Informed Consent in Facial Plastic Surgery

The Primacy of Ethics in Aesthetic Medicine: A Review

Background

The landscape of modern aesthetic medicine has witnessed a paradigm shift from traditional doctor-led care to a consumer-driven model, presenting a plethora of ethical challenges. This review discusses the ethical dimensions of medical aesthetics, exploring the implications of consumer demand, societal influences, and technological advancements on patient care and well-being.

Methods

Drawing upon a comprehensive analysis of existing literature, this review synthesizes evidence regarding the rise of aesthetic medicine, ethical challenges encountered in practice, and the implications of social media and marketing in shaping patient perceptions and decision-making.

Results

Aesthetic medicine confronts unique ethical challenges stemming from its elective nature and the pervasive influence of societal beauty standards. Concerns include the commodification of beauty, conflicts of interest, limited evidence-base of treatments, and the rise of nonphysician providers. Moreover, the evolving role of social media influencers and medical marketing raises ethical dilemmas regarding transparency, patient autonomy, and professional integrity.

Conclusions

The ethical landscape of aesthetic medicine necessitates a proactive approach to address emerging challenges and safeguard patient well-being. Guided by principles of autonomy, beneficence, nonmaleficence, and justice, recommendations are proposed to enhance informed consent practices, mitigate appearance anxiety, facilitate shared decision-making, and promote responsible use of social media. Professional societies are urged to establish clear ethical guidelines and standards to uphold professionalism and patient trust in the field of aesthetic medicine.

Triangulation of a Needs Assessment on High-Tone Pelvic Floor Dysfunction

IMPORTANCE

High-tone pelvic floor dysfunction is a complex condition that is challenging to manage effectively. Pelvic floor physical therapy (PFPT) is often used in the treatment and relies on a coordinated effort between the physician, patient, and physical therapist. Collaboration is crucial for therapy success, but there is limited research that includes personal perspectives from these individuals.

OBJECTIVE

The objective of this qualitative study was to gain further insight from these groups to identify areas for improvement in patient counseling and understanding of the diagnosis of high-tone pelvic floor dysfunction and the role of physical therapy.

STUDY DESIGN

The following participants were recruited: urogynecologists, pelvic floor physical therapists, and patients. Semistructured interviews were conducted exploring participant experiences with therapy and management of the condition and surrounding phenomena.

RESULTS

Participants interviewed included 5 urogynecologists, 5 pelvic floor physical therapists, and 15 patients. Similarities in key themes were identified: (1) the usefulness of pelvic models and illustrations in counseling, (2) appropriate descriptions of therapy, (3) motivating factors for patients, and (4) patient barriers to completing therapy. Several emergent themes revealed a misalignment in perspectives, including (1) patients reporting an unclear understanding of PFPT, (2) patient unawareness of the intimacy of therapy, and (3) reports of unsupportive and unempathetic physician providers.

CONCLUSIONS

There are both similarities and discrepancies in the perspectives among physicians, pelvic floor physical therapists, and patients regarding high-tone pelvic floor dysfunction and PFPT. Acknowledging these comparisons and adapting practices could facilitate patient-centered care and improve patient understanding of their diagnosis.

Association of Practice Setting and Scholarly Activity With Medicolegal Claims in Otolaryngology-Head and Neck Surgery

OBJECTIVE

To characterize the association between scholarly activity, academic rank, practice setting, and malpractice claims among otolaryngologists over the past decade.

METHODS

Data was extracted from the two legal databases, WestLaw and LexisNexis. The records were obtained from January 2010 to January 2020. Scopus and PubMed databases were used to identify bibliometric data.

RESULTS

Of the 102 malpractice cases identified, 77.5% (N = 79) were ruled in favor of the defendant, 13.7% (N = 14) in favor of the plaintiff, and 8.8% (N = 9) were settled outside of the court. A total amount of $46,533,346.82 was rewarded to plaintiffs in 14 cases. Endoscopic sinus surgery was the procedure associated with the most malpractice claims (N = 16). Alleged improper performance (N = 51) was the most common underlying reason for litigation. Of the 102 defendant surgeons, 82 (80.4%) were in community/private settings. Among the 14 cases in that a surgeon was found at fault, 13 (92.8%) were in the community/private setting. Among the surgeons with at least one publication, the mean Hirsch Index (h-index) was 8.2. There was a statistically significant correlation between the mean h-index and litigation outcome (95% CI: -8.9 to -0.9, P = .017).

CONCLUSION

Our analysis showed that most malpractice litigations were among otolaryngologists practicing in community/private settings. We also found that higher scholarly activity measured by the h-index was associated with verdicts in favor of the defendant/surgeon. This study was limited by not all-inclusive aspects of the legal databases that were used, the small sample size, and the lack of multivariable analysis.

Influence of a Preadmission Procedure-Specific Consent Document on Patient Recall of Informed Consent at 4 Weeks After Total Hip Replacement: A Randomized Controlled Trial

OBJECTIVES

Consent is a legal and ethical requirement for undertaking surgical procedures; however, the literature suggests that there continues to be poor recall among patients of the surgical risks discussed during the consent process. The aim of this study was to evaluate whether the addition of a preadmission procedure-specific consent document would improve patient recall of surgical risks at 4 weeks after total hip replacement in patients consented with a procedure-specific consent form.

METHODS

A prospective randomized controlled trial allocated seventy adult patients who were undergoing a primary total hip replacement to either receive (intervention group) or not receive (control group) a preadmission procedure-specific consent document. All patients were also consented with a procedure-specific consent form on the morning of surgery and were contacted 4 weeks later to assess recall of surgical risks.

RESULTS

There was a very poor recall rate seen in both the intervention group (16%) and the control group (13%), with no statistically significant difference between them (P = 0.49). A large number (30%) of patients could not recall a single risk. A subgroup analysis excluding these "consent nonresponders" did show a significantly increased recall rate in the intervention group (24.5% versus 18.25%, P = 0.02).

CONCLUSIONS

Patient recall of potential complications of total hip replacement was poor despite the intervention. Although not effective overall, the use of a preadmission procedure-specific consent document did improve recall of potential complications of surgery in a subset of patients. The phenomenon of consent nonresponders is worth exploring in future research.

Litigation Arising From Minimally Invasive Cosmetic Procedures: A Review of the Literature

BACKGROUND

Minimally invasive cosmetic procedures are on the rise. To meet this rising demand, increasing numbers of physicians and nonphysicians are performing these procedures. Understanding malpractice trends and reasons for litigation in cosmetic medicine is important to establish safeguards for patient care and minimize liability.

OBJECTIVE

Perform a comprehensive review of the literature on litigation associated with minimally invasive cosmetic procedures and discuss strategies to avoid facing a lawsuit.

MATERIALS AND METHODS

The authors searched PubMed databases using a variety of keywords to identify studies of lawsuits arising from minimally invasive cosmetic procedures through December 2020.

RESULTS

A total of 12 studies of litigation meeting inclusion criteria were identified: botulinum toxin (1), soft tissue fillers (3), lasers (5), body contouring/liposuction (1), chemical peels/dermabrasion (1), and sclerotherapy (1). Principle factors associated with litigation included negligence, lack of informed consent, vicarious liability for action of delegates, lack of communication, poor cosmetic result, failure to inform of risks, inappropriate treatment or dose, and failure to recognize or treat injury.

CONCLUSION

Understanding malpractice trends and reasons for litigation in minimally invasive cosmetic procedures can strengthen the patient-provider relationship, establish safeguards for patient care, and may minimize future risk of a lawsuit.

