‘All by myself’: interns’ reports of their experiences taking consent in Irish hospitals

Artificial Intelligence-Powered Surgical Consent: Patient Insights

Introduction The integration of artificial intelligence (AI) in healthcare has revolutionized patient interactions and service delivery. AI's role extends from supporting clinical diagnostics and enhancing operational efficiencies to potentially improving informed consent processes in surgical settings. This study investigates the application of AI, particularly large language models like OpenAI's ChatGPT, in facilitating surgical consent, focusing on patient understanding, satisfaction, and trust. Methods We employed a mixed-methods approach involving 86 participants, including laypeople and medical staff, who engaged in a simulated AI-driven consent process for a tonsillectomy. Participants interacted with ChatGPT-4, which provided detailed procedure explanations, risks, and benefits. Post-interaction, participants completed a survey assessing their experience through quantitative and qualitative measures. Results Participants had a cautiously optimistic response to AI in the surgical consent process. Notably, 71% felt adequately informed, 86% found the information clear, and 71% felt they could make informed decisions. Overall, 71% were satisfied, 57% felt respected and confident, and 57% would recommend it, indicating areas needing refinement. However, concerns about data privacy and the lack of personal interaction were significant, with only 42% reassured about the security of their data. The standardization of information provided by AI was appreciated for potentially reducing human error, but the absence of empathetic human interaction was noted as a drawback. Discussion While AI shows promise in enhancing the consistency and comprehensiveness of information delivered during the consent process, significant challenges remain. These include addressing data privacy concerns and bridging the gap in personal interaction. The potential for AI to misinform due to system "hallucinations" or inherent biases also needs consideration. Future research should focus on refining AI interactions to support more nuanced and empathetic engagements, ensuring that AI supplements rather than replacing human elements in healthcare. Conclusion The integration of AI into surgical consent processes could standardize and potentially improve the delivery of information but must be balanced with efforts to maintain the critical human elements of care. Collaborative efforts between developers, clinicians, and ethicists are essential to optimize AI use, ensuring it complements the traditional consent process while enhancing patient satisfaction and trust.

Persistence of inadequate consent training for interns

BACKGROUND

Informed consent is a continuous process of communication with the patient and not merely the signing of a form. The Irish Medical Council's Guide to Good Practice and Ethics state that no part of the consent process should be delegated to an intern unless the procedure is a minor with which the intern is very familiar and all relevant information has first been explained to the intern.

AIMS

We aimed to evaluate whether practices regarding interns and consent had changed in the past five years.

METHODS

An anonymous Google Forms survey was distributed to interns from all intern networks between 24-August and 26-November 2021.

RESULTS

Of 854 interns, there were 147(17.2%) survey responses. 129(87.8%) participants had consented for a procedure. 111(86%) responded that they had consented for procedures that they had not witnessed before. 92(71.3%) reported that their medical supervisor did not explain procedures to them prior to obtaining consent. 128(99.2%) of interns were not usually observed by a more senior doctor when obtaining consent. 116(89.9%) were expected to obtain consent from patients on a regular basis, with 78(60.5%) feeling pressured into doing so on at least one occasion. Results were largely unchanged compared to when the same survey was circulated in 2016.

CONCLUSIONS

Interns remain routinely involved in the consent process without adequate training or supervision. This is unfair on our most junior doctors and on patients. Steps must be taken to ensure the IMC guidance is adhered to and this deficiency must be highlighted to Senior Clinicians.

Consent-GPT: is it ethical to delegate procedural consent to conversational AI?

