingrown
toenail. Surgical procedures are not like mathematics, where two plus
two always equals four.
There's another crucial dilemma today. Doctors must convince patients
to rid themselves of unreasonable expectations. No better example of
this is obstetrical delivery in which women seem to have become
programmed to expect a 100 percent normal baby.
I'm convinced (but few agree with me) that bringing fathers and
sometimes whole families into the delivery room started a dangerous
trend. It helped to foster misconceptions about childbirth, that having
a baby is such a natural process that nothing should or could go wrong.
And if a less-than-perfect baby results, it's automatically the
doctor's fault.
Today this has become such a problem that any young doctor considering
a career in obstetrics should first consider getting psychiatric care.
The delivery of babies has simply become a lose-lose medicolegal
situation.
Many older obstetricians have heard this message loud and clear. They
know the odds of lawsuits are so high that they've discontinued their
obstetrical practice. It's a symptom of the times we live in today, and
in the end it's the patient who loses.
The difficulty is how to pass along the essential A's and B's of
potential surgical pitfalls without scaring patients half to death.
Some hospitals, particularly those in the U.S., require that patients
sign a 15-page document describing a procedure in hopes of improved
communication with patients. With more lawyers in the U.S. than in any
other nation, doctors and hospitals hope such a document will keep them
out of court. But studies show that many patients read neither short
nor long explanatory documents, or if they do, they can't recall the
content.
Video presentations are also being used to educate patients. As
expected, this approach has been shown to penetrate the patient's
psyche better than the written word. But patient recall of the message
is still only 50 percent better than the written word. I suspect that
video presentations of the operation may also give patients second
thoughts about proceeding with surgery.
Hi-tech presentations may be part of the answer. But I doubt there's
anything better than a few moments of discussion with the doctor to
make sure patients understand basic risks, such as a post-operative
blood clot that could be fatal or the possibility of wound infection.
And today with so many obese, diabetic and hypertensive patients,
people need to be made aware that these conditions increase the chance
of heart attack and stroke.
How much risk a patient is willing to accept is always a personal
matter. A 2 percent chance of death may be acceptable. But if mixing A
with B means a 20 percent chance of lighting a lethal fuse, patients
may elect either nonsurgical treatment or none at all.
Dr. Gifford-Jones is a medical journalist with a private medical practice in Toronto.