The Impact of the Informed Consent Process on the Anxiety Levels of Patients Undergoing Rhinoplasty

ABSTRACT

Septorhinoplasty is one of the most common elective surgical procedures in otolaryngology. The present study aimed to evaluate the anxiety levels of patients who underwent septorhinoplasty at different times, compare the information methods, and determine the understanding of the informed consent through recall rates of the complications explained in the informed consent process. The patients were divided into the following 2 groups: Group 1 (giving information 14 days before the surgery) and Group 2 (giving information 3 days before the surgery). For the preoperative anxiety measurement, the State anxiety scale of the State-Trait Anxiety Inventory (STAI) was used. All patients were asked to recall the complications they remembered from the consent form on the day before the surgery. Each group has consisted of 25 patients. No significant difference was found between the STAI-1 and STAI-2a anxiety scores between groups. In Group 1, the STAI-2b anxiety score was significantly lower than the STAI-1 and STAI-2a scores (P < 0.05). In Group 2, the mean score of STAI-2b was not significantly higher than the STAI-1 and STAI-2 scores (P > 0.05). When the STAI-2b scores of the two groups were compared, the scores of Group 2 were significantly higher (P < 0.05). The most commonly remembered complications were bruising and swelling in both of the groups. In conclusion, the authors believe that long-term cooperation between the surgical team and the patient will reduce the anxiety levels of the patients and increase patients' satisfaction, resulting in a significant reduction in the amount of potential legal processes.Level of Evidence: 2.

Improving Surgical Informed Consent: Unanswered Questions

Objective

This study reviews randomized clinical trials that have attempted to improve the process of informed consent. Consent should be guided by the ethical imperatives of autonomy, beneficence, and social justice.

Summary Background

Informed consent is constantly evolving. Yet our review of the randomized trials done to improve the surgical informed consent process raises a number of questions: How does one define surgical informed consent? What interventions have been tried to measure and improve informed consent? Have the interventions in informed consent actually led to improvements? What efforts have been made to improve informed consent? And what steps can be taken to improve the process further?

Methods

A literature search for randomized controlled trials (RCTs)on informed consent identified 70 trials. Demographics, interventions, assessments, and a semi-quantitative summary of the findings were tabulated. The assessments done in the RCTs, show the surrogate for patient autonomy was comprehension; for beneficence, satisfaction and mental state (anxiety or depression); and, for social justice, language, literacy, learning needs, and cost.

Results

There were 4 basic categories of interventions: printed matter; non-interactive audiovisual tools; interactive multimedia; and a smaller group defying easy description. Improvement was documented in 46 of the 65 trials that studied comprehension. Thirteen of 33 trials showed improved satisfaction. Three of 30 studies showed an increase in anxiety. Few studies tried to assess primary language or literacy, and none looked at learning needs or cost.

Conclusions

No single study improved all 3 principles of informed consent. Validated interventions and assessments were associated with greater impact on outcomes. All 3 ethical principles should be assessed; autonomy (as comprehension), beneficence (as satisfaction, anxiety), and social justice. Not enough consideration has been given to social justice; appropriate language translation, standardized reading levels, assessment of learning needs, and cost to the individual are all important elements worthy of future study.

Development and Assessment of a Video-Based Intervention to Improve Rhinoplasty Informed Consent

There has been a growing interest in improving the informed consent process to ensure patients truly understand the benefits, risks, and alternatives of their procedures. Herein, we sought to describe the production of an educational video to supplement the traditional rhinoplasty informed consent process. Additionally, we evaluate satisfaction and risk recall among prospective rhinoplasty patients who participated in the video-assisted informed consent process. One author attended 30 rhinoplasty consultations where informed consent was performed and generated 65 questions related to the benefits, risks, alternatives, and general knowledge of rhinoplasty operations. A video of the senior author answering these questions was filmed and edited to 25 minutes. Prospective rhinoplasty patients watched the video before their initial consultation and were asked to complete two surveys assessing their satisfaction with the video-assisted process as well as their ability to recall risks discussed in the video. Understandability and actionability of the video was assessed by three independent reviewers using the Patient Education Materials Assessment Tool. Postvideo surveys were completed by 40 patients. Patients strongly agreed that the video informed them about rhinoplasty risks and benefits (4.90/5.00), effectively answered their questions and/or concerns (4.78/5.00), and provided adequate information before surgery (4.85/5.00). Participants strongly recommended that all prospective patients watch the video prior to surgery (4.97/5.00). Participants on average correctly answered 4.00 ± 0.877 out of five risk recall questions. There was no statistically significant difference in risk recall performance between college graduates (4.19 ± 0.602) and those who did not graduate college (3.79 ± 1.08), p = 0.076. No significant correlation was found between patient age and recall performance (r = -0.011), p = 0.943. The overall mean understandability and actionability scores for the video were 100%. Video-assisted informed consent for rhinoplasty may enhance and overcome limitations to the traditional verbal consent process by ensuring comprehensive, standardized, and readily understandable information.

A Century in Review: Medicolegal Implications of Facial Nerve Paralysis

Importance: It is important to recognize factors that may mitigate the risk of a potential lawsuit and increase knowledge and awareness of physicians. Objective: To evaluate and characterize facial nerve paralysis litigation claims and related potential causes. Design, Setting, and Participants: These data were extracted from the two main computerized legal databases: WestLaw and LexisNexis. The data were queried on April 2, 2020. The records from 1919 to 2020 were obtained from a population-based setting. A total of 186 cases were included. Data were gathered for all alleged cases of facial nerve paralysis. Main Outcomes and Measures: There was a continuous rise in the amount of malpractice payments with the highest mean amount being in the past decade. Results: From 1919 to 2020, a total of 186 malpractice cases for facial nerve damage were identified. A total amount of $89,178,857.99 was rewarded to plaintiffs in 66 cases. The mean amount of paid malpractice claim was $1,351,194.80. Improper performance/treatment was the most common reason for alleged litigation (n = 97). This was followed by misdiagnosis/delayed diagnosis (n = 47), and failure of informed consent (n = 34). The highest number of malpractice claims with a total of 53 cases was from 1991 to 2000. The highest mean amount per payment was in the past decade (2011-2020) with a mean of $3,841,052.68. Conclusions and Relevance: Over the past century, improper performance/procedure, delayed/misdiagnosis, and failure of informed consent were the most common reasons for litigations related to facial nerve paralysis.

Aesthetic/Cosmetic Surgery and Ethical Challenges

Is aesthetic surgery a business guided by market structures aimed primarily at material gain and profit or a surgical intervention intended to benefit patients and an integral part of the health-care system? Is it a frivolous subspecialty or does it provide a real and much needed service to a wide range of patients? At present, cosmetic surgery is passing through an identity crisis as well as an acute ethical dilemma. A closer look from an ethical viewpoint makes clear that the doctor who offers aesthetic interventions faces many serious ethical problems which have to do with the identity of the surgeon as a healer. Aesthetic surgery that works only according to market categories runs the risk of losing the view for the real need of patients and will be nothing else than a part of a beauty industry which has the only aim to sell something, not to help people. Such an aesthetic surgery is losing sight of real values and makes profit from the ideology of a society that serves only vanity, youthfulness, and personal success. Unfortunately, some colleagues brag that they chose the plastic surgery specialty just to become rich aesthetic surgeons, using marketing tactics to promote their practice. This is, at present, the image we project. As rightly proposed, going back a little to Hippocrates, to the basics of being a physician, is urgently warranted! Being a physician is all that a ''cosmetic'' surgeon should be. In the long run, how one skillfully and ethically practices the art of plastic surgery will always speak louder than any words.

