If you're a physician, think back to that first time you sat down with a patient to obtain his or her informed consent. Did you know what to say – and how to say it? According to Kevin Pho, MD, a New Hampshire internist and author of the prolific and popular medical Internet blog KevinMD.com, "most medical students don't take classes on how to discuss informed consent, that is, talking about the risks and benefits of a medical procedure with a patient." He suggested that all medical schools should at least find the time for a single day-long session devoted to the issue.

 

Just how do medical schools in the region approach education regarding informed consent? "My guess is you would find a pretty wide variation across different schools," said Richard P. DiCarlo, MD, assistant dean for Undergraduate Education at the LSU Health Sciences Center in New Orleans. While he noted that specific informed-consent instruction isn't a formal accreditation requirement, it's "implicit" in the required teaching of both ethics and communication skills. "One of the basic principles of medical ethics is patient autonomy and respect for that patient's autonomy. That's something we come back to over and over again when we discuss cases," he said. "Informed consent is really one of the pillars of that principle."

 

At the University of Arkansas for Medical Sciences, informed consent is covered in the classes taught at the Center for Clinical Skills Education, where 10 fully equipped patient examination rooms offer students the opportunity to role play physician-patient interaction while they are observed by professors. Actors may portray patients and the conversations may be videotaped for later critique, according to Associate Professor Sara Tariq, MD, who is the medical director of the center. In this reciprocal environment, which spans three years of medical school, students learn how to take a patient's history, how to approach an examination, how to overcome language barriers, how to deliver bad news, how to deal with angry patients and, yes, how to obtain informed consent. Tariq said students lose points for using medical jargon, which hinders most informed-consent discussions. By their third year during clerkships, students are alongside physicians to witness informed-consent interactions, she said.

 

Tariq attended medical school at the University of Arkansas. "I didn't realize if I was ready or not [to have the informed-consent discussion] until I actually went into the room and had to do it for the first time. It's one of those things that you just have to do for yourself to figure if you're good at this or not. I actually felt fairly prepared," she said.

 

Tariq said much about that critical discussion has to do with simple communication. "The ability of a physician to take informed consent in an appropriate, concise and open manner really relies on your basic communication skills. If you're confident as a communicator, that's a huge building block," she said. That includes talking deliberately, pausing between sentences and making eye contact. "If you're in a rush, you don't need to be taking an informed consent on anybody," she said, recommending that physicians set aside as much as 20-25 minutes for the discussion and patient questions.

 

Haavi Morreim is on the same wavelength as Tariq. A professor at the University of Tennessee Health Science Center in Memphis, Morreim is a bioethics specialist. She suggested that one of the first rules of informed consent is for the physician to sit at the same level with the patient. "If you're standing with one hand on the door knob and one foot out the door, this is not an invitation for an informed-consent conversation," she said. Otherwise, the exchange could be "offensive" from the patient's point of view, she noted.

 

With time constraints on physicians today, setting aside adequate time is not so easy, both acknowledged. Confounding the issue is that more and more treatment options exist, and physicians are ethically bound and if medically appropriate to present patients with options conservative, aggressive and middle of the road. "We like to distinguish between informed consent as an ethical process versus informed consent as a piece of paper with a signature," said Morreim, who works with residents and fellows predominately in the departments of Internal Medicine and Pediatrics.

 

In the abstract, informed means that a patient is filled in on all the pros and cons of all reasonable alternatives. Yet presenting a "Swedish smorgasbord" of options and asking the patient to pick one still leaves much to be desired, Morreim explained. "That's not a very good informed-consent conversation, because the goal here is to elicit the patient's values and help the patient figure out which option fits the patient's values," she said. Patients value different things, she continued, and it's up to the doctor to "ferret out any confusions" and help the patient reach a decision that best fits his or her life.

 

Morreim added that young physicians shouldn't be taken aback by patient questions that may be more practical than medical – Where will the surgery take place? How long will I be out of work? How much will this cost me out-of-pocket?

 

Finally, there's the issue of patient understanding. "One of the major barriers to patients feeling confident about actually signing that piece of paper has to do not only with the physician's ability to explain the procedure in a concise and clear manner, but the physician has to be cognizant also of the patient's own baseline health literacy," Tariq said. Thus, gauging a patient's medical sophistication is critical to "true" informed consent, she said.