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Using computer imaging as an informed consent tool
My Practice To Yours
Using Computer Imaging as an Informed Consent Tool
T
he concept of informed consent for surgery has evolved significantly over the years. The courts presently require that the patient be made fully aware of the planned procedures and that the physician discuss with the patient the nature of the disease, injury, or condition, the goals and limitations of the treatment, and the alternatives, risks, and potential complications. If any one of these elements is missing from the consultation, the physician has not met the established standard of care and has opened the door for future litigation. Furthermore, the discussion of these issues must be clearly documented in the patient’s record. The mere presence of a signed consent form may not be sufficient evidence that these requirements have been met. There are numerous documented instances in which the outcome of a court case has rested on the defendant’s ability to prove that informed consent had occurred above and beyond the written consent. Long-term patient satisfaction is also directly linked to adequate informed consent. Patients who are wellinformed before a procedure are more likely to be satisfied with the outcome, even if the results are less than optimal. Every patient requesting a cosmetic surgical procedure would participate in a computer imaging session. The purpose of this session is to identify patient goals, provide an approximation of the postoperative results, ensure that the surgeon and patient agree on the anticipated aesthetic goals for the surgery, and document that the risks, benefits, and alternatives to the procedure have been discussed. Once an altered image that is surgically feasible and satisfies the patient’s expectations has been produced, we address the technical aspects of the procedure. The proposed incisions, areas of dissection, and internal structures are illustrated on the altered image. When the patient feels comfortable with the technical aspects of the procedure, we discuss the risks that are involved. Each potential complication is listed alongside the altered image. Alternative procedures are then listed, and if the patient desires, computer images associated with the alternative procedure are produced. Two copies of each altered image are produced, one for the patient and one
AESTHETIC
for the permanent record. We require patients to sign and date both copies as proof that they have received this information. Typical examples of face lift and breast reduction consultations in which the computer imager was used are shown in Figures 1-4.
Richard W. Dabb, MD, York, PA, is a board-certified plastic surgeon and an ASAPS member.
All physicians recognize the importance of proper preoperative education and informed consent for longterm patient satisfaction. Unfortunately, we have become increasingly aware of the importance of consent from a legal standpoint. Most lawsuits, at least in part, attack the informed Scott W. Wrye, MD, Hershey, consent process. Some lawPA, is Chief Resident, Department of Plastic Surgery, suits are won entirely on the Penn State Medical Center. basis of a physician’s inability to prove that informed consent was obtained. This can happen despite the presence of a signed consent form in the patient record.1 The difficulty lies in proving that the risks and alternatives for a procedure were adequately explained by the physician to the patient. Many studies have proven that patient recall of the preoperative consultation—ie, of the discussion of risks, benefits, and alternatives—is poor.2-4 Some studies suggest that patients recall less that 25% of the information provided to them before surgery.5 In the past, physicians relied on their office notes as proof that informed consent had taken place. Office notes, however, are often insufficient. Lines such as “The risks, benefit, and alternatives to the procedure were explained to the patient” may be insufficient to convince a jury that the patient completely understood the risks involved. For office notes to be of any value, they must fully describe
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2000
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My Practice To Yours
the risks explained to the patient and the details of the given alternatives. Office notes are often dictated at the end of a busy day, and important details of each individual consultation may be omitted. These details may represent the deciding factor in court. In addition to office notes, some physicians draft a letter to the patient in which the details of the procedure and its risks, benefits, and alternatives are discussed. When the letter is included as part of the patient record, it provides sound documentation that informed consent has occurred and has the added benefit of strengthening the doctor/patient relationship. The difficulty with this approach, however, is that writing a detailed letter to each patient can be time consuming.
A
Figure 1. A, Original image. B, Altered image for an endoscopic brow lift, upper blepharoplasty, full face lift, and platysma plication.
