Enhanced Informed Consent in Hand Surgery: Techniques to Improve the Informed Consent Process

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Enhanced informed consent refers to the use of diverse modalities to transform the informed consent process from a brief discussion of paperwork to an educational information transfer between patient and physician. Effective execution of this process lays the foundation for a successful operative procedure, a satisfied patient, and optimized protection of the surgeon from litigation. Herein, we detail enhancements designed to obtain a complete informed consent, which involves patient counseling, education, and documentation. These refinements are aimed at improving all components of the consent discussion.
Although optimum patient care is always a primary concern, improving informed consent has obvious medico-legal ramifications. According to the Physician Practice Information survey conducted by the American Medical Association, a staggering 57% of subspecialized surgeons reported experiencing a medical malpractice claim during the course of their career.1 Literature on the medicolegal side of hand surgery in the United States is relatively sparse, but data regarding European hand surgery litigation are more available. In the largest review of 2312 successful malpractice claims in the United Kingdom against orthopedic surgeons between 2000 and 2006 collected through analysis of the United Kingdom National Health Society Litigation Authority database, 69 of these cases involved surgery of the hand and wrist with more than half of these claims related to release of the carpal tunnel.2 In a root cause analysis conducted by the authors, the most common indication for successful litigation was related to the presence or sequelae of infection; however, in the remaining cases, successful litigation appeared to be related to two common themes—failure of the consent process and failure of diagnosis and management of common orthopedic conditions. In a recent review of medical malpractice claims in surgery of the hand and upper extremity, Pappas et al3 describe 4 core concepts that must be maintained to protect oneself from a malpractice claim: practicing within accepted standards of practice, developing favorable patient interpersonal relationships, providing patients with comprehensive informed consent, and meticulously documenting all patient encounters. The authors acknowledge that not all medical malpractice claims are avoidable; however, respecting these tenets, including a thorough informed consent, optimizes the process for both the patient and surgeon.
A common adage in surgery is, “information prior to an intervention is enlightening while information provided after an intervention is an excuse.” To this end, we describe techniques, refined over the course of the senior author’s (R.F.M.) career, for enhanced informed consent—designed to improve patient-surgeon communication, improve patient comprehension of the operative procedure, and protect the surgeon from medical malpractice claims. These enhancements are a combination of detailed preoperative markings, preoperative simulation of fixation, communication of goals of the operative procedure, multimodality visual aids to communicate relevant anatomy and operative plans, and judicious use of local anesthesia. The concept of enhanced informed consent is derived from the novel concept of operative simulation, in which advanced illustrative techniques, 3-dimensional imaging, and patient simulation is used preoperatively to increase patient comprehension of the alternatives, benefits, complications, and risks (The ABCRs of preoperative documentation) of a planned operative procedure. Similar techniques have been described in the plastic surgery literature and found to improve patient understanding and patient satisfaction with their reconstructive outcome.

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