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Sunday, October 4, 2009

Informing and consenting

I read a piece on Medscape summarizing the findings from a recent Archives of Internal Medicine article (Hoffman - Arch Intern Med. 2009;169:1557-1559, 1611-1618.). In this study they found that fully one third of men who underwent PSA testing where not counseled ahead of time regarding the purpose, implications, and limitations of the screening test.

I can't say this was surprising. From first hand experience I can attest to the fact that we medical training focuses on wrote memorization of vast amounts of trivia, development of specific technical skills, and a culture of testing which relies on multiple choice tests which substitutes forced selection of the "right" answer for any actual appreciation of nuance and uncertainty. How can a physician present choices when this discussion has rarely been entertained in their training environment.

There are so many structural and cultural problems which influence this outcome that it is hard to begin to look where to make changes. I believe there are two principles which should guide us with our encounters with patients. First,after we have intervened we should be relatively confident that the patient is better off than before we intervened. Second, the principle of patient autonomy is (or at least should be) central to everything we do. Basically, adherence to these two principles will result in no intervention unless we believe the patient is better off AND we can convince the patient of this.

With this as a starting point, perhaps we should consider changing some terminology. We now engage in a process which is termed informed consent. Just the way the wording is set up places the emphasis on the consent, informing being just a modifier of the consent process. I propose we change this to informing and consenting. This places equal weight on both processes since the consent is actually meaningless without the informed piece.

There is an organization called the Foundation for Informed Medical Decision Making which is developing educational tools for patients to make such decisions ( This has tremendous potential but has a number of potential unintended consequences. It will be a source of pressure on physicians to remain informed. I have no doubt of the ability of information systems to outstrip the knowledge base of even well read providers. It will also provide a challenge in terms of who can and will vet the information. Perhaps a "Wikopedia" like model will develop with multiple editors. I am sure that will serve as a challenge to the keepers of the temple of knowledge. What is sure is physicians will be challenged in terms of being the sole source of proprietary knowledge. The asymmetry of information noted by Kenneth Arrow 50 years ago may have been a temporary state.

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