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Tunzi M, Day PG, Satin DJ. It's a spiral staircase, not just two steps: An iterative approach to assessing patient capacity for medical decision-making. PATIENT EDUCATION AND COUNSELING 2024; 127:108362. [PMID: 38981404 DOI: 10.1016/j.pec.2024.108362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 06/14/2024] [Accepted: 06/24/2024] [Indexed: 07/11/2024]
Abstract
The assessment of medical decision-making capacity as part of the process of clinical informed consent has been considered a bioethical housekeeping matter for decades. Yet in practice, the reality bears little resemblance to what is described in the medical literature and professed in medical education. Most literature on informed consent refers to medical decision-making capacity as a precondition to the consent process. That is, a clinician must first determine if a patient has capacity, and only then may the clinician engage with the patient for the rest of informed consent. The problem with this two-step approach is that it makes no sense in actual practice. We see the assessment of medical decision-making capacity within the process of informed consent as a spiral staircase, not just two steps, requiring clinicians to keep circling up and around, making progress, until they get to where they need to be: 1. Clinicians start with a general presumption of capacity for most adults, sometimes having a provisional appraisal of capacity based on prior patient contact. 2. Then, they begin performing informed consent for the current situation and intervention options. 3. Next, they must reassess capacity during this process. 4. After that, they continue with informed consent. 5. If capacity is not yet clear, they repeat 1-4.
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Affiliation(s)
- Marc Tunzi
- Family Medicine Residency, Natividad Medical Center, 1441 Constitution Boulevard, Salinas, CA 93906, USA; Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Philip G Day
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA.
| | - David J Satin
- Department of Family Medicine and Community Health, Affiliate Faculty, Center for Bioethics, University of Minnesota Medical School, Minneapolis, MN, USA.
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Sebastian A, Wyld L, Morgan JL. Examining the variation in consent in general surgery. Ann R Coll Surg Engl 2024; 106:140-149. [PMID: 37218649 PMCID: PMC10830343 DOI: 10.1308/rcsann.2023.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 05/24/2023] Open
Abstract
INTRODUCTION Consent is a fundamental aspect of surgery and expectations around the consent process have changed following the Montgomery vs Lanarkshire Health Board (2015) court ruling. This study aimed to identify trends in litigation pertaining to consent, explore variation in how consent is practised among general surgeons and identify potential causes of this variation. METHODS This mixed-methods study examined temporal variation in litigation rates relating to consent (between 2011 and 2020), using data obtained from National Health Service (NHS) Resolutions. Semi-structured clinician interviews were then conducted to gain qualitative data regarding how general surgeons take consent, their ideologies and their outlook on the recent legal changes. The quantitative component included a questionnaire survey aiming to explore these issues with a larger population to improve the generalisability of the findings. RESULTS NHS Resolutions litigation data showed a significant increase in litigation pertaining to consent following the 2015 health board ruling. The interviews demonstrated considerable variation in how surgeons approach consent. This was corroborated by the survey, which illustrated considerable variation in how consent is documented when different surgeons are presented with the same case vignette. CONCLUSION A clear increase in litigation relating to consent was seen in the post-Montgomery era, which may be due to legal precedent being established and increased awareness of these issues. Findings from this study demonstrate variability in the information patients receive. In some cases, consent practices did not adequately meet current regulations and therefore are susceptible to potential litigation. This study identifies areas for improvement in the practice of consent.
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Affiliation(s)
| | - L Wyld
- University of Sheffield Medical School, UK
| | - JL Morgan
- University of Sheffield Medical School, UK
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Marwaha M, Bhalla R, Rao S, Chen C. Minimum standard assessment of informed consent for internal medicine transition to residency program: A cohort study. Health Sci Rep 2023; 6:e1523. [PMID: 37674619 PMCID: PMC10477888 DOI: 10.1002/hsr2.1523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/29/2023] [Accepted: 08/10/2023] [Indexed: 09/08/2023] Open
Abstract
Background and Aims Interns must be proficient in obtaining informed consent (IC), which is the Association of American Medical College's 11th of 13 Entrustable Professional Activities (EPAs). Medical students have limited opportunity to practice IC during clerkships, resulting in inconsistent proficiency. We aimed to create a tool to assess whether our transition to residency (TTR) workshop enables fourth-year medical students to meet a minimum standard of obtaining IC. Methods Sixty fourth-year medical students were enrolled in the internal medicine virtual TTR course during AY2021. The curriculum prioritizes deliberate practice activities. Pre- and postworkshop assignments involved students typing verbatim what they would say during IC encounters. We modified an IC abstraction tool created by Spatz et al. to assess a minimum standard for students' IC assignments. Our final 7-item tool consisted of the following domains: "What," "Why," "How," "Benefits," "Quantitative Risks," "Qualitative Risks," and "Alternatives," weighing 1 point each. A minimum standard was obtained with a score of 6 or more points by appropriately discussing at least one domain involving risk and all other domains. Results Students scored highly on the prework domains pertaining to "What," "Why," and "How" of the procedure with no significant difference on postwork. Significant improvement was achieved on postwork domains covering "Benefits" (p = 0.039) and "Alternatives" (p = 0.031). For domains involving "Qualitative" and "Quantitative Risks," there were no statistically significant improvements from pre- to postwork scores. Fifteen and 22 students met the minimum standard for IC on pre- and postwork, respectively. Conclusion Our students demonstrated a good a priori understanding of the "What," "Why," and "How" domains. After the workshop, they more reliably discussed "Benefits" and "Alternatives." Our abstraction tool helped assess the strengths and weaknesses in our students' IC skillset and helped recognize areas of our curriculum that will benefit from improvements to bring students to meet the minimum standard.
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Affiliation(s)
- Mannat Marwaha
- Rutgers School of Graduate StudiesRutgers UniversityNew BrunswickNew JerseyUSA
| | - Raman Bhalla
- Department of Medicine, Robert Wood Johnson Medical SchoolRutgers UniversityNew BrunswickNew JerseyUSA
| | - Shivani Rao
- Rutgers School of Graduate StudiesRutgers UniversityNew BrunswickNew JerseyUSA
| | - Catherine Chen
- Department of Medicine, Robert Wood Johnson Medical SchoolRutgers UniversityNew BrunswickNew JerseyUSA
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Gardiner TM, Gillespie BM, Latimer S, Hewitt J. Exploring healthcare professionals' perspective of the process of obtaining consent for adult patient's having planned surgery: A scoping review. J Clin Nurs 2023; 32:5779-5792. [PMID: 37357439 DOI: 10.1111/jocn.16698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 06/27/2023]
Abstract
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.
