Truly Informed Consent? Who Are We Kidding?
Merrill, Ted, Medical Economics
How well does a patient really understand the procedures to which he must consent? The question came home for me two years ago.
It wasn't like previous experience on the operating table, 30 years before. Then, I'd had a large advantage over other patients--I was, after all, a doctor. Moreover, I'd done the same operation, an inguinal-hernia repair, many times myself.
Finally, my surgeon that time was my partner, who'd assisted me, and whom I'd assisted, on similar procedures. I knew the potential pitfalls, from anesthetic to surgical to mechanical to pharmacological. I knew how my partner would place that first stitch in Cooper's ligament, and how unlikely it was that he'd skewer spermatic artery or tighten the external ring too snugly or leave a hematoma forming inside as he closed my wound. When I gave my consent, I was well-informed indeed. All went well, as I had expected it would.
My second time around, two years ago, it was a different story. Despite all my knowledge, and the efforts of everyone involved to provide the information required by our current standards of "informed" consent, I had much less on which to base my decision. I had developed aortic stenosis and was bargaining for a new valve.
I had once referred a patient to a prominent cardiac surgeon and watched that doctor install a Starr-Edwards valve. Since that time, the technology had advanced, the mortality rate for such surgery had decreased, and many accomplished heart surgeons were available. All these thins are improvements--but all contributed to my ignorance.
I knew I had a choice between a mechanical valve and a pig valve. Since I was otherwise in good health, despite being near 70, I knew the pig valve might fail before the rest of me did. But with the mechanical one, I'd be taking Coumadin for the rest of my life.
Worse still, I'd have to choose a surgeon sight unseen. I'd never watched anyone place a pig valve or the mechanical valves now available. What I knew about anesthetic techniques had become obsolete. I'd never operated a heart-lung machine, and I didn't know the person who would run it for me. I had only the sketchiest awareness of the craftsmanship required, the possible complications, the potential for mechanical or electronic failures, problems with blood replacement, the details of starting and stopping the heart. And I knew there were other dire possibilities that hadn't even occurred to me.
When I first noticed I had an aortic systolic murmur, I consulted an internist, Dr. Hart. (I'm not using real names.) I went back for the report on the echocardiogram, and Hart told me the stenosis was quite mild.
"Dr. Smith read your tests, and he's a superb echocardiographer," Hart told me. I had never met Smith, but at that moment, he became my cardiologist. Smith followed my four-year progression from "mild stenosis" to "critical degree of obstruction" and did the angiogram and ventriculography. But I'd never seen him perform any of these tests, and I hadn't compared his success record with those of any other cardiologists.
Smith worked with several surgeons, doing echocardiograms in the operating room to check the newly placed valves for leakage and pressure gradients. It seemed that he should be in a good position to give an opinion.
"If you were choosing a surgeon to give you a new valve," I asked, "whom would you pick?"
After a moment of thought, he said, "Probably Dr. Kane. He works quickly, gets in and out with no wasted time, and does it well."
Since I hadn't yet experienced any of the "big three" symptoms of aortic stenosis--dizziness, angina, or sudden death--there was no clear consensus among my physicians as to when the time was right for surgery. I decided to get a second opinion from another cardiologist I knew. Dr. Allen reviewed the history and the records, listened to my heart and lungs, then took from his shelf a new textbook on heart disease. …