2017 HSC Section 2 - Practice Management

Pianosi et al

Overall, the participants recalled a higher proportion of benefits than risks ( Z = 2 4.25, P \ .001). When partici- pants were divided into those who decided to proceed with surgery (58.3%) versus those who chose watchful waiting (41.7%), parents in the latter group were significantly more likely to recall the risks of surgery (median = 1, SD = 1.05) than were those who chose surgery (median = 0, SD = 0.83; Z = 2 3.75, P \ .001). No significant differences were found in the recall of risks and benefits of surgery at the 2- week follow-up phone call, in terms of the following: con- sulting surgeon, type of surgery, presence of 1 or 2 care- givers during the visit, child’s previous surgical experience, other children’s previous surgical experience in the family, and parental education level ( Tables 4 and 5 ). Discussion The overall recall rate for risks and benefits of surgery was low. Parents remembered about half the benefits of surgery and only one-third the risks mentioned during the consulta- tion. As well, those parents who elected to monitor their children rather than proceed with surgery were significantly more likely to recall the risks of surgery. Selective recall or confirmation bias (tendency to prefer and recall information that will confirm a person’s beliefs/hypotheses) may have played a role, as parents may selectively recall the advan- tages of surgical treatment because they are hopeful that it will alleviate their children’s symptoms. The risk recall rate found in this study was similar to that reported in other studies in surgical settings. 5-9,12-14 A study in pediatric surgery, for example, found that . 20% of parents did not recall any risks being discussed, and \ 40% recalled the commonly mentioned risks, such as bleeding and infection. 13 However, no studies to date have used objective assessment of the consultation interaction and recall of the information discussed during the visit. Specifically, previous research has relied on what the physi- cian remembered stating, sometimes along with an educa- tional aid, as the information given during the consultation and relating it to what was recalled by patients and family members. 5,7-12,14 In our study, we used video recordings of the physician-parent interaction to determine what specific risks and benefits were discussed during the visit. Providers will have different styles of interaction and deliver different amounts of information; thus, it is important to objectively assess exactly what information was shared during the consultation. Although there are a number of theoretical risks for any surgery, some are incredibly rare and may not be mentioned during the consultation. An unexpected finding in this study was that several rare risks and benefits were either not men- tioned or mentioned rarely. Furthermore, some risks and benefits were inconsistently mentioned across providers, even within each provider. Some benefits of surgery docu- mented in the literature but not mentioned included improved school performance 15 and alleviation of head- aches 16 for children with sleep-disordered breathing. Some risks of surgery found in the literature but not mentioned by

Table 3. Risks and Benefits Mentioned and Recalled Associated with Tympanostomy Tube Insertion.

Mentioned during Consultation

Mentioned at 2-wk Follow-up Interview

Benefits of surgery Reduced number of infections Reduced number of oral antibiotics Reduced days of day care/ school/work missed Improved quality of life Temporarily improved hearing

31 15

27

2

1

0

7

7 7 5

14

Improved speech development (young children)

5

Easier to treat future acute otitis media episodes

12

8

Consequences of surgery General anesthesia

35 30 27

17 11 14

Readmission

Tympanic membrane perforation

Otorrhea

26 26

4 2

Water precautions

Premature tube extrusion a

2

5

Retained tube Tube blockage

3 2

1 0

Myringosclerosis or tympanosclerosis a

0

1

a Gray shading indicates that consequence was mentioned by more parents than those who were told in the consultation visit about it.

tube insertion, the risk of tympanic membrane perforation (17%) was most commonly recalled. Thirty-six parents recalled as many benefits as were mentioned during the visit, and 21 parents recalled as many risks as were men- tioned during the child’s consultation. Overall, parents recalled one-third the risks of surgery and half the benefits of surgery mentioned by the surgeons. Nine (10.7%) parents reported that no benefits were dis- cussed during the consultation; the video analysis showed that 1 of these parents had 2 benefits mentioned during con- sultation. Ten (11.9%) parents reported that no risks were mentioned; however, in 5 consultations, risks were men- tioned. Two (2.4%) parents reported that benefits were reviewed during the appointment, but they could not recall the content of those benefits; 2 (2.4%) parents reported that risks were mentioned but could not specify those risks. During 4 visits (4.8%), surgeons used nonspecific language when discussing the risks and benefits (eg, ‘‘Something bad may happen’’), and during 1 visit, the surgeon did not expli- citly state how surgery would improve the child’s symptoms (eg, ‘‘These things may all get better with the surgery’’).

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