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Affiliation(s)
- Therese M Gardiner
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Brigid M Gillespie
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Gold Coast Hospital and Health Service, Southport, Queensland, Australia
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Southport, Queensland, Australia
| | - Sharon Latimer
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Jayne Hewitt
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Griffith Law School, Griffith University, Southport, Queensland, Australia
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Sullivan GA, Harmon K, Gill-Wiehl GF, Kim S, Velasco JM, Chan EY, Schimpke SW. Measuring Impact of Simulation-Based Informed Consent Training on Surgical Intern's Long-Term Confidence. JOURNAL OF SURGICAL EDUCATION 2023; 80:884-891. [PMID: 36967342 DOI: 10.1016/j.jsurg.2023.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 02/03/2023] [Accepted: 02/23/2023] [Indexed: 05/23/2023]
Abstract
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.
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Affiliation(s)
- Gwyneth A Sullivan
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kelly Harmon
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | | | - Seungjun Kim
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jose M Velasco
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Edie Y Chan
- Department of Surgery, Division of Abdominal Transplantation, Rush University Medical Center, Chicago, Illinois
| | - Scott W Schimpke
- Department of Surgery, Division of Bariatric and Minimally Invasive Surgery, Rush University Medical Center, Chicago, Illinois.
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Surgical informed consent: new challenges. Curr Probl Surg 2023; 60:101258. [PMID: 36813352 DOI: 10.1016/j.cpsurg.2022.101258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022]
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White EM, Esposito AC, Kurbatov V, Wang X, Caty MG, Laurans M, Yoo PS. How I Learned is How I Teach - Perspectives on How Faculty Surgeons Approach Informed Consent Education. JOURNAL OF SURGICAL EDUCATION 2022; 79:e181-e193. [PMID: 36253332 DOI: 10.1016/j.jsurg.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/24/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To understand the variability of surgical attending experience and perspectives regarding informed consent and how it impacts resident education DESIGN: A novel survey was distributed electronically to explore faculty surgeon's personal learning experience, knowledge, clinical practice, teaching preferences and beliefs regarding informed consent. Chi-square and Kruskal-Wallis testing was performed to look for associations and a cluster analysis was performed to elucidate additional patterns among. SETTING Single, tertiary, university-affiliated health care system (Yale New Haven Health in Connecticut), including 6 teaching hospitals. PARTICIPANTS Clinical faculty within the Department of Surgery. RESULTS A total of 85 surgeons responded (49% response rate), representing 17 specialties, both private practice and university and/or hospital-employed, with a range of years in practice. Across all ages, specialties, the most common method for both learning (86%) and teaching (82%) informed consent was observation of the attending. Respondents who stated they learned by observing attendings were more likely to report that they teach by having trainees observe them (OR 8.5, 95% CI 1.3-56.5) and participants who recalled learning by having attendings observe them were more likely to observe their trainees (OR 4.1, 95% CI 1.5-11.2).Cluster analysis revealed 5 different attending phenotypes with significant heterogeneity between groups. A cluster of younger attendings reported the least diverse learning experience and high levels of concern for legal liability and resident competency. They engaged in few strategies for teaching residents. By comparison, the cluster that reported the most diverse learning experience also reported the richest diversity of teaching strategies to residents but rarely allowed residents to perform consent with their patients. Meanwhile, 2 other cluster provided a more balanced experience with some opportunities for practice with patients and some diversity of teaching- these clusters, respectively, consist of older, experienced general surgeons and surgeons in trauma and/or critical care. CONCLUSIONS Surgeon's demographics, personal experiences, and specialty appear to significantly influence their teaching styles and the educational experience residents receive regarding informed consent.
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Affiliation(s)
- Erin M White
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Andrew C Esposito
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Vadim Kurbatov
- Yale University School of Medicine, Department of Surgery, Department of Genetics, New Haven, Connecticut
| | - Xujun Wang
- Yale University School of Medicine, Department of Genetics, New Haven, Connecticut
| | - Michael G Caty
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Maxwell Laurans
- Yale University School of Medicine, Department of Neurosurgery, New Haven, Connecticut
| | - Peter S Yoo
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut.
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Singer KE, Baker JE, Elson NC, Wallen TE, Salvator A, Quillin RC, Sussman JJ, Makley AT, Goodman MD. How Informed Is Your Informed Consent: Evaluating Differences Between Resident and Attending Obtained Consents for Cholecystectomy. JOURNAL OF SURGICAL EDUCATION 2022; 79:1509-1515. [PMID: 36030182 DOI: 10.1016/j.jsurg.2022.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/24/2022] [Accepted: 07/16/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE There is considerable variability in surgeons' approach to write and obtain informed consent for surgery, particularly among resident trainees. We analyzed differences in procedures and complications described in documented surgical consents for cholecystectomy between residents and attendings. We hypothesized that attending consents would describe more comprehensive procedures and complications than those done by residents. DESIGN This is a retrospective analysis of 334 patients who underwent cholecystectomy. Charts were queried for demographics, surgical approach, whether the consent was completed electronically, and which provider completed the consent. Specifically, consents were evaluated for inclusion of possible conversion to open procedure, intraoperative cholangiogram, bile duct injury, injury to nearby structures, reoperation, bile leak, as well as if the consent matched the actual procedure performed. SETTING This study was conducted at an accredited general surgery training program at an academic tertiary care center in the Midwest. PARTICIPANTS This was a review of 334 patients who underwent cholecystectomy over a 1 year period. RESULTS Of all documented consents analyzed, 153 (47%) specifically included possible intraoperative cholangiogram, 156 (47%) included bile duct injury, 76 (23%) included injury to nearby structures, 22 (7%) included reoperation, and 62 (19%) included bile leak. In comparing residents and attendings, residents were more likely to consent for bile duct injury (p = 0.002), possible intraoperative cholangiogram (p = 0.0007), injury to nearby structures (p < 0.0001), reoperation (p < 0.0001), and bile leak (p < 0.0001). CONCLUSIONS Significant variation exists between documentation between resident and attending cholecystectomy consents, with residents including more complications than attendings on their consent forms. These data suggest that experience alone does not predict content of written consents, particularly for common ambulatory procedures. Education regarding the purpose of informed consent and what should be included in one may lead to a reduction in variability between providers.