Does using anatomical models improve patient satisfaction in orthopaedic consenting? Single-blinded randomised controlled trial

BACKGROUND

Patient satisfaction in consenting is a major pillar of clinical governance and healthcare quality assessment. The purpose was to observe the effect of using 3D anatomical models of knee and shoulder joints on patient satisfaction during informed consent in the largest single-blinded randomised controlled trial in this field.

METHODS

52 patients undergoing elective knee or shoulder surgery were randomised into two groups when being consented. The intervention group (n = 26) was shown an anatomical model of the knee/shoulder joint while the control group (n = 26) was given only a verbal explanation without a model. Patients rated their satisfaction on the validated Medical Interview Satisfaction Scale (MISS-26) questionnaire. Semi-structured interviews were analysed for specific themes to determine key factors that influenced patient satisfaction. The mean score ±SD were calculated with significance set at p < 0.05.

RESULTS

There was a significant difference in the overall satisfaction between the control and intervention cohorts (MISS-26 score 4.33 [86.6%] ± 0.646 vs 4.70 [94.0%] ± 0.335 respectively, 7.4% improvement, 8.5% difference, p = 0.01). Behavioural criteria showed a 13% increase in satisfaction (p = 0.02). Semi-structured interviews determined that the factors influencing satisfaction included the surgeon's interpersonal manner, the use of the visual aid and seeing the consultant surgeon in clinic. All patients in the intervention cohort identified factors contributing to their satisfaction, whereas a fifth of the control cohort claimed nothing at all made them feel satisfied.

CONCLUSION

Anatomical models as visual aids significantly increased patient satisfaction during the consenting process and played an integral part of the surgeon's explanation. Patients exposed to anatomical models also claimed to be more satisfied with the surgeon's inter-personal skills. This study recommends the use of anatomical models, which are both cost-effective and easily implementable, during explanation and consent for orthopaedic procedures.

Evaluation of anesthesia informed consent in pediatric practice - An observation cohort study

Background and Aims

An informed consent requires active participation by both physicians and patients. It is the responsibility of the physician to give the complete disclosure of information in easy language for the parent to understand. An informed consent process can be a challenge especially for the anesthetists when time is a limiting factor for patient-anesthetist interaction especially in same day admission and day surgery. The aim of this study was to subjectively evaluate the understanding and recall of the informed consent by the parents.

Material and Methods

The validated survey was conducted over 10 weeks and was limited to one parent per child and to the parent who was directly involved in the consent process.

Results

Majority of parents rated positively for adequate disclosure of all items of information. Consent process done on day of surgery was found to be associated with lower parental rating in adequacy of disclosure of pain relief options. Seniority of anesthetists was associated with higher parental rating of adequacy of information regarding post operative plan, specific risk of child and overall consent process. Consent for minor surgeries, on day of surgery, did not significantly affect the parental performance in their recall of disclosed information but was associated with significant lower rating of adequacy of postoperative plan. Postoperative pain is among the areas for improvement especially in day surgery cases.

Conclusion

Consent taken on day of surgery was found to be associated with lower parental rating. Postoperative plan for pain required improvement especially in day surgery cases.

Improving informed consent in cardiac surgery by enhancing preoperative education

OBJECTIVE

To investigate the effect of enhancing preoperative education in improving recall and understanding of a surgical procedure and its application to the informed consent process in cardiac surgery.

METHODS

Four electronic database searches were performed from January 2000 to August 2017. A total of 282 articles were identified from which 22 prospective studies assessing an intervention were selected according to predefined selection criteria.

RESULTS

Most articles that used additional written information and all that used multimedia presentations to enhance informed consent showed that their intervention improved risk recall and patient's understanding of the procedure. A single randomised controlled trial in cardiac surgery showed that audiotaped consultations improved patient's knowledge of the operation.

CONCLUSIONS

Patient recall and understanding of pre-operative information can significantly improve with a variety of educational tools. Procedure-specific forms with or without illustrations as well as interactive multimedia interventions enhance patient recall and understanding of information. In cardiac surgery patients, interventions need to meet patients' preferences, be repetitive on crucial points and consider the nature of the procedure.

The Effect of Written Information on Recall of Surgical Risks of Primary Cleft Palate Repair: A Randomized Controlled Study

OBJECTIVE

To investigate parents' understanding of the risks of primary cleft palate surgery after counseling with and without the use of a written informational aid.

DESIGN

Prospective, randomized, single-blind trial.

SETTING

Academic tertiary care center.

PARTICIPANTS

Parents of children undergoing primary cleft palate surgery.

INTERVENTIONS

Parents were randomized to receive a standard informed consent discussion with or without provision of a written informational aid in the form of a pamphlet.

MAIN OUTCOMES MEASURE

Parents' recall of 9 specific surgical risks 3 weeks after informed consent discussion.

RESULTS

Forty parents enrolled in and completed the study (20 participants each in the control and intervention groups). There were no statistically significant differences between groups in terms of baseline demographics. The mean number of risks recalled were 3.7 (1.6) for the control group and 4.2 (1.9) for the intervention group (P = .37). The most commonly recalled risks were fistula formation and bleeding, while the least frequent were facial growth restriction and need for further surgery. No differences in risk recall were observed based on participant's gender, level of education, or income.

CONCLUSION

Parents of children undergoing primary cleft palate surgery recall less than 50% of counseled risks. The use of a written aid in the form of a pamphlet did not significantly improve recall in this sample. These results demonstrate that surgeons should implement additional measures to improve comprehension of surgical risks.

The efficacy of mobile application use on recall of surgical risks in nasal bone fracture reduction surgery

Background

The number of surgical risks recalled by a patient after surgery can be used as a parameter for assessing how well the patient has understood the informed consent process. No study has investigated the usefulness of a self-developed mobile application in the traditional informed consent process in patients with a nasal bone fracture. This study aimed to investigate whether delivery of information, such as surgical risks, through a mobile application is more effective than delivery of information through only verbal means and a paper.

Methods

This prospective, randomized study included 60 patients with a nasal bone fracture. The experimental group (n=30) received preoperative explanation with the traditional informed consent process in addition to a mobile application, while the control group (n=30) received preoperative explanation with only the traditional informed consent process. Four weeks after surgery, the number of recalled surgical risks was compared for analysis. The following six surgical risks were explained: pain, bleeding, nasal deformity, numbness, nasal obstruction, and nasal cartilage necrosis.

Results

The mean number of recalled surgical risks among all patients was 1.58±0.56. The most frequently recalled surgical risk was nasal deformity in both groups. The mean number of recalled surgical risks was 1.72±0.52 in the experimental group and 1.49±0.57 in the control group. There was a significant association between mobile application use and the mean number of recalled surgical risks (p=0.047). Age, sex, and the level of education were not significantly associated with the mean number of recalled surgical risks.

Conclusion

This study found that a mobile application could contribute to the efficient delivery of information during the informed consent process. With further improvement, it could be used in other plastic surgeries and other surgeries, and such an application can potentially be used for explaining risks as well as delivering other types of information.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are also intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patients' satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The Guideline Development Group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

The Effect of Written Information on Recall of Surgical Risks of Carpal Tunnel Release Surgery: A Randomized Controlled Study

BACKGROUND

Written information has been thought to help patients recall surgical risks discussed during the informed consent process, but has not been assessed for carpal tunnel release, a procedure with the rare but serious risk of complex regional pain syndrome. The authors' objective was to determine whether providing a pamphlet would improve patients' ability to remember the risks of surgery.

METHODS

Sixty patients seen for carpal tunnel release were included in this prospective, single-blind, randomized study. Patients received either a written pamphlet of the risks of surgery or no additional information following a standardized consultation. Two weeks after the initial consultation, patients were contacted to assess their risk recall and whether they had read about the operation from any source.