It has been suggested that the best way to document informed consent is to videotape or tape record all consultations. This would provide indisputable evidence of the informed consent process; however, many patients feel uncomfortable with this approach. Other adjuncts to the informed consent process, including printed supplements, slide presentations, and second consultations, have also been suggested, but these do not provide documentation that informed consent has taken place.
Figure 2. Facial markings. Red lines indicate incisions; green lines indicate SMAS, platysma plication, and corregator/pressarus muscles; yellow lines indicate the direction of soft-tissue pull.
The common theme of all these adjuncts to written informed consent is that they provide a measure of patient education above and beyond the written consent. Any additional effort on the part of the physician to further explain the procedure and its consequences will improve the doctor/patient relationship and show that a sincere attempt to provide fully informed consent has occurred. The computer imager is a valuable adjunct to this process. By clearly listing the proposed incisions, alternatives, risks, and complications directly on the altered image, the physician documents that these issues have been fully discussed with the patient. When signed by the patient and placed in the permanent record, the altered image provides solid evidence that informed consent has taken place. We believe that patients will look at the altered image several times between the consultation and the proposed surgical date. Whenever patients view the image, they will be reminded of the alternatives and potential complications, giving them the opportunity to reflect on the consequences of the planned procedure. This method should leave little doubt that the patient has been fully informed. A potential concern of plastic surgeons using the computer imager in this way is the misconception that it is in some way an implied contract. This has been addressed by
54
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B
Figure 3. Potential complications are indicated on image.
Chavez et al,6 who note that “a careful analysis of law reveals that surgeons who use computer imaging carefully and conservatively, and adopt a few simple precautions, substantially reduce their vulnerability to legal claims.”
2000
Volume 20, Number 1
My Practice To Yours
tial that plaintiffs pursue. Finally, statistics confirm that plastic surgeons face little danger from implied contract claims.”6 “Carefully” and “conservatively” are the 2 key words in the first quotation from Chavez et al. Prudent use of the computer imager does not imply that we have created a contract to achieve a particular result. Patients appear to be very receptive to this informed consent process and are comfortable with the greater level of understanding that this method provides. When used properly, the computer imager becomes a powerful adjunct to the informed consent process. ■ Figure 4. Breast reduction consultation with computer imager shows incisions, areas of dissection, scars, and expected results.
This opinion is based on the following 3 issues: “First, strong policy arguments discourage courts from imposing auxiliary contractural obligations on physicians. The uncertainties of medicine, coupled with the crucial public interest in accessible and exemplary health care, make contract claims against physicians judicially unpopular. Second, contract claims against physicians promise limited damages to potential plaintiffs. Contract causes of action, unlike negligence claims, do not necessarily permit recovery for pain and suffering… Even more important, most malpractice policies exclude coverage for contracts by physicians to realize a certain result, eliminating the deep-pocket poten-
Using Computer Imaging as an Informed Consent Tool
AESTHETIC
References 1. Altchek ED. Informed consent. Plast Reconstr Surg 1988;82:920. 2. Byrne DJ, Napier A, Cuscheiri A. How informed is signed consent? Br J Med 1988;296:839-840. 3. Hekkenverg RJ, Irish JC, Rotstein, LE, Brown DH, Gullane PJ. Informed consent in head and neck surgery: how much do patients actually remember? J Otolaryngol 1997;26:155-159. 4. Dawes PJ, O’Keefe L, Adcock S. Informed consent: the assessment of two structured interview approaches compared to the current approach. J Laryngol Otol 1992;106:420-424. 5. Hutson MM, Blaha JD. Patient’s recall of preoperative instruction for informed consent for an operation. Bone Joint Surg 1991;73-A:160-162. 6. Chavez AE, Dagum P, Koch RJ, Newman JP. Legal issues of computer imaging in plastic surgery: a primer. Plast Reconstr Surg 1997;100:1601-1608. Reprint orders: Mosby, Inc, 11830 Westline Industrial Drive, St Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/104962
SURGERY
JOURNAL
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JANUARY/FEBRUARY
2000
55
Using Computer Imaging as an Informed Consent Tool
T