Obtaining informed consent from patients prior to a medical or surgical procedure is a fundamental part of safe and ethical clinical practice. Currently, it is routine for a significant part of the consent process to be delegated to members of the clinical team not performing the procedure (eg, junior doctors). However, it is common for consent-taking delegates to lack sufficient time and clinical knowledge to adequately promote patient autonomy and informed decision-making. Such problems might be addressed in a number of ways. One possible solution to this clinical dilemma is through the use of conversational artificial intelligence using large language models (LLMs). There is considerable interest in the potential benefits of such models in medicine. For delegated procedural consent, LLM could improve patients' access to the relevant procedural information and therefore enhance informed decision-making.In this paper, we first outline a hypothetical example of delegation of consent to LLMs prior to surgery. We then discuss existing clinical guidelines for consent delegation and some of the ways in which current practice may fail to meet the ethical purposes of informed consent. We outline and discuss the ethical implications of delegating consent to LLMs in medicine concluding that at least in certain clinical situations, the benefits of LLMs potentially far outweigh those of current practices.

Exploring healthcare professionals' perspective of the process of obtaining consent for adult patient's having planned surgery: A scoping review

AIM

The aim of this scoping review was to provide an overview of the literature about the process of obtaining consent from adult patients undergoing planned surgery from the healthcare professionals' perspective and analyse knowledge gaps.

BACKGROUND

The process of obtaining consent for planned elective surgery manifests an individual's fundamental right to decide what happens to their body. The process is often suboptimal and problematic, placing a significant resource burden on health systems globally. Deficiencies in the documentation on consent forms have also been shown to increase the risk of operating room error.

DESIGN

Scoping review.

METHODS

Arksey and O'Malley's (International Journal of Social Research Methodology, 8, 2005 and 19) five-step scoping review methodology was used.

RESULTS

Fifty-three articles were included; 39 primary and 14 secondary research publications. Three key findings were identified; there is currently low-level evidence about surgical consent processes to inform clinical practice; junior doctors obtain surgical consent frequently, yet this process was likely undertaken sub-optimally; and current knowledge gaps include capacity assessment, decision-making and pre-procedural consent checks.

CONCLUSION

Planned surgical consent processes are complex, and both surgeons and perioperative nurses are essential during the process. While surgeons have responsibility to obtain consent, perioperative nurses provide a safety net in the surgical consent process checking the surgical consent information is correct and has been understood by the patient. Such actions may influence consent validity and patient safety in the operating room. Knowledge gaps about capacity assessment, decision-making, pre-procedural checks and the impact of junior doctors obtaining consent on patient understanding, safety and legal claims are evident.

RELEVANCE TO CLINICAL PRACTICE

This review highlights the importance of the surgical nurse's role in the planned surgical consent process. While the responsibility for obtaining surgical consent lies with the surgeon, the nurse's role verifying consent information is crucial as they act as a safety net and can reduce error in the operating room.

NO PATIENT OR PUBLIC CONTRIBUTION

The authors declare that no patient or public contribution was made to this review in accordance with the aim to map existing literature from the healthcare professionals' perspective.

Measuring Impact of Simulation-Based Informed Consent Training on Surgical Intern's Long-Term Confidence

OBJECTIVE

Our objective was to evaluate the outcome of a training program on long-term confidence of interns and attending physicians.

DESIGN

In this prospective cohort study, general surgery interns underwent a training program on informed consent that involved didactics, standardized patient encounters, and supplemental procedure specific guides at the start of the academic year. At the end of the academic year, we surveyed interns from the classes of 2020 (trained) and 2019 (untrained) about their experience and confidence in obtaining an informed consent. Further, we queried attending physicians on their experience and confidence in the interns at the end of each academic year.

SETTING

Single academic general surgery residency program based at 2 urban tertiary hospitals.

PARTICIPANTS

General surgery interns including unmatched preliminary residents and categorical interns from general surgery, interventional radiology, and urology.

RESULTS

Twenty-four incoming interns participated in the training program. Intern confidence discussing operation benefits improved from a median score of 4 to 5 (p = 0.03), and total confidence improved from a median score of 15 to 17.5 (p = 0.08). There was no difference in median total confidence scores (15 vs. 17.5; p = 0.21) between classes. Attending physicians had similar median total confidence scores following intervention (10 vs. 11; p = 0.87). Intern satisfaction was 80% with the didactic session, and 90% with standardized patient encounters. Twenty percent of learners used the supplemental procedure specific guides.