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Affiliation(s)
- Kathleen E Singer
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jennifer E Baker
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Nora C Elson
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Taylor E Wallen
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Ann Salvator
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Ralph C Quillin
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jeffrey J Sussman
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy T Makley
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Michael D Goodman
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio.
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Suresh NV, Shah VN, Fritz CG, Griff JR, Shah S, Watane A, Parikh RS, Nicolli EA. Medical malpractice litigation involving otolaryngology residents and fellows: A case-based 30-year review. World J Otorhinolaryngol 2022; 9:1-11. [DOI: 10.5319/wjo.v9.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/09/2022] [Accepted: 08/18/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Errors, misdiagnoses, and complications can occur while trainees are involved in patient care. Analysis of such events could reveal areas for improvement by residency and fellowship programs.
AIM To examine lawsuits tried at the state and federal level involving otolaryngology trainees.
METHODS The LexisNexis database, an online legal research database containing state and federal case records from across the United States, was retrospectively reviewed for malpractice cases involving otolaryngology residents or fellows from January 1, 1990 to December 31, 2020. Case data collected: Plaintiff/trainee/defendant characteristics, allegations, medical outcomes, and legal outcomes.
RESULTS Over the study period, 20 malpractice lawsuits involving otolaryngology trainees were identified. Plaintiffs raised numerous allegations including procedural error (n = 12, 25.5%), incorrect diagnosis and/or treatment (n = 8, 17.0%), and lack of knowledge of trainee involvement (n = 6, 12.8%). Nine cases (45%) had verdicts in favor of the plaintiff, whereas 5 cases (25%) had verdicts in favor of the defense. Six cases (30%) ended in a settlement. Awards to plaintiffs were heterogenous, with a median of $617,500 (range $32K-17M) for settled cases and verdicts favoring plaintiffs.
CONCLUSION The findings enclosed herein represent the first published analysis of trainee involvement in otolaryngology malpractice cases held at the state/federal level. Otolaryngology trainees can be involved in lawsuits for both procedural and nonprocedural events. This study highlights the importance of education specifically in the domains of procedural errors, informed consent, proper diagnosis/management, and clear communication within patient care teams. Training programs should incorporate these study findings into effective simulation courses and didactic sessions. Educating trainees about common pitfalls holds the promise of decreasing healthcare systems costs, reducing trainee burnout, and, most importantly, benefiting patients.
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Affiliation(s)
- Neeraj V Suresh
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA 19107, United States
| | - Viraj N Shah
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, United States
| | - Christian G Fritz
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA 19107, United States
| | - Jessica R Griff
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, United States
| | - Shreni Shah
- Morsani College of Medicine, University of South Florida, Tampa, FL 33612, United States
| | - Arjun Watane
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, CT 06510, United States
| | - Ravi S Parikh
- Department of Ophthalmology, NYU Grossman School of Medicine, New York, NY 10016, United States
| | - Elizabeth A Nicolli
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, United States
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Pico-Camacho AJ, Vega-Peña NV. La comunicación en el consentimiento informado. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.2147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. El consentimiento informado es un elemento importante en la relación médico-paciente, que involucra la trasmisión de un mensaje. En este contexto, se describe la teoría de la comunicación implícita en un consentimiento informado, las barreras para una transmisión adecuada del mensaje, la responsabilidad en la comunicación y los requisitos para el logro de estos propósitos. El objetivo fue analizar de forma reflexiva los procesos de comunicación surtidos y necesarios durante su diligenciamiento, con algunas propuestas factibles de implementar.
Discusión. El proceso comunicativo implica evaluar la calidad, el contexto, la intencionalidad, la pedagogía y la recepción-emisión del mensaje. La naturaleza de la actividad quirúrgica requiere el perfeccionamiento de la comunicación como una competencia necesaria en los cirujanos. Se señalan oportunidades de mejoramiento para una adecuada ejecución de esta habilidad no técnica, habitualmente no contemplada en la formación médica.
Conclusiones. El consentimiento informado es un acto que trasciende a la transmisión de la información y es el resultado de un proceso complejo, que involucra habilidades comunicativas. Su efectividad se deriva de una toma de decisiones respaldada por el entendimiento claro de la situación y del procedimiento a efectuar. Existen puntos críticos durante su realización que podrían ser objeto de intervenciones futuras, desde esta perspectiva comunicativa.
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Stave EA, Greenberg L, Hamburger E, Ottolini M, Agrawal D, Lewis K, Barber JR, Bost JE, Harahsheh AS. An educational intervention to facilitate appropriate subspecialty referrals: a study assessing resident communication skills. BMC MEDICAL EDUCATION 2022; 22:533. [PMID: 35804336 PMCID: PMC9270829 DOI: 10.1186/s12909-022-03592-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Our goal was to improve pediatric residents' advanced communication skills in the setting of referral to address the entrustable professional activity of subspecialty referral identified by the American Board of Pediatrics. To accomplish this aim, we created a referral and consultation curriculum to teach and assess core communication skills in subspecialty referral involving an adolescent with syncope, an anxiety-provoking symptom that is rarely associated with serious pathology. METHODS We utilized blended multimodal educational interventions to improve resident communication skills in referral of patients. Trainees participated in 1) an interactive online module on syncope focusing on "red-flag" symptoms that would warrant a subspecialty cardiology referral and 2) a 4-h intervention with Standardized Parents (SPs), focusing on the case-based application of communication skills. Communication skills were assessed by two pre- and post- Objective Structured Clinical Examination encounters of patients with syncope, with an SP evaluation using a 20-item checklist. Analysis was performed with Sign test and McNemar's test. Trainees provided feedback on a Critical Incident Questionnaire, which was analyzed qualitatively. RESULTS Sixty-four residents participated. There was an overall improvement in communication skills based on SP scores (82.7 ± 10.9% to 91.7 ± 5.0%, p < 0.001), and 13/20 items demonstrated significant improvement post-intervention. Residents' improved performance enabled them to address patient/family emotions, explain referral logistics, and clarify concerns to agree on a plan. CONCLUSIONS By participating in this curriculum, residents' communication skills improved immediately post-intervention. Further research is needed to assess if this intervention improves patient care by providing residents with enduring skills to judiciously manage the referral process.