RESULTS

There was no difference in terms of the number of risks recalled between pamphlet (1.33 ± 1.21) or control groups (1.45 ± 1.22; p = 0.73). Recall of infection was better in the pamphlet group (p < 0.05). No patients remembered complex regional pain syndrome. There was no difference in the proportion of people who read additional information about carpal tunnel release surgery between the pamphlet (34.8 percent) and control groups (21.4 percent; p = 0.39), but reading about carpal tunnel release surgery was associated with improved recall (2.45 ± 1.13 versus 0.77 ± 0.91; p < 0.01).

CONCLUSIONS

Reading about surgery improved risk recall, but providing this information in the form of a pamphlet did not, nor did it affect patients' ability to recall the risk of complex regional pain syndrome. These results demonstrate that surgeons should implement additional measures to improve comprehension of surgical risks.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Shared medical appointments as a new model for carpal tunnel surgery consultation: A randomized clinical trial

Background

In chronic disease management, shared medical appointments have been shown to improve clinic access, productivity and patient education. However, adoption of this model in surgical consultation is limited, and its effect on surgical patients' satisfaction, comfort and surgical risk recall is unknown.

Objective

To determine whether shared medical appointments could be applied to carpal tunnel surgery consultation while being equally effective as individual consultation for risk recall, patient comfort and satisfaction.

Methods

A prospective randomized trial involving 80 patients referred for carpal tunnel release consultation, in which patients were assigned to an educational discussion individually or as part of a shared appointment, was conducted. In a blinded fashion, patients were contacted preoperatively to assess their risk recall and postoperatively to rate their overall satisfaction, comfort and satisfaction with the surgeon.

Results

Patient demographics were equal. Surgical risk recall was equivalent between shared and individual consults (2.06±1.15 versus 1.64±1.04; P=0.11). More participants in the shared appointments condition remembered the specific risks of infection (61.1% versus 33.3%; P=0.020) and bleeding (30.6% versus 10.3%; P=0.028). There was no difference in overall satisfaction (8.70 versus 8.88; P=0.75), satisfaction with the surgeon (8.05 versus 8.13; P=0.92) or overall comfort (8.80 versus 8.31; P=0.46).

Discussion

Shared medical appointments for carpal tunnel surgery consultation were equivalent to individual consultation in terms of surgical risk recall, patient satisfaction and comfort.

Conclusion

These results support the use of shared appointments for large-volume, low-variation surgery.

Assessment of the effectiveness of SFCR patient information sheets before scheduled spinal surgery

INTRODUCTION

Patient information is an essential component of any surgical procedure as it allows the surgeon to collect informed consent. This is a legal obligation in the civil code and a professional obligation in the code of medical ethics. As a result, the French spinal surgery society (SFCR) decided to make a model information sheet available on the Internet. The goal of this prospective study was to evaluate the impact of this information sheet when given to patients before scheduled spinal surgery.

METHODS

This was a single-centre prospective study performed between November 2014 and February 2015. Seventy patients filled out two questionnaires. The first was about the quality of the medical information given orally by the surgeon; it was administered to patients after the preoperative consultation. The second was about the quality of the medical information contained in the information sheet; it was administered after patients had read this sheet. For each of the questions, patients could either select "yes" if they found the information to be correct/useful (1 point) or "no" if not (0 point).

RESULTS

The mean patient age was 56.7 years (range: 28-86). The average number of "yes" answers was 7.07 (out of 12) in the first questionnaire. The average number of "yes" answers was 10.3 (out of 12) after reading the information sheet. This indicates that patients were significantly better informed after reading the SFCR sheet. The written document was deemed to be understandable (mean: 8/10). It answered the patients' questions (mean: 6.7/10) and helped them understand how the surgical procedure would be carried out (mean: 7.3/10). The patients' level of education did not significantly alter these findings.

CONCLUSION

Adding a written SFCR information sheet to the preoperative consultation improved patients' understanding before scheduled spine surgery.

LEVEL OF EVIDENCE

Low-powered prospective study.

Shared medical appointments as a new model for carpal tunnel surgery consultation: A randomized clinical trial

BACKGROUND

In chronic disease management, shared medical appointments have been shown to improve clinic access, productivity and patient education. However, adoption of this model in surgical consultation is limited, and its effect on surgical patients' satisfaction, comfort and surgical risk recall is unknown.

OBJECTIVE

To determine whether shared medical appointments could be applied to carpal tunnel surgery consultation while being equally effective as individual consultation for risk recall, patient comfort and satisfaction.

METHODS

A prospective randomized trial involving 80 patients referred for carpal tunnel release consultation, in which patients were assigned to an educational discussion individually or as part of a shared appointment, was conducted. In a blinded fashion, patients were contacted preoperatively to assess their risk recall and postoperatively to rate their overall satisfaction, comfort and satisfaction with the surgeon.

RESULTS

Patient demographics were equal. Surgical risk recall was equivalent between shared and individual consults (2.06±1.15 versus 1.64±1.04; P=0.11). More participants in the shared appointments condition remembered the specific risks of infection (61.1% versus 33.3%; P=0.020) and bleeding (30.6% versus 10.3%; P=0.028). There was no difference in overall satisfaction (8.70 versus 8.88; P=0.75), satisfaction with the surgeon (8.05 versus 8.13; P=0.92) or overall comfort (8.80 versus 8.31; P=0.46).

DISCUSSION

Shared medical appointments for carpal tunnel surgery consultation were equivalent to individual consultation in terms of surgical risk recall, patient satisfaction and comfort.

CONCLUSION

These results support the use of shared appointments for large-volume, low-variation surgery.

Multimedia in the informed consent process for endoscopic sinus surgery: A randomized control trial

OBJECTIVES/HYPOTHESIS

To determine patient recall of specific risks associated with endoscopic sinus surgery and whether an adjunct multimedia education module is an effective patient tool in enhancing the standard informed consent process.

STUDY DESIGN

Prospective, randomized, controlled trial.

METHODS

Fifty consecutive adult patients scheduled for endoscopic sinus surgery at a rhinology clinic of a tertiary care hospital were recruited for this study. Informed consent was studied by comparing the number of risks recalled when patients had a verbal discussion in conjunction with a 6-minute interactive module or the verbal discussion alone. Early recall was measured immediately following the informed consent process, and delayed recall was measured 3 to 4 weeks after patient preference details were also collected.

RESULTS

Early risk recall in the multimedia group was significantly higher than the control group (P = .0036); however, there was no difference between the groups in delayed risk recall. Seventy-six percent of participants expressed interest in viewing the multimedia module if available online between the preoperative and procedural day. Sixty-eight percent of patients preferred having the multimedia module as an adjunct to the informed consent process as opposed to the multimedia consent process alone.

CONCLUSIONS

There is an early improvement in overall risk recall in patients who complete an interactive multimedia module, with a clear patient preference for this method. Here we emphasize the well-known challenges of patient education and demonstrate the effectiveness of integrating technology into clinical practice in order to enhance the informed consent process.

LEVEL OF EVIDENCE

1b Laryngoscope, 126:1273-1278, 2016.

Improving patient recall of information: Harnessing the power of structure

OBJECTIVE

Assess the amount of medical information laypeople recall, investigate the impact of structured presentation on recall.

METHODS

105 first-year psychology students (mean age 21.5±3.8 years; 85% female) were randomised to two information-presentation conditions: structured (S group) and nonstructured (NS group). Students watched a video of a physician discharging a patient from the emergency department. In the S Group, content (28 items of information) was divided into explicit "chapters" with "chapter headings" preceding new information. Afterwards, participants wrote down all information they recalled on an empty sheet of paper.