he concept of informed consent for surgery has evolved significantly over the years. The courts presently require that the patient be made fully aware of the planned procedures and that the physician discuss with the patient the nature of the disease, injury, or condition, the goals and limitations of the treatment, and the alternatives, risks, and potential complications. If any one of these elements is missing from the consultation, the physician has not met the established standard of care and has opened the door for future litigation. Furthermore, the discussion of these issues must be clearly documented in the patient’s record. The mere presence of a signed consent form may not be sufficient evidence that these requirements have been met. There are numerous documented instances in which the outcome of a court case has rested on the defendant’s ability to prove that informed consent had occurred above and beyond the written consent. Long-term patient satisfaction is also directly linked to adequate informed consent. Patients who are wellinformed before a procedure are more likely to be satisfied with the outcome, even if the results are less than optimal. Every patient requesting a cosmetic surgical procedure would participate in a computer imaging session. The purpose of this session is to identify patient goals, provide an approximation of the postoperative results, ensure that the surgeon and patient agree on the anticipated aesthetic goals for the surgery, and document that the risks, benefits, and alternatives to the procedure have been discussed. Once an altered image that is surgically feasible and satisfies the patient’s expectations has been produced, we address the technical aspects of the procedure. The proposed incisions, areas of dissection, and internal structures are illustrated on the altered image. When the patient feels comfortable with the technical aspects of the procedure, we discuss the risks that are involved. Each potential complication is listed alongside the altered image. Alternative procedures are then listed, and if the patient desires, computer images associated with the alternative procedure are produced. Two copies of each altered image are produced, one for the patient and one
AESTHETIC
for the permanent record. We require patients to sign and date both copies as proof that they have received this information. Typical examples of face lift and breast reduction consultations in which the computer imager was used are shown in Figures 1-4.
Richard W. Dabb, MD, York, PA, is a board-certified plastic surgeon and an ASAPS member.
All physicians recognize the importance of proper preoperative education and informed consent for longterm patient satisfaction. Unfortunately, we have become increasingly aware of the importance of consent from a legal standpoint. Most lawsuits, at least in part, attack the informed Scott W. Wrye, MD, Hershey, consent process. Some lawPA, is Chief Resident, Department of Plastic Surgery, suits are won entirely on the Penn State Medical Center. basis of a physician’s inability to prove that informed consent was obtained. This can happen despite the presence of a signed consent form in the patient record.1 The difficulty lies in proving that the risks and alternatives for a procedure were adequately explained by the physician to the patient. Many studies have proven that patient recall of the preoperative consultation—ie, of the discussion of risks, benefits, and alternatives—is poor.2-4 Some studies suggest that patients recall less that 25% of the information provided to them before surgery.5 In the past, physicians relied on their office notes as proof that informed consent had taken place. Office notes, however, are often insufficient. Lines such as “The risks, benefit, and alternatives to the procedure were explained to the patient” may be insufficient to convince a jury that the patient completely understood the risks involved. For office notes to be of any value, they must fully describe
SURGERY
JOURNAL
~
JANUARY/FEBRUARY
2000
53
My Practice To Yours
the risks explained to the patient and the details of the given alternatives. Office notes are often dictated at the end of a busy day, and important details of each individual consultation may be omitted. These details may represent the deciding factor in court. In addition to office notes, some physicians draft a letter to the patient in which the details of the procedure and its risks, benefits, and alternatives are discussed. When the letter is included as part of the patient record, it provides sound documentation that informed consent has occurred and has the added benefit of strengthening the doctor/patient relationship. The difficulty with this approach, however, is that writing a detailed letter to each patient can be time consuming.
A
Figure 1. A, Original image. B, Altered image for an endoscopic brow lift, upper blepharoplasty, full face lift, and platysma plication.
It has been suggested that the best way to document informed consent is to videotape or tape record all consultations. This would provide indisputable evidence of the informed consent process; however, many patients feel uncomfortable with this approach. Other adjuncts to the informed consent process, including printed supplements, slide presentations, and second consultations, have also been suggested, but these do not provide documentation that informed consent has taken place.