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Affiliation(s)
- Elise A Stave
- Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Larrie Greenberg
- Pediatrics, Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ellen Hamburger
- Pediatrics, Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Dewesh Agrawal
- Pediatrics, Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Karen Lewis
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - John R Barber
- Pediatrics, Children's National Hospital, Washington, DC, USA
| | - James E Bost
- Pediatrics, Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ashraf S Harahsheh
- Pediatrics, Children's National Hospital, Washington, DC, USA.
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
- Division of Cardiology, Children's National Hospital, 111 Michigan Ave, Washington, DC, NW, 20010, USA.
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Yong V, Zhao H, Gilmore K, Cripe J, Conklin C, Dauer E. Procedural-based Specialties Benefit from a Formal Informed Consent and Disclosures Educational Program. JOURNAL OF SURGICAL EDUCATION 2022; 79:725-731. [PMID: 35000886 DOI: 10.1016/j.jsurg.2021.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/02/2021] [Accepted: 12/12/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE At our tertiary academic center, residents undergo formalized training in obtaining informed consent and disclosing a complication. The informed consent portion has previously been shown to benefit a group of surgical and emergency medicine residents. We aimed to determine if the benefits from training persist across a larger number of procedural-based specialties and to ascertain the benefit of training in disclosing complications. DESIGN This retrospective cohort study examined first-year residents from seven procedural-based specialties who participated in a formal informed consent and disclosures training program, consisting of a didactic lecture and two-part simulation. Two years after the start of the program, the disclosure scenario was added. Participants were given pre- and post-surveys assessing comfort and confidence in the informed consent and disclosure scenarios. Survey results were compared using the signed-rank test and Kruskal-Wallis test as appropriate. SETTING This study occurred at Temple University Hospital, a tertiary academic institution in Philadelphia, PA. PARTICIPANTS First-year residents from 2014 to 2020 in seven procedural-based specialties, including general surgery, orthopedic surgery, otolaryngology, obstetrics and gynecology, emergency medicine, radiology, and anesthesia, participated in this study. One hundred and ninety-three residents completed the program and surveys. RESULTS Residents reported improved confidence in filling out an informed consent form (p = 0.036) and more comfortable in obtaining informed consent (p = 0.041), as well as more confidence (p = 0.018) and comfort (p = 0.001) in disclosing a complication. Surgical residents demonstrated greater confidence in obtaining informed consent (p = 0.009) and disclosing a complication (p = 0.0002) after training than non-surgical residents. CONCLUSIONS Across multiple procedural-based specialties, formal training in informed consent and disclosure of complications increases resident ability to perform these tasks. A formal training program is valuable for residents who are expected to perform these tasks across various specialties.
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Affiliation(s)
- Valeda Yong
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania.
| | - Huaqing Zhao
- Department of Biomedical Education and Data Science, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Kimberly Gilmore
- Temple University Lewis Katz School of Medicine, William Maul Measey Institute for Clinical Simulation and Patient Safety, Philadelphia, Pennsylvania
| | - Jane Cripe
- Temple University Lewis Katz School of Medicine, William Maul Measey Institute for Clinical Simulation and Patient Safety, Philadelphia, Pennsylvania
| | - Charles Conklin
- Department of Risk Management, Temple University Hospital, Temple University Health System, Philadelphia, Pennsylvania
| | - Elizabeth Dauer
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
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13
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Checklist-based Training Improves Consenting Skills Among Radiology Residents. Acad Radiol 2022; 29 Suppl 5:S103-S110. [PMID: 34996686 DOI: 10.1016/j.acra.2021.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/14/2021] [Accepted: 11/18/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE This study aimed to demonstrate whether a curriculum based on an informed consent conversation checklist led to improvement in a resident's ability to obtain patient centered and legally sound consent. MATERIAL/METHODS In this prospective, IRB approved study, Radiology residents from a single institution were asked to obtain informed consent for an imaging study or image-guided procedure from a standardized patient (SP). Encounters were scored by an attending radiologist on a 20-point checklist as well as by the SPs on four consent related questions. Residents were then provided reading material, a lecture, and a consent checklist pocket card. Residents participated in a post-intervention SP encounter. Wilcoxon Signed-Ranks Test was performed to determine if there was a significant improvement in scores after intervention. RESULTS Twenty-one residents completed all aspects of the program. There was statistically significant improvement in consenting skills as measured by the attending scores and the SP scores after receiving formal education. Pre-intervention scores had a mean of 9.29 of 20 (SD 1.39), while post-intervention scores had a mean of 16.95 of 20 (SD 1.83). 95.2% (20/21) of residents found the training useful and stated they would recommend it to future trainees. CONCLUSION Checklist-based consent training improved radiology residents' ability to obtain informed consent.
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14
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Atkin J, Incoll IW, Owen J, Conyard C. Informed consent: perceptions and practice of orthopaedic trainees. ANZ J Surg 2022; 92:819-824. [PMID: 35119699 DOI: 10.1111/ans.17517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/14/2021] [Accepted: 01/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose of informed consent is to provide patients with adequate information about a proposed plan or intervention, including the benefits and risks, so that they can make an informed decision about their medical treatment. The literature suggests that trainees are often delegated the task of obtaining consent with inadequate knowledge, skill or experience. The aim of this study is to determine the extent orthopaedic surgical trainees have been exposed to education about the informed consent, their perceived ability to obtain consent effectively and the frequency with which they routinely address elements of the process when consenting patients. METHODS An eight-item questionnaire assessing trainees' experience with informed consent was distributed to trainees undertaking Australian orthopaedic surgery training in 2019. RESULTS Of the 239 trainees, 102 completed the questionnaire. Although 99% of trainees were confident that they can obtain valid consent from patients, when asked about aspects of the process, many trainees do not address them. Only 29% of trainees always ask patients about goals of care and 21% always advise the patient of who will be performing the procedure. Trainees who indicated that they had received education on informed consent during surgical training are significantly more likely to address key elements. CONCLUSION Trainees' perceptions of their knowledge and skill in relation to informed consent does not align with their reported practice. Although the majority of trainees had received some education on informed consent, greater emphasis on explicit teaching and formal assessment should be undertaken during surgical training, prior to trainees completing this activity independently.