CONCLUSIONS

Implementation of an intern targeted program on informed consent that incorporated didactics and standardized patient encounters was viewed as useful and may contribute to long-term improvements in confidence.

Evaluating first year residents' communication skills: a health literacy curriculum needs assessment

BACKGROUND

High quality communication skills are necessary for competent and ethical practice. When patients present with low health literacy, physicians' skills may be lacking, which can put patients' safety and satisfaction at risk. The authors' developed and executed a simulation-based needs assessment following conflicting internal reports about the communications skills of new residents.

METHODS

The current study recruited first year residents (N = 30) during the 2019 first post-graduate year (PGY-1) orientation at a southeastern university hospital simulation center. The residents completed an Objective Structured Clinical Examination (OSCE) which focused on obtaining informed consent from a patient's health care proxy who presented with limited literacy and health literacy and poor communication skills. After completing the OSCE, the residents, simulated patients (SP), and independent observers assessed the residents' performance.

RESULTS

Residents assessed their performance higher when compared with the ratings from independent observers and patient raters. Residents who spent more time with SPs were given higher ratings by the SPs and independent observers. Finally, residents' ratings of themselves had a positive correlation with their reported confidence, but no correlation between self-confidence and the ratings provided by SPs or observers.

CONCLUSION

PGY-1 residents demonstrate a continued need for health literacy and informed consent education, despite faculty believing that these skills were covered enough in medical school. These residents also demonstrated limited self-assessment ability or skills below the expectations of health literacy experts. Curriculum changes included improving the focus on health literacy, communication skills, and additional practice opportunities throughout their internship year.

Junior doctor experiences and challenges in obtaining surgical informed consent: A qualitative systematic review & meta-ethnography

INTRODUCTION

Surgical informed consent (SIC) to procedures is necessary to ensure patient autonomy is adequately respected. It is also necessary to protect doctors, and their institutions, from claims of negligence. While SIC is often acquired by senior consultants, it also commonly falls to the junior doctors on a team to ensure SIC is adequately acquired and documented. A growing body of literature suggests that junior doctors are not sufficiently educated about the legal and practical issues concerned with obtaining medical consent. This may open up this cohort, and their hospitals, to medico-legal liability.

AIMS

to provide a systematic review of the qualitative literature on junior doctors' experiences and challenges in consenting surgical patients and to synthesize evidence on this issue in order to guide policy-makers in the medicolegal and medical education spheres.

METHODS

a systematic review of qualitative literature was performed. Analysis of the literature was guided by Noblit and Hare's seven-step approach to meta-ethnography, with the final synthesis presented as a thematic analysis of the literature.

CONCLUSION

This research concludes that a significant proportion of SIC is likely to be acquired by junior doctors, many of whom are Post-Graduate Year (PGY) 1-2 and who lack adequate training and education. This cohort face challenges in assessing capacity, in ensuring adequate disclosure related to surgical procedures, and in adequately documenting consent. This may impact the validity of any SIC they acquire. Medical educators and policy-makers should be aware of these issues when creating policies impacting SIC, and when designing surgical education programs for medical students and junior doctors alike.

"Let's Get the Consent Together": Rethinking How Surgeons Become Competent to Discuss Informed Consent

OBJECTIVE

Eliciting informed consent is a clinical skill that many residents are tasked to conduct without sufficient training and before they are competent to do so. Even senior residents and often attending physicians fall short of following best practices when conducting consent conversations.

DESIGN

This is a perspective on strategies to improve how residents learn to collect informed consent based on current literature.

CONCLUSIONS

We advocate that surgical educators approach teaching informed consent with a similar framework as is used for other surgical skills. Informed consent should be defined as a core clinical skill for which attendings themselves should be sufficiently competent and residents should be assessed through direct observation prior to entrustment.