RESULTS

The S group (N=57) recalled significantly more items than NS group (N=41) (8.12±4.31 vs. 5.71±3.73; p=0.005), rated information as easier to understand (8.0±1.9 vs. 6.1±2.2; p<0.001) and better structured (8.5±1.5 vs. 5.5±2.7; p<0.001); they rather recommended the physician to friends (7.1±2.7 vs. 5.8±2.6; p<0.01).

CONCLUSION

University students recalled around 7/28 items of information presented. Explicit structure improved recall.

PRACTICE IMPLICATIONS

Practitioners must reduce the amount of information conveyed and structure information to improve recall.

Patients' recall of diagnostic and treatment information improves with use of the Pain Explanation and Treatment Diagram in an outpatient chronic pain clinic

Educating patients about their condition and treatment plan is an essential component of successful treatment. Patients need to understand their condition, recall treatment suggestions and comply with the treatment protocol. Unfortunately, the method of patient education most commonly used by physicians is verbal teaching and discussion, which leads to poor patient recall. The authors of this article developed the Pain Explanation and Treatment Diagram, a worksheet that the clinician completes with the patient during their first consultation to function as a record of their diagnosis, pain risk factors and an action plan for when pain occurs. In this study, patient recall, among other variables, was assessed as a function of time since first appointment.

BACKGROUND:

To maximize the benefit of therapies, patients must understand their condition, recall treatment suggestions and comply with treatments. The Pain Explanation and Treatment Diagram (PETD) is a one-page worksheet that identifies risk factors (health-related habits, sleep, exercise, ergonomics and psychosocial factors) involved in chronic pain. Clinician and patient complete the PETD together, and the clinician notes recommended treatments and lifestyle changes.

OBJECTIVES:

To examine the effect of use of the PETD on patient recall of diagnostic and treatment information on the sheet.

METHODS:

The present study was a cross-sectional analysis. Patients with chronic musculoskeletal pain seen by one physiatrist at an outpatient pain clinic in a university-affiliated hospital between 2009 and 2012 (all of whom received the PETD) were eligible. A structured telephone interview lasting approximately 1 h was used to determine recall of PETD diagnostic and treatment information.

RESULTS:

Of the 84 eligible patients, 46 were contacted and 29 completed the telephone interview. Participants recalled an average of 12.2% (95% CI 7.8% to 17.4%) of items without prompting and 48.5% (95% CI 42.0% to 53.5%) when prompted. Participants who referred to the PETD at home (n=13) recalled significantly more items than those who did not (n=15) (17.6% [95% CI 11.1% to 23.9%] versus 5.2% [95% CI 3.0% to 14.5%], P=0.004); when prompted, the rates increased to 54.3% (95% CI 48.3% to 61.2%) and 41.2% (95% CI 34.7% to 50.7%), respectively (P=0.032).

CONCLUSIONS:

The PETD is a promising, feasible and inexpensive tool that can improve patients’ recall of diagnostic- and treatment-related information.

Psychosocial predictors, assessment, and outcomes of cosmetic procedures: a systematic rapid evidence assessment

BACKGROUND

Recent breast implant complications led to a UK government policy review of the evidence concerning cosmetic interventions. We synthesised cosmetic intervention research evidence covering psychosocial factors associated with requesting procedures and psychological outcomes, effects of procedures on psychological outcomes, preintervention assessments for identifying those at risk, alternative therapy effectiveness, and issues in achieving informed consent.

METHODS

Undertaking a systematic rapid evidence assessment, six databases and three journals were searched. Included studies were systematic reviews or primary studies of participants requesting cosmetic procedures; published 2002-2012; containing either psychological or psychosocial measures, a psychological outcome, or evaluation of informed consent. Reviewers independently assessed study eligibility, extracted data, and assessed quality, undertaking narrative synthesis.

RESULTS

Methodological quality of the included 13 systematic reviews and 179 primary studies was low, with wide variation in psychosocial measures. Findings suggest several psychosocial factors (e.g., intimate partner violence) may be associated with requesting cosmetic surgery. Multiple factors (e.g., unrealistic expectations) may predict poor psychological outcomes. Current psychological screening tools focus predominantly on body dysmorphic disorder (BDD) symptoms. Psychological and pharmacological interventions are effective alternative BDD treatments. Patients and doctors bring different needs to informed consent discussions, inconsistently matched to those required by professional ethics, litigation risk, and facilitating profit.

CONCLUSIONS

Systematically reviewing this literature for UK policy has highlighted that some groups may be at risk of poor post-cosmetic procedure outcomes. Practitioners and patients must explore reasons for seeking cosmetic procedures and discuss all potential results and alternative solutions. Future research should employ more robust methodologies to identify effects in those at risk, led by consensus on a core set of psychological outcomes.

Informed consent when prescribing medication: a randomized controlled trial

OBJECTIVES/HYPOTHESIS

To determine patient recall of specific risks associated with medication prescription and whether or not handouts are an effective tool to augment the informed consent process.

STUDY DESIGN

Double-blinded, randomized, controlled trial.

METHODS

Informed consent for prednisone prescriptions was studied by comparing the effect of a verbal discussion (describing 10 specific adverse drug reactions) in conjunction with a handout going over same, to a verbal discussion alone. Blinded assessments occurred by telephone interview 2 to 4 weeks following the intervention. Outcomes assessed were the number of risks of prednisone that patients could list and the number of risks they recalled having discussed with their physician. Other demographic details were also collected.

RESULTS

Twenty-five participants were randomly allocated to each group. Without prompting, the median number of risks spontaneously recalled by the handout group was not significantly different than the control group, and both groups had very low recall (two vs. one, P = .24). When provided a list of potential side effects, it was observed that the handout group recalled a higher median number of risks having been discussed with their physician compared to patients in the control group (eight vs. five, P = .003). The groups' demographics were otherwise identical.

CONCLUSIONS

Patients in general did not remember discussing adverse prednisone risks with their physician even a short time after the discussion took place. Although the patient handout resulted in improved recall of risks following the prescription of prednisone, its importance in the informed medication consent process remains an open question.

LEVEL OF EVIDENCE

1b.

Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures

BACKGROUND

Achieving informed consent is a core clinical procedure and is required before any surgical or invasive procedure is undertaken.  However, it is a complex process which requires patients be provided with information which they can understand and retain, opportunity to consider their options, and to be able to express their opinions and ask questions.  There is evidence that at present some patients undergo procedures without informed consent being achieved.

OBJECTIVES

To assess the effects on patients, clinicians and the healthcare system of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare treatments and procedures.

SEARCH METHODS

We searched the following databases using keywords and medical subject headings: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 5, 2012), MEDLINE (OvidSP) (1950 to July 2011), EMBASE (OvidSP) (1980 to July 2011) and PsycINFO (OvidSP) (1806 to July 2011). We applied no language or date restrictions within the search. We also searched reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials and cluster randomised trials of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. We considered an intervention to be intended to promote informed consent when information delivery about the procedure was enhanced (either by providing more information or through, for example, using new written materials), or if more opportunity to consider or deliberate on the information was provided.

DATA COLLECTION AND ANALYSIS

Two authors assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of outcomes where there were sufficient data.

