Informed consent to inguinal herniorrhaphy and cholecystectomy: differences between what surgeons say they discuss and what they actually do discuss

Hall DE, Morrison PK, Nikolajski C, Arnold RM, Fine MJ, Zickmund SL. Informed consent to inguinal herniorrhaphy and cholecystectomy: differences between what surgeons say they discuss and what they actually do discuss. Paper presented at: Academic Surgical Congress; 2013 Feb 7; New Orleans, LA.

Related HSR&D Project(s)

• CDA 08-281 – Improving Surgical Informed Consent to Better Meet Patient Preference

Introduction: Much is written about the standards for informed consent, but little is known about what surgeons actually discuss during the informed consent process. We sought to describe surgeon attitudes about and practices of informed consent. Methods: We recruited participants from a general surgery clinic from October 2009 to August 2010. We included all patients presenting for possible surgical management of inguinal herniorrhaphy or benign biliary disease. We also included all attending surgeons, physician assistants (PAs) and surgical residents staffing the clinic. We gave the patients portable audio recorders to capture the discussions during their clinic visit. We also recorded semi-structured telephone interviews with the provider participants that explored how they approached the process of informed consent. For each set of recordings (e.g., provider interviews and patient-provider discussions), we developed codebooks using the "editing style" approach to qualitative analysis, developed by Crabtree and Miller for use within medical settings. Two trained analysts independently listened to each set of recordings and coded the responses using the appropriate iteratively derived codebook. We then summarized the frequencies of codes as a proportion of the respondents and linked the codes to representative quotations. Results: We recorded the patient-provider discussions from a cohort of 73 consecutively enrolled patients. We also enrolled 15 residents, 5 chief residents, 3 physician assistants, and 2 staff surgeons. Mean Kappa across all codes was 0.96 for the provider interviews and 0.93 for the patient-provider discussions, representing what Landis and Koch describe as "almost perfect" agreement between the qualitative analysts (0.81-1.00). When asked what kinds information they routinely discuss during the consent process, most providers mentioned risks (100%) and benefits (95%), and slightly less mentioned alternatives (84%), surgical technique (84%), logistics of care (79%) and typical patient experience (68%). However, in the recorded patient-provider discussions, providers frequently discussed risks (92%), technique (90%) and logistics (82%), but they discussed a benefits (36%), and alternatives (54%) much less frequently. Conclusions: Most of these providers demonstrated awareness of the common legal and ethical standards for discussing risks, benefits, and alternatives during the process of informed consent. However, in practice, they focused primarily on risks and surgical technique, frequently omitting discussion of the benefits and alternatives of the procedures. Reasons for this discrepancy are unclear. Providers may be responding to patient preferences for less information, but further research is needed to determine if the discrepancy requires action, and if so, what kinds of action would most effectively support high quality informed consent.