Figure 2. Facial markings. Red lines indicate incisions; green lines indicate SMAS, platysma plication, and corregator/pressarus muscles; yellow lines indicate the direction of soft-tissue pull.
The common theme of all these adjuncts to written informed consent is that they provide a measure of patient education above and beyond the written consent. Any additional effort on the part of the physician to further explain the procedure and its consequences will improve the doctor/patient relationship and show that a sincere attempt to provide fully informed consent has occurred. The computer imager is a valuable adjunct to this process. By clearly listing the proposed incisions, alternatives, risks, and complications directly on the altered image, the physician documents that these issues have been fully discussed with the patient. When signed by the patient and placed in the permanent record, the altered image provides solid evidence that informed consent has taken place. We believe that patients will look at the altered image several times between the consultation and the proposed surgical date. Whenever patients view the image, they will be reminded of the alternatives and potential complications, giving them the opportunity to reflect on the consequences of the planned procedure. This method should leave little doubt that the patient has been fully informed. A potential concern of plastic surgeons using the computer imager in this way is the misconception that it is in some way an implied contract. This has been addressed by
54
AESTHETIC
SURGERY
JOURNAL
~
JANUARY/FEBRUARY
B
Figure 3. Potential complications are indicated on image.
Chavez et al,6 who note that “a careful analysis of law reveals that surgeons who use computer imaging carefully and conservatively, and adopt a few simple precautions, substantially reduce their vulnerability to legal claims.”
2000
Volume 20, Number 1
My Practice To Yours
tial that plaintiffs pursue. Finally, statistics confirm that plastic surgeons face little danger from implied contract claims.”6 “Carefully” and “conservatively” are the 2 key words in the first quotation from Chavez et al. Prudent use of the computer imager does not imply that we have created a contract to achieve a particular result. Patients appear to be very receptive to this informed consent process and are comfortable with the greater level of understanding that this method provides. When used properly, the computer imager becomes a powerful adjunct to the informed consent process. ■ Figure 4. Breast reduction consultation with computer imager shows incisions, areas of dissection, scars, and expected results.
This opinion is based on the following 3 issues: “First, strong policy arguments discourage courts from imposing auxiliary contractural obligations on physicians. The uncertainties of medicine, coupled with the crucial public interest in accessible and exemplary health care, make contract claims against physicians judicially unpopular. Second, contract claims against physicians promise limited damages to potential plaintiffs. Contract causes of action, unlike negligence claims, do not necessarily permit recovery for pain and suffering… Even more important, most malpractice policies exclude coverage for contracts by physicians to realize a certain result, eliminating the deep-pocket poten-
Using Computer Imaging as an Informed Consent Tool
AESTHETIC
References 1. Altchek ED. Informed consent. Plast Reconstr Surg 1988;82:920. 2. Byrne DJ, Napier A, Cuscheiri A. How informed is signed consent? Br J Med 1988;296:839-840. 3. Hekkenverg RJ, Irish JC, Rotstein, LE, Brown DH, Gullane PJ. Informed consent in head and neck surgery: how much do patients actually remember? J Otolaryngol 1997;26:155-159. 4. Dawes PJ, O’Keefe L, Adcock S. Informed consent: the assessment of two structured interview approaches compared to the current approach. J Laryngol Otol 1992;106:420-424. 5. Hutson MM, Blaha JD. Patient’s recall of preoperative instruction for informed consent for an operation. Bone Joint Surg 1991;73-A:160-162. 6. Chavez AE, Dagum P, Koch RJ, Newman JP. Legal issues of computer imaging in plastic surgery: a primer. Plast Reconstr Surg 1997;100:1601-1608. Reprint orders: Mosby, Inc, 11830 Westline Industrial Drive, St Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/104962
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JOURNAL
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JANUARY/FEBRUARY
2000
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