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Affiliation(s)
- Jodie Atkin
- Nikta Projects, Sydney, New South Wales, Australia
| | - Ian W Incoll
- Faculty of Health and Medicine, The University of Newcastle, Newcastle, New South Wales, Australia.,Graduate Programs in Surgical Education, The University of Melbourne, Melbourne, Victoria, Australia
| | - John Owen
- The Australian Orthopaedic Association, Sydney, New South Wales, Australia
| | - Chris Conyard
- The Australian Orthopaedic Association, Sydney, New South Wales, Australia
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Cohen-Bearak A, Meyer EC, Mednick L, Varrin P, Burgess L, Kuhlmann PH, Bell S, Lillehei C. Aligning Family-Clinician Expectations During Pediatric Surgical Informed Consent: Development and Implementation of an Innovative Communication Skills Workshop. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2021; 41:279-285. [PMID: 34609349 DOI: 10.1097/ceh.0000000000000396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Aligning expectations during the informed consent process before a child's surgery is an important element of good communication that benefits both surgical staff and families. We developed and evaluated a 2-hour pilot interprofessional workshop to improve the communication and relational skills of pediatric surgeons and nurse practitioners. METHODS Focus groups with families identified key challenges in the process of informed consent. An interprofessional team, including parents whose children had experienced complex surgeries, developed the workshop collaboratively. A realistic simulation with professional actors portraying parents allowed surgical staff to practice communication skills and receive feedback about the parent perspective. Participants completed a postworkshop evaluation to determine whether the workshop met its objectives and whether they would change practice. RESULTS Five key themes identified for the workshop included customize communication; align expectations; share clinical uncertainty; recognize/attend to emotions; and identify team members. Thirty-five clinicians participated in a workshop, and 89% completed evaluations. Three-quarters reported the learning to be valuable, and 64% were likely to change practice. Eighty-seven percent would recommend the workshop to other colleagues, and 58 to 74% felt more prepared to achieve each of eight specific skills. DISCUSSION An innovative workshop for pediatric surgical practitioners to align family-clinician expectations can help improve clinician communication skills and comfort with informed consent. Keys to workshop development included involving parents to identify themes and participate as workshop co-faculty; enlisting leadership and recruiting surgical champions; and using pre-existing meetings to ease scheduling challenges of busy practitioners. Booster sessions may facilitate the desired cultural changes.
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Affiliation(s)
- Adena Cohen-Bearak
- Ms. Cohen-Bearak: Project Manager, Center for Healthcare Organization and Implementation Research, Bedford VA Healthcare System, Bedford, MA. Dr. Meyer: Boston Children's Hospital, Center for Bioethics, and Associate Professor of Psychology, Harvard Medical School, Boston, MA. Dr. Mednick: Clinical Psychologist, Boston Children's Hospital, and Assistant Professor of Psychology, Harvard Medical School, Boston, MA. Dr. Varrin: Clinical Psychologist, Family Support Coordinator, Cotting School, Lexington, MA. Ms. Burgess: AA, Advisor Emeritus-Family Advisory Council, Boston Children's Hospital, Boston, MA. Dr. Kuhlmann: Chair for Pediatrics, Department of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany, and Division of Pediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University, Munich, Germany. Dr. Bell: Associate Professor, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Dr. Lillehei: Associate Professor of Surgery, Harvard Medical School; Chair of Surgical Education, Boston Children's Hospital, Boston, MA
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16
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Junior doctor experiences and challenges in obtaining surgical informed consent: A qualitative systematic review & meta-ethnography. J Surg Res 2021; 267:143-150. [PMID: 34147004 DOI: 10.1016/j.jss.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/20/2021] [Accepted: 05/07/2021] [Indexed: 11/20/2022]
Abstract
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.
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17
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Anderson TN, Kaba A, Gros E, Schmiederer IS, Shi R, Aalami LR, Lin DT, Lau JN. A Novel Blended Curriculum for Communication of Informed Consent With Surgical Interns. J Grad Med Educ 2021; 13:411-416. [PMID: 34178267 PMCID: PMC8207932 DOI: 10.4300/jgme-d-20-01057.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/14/2020] [Accepted: 03/17/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Interns often conduct procedural informed consent discussions (ICDs), identified as a core entrustable professional activity. Deficiencies in the training process for ICDs span across specialties. OBJECTIVE We provide evidence for a curriculum and assessment designed to standardize the training process and ensure ICD competency in surgical interns. METHODS In March 2019, PowerPoint educational materials were emailed to one academic institution's new surgical interns, who in June participated in an onsite 1-hour role-play "hot seat" group activity (GA) with an untrained simulated patient, and in October completed a single trained simulated patient (real-time raters) verification of proficiency (VOP) assessment. Curriculum evaluation was measured through intern pre-/post-confidence (5-point scale), and the VOP's Cronbach's alpha and test-retest were examined. Data were analyzed with descriptive statistics, paired t tests, and 2-way random effects models. RESULTS Of 44 new interns, 40 (91%) participated in the remote teaching and live GA and were assessed by the VOP. Pre-/post-GA confidence increased a mean difference of 1.3 (SD = 0.63, P < .001). The VOP's Cronbach's alpha was 0.88 and test-retest was 0.84 (95% CI 0.67-0.93, P < .001), with a 95% pass rate. The 2 first-time fail students required remediation. Time commitment included 1 hour maximum for individual training and implementation and 30 minutes for assessment. The use of volunteers and donated space mitigated additional costs. CONCLUSIONS Remote asynchronous and group skills teaching for new general surgical interns improved their confidence in conducting procedural ICDs. A patient-simulation verification process appeared feasible with preliminary evidence of retest and internal consistency.
