Patient informed consent?

Patient informed consent?
BitterCrank
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#11 - Quote - Permalink
Posted Feb 9, 2013 - 10:48 AM:

greencart wrote:
Thank you very much.

And what do you think about an argument that if patients are to decide there will be hardly any learning going on as everyone tends to want experienced doctors and not residents to receive treatment from?


I don't think patient refusal is a big problem. I've had other skin cancers removed since and in two instances a student did the removal and I felt fine about them doing it. But the one I refused on was kind of large, and it was a first for me.

The consent form the university clinic uses states that medical students participate in diagnosis and treatment at the discretion of the supervising doctor, not at the discretion of the patient. So, even though the students ask first, I think if the doctor wanted them to do something, the MD would intercede on behalf of the student.

You know, experienced doctors don't ask their patients whether they can do x, y, or z; they just tell the patient that we are going to do x, y, or z, and do you have any questions about it. After all, consent has already been given before one sees the doctor.

I know of a couple of instances where a cancer patient refused a treatment and the doctor declined to see the patient in the future.
prothero
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#12 - Quote - Permalink
Posted Feb 10, 2013 - 8:25 AM:

richrf wrote:
More than informed consent, I believe that patients should be much better informed about what they are getting into.

How to Stop Hospitals from Killing Us

"The world of American medicine is far deadlier: Medical mistakes kill enough people each week to fill four jumbo jets. But these mistakes go largely unnoticed by the world at large, and the medical community rarely learns from them. The same preventable mistakes are made over and over again, and patients are left in the dark about which hospitals have significantly better (or worse) safety records than their peers."

Medical Errors - A Leading Cause of Death



By far and away the vast share or number of adverse outcomes in the medical care system are due to the natural progression of disease not due to medical errors or errors in decision making, procedures and treatments. So the fact that a patient dies or suffers an adverse or less than optimal outcome from a treatment or a procedure is not de facto evidence of medical malpractice or medical error. If should be remembered people are living longer, healthier and surviving diseases and Injuries which just a few decades ago would have been uniformly fatal, crippling or permanently disabling.


Having said this, it is clear that some errors in medical care and decision making do result in patient injury, less than optimal outcomes and even patient deaths. Some of these errors are errors of omission (failure to properly diagnose, failure to properly treat) probably the most common errors. A smaller number of errors are errors of commission: improper performance of a procedure or an attempt to perform a procedure for which one lacks the proper equipment, training or skill.


With respect to errors the current system largely relies on punitive measures in an effort to prevent them (revoking or restricting licensure, removing hospital or operating room privileges, malpractice attorneys and law suits). One should reflect on whether such systems are the best way to achieve the desired results of fewer errors and fewer adverse outcomes. Do we wish to punish errors or prevent them? Do we wish to fix the blame or to prevent the problem? Systems which rely on punishments do not encourage people to admit errors, to bring errors to the attention of others or to make the necessary changes in procedures and systems which systematically reduce the incidence of errors. Many (most) errors are in fact systematic and repeated errors and are in fact preventable but only through a process of full disclosure and shared experience and information.

There are rouge and incompetent physicians no doubt but by far and away the largest number of preventable adverse outcomes are the result of failures in systems and in information sharing and the solution lies not in lawsuits and punishments but in redesigning processes and systems and in greater disclosure and information sharing.
prothero
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Posted Feb 10, 2013 - 8:27 AM:

greencart wrote:
Thank you very much. It's all true. And the consent is not only to waive responsibility - is it ethical to "use" a patient to "train" the resident? (it is a fact that residents make more mistakes)

The surgeon situation is just an illustration to the general case where:

1) medical service is delivered by a resident who are qualified to do the intervention, yet that is his first time actually doing that,
2) he is assisted by an experienced md, but it does not change the thing that less experienced one can do harm that more experienced will not do.

So the conflict may be between the ability to deliver top notch service versus the ability to learn how to practice in an environment where people in general will choose a more experienced doctor - if they are asked.

