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Are you raising false hopes? | |||||
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Medicine is all about probabilities—the probability of a calcium channel blocker averting a stroke, of a Pap smear detecting abnormal cells, of a Botox injection making it difficult to swallow. Here's one more probability: When a patient is surprised and upset by a treatment failure or complication, he may sue you, even though you're not at fault. That's all the more reason to carefully approach informed consent, that exam room ritual of securing a patient's permission for a test or treatment after discussing its benefits, risks, and alternative measures. If you help a patient form reasonable expectations about a course of action, he's not only in a better position to say Yes or No, but he's also less likely to legally retaliate when medical results are less than perfect, says San Francisco GP and JD Dan Tennenhouse, co-author of Risk Prevention Skills for Physicians. "The surprised patient is often an angry patient who mistakenly assumes that a bad outcome shouldn't have happened and his doctor therefore must have done something wrong," says Tennenhouse, who lectures on healthcare legal issues at the University of California, San Francisco, and in Kaiser Permanente facilities. "So he sues for malpractice, but the root of the lawsuit is in the informed consent process." To help you avoid this debacle, we've identified ways that doctors inadvertently lead patients to expect too much from proposed treatment, as well as stratagems to set patients straight. Odd beliefs about odds, and other challenges "The risk of this complication is low, Mrs. Jones." That sounds like good informed consent, doesn't it? Unfortunately, what you mean by "low" and what Mrs. Jones means by "low" may be two different things, says John Paling, educator and author of Helping Patients Understand Risks. "A doctor performing a kidney transplant may think that odds of 1 in 100 for a complication represent a low risk, while a patient may think they're huge." Paling preaches the importance of establishing common linguistic ground. He suggests that doctors peg risk descriptors to a range of odds; such as 1 in 1,000 to 1 in 10,000 for "low" and 1 in 100,000 to 1 in a million for "minimal." Doctors, in turn, could share these standards with patients. Descriptive words alone aren't sufficient for informed consent, he says, and should be complemented by some statistical expressions of risk. That's familiar territory for doctors who are taught to think like scientists. However, patients may be less well-schooled, so doctors must guard against statistical misunderstandings, too, says Paling. "If you tell patients the odds of Complication A are 1 in 250 and the odds of Complication B are 1 in 25, many will view the second complication as less likely, because the denominator is lower," says Paling. Always compare risks in terms of a common denominator—4 in 1,000 vs 40 in 1,000, for example. Likewise, put expressions of relative risk such as "Drug XYZ reduces the chances of such and such disease by 50 percent" into context, he says. A patient may find this benefit compelling, but for a better understanding, he also needs to hear about the absolute risk. How many people in 10,000 normally contract the disease when untreated, and how many do so on the medication? Let's assume the medication reduces the number from 2 in 10,000 to 1 in 10,000. A patient may have second thoughts about taking it, particularly if it comes with a high risk of debilitating side effects. A visual aid can simplify explanations of absolute risk and its dizzying numbers. Paling has devised a notepad-sized visual aid dubbed the Paling Palette with 1,000 tiny icons of the human body. To display the annual risk of breast cancer for women on estrogen-progestin hormone therapy, you'd circle four icons, compared to three icons for women on a placebo. Or, you could devise your own way to graphically illustrate the risks. "Using a picture crosses the language barrier as well as builds up a patient's trust in the doctor—she cared enough to make things clear," says Paling. Expressions of absolute risk may not mean much if you don't relate them to everyday hazards, Paling adds. The annual risk of a pedestrian getting killed by a motor vehicle, for instance, is 2 in 100,000, according to the National Safety Council. Knowing that, a patient may feel more comfortable about undergoing a procedure with the same odds of a serious complication. However, it's imperative to make accurate comparisons. You don't want to compare a lifetime risk to an annual risk, for example. And beware off-the-cuff "guesstimates," adds Dan Tennenhouse. "A doctor told a young man facing surgery that the chances of him ending up a paraplegic were as unlikely as having