MAIN RESULTS

We included 65 randomised controlled trials from 12 countries involving patients undergoing a variety of procedures in hospitals. Nine thousand and twenty one patients were randomised and entered into these studies. Interventions used various designs and formats but the main data for results were from studies using written materials, audio-visual materials and decision aids. Some interventions were delivered before admission to hospital for the procedure while others were delivered on admission.Only one study attempted to measure the primary outcome, which was informed consent as a unified concept, but this study was at high risk of bias.  More commonly, studies measured secondary outcomes which were individual components of informed consent such as knowledge, anxiety, and satisfaction with the consent process.  Important but less commonly-measured outcomes were deliberation, decisional conflict, uptake of procedures and length of consultation.Meta-analyses showed statistically-significant improvements in knowledge when measured immediately after interventions (SMD 0.53 (95% CI 0.37 to 0.69) I(2) 73%), shortly afterwards (between 24 hours and 14 days) (SMD 0.68 (95% CI 0.42 to 0.93) I(2) 85%) and at a later date (15 days or more) (SMD 0.78 (95% CI 0.50 to 1.06) I(2) 82%). Satisfaction with decision making was also increased (SMD 2.25 (95% CI 1.36 to 3.15) I(2) 99%) and decisional conflict was reduced (SMD -1.80 (95% CI -3.46 to -0.14) I(2) 99%). No statistically-significant differences were found for generalised anxiety (SMD -0.11 (95% CI -0.35 to 0.13) I(2) 82%), anxiety with the consent process (SMD 0.01 (95% CI -0.21 to 0.23) I(2) 70%) and satisfaction with the consent process (SMD 0.12 (95% CI -0.09 to 0.32) I(2) 76%). Consultation length was increased in those studies with continuous data (mean increase 1.66 minutes (95% CI 0.82 to 2.50) I(2) 0%) and in the one study with non-parametric data (control 8.0 minutes versus intervention 11.9 minutes, interquartile range (IQR) of 4 to 11.9 and 7.2 to 15.0 respectively). There were limited data for other outcomes.In general, sensitivity analyses removing studies at high risk of bias made little difference to the overall results. 

AUTHORS' CONCLUSIONS

Informed consent is an important ethical and practical part of patient care.  We have identified efforts by researchers to investigate interventions which seek to improve information delivery and consideration of information to enhance informed consent.  The interventions used consistently improve patient knowledge, an important prerequisite for informed consent.  This is encouraging and these measures could be widely employed although we are not able to say with confidence which types of interventions are preferable. Our results should be interpreted with caution due to the high levels of heterogeneity associated with many of the main analyses although we believe there is broad evidence of beneficial outcomes for patients with the pragmatic application of interventions. Only one study attempted to measure informed consent as a unified concept.

Patient recollections of perioperative anaesthesia risks

There is widespread variation as to the method of presentation of informed anaesthetic consent with little empirical data on the nature of communication and how much information is retained. At a dedicated anaesthesia pre-admission clinic, 149 patients undergoing elective surgery under general anaesthesia were both verbally informed and shown written information about four major and three minor anaesthesia risks. The major risks were death, pneumonia, heart attack and stroke. The minor risks were dental damage, nausea and vomiting. On the day of scheduled surgery, retention of information about these anaesthetic risks was examined. Thirty-eight patients (26%) could not recall any anaesthesia risks, 55 patients (37%) could not recall any major risks and 126 patients (84%) could not recall any minor risks. Our findings indicate that patients should receive a second explanation on the day of surgery, even if informed consent was provided only two weeks earlier.

Multimedia approach to preoperative adenotonsillectomy counseling

OBJECTIVE

The primary objective was to compare retention of knowledge of surgical risks in parents of children having an adenotonsillectomy who received a preoperative handout or watched a video, in addition to standard counseling. A secondary objective was to determine whether time from counseling to day of surgery affects risk retention.

STUDY DESIGN

Prospective randomized control study.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

The study, conducted March 2010 through April 2011, included participants who had children undergoing adenotonsillectomy. The preoperative and postoperative test scores of those undergoing verbal counseling, counseling with handout, or counseling with video were compared.

RESULTS

Forty-five participants were tasked to identify 9 risks of adenotonsillectomy. Preoperatively, participants identified an average of 6.8 (95% confidence interval [CI], 6.2-7.3) in the counseling group, 7.3 (95% CI, 6.4-8.3) in the counseling and handout group, and 6.6 (95% CI, 5.9-7.3) in the counseling and video group (P = .32). Postoperatively, participants identified an average of 5.8 (95% CI, 4.9-6.7) in the counseling group, 6.5 (95% CI, 5.3-7.6) in the counseling and handout group, and 5.2 (95% CI, 4.1-6.3) in the counseling and video group (P = .19). Time between preoperative counseling and day of surgery was inversely correlated with postoperative score (β -.34, P = .02).

CONCLUSION

Participants were not able to identify all of the risks associated with adenotonsillectomy. There was no difference in identification of risks associated with adenotonsillectomy among different modalities of counseling. Participants retained more information when there was less time between the preoperative counseling and day of surgery.

Medical information prior to invasive medical procedures in otorhinolaryngology-head and neck surgery in France

Based on a review of the medical literature (PubMed database, keywords: medical information, informed consent), the authors analyse the main medicolegal aspects concerning the patient information that must be provided in France prior to any invasive diagnostic or therapeutic medical procedures in otorhinolaryngology head and neck surgery, as well as the patient's perception and recall of the information provided, the quality of the information provided and problems encountered in providing this information. In the light of this review, several solutions are recommended to improve this essential phase prior to obtaining the patient's informed consent.

Effect of informed consent format on patient anxiety, knowledge, and satisfaction

BACKGROUND

Multiple formats have been used to deliver information needed for informed consent before a medical procedure, but data comparing formats are conflicting.

METHODS

Sixty-three patients (45 men, age 61 ± 16 years) undergoing an initial diagnostic cardiac electrophysiology study were randomly assigned to 1 of 3 groups: oral, written, or video informed consent using a standardized text for all 3 formats. Anxiety levels were assessed with the Spielberger State-Trait Anxiety Inventory (STAI), and questionnaires were used to assess patient comprehension and satisfaction with the informed consent process. Physician time needed to obtain informed consent was also measured. The effect of informed consent format on anxiety state was evaluated by comparing STAI before and after consent. Multivariable analysis was performed to assess the effects of baseline characteristics on the state anxiety scores.

RESULTS

For the oral, written, and video formats, the mean anxiety trait scores were 39 ± 9, 34 ± 8, and 31 ± 7, respectively (P = .005), and baseline anxiety state scores were 49 ± 12, 37 ± 12, and 36 ± 11, respectively (P = .0006). None of the formats had a significant effect on patient anxiety state after consent was obtained. After the procedure, anxiety state declined (P < .0001). There were no differences among the comprehension scores, and patient satisfaction was equivalent among formats. The oral format required the longest physician time (P = .06).

CONCLUSION

For electrophysiologic testing, all 3 formats have similar effects on anxiety and produce equivalent patient comprehension. The oral format requires more physician time. Given the standardization achievable with a written or video format, physicians may consider these options to facilitate obtaining informed consent.

Patient understanding and satisfaction in informed consent for total knee arthroplasty: a randomized study

OBJECTIVE

Informed consent is a critical component of all surgical procedures, but patients' understanding and recall of the potential risks/benefits is poor. We hypothesized that utilization of multiple standardized education modalities in the informed consent process would allow for better retention and a more informed patient.

METHODS

A total of 151 patients undergoing primary total knee arthroplasty (TKA) were randomized to 3 groups: group 1 received standardized informed consent and a paper handout detailing the risks/benefits of TKA; group 2 received standardized informed consent, a paper handout, and a video discussing the risks/benefits of TKA; and group 3 followed the same process as group 2 plus formal nurse education. All patients completed a 15-item questionnaire (risks, indications, and expectations) immediately following this consent process on the morning of surgery and 6 weeks postoperatively. We used t-test and analysis of variance for data analyses.