So as it is easier to find arguments for asking people's consent (and ethical guidelines are full of those), I'd like to ask for arguments against too, if you can come up with any.


Informed consent does not prevent medical errors or adverse outcomes as a result of disease progression. In fact informed consent is largely a legal concept and much less of a philosophical and ethical concept. A physician cannot impart to a patient a full knowledge of the risks and benefits of proposed treatment, the nature of your disease and all possible complications or your treatment or procedure. Your physician generally (hopefully) has years of training and experience only a small portion of which can he convey to you in a short conversation or on a page long written document which serves as the legal protection of …informed consent". Although patients should be encouraged to investigate their options and learn about their disease and proposed treatments; a few weeks on the internet or in second opinions is not going to bring you up to speed with your doctors knowledge and experience base. If you do not trust your doctor get another one but do not expect to fully grasp what others have acquired over years of experience.

With respect to the question in the OP, the patient has every right to inquire into the physician’s degree of training, experience and skill for the proposed procedure or treatment. Not all physicians have the same experience with particular diseases or procedures and if your condition is a rare or unusual one or the procedure is a rare and complicated one you would be wise to seek out a physician highly experienced with your condition. Most physicians stick to procedures with which they are comfortable and have considerable experience. Surgical training is long and hard and physicians in training are given a graduated scale of responsibilities always under the supervision of a more experienced physician. First you hold the retractor, then you get to close the incision, later you might make the incision; at some advanced point in your training you do the procedure under the watchful eye of a senior physician. Only when you are judged to be fully competent and experienced and have performed a procedure multiple times under supervision would you be allowed to operate as the senior physician yourself. Most physicians do not mind polite inquiries into their level of experience and training. They do have a concern if it looks like the patient completely lacks trust and confidence in their abilities and under those circumstances might think the patient physician relationship is less than optimal. Patients have a right to be and need to be their own advocates but they also need to acknowledge the complexity of the problems and the fact that you and your doctors largely share the same goal of maintaining or restoring your health. Medicine is largely a cooperative venture not an adversarial or confrontational venture.
richrf
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#14 - Quote - Permalink
Posted Feb 10, 2013 - 8:38 AM:

prothero wrote:


By far and away the vast share or number of adverse outcomes in the medical care system are due to the natural progression of disease not due to medical errors or errors in decision making, procedures and treatments.


I think you missed the point of the articles. The articles are talking about medical errors not natural progression. Tens of thousands of people are literally killed every year in hospitals due to medical errors. This does not include the amount that have been permanently injured in hospitals nor does it include the number who suffer from permanent harm from out-of-hospital procedures or phamaceuticals:

Opiod drug champion has second thoughts - Wall Street Journal

"Opioids are also behind the country's deadliest drug epidemic. More than 16,500 people die of overdoses annually, more than all illegal drugs combined."

"Earlier this year, he [Portenoy] said, he asked his mother whether she would stop taking her hydrocodone as part of a scientific study. She said no.

"How difficult is it for her to get off these drugs?" Dr. Portenoy asked. "You have no idea and neither do I, because no one knows."

Modern medicine is probably the leading cause of premature deaths in this country.

Edited by richrf on Feb 10, 2013 - 8:45 AM
prothero
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Posted Feb 10, 2013 - 11:42 AM:

richrf wrote:


I think you missed the point of the articles. The articles are talking about medical errors not natural progression. Tens of thousands of people are literally killed every year in hospitals due to medical errors. This does not include the amount that have been permanently injured in hospitals nor does it include the number who suffer from permanent harm from out-of-hospital procedures or phamaceuticals:

Opiod drug champion has second thoughts - Wall Street Journal

"Opioids are also behind the country's deadliest drug epidemic. More than 16,500 people die of overdoses annually, more than all illegal drugs combined."