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Affiliation(s)
- Tiffany N. Anderson
- All authors are with Stanford University School of Medicine, Department of Surgery
- Tiffany N. Anderson, MD, MHPE, is a Surgical Education Fellow
| | - Aboubacar Kaba
- All authors are with Stanford University School of Medicine, Department of Surgery
- Aboubacar Kaba, BS, is a Medical Student
| | - Eniola Gros
- All authors are with Stanford University School of Medicine, Department of Surgery
- Eniola Gros, BA, is a Medical Student
| | - Ingrid S. Schmiederer
- All authors are with Stanford University School of Medicine, Department of Surgery
- Ingrid S. Schmiederer, MD, is a Surgical Education Fellow
| | - Robert Shi
- All authors are with Stanford University School of Medicine, Department of Surgery
- Robert Shi, MS, is a Research Assistant
| | - Lauren R. Aalami
- All authors are with Stanford University School of Medicine, Department of Surgery
- Lauren R. Aalami, BS, is a Research Assistant
| | - Dana T. Lin
- All authors are with Stanford University School of Medicine, Department of Surgery
- Dana T. Lin, MD, is Assistant Program Director
| | - James N. Lau
- All authors are with Stanford University School of Medicine, Department of Surgery
- James N. Lau, MD, MHPE, FACS, is Associate Professor, Surgical Education Program, and Director
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Diana E, Hamaoka D, Goldenberg M, Cozza KL. Psychotropic Medication Informed Consent: A Cross-Specialty Role-Playing Skill Builder. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2021; 17:11152. [PMID: 34013021 PMCID: PMC8096884 DOI: 10.15766/mep_2374-8265.11152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 03/08/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Obtaining informed consent (IC) is an essential medical practice. Utilization of IC role-playing training with medication study cards and self-peer-supervisor review should improve student fund of knowledge and strengthen IC skills for clerkship-level medical students. METHODS Between 2017 and 2020, approximately 555 clerkship medical students used our formative role-playing exercise tools. Students independently prepared psychotropic medication study cards and role-played IC during group didactics. Peer and supervisor reviews were not recorded but were discussed as a group. Students completed routine anonymous postclerkship surveys regarding the IC exercise. An enhanced IC curriculum was deployed in 2020, adding a training video and peer/supervisor feedback form. Student feedback and specialty shelf exam scores were reviewed to assess the exercise's effectiveness. RESULTS Surveys indicated satisfaction with the exercise and increased confidence in obtaining IC. Interestingly, the student group that received enhanced IC training had fewer shelf exam failures than those without, perhaps indicating improved fund of psychotropic medication knowledge. DISCUSSION Peer role-playing IC training is well accepted by students, allows practice of essential elements of IC and shared decision-making, and provides an engaging way to improve medication fund of knowledge. Our clerkship has initiated development of an IC objective structured clinical examination station and is adapting the exercise across specialties for longitudinal learning in response to the positive feedback and ease of use. Structured review of psychotropics and peer IC role-playing can be tailored for other specialties, medications, and procedures and further developed for use in pre- and postclerkship education.
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Affiliation(s)
- Emily Diana
- Fourth-Year Medical Student, Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine
| | - Derrick Hamaoka
- Associate Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences
| | | | - Kelly L. Cozza
- Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences
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Jochum SB, Venkatramani M, Ritz EM, Favuzza J, Hayden DM, Saclarides TJ, Bhama AR. Surgical Residents' Perspective on Informed Consent-How Does It Compare With Attending Surgeons? J Surg Res 2020; 260:88-94. [PMID: 33333384 DOI: 10.1016/j.jss.2020.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/27/2020] [Accepted: 10/31/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The informed consent discussion (ICD) is a compulsory element of clinical practice. Surgical residents are often tasked with obtaining informed consent, but formal instruction is not included in standard curricula. This study aims to examine attitudes of surgeons and residents concerning ICD. MATERIALS AND METHODS A survey regarding ICD was administered to residents and attending surgeons at an academic medical center with an Accreditation Council for Graduate Medical Education-accredited general surgery residency. RESULTS In total, 44 of 64 (68.75%) residents and 37 of 50 (72%) attending surgeons participated. Most residents felt comfortable consenting for elective (93%) and emergent (82%) cases, but attending surgeons were less comfortable with resident-led ICD (51% elective, 73% emergent). Resident comfort increased with postgraduate year (PGY) (PGY1 = 39%, PGY5 = 85%). A majority of participants (80% attending surgeons, 73% residents) believed resident ICD skills should be formally evaluated, and most residents in PGY1 (61%) requested formal instruction. High percentages of residents (86%) and attendings (100%) believed that ICD skills were best learned from direct observation of attending surgeons. CONCLUSIONS Resident comfort with ICD increases as residents advance through training. Residents acknowledge the importance of their participation in this process, and in particular, junior residents believe formal instruction is important. Attending surgeons are not universally comfortable with resident-led ICDs, particularly for elective surgeries. Efforts for improving ICD education including direct observation between attending surgeons and residents and formal evaluation may benefit the residency curriculum.
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Affiliation(s)
- Sarah B Jochum
- Rush University Medical Center, Department of Surgery, Chicago, Illinois
| | | | - Ethan M Ritz
- Rush University Medical Center, Bioinformatics and Biostatistics Core, Chicago, Illinois
| | - Joanne Favuzza
- Rush University Medical Center, Division of Colon and Rectal Surgery, Department of Surgery, Chicago, Illinois
| | - Dana M Hayden
- Rush University Medical Center, Division of Colon and Rectal Surgery, Department of Surgery, Chicago, Illinois
| | - Theodore J Saclarides
- Rush University Medical Center, Division of Colon and Rectal Surgery, Department of Surgery, Chicago, Illinois
| | - Anuradha R Bhama
- Rush University Medical Center, Division of Colon and Rectal Surgery, Department of Surgery, Chicago, Illinois.