RESULTS

There was no difference (P = 0.79) in satisfaction with the consent process between the 3 groups; 92-97% of the patients rated the consent process as good to excellent at all time points. The number of correct answers did not differ significantly between the groups at any time period (P = 0.31-0.81). Scores dropped significantly (P = 0.004) from preoperatively to the 6-week postoperative visit in all groups combined. A higher level of satisfaction with the process was reflected in higher scores preoperatively in all groups (P = 0.028).

CONCLUSION

Preoperatively, patients satisfied with the consent process may have better recall of risks/benefits and expectations of surgery. Neither retention nor satisfaction was influenced by reinforcement methods, such as video or nurse education; they may therefore be unnecessary.

A review of surgical informed consent: past, present, and future. A quest to help patients make better decisions

Background

Informed consent (IC) is a process requiring a competent doctor, adequate transfer of information, and consent of the patient. It is not just a signature on a piece of paper. Current consent processes in surgery are probably outdated and may require major changes to adjust them to modern day legislation. A literature search may provide an opportunity for enhancing the quality of the surgical IC (SIC) process.

Methods

Relevant English literature obtained from PubMed, Picarta, PsycINFO, and Google between 1993 and 2009 was reviewed.

Results

The body of literature with respect to SIC is slim and of moderate quality. The SIC process is an underestimated part of surgery and neither surgeons nor patients sufficiently realize its importance. Surgeons are not specifically trained and lack the competence to guide patients through a legally correct SIC process. Computerized programs can support the SIC process significantly but are rarely used for this purpose.

Conclusions

IC should be integrated into our surgical practice. Unfortunately, a big gap exists between the theoretical/legal best practice and the daily practice of IC. An optimally informed patient will have more realistic expectations regarding a surgical procedure and its associated risks. Well-informed patients will be more satisfied and file fewer legal claims. The use of interactive computer-based programs provides opportunities to improve the SIC process.

Comparison of group counseling with individual counseling in the comprehension of informed consent: a randomized controlled trial

Background

Studies on different methods to supplement the traditional informed consent process have generated conflicting results. This study was designed to evaluate whether participants who received group counseling prior to administration of informed consent understood the key components of the study and the consent better than those who received individual counseling, based on the hypothesis that group counseling would foster discussion among potential participants and enhance their understanding of the informed consent.

Methods

Parents of children participating in a trial of nutritional supplementation were randomized to receive either group counseling or individual counseling prior to administration of the informed consent. To assess the participant's comprehension, a structured questionnaire was administered approximately 48-72 hours afterwards by interviewers who were blinded to the allocation group of the respondents.

Results

A total of 128 parents were recruited and follow up was established with 118 (90.2%) for the study. All respondents were aware of their child's participation in a research study and the details of sample collection. However, their understanding of study purpose, randomization and withdrawal was poor. There was no difference in comprehension of key elements of the informed consent between the intervention and control arm.

Conclusions

The results suggest that the group counseling might not influence the overall comprehension of the informed consent process. Further research is required to devise better ways of improving participants' understanding of randomization in clinical trials.

Trial Registration

Clinical Trial Registry - India (CTRI): CTRI/2009/091/000612

Interventions to improve patient comprehension in informed consent for medical and surgical procedures: a systematic review

BACKGROUND

Patient understanding in clinical informed consent is often poor. Little is known about the effectiveness of interventions to improve comprehension or the extent to which such interventions address different elements of understanding in informed consent.

PURPOSE

. To systematically review communication interventions to improve patient comprehension in informed consent for medical and surgical procedures. Data Sources. A systematic literature search of English-language articles in MEDLINE (1949-2008) and EMBASE (1974-2008) was performed. In addition, a published bibliography of empirical research on informed consent and the reference lists of all eligible studies were reviewed. Study Selection. Randomized controlled trials and controlled trials with nonrandom allocation were included if they compared comprehension in informed consent for a medical or surgical procedure. Only studies that used a quantitative, objective measure of understanding were included. All studies addressed informed consent for a needed or recommended procedure in actual patients. Data Extraction. Reviewers independently extracted data using a standardized form. All results were compared, and disagreements were resolved by consensus. Data Synthesis. Forty-four studies were eligible. Intervention categories included written information, audiovisual/multimedia, extended discussions, and test/feedback techniques. The majority of studies assessed patient understanding of procedural risks; other elements included benefits, alternatives, and general knowledge about the procedure. Only 6 of 44 studies assessed all 4 elements of understanding. Interventions were generally effective in improving patient comprehension, especially regarding risks and general knowledge. Limitations. Many studies failed to include adequate description of the study population, and outcome measures varied widely.

CONCLUSIONS

. A wide range of communication interventions improve comprehension in clinical informed consent. Decisions to enhance informed consent should consider the importance of different elements of understanding, beyond procedural risks, as well as feasibility and acceptability of the intervention to clinicians and patients. Conceptual clarity regarding the key elements of informed consent knowledge will help to focus improvements and standardize evaluations.

A systematic review of ethical principles in the plastic surgery literature

BACKGROUND

This purpose of this study was to perform a systematic review to identify articles that discuss ethical issues relating to the field of plastic and reconstructive surgery and to evaluate whether ethical issues are underrepresented in the plastic surgery literature.

METHODS

Four medical databases were selected to search through the medical literature with specific inclusion criteria to disqualify irrelevant articles from the study. Appropriate articles were extracted, and their quality and validity were assessed by multiple investigators to maximize reproducibility. The data were then synthesized and analyzed for associations among the ethical principles.

RESULTS

Of a total library search of more than 100,000 plastic surgery-oriented articles, only 110 clearly focused on ethical principles. Autonomy (53 percent) was the most common major theme, whereas distributive justice (15 percent) represented the least frequently emphasized ethical principle. The proportions of each ethical principle were tested against each other for equality using Cochran's Q test; the Q test reached statistical significance (Q = 67.04, df = 3, p < 0.0001), indicating that the ethical principles were not discussed equally in plastic surgery literature, which was expected because autonomy represented 53 percent of the articles, whereas distributive justice represented only 15 percent of articles. When examining both major and minor themes, more than half of the articles (61 percent) addressed two or more ethical principles. Beneficence and nonmaleficence were strongly associated (Pearson's chi = 55.38, df = 1,p < 0.0001).

CONCLUSION

Despite the extensive number of ethical issues that plastic surgeons face, a relatively small proportion of plastic surgery literature was dedicated to discussing ethical principles.

A systematic review of interventions to improve recall of medical advice in healthcare consultations

BACKGROUND

In order for patients to adhere to healthcare advice, it is essential that they are able to recall this following a consultation. Although psychological research exists which highlights techniques and factors postulated to influence recall, only a limited body of work has been conducted to evaluate their effectiveness in a clinical context.

AIM

To carry out a systematic review of intervention trials designed to enhance recall of medical information.

METHODS

We searched Medline (1950-April 2007); Embase (1980-April 2007); Cinahl (1982-April 2007); PsychINFO (1969-2007); and the Cochrane Library Collection. Secondary searches were made through reference to relevant journals and reference lists from relevant papers/review papers.

RESULTS

From 69 papers provisionally identified, 34 papers met the inclusion criteria. Nine recall interventions had been evaluated (audio recordings, written materials, adjunct questions, prompt sheets, visual aids, cognitive strategies, rehearsal, communication styles and personalized teaching). Despite the experimental and theoretical evidence which could have informed cognitive interventions to enhance recall of healthcare advice, most studies primarily focused on the use of written and/or audio-recorded medical instructions. Although the majority of studies supported these approaches insofar as they enhanced recall, the findings were equivocal.