"Earlier this year, he [Portenoy] said, he asked his mother whether she would stop taking her hydrocodone as part of a scientific study. She said no.

"How difficult is it for her to get off these drugs?" Dr. Portenoy asked. "You have no idea and neither do I, because no one knows."

Modern medicine is probably the leading cause of premature deaths in this country.


Starfield JAMA article: Barbara Starfield's JAMA article (Volume 284, No. 4, 2000), gives very large estimates of death due to medical treatment. A total of 225,000 deaths are attributed to various iatrogenic causes. This figure puts them at the 3rd highest cause of death, only after heart disease and cancer. With roughly 2.4 million US deaths in 1999, these estimates would put iatrogenic causes at approximately 9.3% of deaths.


However, not all of these deaths are necessarily from "mistakes" with 106,000 deaths due to "nonerror adverse events of medications". In other words, people had adverse reactions to a medication but it was not an error because they had no previous indication of a risk factor. Another 80,000 deaths are attributed to nosocomial infections, which are also not necessarily due to a particular "error" since there is always a risk of infection in hospitals. Her report also cites 12,000 deaths from unnecessary surgery, 7,000 deaths from medication errors in hospitals, and 20,000 deaths in hospitals from causes other than medication errors.


In a perfect world no one would ever have a fatal adverse drug reaction nor acquire a fatal infection but we do not live in a perfect world. These deaths included as the majority of deaths due to …medical treatment" are not necessarily due to medical …error" nor is it clear they are preventable. The notion that medicine is killing more patients than it saves and that receiving care is more likely a threat to your health than something that prolongs your life and improves your quality of life is a serious failure of risk assessment, something which Americans in particular seem prone to. Doctors do overprescribe, over test and over treat and some of these interventions result in patient injury but the vast majority of deaths due to medical treatment are not due to medical error nor is it clear how many are preventable.
BitterCrank
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Posted Feb 10, 2013 - 12:04 PM:

I've seen adverse outcomes up close, and you know, it isn't always glaringly obvious that a "mistake" was made -- like cutting off the wrong hand, which is pretty obvious. Someone walks in with a cancer, a cyst, or...something -- it isn't clear. Sometimes diseases don't present clear symptoms. Diagnosis and treatment could go in several directions, and each one offers opportunity for error, maybe fatal error.

Patients sometimes live with symptoms for quite some time (they don't know what the cause is, and it isn't necessarily clear to them what the problem is). When they see a doctor, it may be too late to prevent serious damage or death. Quite often doing nothing turns out to be an OK approach. The pain goes away and never comes back.

Really, it's surprising that more people don't die in hospital, not because hospitals are run by morons but because a hospital is a terrifically complex operation where people might make mistakes, systems might fail, and when they do the results can be catastrophic.

One of the most effective methods of reducing errors turns out to be check-off lists: Confirm that the prospective drug can be prescribed safely; confirm that the drug prescribed is the drug in hand; confirm who this patient is before administering a drug. Confirm that the chart has been checked. Then administer the drug. Confirm that the latest drug has been properly charted.

Check off lists in surgery can help prevent big errors there too.
prothero
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Posted Feb 10, 2013 - 2:11 PM:

BitterCrank wrote:
I've seen adverse outcomes up close, and you know, it isn't always glaringly obvious that a "mistake" was made -- like cutting off the wrong hand, which is pretty obvious. Someone walks in with a cancer, a cyst, or...something -- it isn't clear. Sometimes diseases don't present clear symptoms. Diagnosis and treatment could go in several directions, and each one offers opportunity for error, maybe fatal error.

Patients sometimes live with symptoms for quite some time (they don't know what the cause is, and it isn't necessarily clear to them what the problem is). When they see a doctor, it may be too late to prevent serious damage or death. Quite often doing nothing turns out to be an OK approach. The pain goes away and never comes back.

Really, it's surprising that more people don't die in hospital, not because hospitals are run by morons but because a hospital is a terrifically complex operation where people might make mistakes, systems might fail, and when they do the results can be catastrophic.