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20
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White EM, Miller SM, Esposito AC, Yoo PS. "Let's Get the Consent Together": Rethinking How Surgeons Become Competent to Discuss Informed Consent. JOURNAL OF SURGICAL EDUCATION 2020; 77:e47-e51. [PMID: 32753261 DOI: 10.1016/j.jsurg.2020.07.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/16/2020] [Accepted: 07/18/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Erin M White
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut.
| | - Samuel M Miller
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Andrew C Esposito
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Peter S Yoo
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
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21
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Wright JM, Raghavan A, Wright CH, Shammassian B, Duan Y, Sajatovic M, Selman WR. Back to the future: surgical rehearsal platform technology as a means to improve surgeon-patient alliance, patient satisfaction, and resident experience. J Neurosurg 2020; 135:384-391. [PMID: 33096533 DOI: 10.3171/2020.6.jns201865] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Informed consent, when performed appropriately, serves many roles beyond simply obtaining the prerequisite medicolegal paperwork to perform a surgery. Prior studies have suggested that patient understanding is poor when verbal communication is the sole means of education. Virtual reality platforms have proven effective in enhancing medical education. No studies exist that have demonstrated the utility of virtual reality-facilitated informed consent (VR-IC) in improving the physician-patient alliance. The aim of this study was to determine the utility of VR-IC among patients providing consent for surgery and the impact of this educational and information technology-based strategy on enhancing the physician-patient alliance, patient satisfaction, and resident-physician perception of the consent process. METHODS Prospective, single-site, pre- and postconsent surveys were administered to assess patient and resident perception of informed consent performed with the aid of VR-IC at a large tertiary academic medical center in the US. Participants were adult patients (n = 50) undergoing elective surgery for tumor resection and neurosurgical residents (n = 19) who obtained patient informed consent for these surgical procedures. Outcome measures included scores on the Patient-Doctor Relationship Questionnaire (PDRQ-9), the modified Satisfaction with Simulation Experience Scale, and the Maslach Burnout Inventory. Patient pre- and postconsent data were recorded in real time using a secure online research data platform (REDCap). RESULTS A total of 48 patients and 2 family members provided consent using VR-IC and completed the surveys pre- and postconsent; 47.9% of patients were women. The mean patient age was 57.5 years. There was a statistically significant improvement from pre- to post-VR-IC consent in patient satisfaction scores. Measures of patient-physician alliance, trust, and understanding of their illness all increased. Among the 19 trainees, perceived comfort and preparedness with the informed consent process significantly improved. CONCLUSIONS VR-IC led to improved patient satisfaction, patient-physician alliance, and patient understanding of their illness as measured by the PDRQ-9. Using VR-IC contributed to residents' increased comfort in the consent-gathering process and handling patient questions. In an era in which satisfaction scores are directly linked with hospital and service-line outcomes and reimbursement, positive results from VR-IC may augment physician and hospital satisfaction scores in addition to increasing measures of trust between physicians and patients.
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Affiliation(s)
| | | | | | | | | | - Martha Sajatovic
- 3Neurological and Behavioral Outcomes Center, Department of Psychiatry, University Hospitals Cleveland Medical Center; and
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22
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Kabiri N, Hajebrahimi S, Alizadeh G, Azimzadeh S, Farajzadeh N, Talebpour A. Promoting informed consent in a children's hospital in Tabriz, Iran: a best practice implementation project. ACTA ACUST UNITED AC 2020; 17:2570-2577. [PMID: 31453843 DOI: 10.11124/jbisrir-d-19-00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Informed consent is a continuous and dynamic process. It is a crucial part of healthcare procedures that becomes more complex in a pediatric clinical practice, where parents must make decisions for their children. OBJECTIVES The aim of this implementation project was to evaluate the current practice and implement the best practice related to obtaining informed consent in a children's hospital in Tabriz, Iran. METHODS A clinical audit was undertaken using the JBI Practical Application of Clinical Evidence System (JBI PACES) tool. Five audit criteria representing the best-practice recommendations for informed consent were used. A baseline audit was conducted, followed by the implementation of multiple strategies. The project was finalized with a follow-up audit to determine change in practice. RESULTS The compliance rate of all criteria improved from baseline to follow-up audit. Criteria 1 (obtaining informed consent prior to all nursing procedures) and 5 (provision of information related to the necessity of the treatment) reached 97% compliance in the follow-up cycle. Criterion 4 (provision of information related to the nature and effect of the treatment) achieved 74% compliance. Both criteria 2 and 3 (provision of information related to alternative treatments and consequences of refusing treatment) reached 57% in the follow-up cycle. To improve compliance, meetings were organized with the heads of departments, nurses and residents regarding informed consent. Also, staff were encouraged to report cases where informed consent was not obtained. CONCLUSION The audit results indicated an improvement in obtaining informed consent in the included departments. The interventions that were employed can facilitate the implementation of evidence into clinical practice.
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Affiliation(s)
- Neda Kabiri
- Iranian Center of Excellence in Health Management, School of Management and Medical Information, Tabriz University of Medical Sciences, Tabriz, Iran.,Iranian EBM Centre: a Joanna Briggs Institute Affiliated Group
| | - Sakineh Hajebrahimi
- Iranian EBM Centre: a Joanna Briggs Institute Affiliated Group.,Research Center for Evidence-Based Medicine, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Gisoo Alizadeh
- Iranian Center of Excellence in Health Management, School of Management and Medical Information, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Solmaz Azimzadeh
- Iranian Center of Excellence in Health Management, School of Management and Medical Information, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Amin Talebpour
- Iranian EBM Centre: a Joanna Briggs Institute Affiliated Group.,Research Center for Evidence-Based Medicine, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
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Aasen DM, Wiesen BM, Singh AB, Piper C, Harnke B, Prochazka AV, Fink AS, Hammermeister KE, Meguid RA. Systematic Review of Preoperative Risk Discussion in Practice. JOURNAL OF SURGICAL EDUCATION 2020; 77:911-920. [PMID: 32192884 DOI: 10.1016/j.jsurg.2020.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/22/2020] [Accepted: 02/15/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Informed consent is an ethical imperative of surgical practice. This requires effective communication of procedural risks to patients and is learned during residency. No systematic review has yet examined current risk disclosure. This systematic review aims to use existing published information to assess preoperative provision of risk information by surgeons. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses as a guide, a standardized search in Ovid MEDLINE, Embase, CINHAL, and PubMed was performed. Three reviewers performed the study screening, with 2-reviewer consensus required at each stage. Studies containing objective information concerning preoperative risk provision in adult surgical patients were selected for inclusion. Studies exclusively addressing interventions for pediatric patients or trauma were excluded, as were studies addressing risks of anesthesia. RESULTS The initial search returned 12,988 papers after deduplication, 33 of which met inclusion criteria. These studies primarily evaluated consent through surveys of providers, record reviews and consent recordings. The most ubiquitous finding of all study types was high levels of intra-surgeon variation in what risk information is provided to patients preoperatively. Studies recording consents found the lowest rates of risk disclosure. Studies using multiple forms of investigation corroborated this, finding disparity between verbally provided information vs chart documentation. CONCLUSIONS The wide variance in what information is provided to patients preoperatively inhibits the realization of the ethical and practical components of informed consent. The findings of this review indicate that significant opportunities exist for practice improvement. Future development of surgical communication tools and techniques should emphasize standardizing what risks are shared with patients.
