2017 HSC Section 2 - Practice Management

Pianosi et al

the surgeons included death and tongue/uvular swelling. 17 The reason for which specific risks and benefits were men- tioned during consultation is unclear; however, it likely depends on the experience (eg, recent occurrence of a rare complication) and training of the surgeon. As well, some of the benefits of surgery could have been considered to be intuitive by the provider (eg, ear tubes will improve ear infections). Although the inconsistencies among surgeons can be concerning, each interaction between the surgeon and parent is unique. Thus, it is incumbent on the surgeon to provide appropriate amount of information for that spe- cific interaction. For instance, if the surgeon gets an impres- sion that a parent is anxious and does not want to hear the details about surgery, then perhaps only the essential infor- mation should be shared. However, if a parent is asking many questions and is being inquisitive, the surgeon may provide more details. Surgeons must make decisions about what risks and ben- efits to discuss with their patients. However, mentioning all possible risks of surgical procedures is not practical or likely beneficial. 18 This concept of the ethics of ‘‘everyday clinical’’ practice—which changes with each clinical encounter and relationship with patients—is known as microethics . 19 Microethics is an important concept not tradi- tionally discussed or taught in medical schools, as most ethical training involves extreme or unusual cases (eg, Jehovah’s witness patient refusing blood transfusion). However, microethics deals with the constant small ethical decisions that occur every day in the clinical setting, such as questioning which risks and benefits should be discussed with the patient/family members. 19 Further studies in this area are needed to help clinicians fully recognize that microethical decisions are important and relevant to every- day practice. A number of risks and benefits recalled by parents were not actually mentioned by the providers during the visit. In these cases, it may be that parents obtained supplementary information about the treatment options from sources out- side the surgeon. In particular, they may seek advice or information from family members, other parents, their pri- mary care providers, or the Internet. 6,20,21 All together, the implication is that parents are actively seeking more infor- mation beyond what was provided during consultation. Therefore, health care providers should consider developing educational tools with accurate information that can be pro- vided for parents to review at home. As well, surgeons should emphasize the important and relatively common risks (eg, bleeding posttonsillectomy) so that parents are better able to retain information and handle the potential complications. Several demographic and contextual factors were assessed in this study, and none of them (except the deci- sion on whether to proceed with surgery or not) were signif- icantly related to the proportion of recalled risks and benefits. This is in contrast to previous studies showing that education levels influenced surgical risk recall. Specifically, research has suggested that patients with higher levels of

education are more likely to recall 50% of the risks, 22 while patients with lower levels of education tend to recall \ 50%. 12,23 However, other studies have found a negative correlation with education levels, where parents of pediatric patients with postsecondary education had poorer recall of surgical risks for their children’s surgery. 11 Similar to edu- cation, a prior surgical history for any child in the family did not influence recall rate. It seems that regardless of edu- cation level and previous experience, some parents will have less-than-ideal recall and may therefore benefit from further support during the informed consent process. This study provides preliminary information about paren- tal recall of information shared during pediatric otolaryngol- ogy consultations. Surgeons should be aware that many parents have poor recall and that they tend to remember only a few specific risks and benefits. Moreover, parents were likely seeking additional information from other sources. Hence, surgeons should emphasize the important and common risks involved in a surgical procedure, as well as find ways to increase information retention (eg, via deci- sion aids 24 ). Limitations of this study should be noted. The timeline of the follow-up phone call may have influenced parental recall. In this study, the follow-up occurred 2 weeks after the consultation, and recall may have been different if the time frame was different. Second, we did not assess for dif- ferences in recall based on different ethnicity, since the study sample was homogenous (ie, mostly Caucasian). Therefore, cultural diversity and its influence on recall of risks and benefits are unknown in the current population. Furthermore, it is possible that the results reported in this study may not be generalizable to other centers that have demographically different populations. Third, parents were aware that a phone call would be made by the research assistant after the consultation visit, which may have led to recall bias. However, parents were not aware that specific risks and benefits would be elicited, and thus it is unlikely that a Hawthorne effect would have occurred. Fourth, the surgeons did not have a standardized discussion on risks and benefits. That is, the providers mentioned different risks and benefits even though they worked at the same center; nonetheless, this is another novel finding that requires fur- ther studies to determine why only certain risks and benefits were mentioned by the providers. Although data were avail- able on which specific risks and benefits were mentioned by the participating surgeons, we could not independently ana- lyze these data since there was too much variability across and even within individual surgeons. Even though all sur- geons mentioned the common risks of surgery (eg, postton- sillectomy bleed), many instances were observed where other information was mentioned in a tremendously varied manner (eg, premature tube extrusion, improved quality of life). Therefore, we could not analyze these data at the level of which specific risks and benefits were mentioned by the providers. Finally, a relatively small number of surgeons were included in this study, thus representing a restricted range of potential provider influences. A larger number of

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