Lost in translation

What the doctor says, and what the patient hears and understands, are sometimes not the same thing at all.

A new study, published in the Annals of Internal Medicine, examines this communication gap by focusing on a specific procedure: percutaneous coronary intervention for stable coronary artery disease – or, in layperson’s terms, threading a catheter and stent into one or more of the major blood vessels of the heart to reduce blockage.

It’s a fairly common procedure for people with heart disease. Often it can reduce the chest pain that’s associated with angina – but it doesn’t necessarily reduce the risk of a future heart attack, and it’s no guarantee the patient won’t have a fatal heart attack at some point. These last points aren’t always grasped by patients, however, according to the authors of the Annals study.

The authors surveyed 153 patients who had consented to undergoing percutaneous coronary intervention if other tests showed blocked blood vessels. They also surveyed 27 cardiologists who had either referred the patient or performed the procedure.

What they found was that 88 percent of the patients mistakenly thought the procedure would reduce their risk of heart attack, and 82 percent thought it would reduce their risk of dying from a heart attack. Among the cardiologists, however, the majority believed these patients would only see relief from angina.

It’s hard to draw any firm conclusions from this study. It was quite small, involving a single hospital, fewer than 30 cardiologists and only slightly more than 150 patients. The researchers didn’t have access to the amount or quality of the discussion the cardiologists had with their patients before the procedure, nor did they measure what the patients’ beliefs may have been before and after the discussion to give informed consent.

Nevertheless, it’s an interesting study for how it reveals the differences in perception that often exist between patients and clinicians. There could be two possible ways of looking at the findings: Either doctors aren’t very good communicators, or patients aren’t very good at listening or understanding what they’re told, or some combination of all three. I suspect, however, that what this study has uncovered is more subtle than this.

There’s an inevitable knowledge gap between patients and physicians. Sometimes it leads physicians to assume that what’s obvious to them – in this case, that PCI has little if any effect on heart attack risk – is equally obvious to the patient. It’s not a safe assumption to make, but it often goes unchallenged. It might not even occur to the doctor to ask patients to clarify their understanding of the benefits of the procedure they’re about to undergo. And sometimes, of course, patients hear what they want to hear, even when what they think they heard isn’t what was actually said.

The other issue is the high expectations to which we in the United States are acculturated. The public frequently overestimates what medicine can deliver. I’d be one of the first to admit the media have often been complicit in this by playing up the benefits and not being clear enough about the limitations. Physicians are usually much more realistic but it’s not always a message that’s heard.

A companion piece to the Annals study makes another important point: The informed consent process usually focuses on the risks of a prescription drug or medical procedure or treatment. Perhaps the process also needs to focus more on the benefits so patients’ expectations are better aligned with reality.

Communication is always a tricky thing but never more so than in health care, where the stakes are high and the information is complex. All too often, even when both parties are doing their best, the message can easily get lost in translation.

Photo: Wikimedia Commons

A failure of transparency

The patient was planning to have her gall bladder removed. Before the procedure, she met with the surgeon to talk about the risks and the surgeon’s skill and experience with laparoscopic surgery. Among the questions the patient asked: Had the doctor ever been sued for malpractice or had sanctions against his medical license? He said no.

You’ve probably guessed where this is heading. During the surgery the patient’s intestine was perforated and she developed an infection. She later found out the surgeon was disciplined subsequent to having a patient die after undergoing the same procedure.

The woman sued, alleging malpractice and lack of informed consent. She lost. Now the case is headed for a retrial after the U.S. appellate court sided with the plaintiff’s appeal of the verdict. At the heart of the issue is whether the trial court erred in tossing out the argument that the physician’s deceit constituted a breach of the patient’s right to informed consent.

I stumbled across this fascinating legal case this week at the Shrink Rap blog, where it has generated considerable discussion. It raises some compelling questions about patients’ rights to informed consent and the extent of the information physicians should be expected to disclose. Shrink Rap wonders how far it should go:

What if the issue wasn’t technical competence? How much “personal background” should a doctor have to tell a patient before treatment can begin? Medical school grades? Failure to pay income tax? Should doctors be required to disclose to patients the fact that they’ve been treated for mental illness themselves?

Grade point average? Income taxes? I have a hard time picturing any kind of case law that would justify this level of prying. That doesn’t appear to be what this case is about, though. It seems to me that the physician’s competence and experience is highly relevant to informed consent. If this patient had known ahead of time that the surgeon was disciplined following the death of a patient – a death involving the same procedure the patient was about to undergo – it’s possible she would have chosen a different surgeon.

And outright dishonesty adds a whole new wrinkle to the case. Is it ever OK for a physician to dissemble in response to a patient’s question? One of the commenters at Shrink Rap concludes it was “moral turpitude, maybe, but not malpractice… Patients have a right to ask any question they want to ask. Doctors have a right to decline to answer, then the patient can decide how to proceed.”

Others disagreed. From one commenter: “It’s not his right to lie to the patient so they’ll sign the consent form so he can make money.” From someone else:

I disagree about it being an issue of “personal background.” Whether or not the doctor had previously lost patients from that procedure, and whether or not he had had action taken against him is professional background, not personal. “Personal” that it affects only the private life of the individual in question. Just because something could go wrong no matter how skilled the surgeon doesn’t justify lying about the outcome of prior surgeries, especially given that the patient directly asked. It wasn’t a lie of omission, it was a flat-out lie about something that the patient clearly considered important information to their decision about the surgery.

I personally think it was a smart question to ask, and one that most medical professionals shouldn’t hesitate to answer honestly.

It’s actually not that hard to find out whether a physician has a valid license or has ever had sanctions against his or her medical license. In Minnesota, the database is maintained by the Board of Medical Practice and it’s easily searchable online. I’m not sure, however, that we can assume most patients know this. The burden tends to be on consumers to either do their own homework, or to be savvy enough to ask the physician (and hope they get an honest answer).

By sheer coincidence, the Center for Public Integrity issued a report this week that takes policymakers to task for failing to make the National Practitioner Data Bank more accessible to the public. The report notes that while the public can view statistical portions of the NPDB, “the law blocks public users from pulling up histories of individual doctors or other health care professionals. Only authorized users such as hospital administrators can do that. A physician can see only his or her own record.”

Theres a complicated push-and-pull over how much information consumers/patients should have. Where should the boundaries be drawn? How much decision-making power should consumers be given? How much of this power are they capable of handling? We haven’t figured it out yet, and I think we’re going to be debating this for a long time to come. While I don’t expect the retrial of the case involving the dishonest surgeon to completely rewrite case law, perhaps it’ll add another layer of insight into how we define informed consent and what level of disclosure is due between physician and patient.