That Creeping Feeling…

First of all, I want to say that Richard’s presentation was so phenomenal today. I distinctly remember hiking up the San Juan mountains in Colorado at last summer’s Telluride conference after a great session the day before thinking, “I’ve found my people.” It really is a special thing. I still see one of the other alums every now and then at hospital meetings and it literally warms my heart to hear his name and that he is doing great things at his home institution.

We talked a lot about informed consent and a patient’s understanding of their own experience in the healthcare system. As a primary care physician, I couldn’t help but wonder how Patty’s son’s primary care doctor felt about the horrific outcomes of his patient at the hands of a surgeon who probably didn’t need to operate in the first place, someone he tried to talk out of doing the surgery…but never ended up speaking with. I was saddened but not surprised to hear that he stepped away from medicine for a while. After all, “a path without a heart is never enjoyable.” In the discussion that followed the film, Dave mentioned that consent is a team process – what IS the role of the PCP in this process? While I can’t go through exactly what will happen with my patients during a surgical procedure and perfectly outline all of the expected (and unexpected) outcomes that may occur as a result of the procedure (simply because of my practice limitations), I can certainly review non-surgical management. I can encourage them to get a second opinion when they have questions. I can support them when they decide not to go through with a procedure and optimize their non-surgical management. In my mind, the informed consent process starts before the referral to the surgeon is even made, and it should include the PCP until the day the procedure is completed.

Our discussions today also made me realize the number of minimally invasive procedures we do on a daily basis that we don’t consent patients for but that nonetheless put them at risk for harm: IV lines, daily phlebotomy, Foley insertion. If a patient implicitly consents to have an IV put in their arm and a Foley catheter inserted into their bladder, surely they have no problem with an NG tube…if they have no problem with an NG tube, surely they have no problem with an endoscopy…if they have no problem with an endoscopy, surely they have no problem with an ERCP. We start to develop “consent creep”, where our expectations of what patients are willing to undergo without fully understanding the risks and alternatives gets really blurry. What if we were forced to explain the alternatives to IV fluids? What if we had to tell a mother that her 3 year old daughter could develop an infiltration of her IV that causes such a bad skin reaction that she might need multiple surgical procedures and have a lifelong deformity? What if we had to tell the son and daughter-in-law of an 87 year old bedbound patient with incontinence that the Foley we want to put in to prevent skin breakdown could cause a UTI and sepsis? Would we be so cavalier about checking off those boxes in our admission orders? Would our patients want these therapies?

So many of us promised to ask ourselves these questions in our future practice. We need to encourage others to do the same. Be the sounding board – and you will change the culture.

One quote that made me think today:

“Do we really know what our patients want?”

Do we ask them? Do we give them the tools and the freedom to know?

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