One of the most effective methods of reducing errors turns out to be check-off lists: Confirm that the prospective drug can be prescribed safely; confirm that the drug prescribed is the drug in hand; confirm who this patient is before administering a drug. Confirm that the chart has been checked. Then administer the drug. Confirm that the latest drug has been properly charted.

Check off lists in surgery can help prevent big errors there too.


My aunt refused to go to the world reknown local medical center and university because some people she knew had died there. It did not seem to occur to her that the reason they went there and were hospitalized is because they had advanced and life threatning disease to start with.

There is no doubt errors in diagnosis and treatment occur and that some patients are injured and that we should take all reasonable measures to prevent this.

My objection is to the assertion that medical errors as opposed to complications of medical treatments are a leading cause of death. Such assertions grab attention and headlines but are not based in any kind of good scientific analysis. Cancer patients no doubt die as a result of their chemotherapy but is that an error or a complication of treatment for a life threatening disease. When one removes unpredictable drug reactions and infections (some but not all preventable) the numbers look quite different.

People are overtreated in the U.S. The reasons are complex but relate to the fact that we have a fee for service system, failure to diagnosis or perform a test is a frequent complaint in lawsuits and patients often insist on being treated and investigated for even minor complaints. We spend at least 50% more on health care than other first world countries and statiscally (longevity, infant mortality, etc.) have little to show for it. Every drug and every treatment carries its own risk in addition to the risk of the condition being treated.
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#18 - Quote - Permalink
Posted Feb 10, 2013 - 4:23 PM:

hyena in petticoat wrote:
I'm not very sure about this, but aren't new doctors assisted by experienced ones during surgery? Before which they assisted experienced doctors to gain exposure on how things are done in actual? Before which they studied extensively and passed licensure exams to ensure they are qualified to do their job?

I wouldn't say they have limited qualifications, only there are doctors who are more experienced.


This is exactly right, at least here in Australia. With the exception of very rare operations, you will first watch several at close quarters, then do several under the close supervision of an experienced surgeon, who can instantly intervene to prevent you cutting something you shouldn't should you show any signs of doing so. So by the time you do the operation unsupervised by somebody more experienced, you are already pretty experienced yourself.

You can't do this for very rare operations on rare conditions. But the patient will always be made aware in that case that the surgery is in a sense 'experimental', and will usually only choose to go ahead if the risks of not doing so are greater.

By the way, the exact same question applies to commercial pilots of passenger aeroplanes. Anyone that flies frequently has probably at some stage, unbeknown to them, been in a plane in which the pilot with primary control of the landing was doing that (having primary control) for the first time. But I bet they didn't announce that over the PA!

The pilot will have gone through the same process of building up experience under supervision as the surgeon. Flight simulators add an extra dimension of safety for training commercial pilots, but surgical simulators are probably not far away in the future, and I think some may already be here.
On Feb 11, 2013 - 8:14 AM, prothero responded: How else could it or should it be done? Supervised practice and acquired experience.
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#19 - Quote - Permalink
Posted Feb 12, 2013 - 6:58 PM:

The problem of the scenario is that we have to define what is "pertinent information". One large problem we will run into is whether or not a person who is about to go 'under the night' is capable and fit to decide upon a doctor better than a board of supervisors or a director of a hospital.

This will likely run into the conclusion that those 'in the know' of what a surgeon must possess by way of skills are more capable than the person being operated on.

That conclusion will run directly into the consideration "what of their right to their own body? Shouldn't one have the final say."

Toward that consideration that we can either withhold in a paternal action of "not worrying those who ought not be worried" OR we can say that they do retain the final say and do so at their own peril.

There are also so many considerations to exact scenarios that we can come up with a large array of probable outcomes that fit said scenes but not others.

In the end, you have posed a complicated question that likely has to take a considerable amount of conceptualizing before it can be answered.
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