Can A Conversation Change An Outcome?

Keeping with our recent theme of story, narrative and film as powerful patient safety education tools, the second day at the Telluride Patient Safety Summer Camp finished with the residents viewing the award-winning film, The Faces of Medical Error…From Tears to Transparency: The Story of Michael Skolnik. The film addresses the important differences between informed consent and shared decision-making–important differences as they relate to open and honest communication in healthcare. The movie asks the question “Can a conversation change an outcome? Can a conversation save a life?” Through Michael’s clinical course and resulting outcome, viewers understand and appreciate that a shared decision-making conversation can change an outcome and save a life.

After watching the film, residents engaged in a two-hour conversation with faculty and safety leaders on issues related to informed consent and shared decision-making. The audience engagement in discussions and the consensus building that follows a film like The Story of Michael Skolnik are always lively and very educating. One of our residents, Todd Guth, posted a great reflection on the session at the Transparent Health blog. Here is an excerpt from that post:

Informed consent is a shared decision-making opportunity between patient and physician.  At its core, informed consent is a conversation with the goal of allowing the patient to ask questions and hopefully come away with a clear understanding of the procedure to be performed, as well and the risks and benefits of the procedure. Procedures, diagnostic tests, and medications can all be conversations that are pursued with patients under the vigilance of informed consent.

While the conversation is the essential element of informed consent, the informed consent paperwork can serve as both a checklist for the provider and a physical reminder to the patient that we are discussing potential harm and the physician will need the patient’s approval before pursuing any potentially risky treatment plans.

A discussion about informed consent to the level of detail that we had today needs to be part of all residency training in the first days of orientation and as refresher training later on in training.  All physicians can, and should, do much better in providing informed consent.

At the end of the session, Paul Levy asked the residents how much informed consent training they receive during medical school and residency. With a show of hands, every resident acknowledged the three-hour session on informed consent/shared decision-making at the Telluride Summer Camp was more training than they received during their entire medical school and residency combined. We all agreed this was a sad commentary on the current state of medical education in areas of patient centered care, and the data around informed consent taking place in hospitals is also discouraging. According to a March 2010 JAMA article written by Harlan Krumholz MD, Harold Hines Jr. Professor of Medicine (Cardiology) at Yale University, informed consent documents from 157 randomly selected US hospitals were shown to have limited educational value. Krumholz also shares results from two additional studies which found almost 70% of surgical patients studied did not read the informed consent form, and that many patients misunderstand the benefits and risks of their procedure altogether.

We cannot achieve a true partnership with our patients unless we have meaningful shared decision-making conversations that include a full understanding of a patient’s needs, preferences, values and goals. I echo Todd’s reflective assessment – All physicians can, and should, do much better in providing informed consent.

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