The Well Informed Patient

In a recent editorial in the Journal of Oral and Maxillofacial surgery (vol. 69. page 1263, 2011),  titled “Shouldn’t All Clinical Research Be Scientific?”, Dr. Thomas B. Dodson,  talks to his fellow oral surgeon colleagues and says

“Not only do we face rapid advances in science and technology, but we have new accountability from economic, legal, and regulatory challenges, as well as a new brand of well-informed patient.”

I personally would hope that the well-informed patient are patients who are being informed by oral and maxillofacial surgeons and dentists. However, I do not believe that is really the case here. One question to ask is why patients in the past were not well informed? The other and more pressing question to ask is why are these patients still not being properly informed today? (This also applies to other doctors and physicians as well).

One of the reasons for this is due to the legal standard of informed consent in the U.S. as stated in “Toward The ‘Tipping Point’: Decision Aids and Informed Patient Choice” by Annette M. O’Connor et al., appearing in Health Affairs, pages 716-725, May/June 2007.

“The [U.S.] states are largely divided between two categories of informed-consent standards: physician-based and patient-based. In physician-based states, physicians must provide patients with the same information that a reasonable physician would under similar circumstances. In patient based states, physicians must provide patients with all of the information that an objective, reasonable patient would want under similar circumstances.”

For those interested in further discussion of some of the differences between informed consent and informed choice an excellent article is “Rethinking Informed Consent: The Case for Shared Medical Decision Making” by Jaime Staples King and Benjamin Moulton in the American Journal of Law and Medicine (vol. 32, pages 429-501, 2006).

For the physician based standard

“(f)or a medical malpractice action, the standard of care generally requires physicians to ‘inform a patient of the dangers of, possible negative consequences of, and alternatives to a proposed treatment or procedure’ to the same degree that a ‘reasonably prudent practitioner in the same field of practice or specialty in [that state]’ would. In order to bring a claim for breach of informed consent, a patient must prove (1) that a ‘reasonably prudent practitioner’ would have provided the additional information, (2) that the patient would not have undergone the procedure had that information been given, and (3) therefore, the physician’s omissions were the proximate cause of the patient’s injuries.”

On the other hand for the patient based standard

“…[it] requires a physician to disclose any material risk. A risk is material if the physician believes that a reasonable person in the patient’s position ‘would be likely to attach significance to the risk or cluster of risks in deciding whether or not to forego the proposed therapy.’ In order to win a claim for breach of informed consent, a patient must prove (1) that the physician failed to provide information on a ‘material risk’, (2) that the patient would not have undergone the procedure had that information been given, and (3) therefore the physician’s omissions were the proximate cause of the patient’s injuries.”

Both standards have problems in that defining the reasonable physician and the reasonable person in the patients position can be challenging due to geographical variations in practice patterns for physicians and in values, preferences, and lifestyles for patients.

In recent years a new alternative to informed consent has arose called shared medical decision-making.

“While shared medical decision-making could be considered one appropriate form of patient-based consent, it goes two steps further by incorporating evidence-based medicine and by requiring both the patient and the physician to contribute information and participate in the decision-making process. The goal of shared decision-making is to strike a compromise between the preservation of individual autonomy afforded by the subjective patient-based standard and the practicality of the objective patient-based standard.”

The article by O’Connor et al. goes on to say

“In fact, evidence suggests that shared medical decision making strengthens the therapeutic alliance between the physician and patient and improves patient satisfaction.”

Recently, in May 2007, the state of Washington signed into law legislation that supported the use of shared decision-making.

There is even a Foundation for Informed Medical Decision Making which states on it’s website

“Shared decision making is the process by which a health care provider communicates to the patient personalized information about the options, outcomes, probabilities, and scientific uncertainties of available treatment options and the patient communicates his or her values and the relative importance he or she places on benefits and harms. Shared decision making has been widely advocated as an effective means for reaching agreement on the best strategy for treatment.”

As stated on the controversy section of my website, organizations and authors in publications have called on health care provides to provide their patients with all the necessary information they should be rightfully informed of regarding wisdom teeth extractions.For example in The Australian Dental Journal in an article by S Kandasamy and DJ Rinchuse (vol. 54, pages 284-292. 2009) the authors state

“The patient should be involved in the decision and informed of all possible options.”

Hence I would have to argue that patients seeing oral surgeons (at least many of them in the U.S.) are not being well informed. We as a country need to move away from informed consent and towards informed patient choice through shared decision making.

In my opinion, doctors accountability first and foremost is to their patients. If they are accountable to their patients then most of the other challenges should fall into place. The reason for many of these challenges Dr. Dodson talks of is due to doctors not being accountable to their patients.