CONCLUSION

While written and tape-recorded instructions appear to improve recall in most situations, a dearth of interventions incorporating psychological theory was readily apparent. Further research is required in clinical settings to determine if cognitive interventions based on a more over-arching psychological model of recall are effective.

Aesthetic/Cosmetic surgery and ethical challenges

Is aesthetic surgery a business guided by market structures aimed primarily at material gain and profit or a surgical intervention intended to benefit patients and an integral part of the health-care system? Is it a frivolous subspecialty or does it provide a real and much needed service to a wide range of patients? At present, cosmetic surgery is passing through an identity crisis as well as an acute ethical dilemma. A closer look from an ethical viewpoint makes clear that the doctor who offers aesthetic interventions faces many serious ethical problems which have to do with the identity of the surgeon as a healer. Aesthetic surgery that works only according to market categories runs the risk of losing the view for the real need of patients and will be nothing else than a part of a beauty industry which has the only aim to sell something, not to help people. Such an aesthetic surgery is losing sight of real values and makes profit from the ideology of a society that serves only vanity, youthfulness, and personal success. Unfortunately, some colleagues brag that they chose the plastic surgery specialty just to become rich aesthetic surgeons, using marketing tactics to promote their practice. This is, at present, the image we project. As rightly proposed, going back a little to Hippocrates, to the basics of being a physician, is urgently warranted! Being a physician is all that a "cosmetic" surgeon should be. In the long run, how one skillfully and ethically practices the art of plastic surgery will always speak louder than any words.

Communication during ward rounds in internal medicine. An analysis of patient-nurse-physician interactions using RIAS

OBJECTIVE

Describe the content and of mode of patient-physician-nurse interactions during ward-rounds in Internal Medicine.

METHODS

In 267/448 patients, 13 nurses, and 8 physicians from two wards in General Internal Medicine 448 interactions on ward rounds were tape recorded by observers. After exclusion of interactions with more than three participants (N=150), a random sample of 90 interactions was drawn. Data were analysed with a modified RIAS version that allowed for the registration of a third contributor and for the assessment of the direction of a communicative action (e.g.: nurse-->patient, etc.). Furthermore, time spent per individual patient was registered with a stop-watch.

RESULTS

A total of 12,078 utterances (144 per ward round) were recorded. Due to problems with the comprehensibility of some interactions the final data set contains 71 ward round interactions with 10,713 utterances (151 per ward round interaction). The average time allotted to an individual patient during ward-rounds was 7.5 min (range: 3-16 min). The exchange of medical information is the main topic in physicians (39%) and nurses (25%), second common topic in patients (28%), in whom communicative actions like agreement or checking are more common (30% patients/25% physicians/22% nurses). Physicians and patients use a substantial number of communicative actions (1397/5531 physicians; 1119/3733 patients). Patients receive about 20 bits of medical or therapeutic information per contact during ward-rounds.

CONCLUSIONS

If ward rounds serve as the central marketplace of information nurses' knowledge is under-represented. Further research should try to determine whether the quality of patient care is related to a well balanced exchange of information, to which nurses, physicians, and patients contribute their specific knowledge.

PRACTICE IMPLICATIONS

Given the fact that in-patients in Interna Medicine usually present complex problems, the exchange of factual information, expectations, and concepts is of paramount importance. We hope that this paper is going to direct the attention of the scientific community to the characteristics of ward-rounds because they will remain the central marketplace of communication in hospital.

A randomised study of three different informational AIDS prior to coronary angiography, measuring patient recall, satisfaction and anxiety

BACKGROUND

Informed consent is a basic standard of care for all patients undergoing medical procedures, but recall of information has been shown to be poor. We sought to compare verbal, written and animated audiovisual information delivery, during consent for coronary angiography, by measuring improvement in recall.

METHOD

A sample population of 99 cardiac patients at Flinders Medical Centre was randomised (1:1:1) to receive one of three information delivery methods. The information content was standardised by a risk proforma, which explained the procedure and defined 12 specific risks. Recall, satisfaction and anxiety were assessed by a questionnaire administered at three different time points: post-consent, post-procedure and at 30 days. Effect of delivery method on satisfaction and anxiety was rated on a self-reported scale from 1-5, with 5 representing very satisfied or very anxious. Groups were compared by non-parametric testing and a p-value of <0.05 was considered statistically significant.

RESULTS

Patients were a median age of 64 (i.q.r. 56, 72) years. Information delivery method had no effect on recall of risks at any time-point (p=0.2, 0.7, 0.5, respectively) and the average recall score across the population was 3-4 out of 12. There was no significant effect on median satisfaction scores: verbal; 5 (i.q.r.4, 5) versus written/audiovisual; 4 (i.q.r.4, 5) (p=ns), or on median anxiety scores: verbal; 3 (i.q.r.2, 4) versus written/audiovisual; 3 (i.q.r.2, 4) (p=ns).

CONCLUSION

Despite careful design of an innovative audiovisual delivery technique aimed at optimising comprehension and aiding memory, recall of information was poor and informational aids showed no improvement. Modes of information delivery are not the key to patient assimilation of complex medical information.

Consent to orthodontic treatment – is it working?

OBJECTIVE

To determine the level of patient and/or parent recall of previous consent to orthodontic treatment.

DESIGN

Patients and/or parents of children who had been consented for orthodontic treatment were asked to complete a questionnaire on consent at least six months into their treatment.

SETTING

Bristol Dental Hospital.

SUBJECTS AND METHODS

Forty-one consecutive patients and eight of their parents, with a combined age range of 12-59 years, with 61% being female and 39% male. The patients, and where applicable their parents, were identified as having previously signed a consent form at least six months previously. Each was asked to complete a questionnaire on aspects of the consent process.

RESULTS

Patients and parents demonstrated a high level of recall for the consent process concerning appliance type (89.8%), the reasons for treatment (96%), risks (75.5%), length of treatment (83.3%), the opportunity to ask questions (96%), and whether other information was provided (94%). However, further questioning on risks demonstrated poor recall for important factors such as decay (36.8%), root resorption (less than 21%), retention (56.3%) and length of retention (35%).

CONCLUSIONS

Overall the consent process works well but specific areas of concern centre around the risks of orthodontic treatment.

Cosmetic orbital surgery

PURPOSE

Current indications for orbital surgery primarily aimed at improving cosmesis are considered in the context of subspecialist orbital practice by an ophthalmologist.

SCOPE

Thyroid eye disease, orbital vascular anomalies, and dermolipomas are common orbital diseases in which the symptoms can be purely cosmetic. Accurate anatomical awareness, preoperative scanning, control of medical factors including smoking and thyroid status, and endoscopic techniques have all contributed to the aesthetic outcome of orbital surgery. The threshold for performing reconstructive orbital surgery has also been lowered by public demand.

CONCLUSIONS

Orbital surgeons can therefore offer the familiar techniques, such as orbital decompression, for pure cosmesis. Sensitive history taking and awareness of the psychological element are of paramount importance for the orbital surgeon who develops a cosmetic practice.

Enhancing the informed consent process: a conceptual overview

Concern about limitations in the ability to give valid informed consent among certain groups of individuals has led to increased interest in defining, measuring, and enhancing consent-related decision-making. In this overview, we summarize issues related to the definition of decision-making capacity, discuss methods that have been used to assess decision-making abilities and other aspects of informed consent, and briefly describe studies that aim to understand variation in different elements of informed consent. We then review strategies that have been used with the intent of improving aspects of the informed consent process. Finally, we provide an outline of areas that are in need of future studies in order to reach the ultimate goal of preserving as much autonomy as possible in at-risk populations, while still achieving valuable research and treatment goals.