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Affiliation(s)
- Davis M Aasen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Brett M Wiesen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Abhinav B Singh
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Christi Piper
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ben Harnke
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Allan V Prochazka
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Aaron S Fink
- Professor Emeritus of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Karl E Hammermeister
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; Adult and Child Collaborative for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado; Adult and Child Collaborative for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado.
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Anderson TN, Aalami LR, Lee EW, Merrell SB, Sgroi MD, Lin DT, Lau JN. Perception and confidence of medical students in informed consent: A core EPA. Surgery 2020; 167:712-716. [DOI: 10.1016/j.surg.2019.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 09/17/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
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Silva AHD, Wijesinghe H, Mundil N, Lo W, Walsh AR, Solanki GA, Rodrigues D. Consent in paediatric neurosurgery: adequacy of documentation and parental perspectives. Childs Nerv Syst 2019; 35:2363-2369. [PMID: 31289855 DOI: 10.1007/s00381-019-04285-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/27/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Consenting paediatric patients for surgical procedures remains inherently unique in that it is underpinned by principles such as parental responsibility, assessment of the child's capacity to consent, and adherence to national/legal guidelines. Quality record keeping is an important objective evidence to demonstrate the highest standards of medical care provided to our patients. The consent form is a crucial medical record encapsulating the attainment of informed consent from a parent/guardian for performing a procedure on their child. We aimed to prospectively evaluate the consenting process in our department to assess adequacy of documentation and parental perspectives. METHODS A prospective study using qualitative descriptive design was conducted with parents of 50 children requiring neurosurgical procedures over a 3-month period. RESULTS All patients understood the primary diagnosis and type of surgery. Procedure-specific risks were understood by 98% and 84% could remember the mentioning of general risks of surgery. Only a minority of parents (24%) could recollect that alternative options of management including no treatment were discussed. In cases where relevant, laterality was only documented in 56% of consent forms. All patients felt that an informed decision regarding consent to surgery was made. However, 12% suggested areas where further improvement could be made in the timing of consent and the way information could be better provided. DISCUSSION Consent is more than a signature on a form. It provides objective evidence of a shared decision-making process between the surgeon, patient, and their parent/guardian. Our initial study highlights multiple areas for improvement.
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Affiliation(s)
- Adikarige H D Silva
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Haren Wijesinghe
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Nilesh Mundil
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - William Lo
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - A Richard Walsh
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Guirish A Solanki
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Desiderio Rodrigues
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.
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Meredyth NA, de Melo-Martin I. (Under)Valuing Surgical Informed Consent. J Am Coll Surg 2019; 230:257-262. [PMID: 31622768 DOI: 10.1016/j.jamcollsurg.2019.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/03/2019] [Accepted: 10/03/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Nicole A Meredyth
- Department of Medicine, Division of Medical Ethics, Weill-Cornell Medical Center, New York, NY; Department of Surgery, Weill-Cornell Medical Center, New York, NY.
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Ibrahim MA, Alshogran OY, Khabour OF, Alzoubi KH. The quality of consent form structure in biomedical research: a study from Jordan and Sudan. J Multidiscip Healthc 2019; 12:727-731. [PMID: 31564889 PMCID: PMC6731522 DOI: 10.2147/jmdh.s219316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 08/20/2019] [Indexed: 11/23/2022] Open
Abstract
Background Informed consent is one of the primary standards of ethical clinical research. This study assessed the quality of the informed consent forms (ICF) utilized in medical research conducted in Sudan and Jordan. Subjects and methods A total of 435 studies that were performed at health sciences schools in Jordan and Sudan were initially screened for the presence of ICF. Of these, 189 studies were reviewed for the major components of ICF using a standard checklist. Results The majority of the reviewed ICFs did not achieve the full standards of the universal guidelines for the informed consent structure. The following elements were described in >50% of consent forms reviewed from both countries: study title, objectives, research investigators, description of study procedure, and confidentiality. Other essential elements such as duration of the subject's participation, risks/benefits, compensation, voluntary participation, and contact information were poorly described. Conclusion The major elements of ICFs were not adequately described in medical research studies from Jordan and Sudan. Improved understanding of major elements of ICF among researchers in the examined countries is necessary. Clear and informative consent template can be very valuable in this perspective.
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Affiliation(s)
- Mariam Abbas Ibrahim
- Department of Clinical Chemistry, Sudan University of Science and Technology, Khartoum, Sudan
| | - Osama Y Alshogran
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Omar F Khabour
- Department of Medical Laboratory Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Karem H Alzoubi
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan
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Surgical education research: How to move beyond the survey. Surgery 2019; 167:269-272. [PMID: 31253415 DOI: 10.1016/j.surg.2019.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 05/15/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Surgical education serves as the foundation for high-quality, efficient patient care. Because clinical knowledge is gained and newer surgical techniques developed, this material is incorporated into the curricula of surgical trainees. Methods for studying this integration vary widely, however, providing data that, at times, is challenging to interpret in the context of patient care and outcomes. METHODS A review of the literature was conducted to evaluate current practices in surgical education research, as well as topics areas of focus. RESULTS Several techniques in surgical education research currently exist, including surveys, knowledge assessments, tests of skill, and single-arm educational interventions, which may or may not include a prepost design with assessments administered both before and immediately following the intervention. The applicability of these measures to patient outcomes is variable. CONCLUSION Research in surgical education represents a field of great interest, with opportunity for novel investigations among a broad collection of topic areas. Educational research should be approached in a methodologically rigorous fashion with high investigational standards in order to advance the education of surgical trainees and the care of surgical patients.
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McKinnon C, Loughran D, Finn R, Coxwell-Matthewman M, Jeyaretna DS, Williams AP. Surgical consent practice in the UK following the Montgomery ruling: A national cross-sectional questionnaire study. Int J Surg 2018; 55:66-72. [DOI: 10.1016/j.ijsu.2018.05.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 02/26/2018] [Accepted: 05/08/2018] [Indexed: 12/21/2022]
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