an accident while driving from San Francisco to Modesto," says Tennenhouse. "The man consented to the surgery, and unfortunately, it left him a paraplegic. "He sued the surgeon for lack of informed consent and won a million-dollar verdict. His attorney argued that while the odds of paralysis following surgery were about 2 or 3 percent, the odds of an accident on that particular stretch of highway were more like one in a million." Cautious optimism, but not wild optimism Even if you clearly communicate the benefits and risks of medical treatment with statistics, visual aids, and apt comparisons, you still can raise unreasonable expectations with a well-meaning blanket reassurance. It's natural to want patients to feel confident about a treatment you recommend, says Dan Tennenhouse. But you don't want to set up anyone for an unpleasant surprise. Consider a patient facing knee surgery. You'd be overpromising, Tennenhouse says, if you say that, after the surgery, the knee would be as good as new, or normal, or just as good as the other one. "The prudent thing to say would be 'substantially improved.' " Likewise, don't soft-pedal complications with statements like "It's a routine procedure and you can expect to do just fine" or "It's a safe procedure and nothing much ever goes wrong." You're on the right track, says Tennenhouse, with a statement like "You can be optimistic. Serious complications aren't common." Learning the right things to say is just as important for your employees. "A patient could ask the receptionist, 'I'm going to have this procedure. Should I be worried?' " says Tennenhouse. "If the receptionist says 'Dr. Jones has never had a problem with that before,' she's undone everything you've tried to accomplish." Some doctors worry that the informed consent process, with all the gory details laid out, could scare away patients from a needed test or treatment. However, patients desire more information than you might imagine. A study published in 2001 in the Archives of Internal Medicine reported that 76 percent of patients want doctors to disclose all possible adverse effects of a medication, regardless of their rarity, and this percentage generally held for all demographic groups, such as seniors. When warranted, cautious optimism is never out of place in the exam room. John Paling says that besides pointing out that five patients in 1,000 experience a side effect, a doctor also can add that the other 995 don't. That's a technique called "positive framing." Caution—never engage in either positive or negative framing alone, which may unduly influence a patient. Some doctors go a step further and frame a medical option in personal terms, especially if the patient asks, "What would you do?" "You can say that you'd be comfortable with your mother undergoing a particular treatment, if you truly feel that way," says FP Tripp Bradd in Front Royal, VA. The ultimate decision about taking this medication or having that surgery lies with the patient. Do informed consent correctly, and he'll probably be prepared for all of medicine's good and not so good probabilities.
What's the right thing to tell a worried patient? You're about to prescribe a new medication with rare, but serious side effects for your patient. After you explain the risks, the patient asks, "Should I be scared of this drug?" What should you say? GP and malpractice expert Dan Tennenhouse offers these guidelines: Avoid exaggerated reassurances: "This drug is very safe. It hasn't harmed anyone." "This drug has been tested extensively. It's about as safe as they can make it." Avoid undermining the patient's confidence: "The medicine probably won't cause any problems for you." "I can't promise anything about this drug, but it seems pretty safe." Use a phrase that is neither overly optimistic nor discouraging: "The serious side effects that I described are possible, but unlikely."
Want to know more? Consult your malpractice carrier for guidance on informed consent. Its website may carry articles on the subject as well as procedure-specific consent forms that feature more-detailed information than all-purpose consent forms. The book Risk Prevention Skills for Physicians by Dan J. Tennenhouse, Mary P. Kasher, and Linda M. Harvey devotes a chapter to informed consent. It's available from Horizon Consulting Group (www.dentalriskprevention.com) for $99, plus $9.25 for shipping. The Risk Communication Institute www.riskcomm.com sells John Paling's Helping Patients Understand Risks for $29.95, plus $2 for shipping. To help patients weigh the pros and cons of a medical treatment, give them the Ottawa Personal Decision Guide, available free of charge at decisionaid.ohri.ca/decguide.html from the Ottawa Health Research Institute. You can find similar guides at WebMD (www.webmd.com) by searching the website with the term "Decision Point topics." |
