David Gage

Despite its utmost importance, the act of obtaining informed consent is often regarded as a bothersome task and a burden by healthcare providers and radiologists. It is what stands in the way of the patient undergoing the procedure that has already been deemed necessary for them. It is always obtained, but not always discussed optimally or properly as it should. So, how does one move beyond this letter-of-the-law type consent process and truly fulfill the higher role of radiologist as an educator and patient advocate?

There are several factors, but each is related to one of the three main components of the informed consent process: the information to be communicated, the patient, and the physician. Each of these factors can become a stumbling block if the radiologist is not cognizant of their potentially deleterious effects: the “readability” of the information, the patient’s knowledge level and cultural background, and the radiologist’s biases. Awareness of these factors will allow the radiologist to more artfully craft a dialogue that better encourages patients’ autonomy as they navigate the complex world of healthcare.

The readability of information presented to patients in word and in writing is often above their reading level, hindering the ability of informed consent. The information to be communicated to patients often involves advanced specialized medical language that requires advanced degrees to understand. Even words that are commonplace amongst healthcare professionals are incorrect to use in informational material given to patients. Words such as “indicated” or “lesion” may confuse the patient. Several methods exist for insuring readability of information during informed consent. One such method is the Simple Measure of Gobbledygook (SMOG) readability formula, which allows one to determine the reading level of written materials [1]. According to the United States Department of Health and Human Services, the average reading level for an American is the 7th grade reading level [2]. Realizing that half of the patient population will be below this level will hopefully call attention to the importance of careful examination of written and verbal information given to patients in order to increase the likelihood of adequate understanding.

Being cognizant of the knowledge level of the patient, both globally and regarding the imaging-guided procedure for which consent is to be obtained, is crucial to carefully approaching the consent process. The patient’s knowledge level determines how procedures are described and can impact discussions regarding risk, which is a potential area of misunderstanding. They may struggle with concepts such as risk, especially as it is quantified, either thinking nothing bad can happen or that everything bad will happen. Patients may require additional time to consolidate the information provided to them, so that they can properly understand the material and make an educated decision. Providers need to understand where the patient is in terms of existing knowledge, so their knowledge can be built up from an appropriate starting point.

Poor information readability and poor patient knowledge level may contribute to patient uncertainty. What is one to do when, after a thorough explanation, the patient is uncertain as to how they would like to move forward with their care? When a radiologist has several other patients waiting to be consented for LPs or breast biopsies, the natural tendency might be to nudge the patient in the direction of action that was being planned. Having already decided this is the appropriate action, the radiologist might do so without feeling they have influenced the patient too much. However, uncertainty is not an excuse to simply influence the patient what to do; it is rather an invitation to teach the patient. It is the radiologist’s duty to fully uphold a patient’s autonomy. Just as radiologists must gather and synthesize additional data to make a correct diagnosis, patients deserve the right to go through a similar process when making decisions about their care.

The cultural background of a patient can further have many effects on a patient during the consent process that might lead to a sub-par consent. In our diverse country, it behooves physicians to be cognizant of the cultural components that can affect this process. For instance, some cultures teach unquestioning respect for and trust in doctors or other professionals. They might not make eye contact with the physician, or only respond with repeated yes’s. This should not become a free pass for an easy consent process. The radiologist, while remaining appropriately culturally competent, should do all they reasonably can to ascertain the level of understanding of the patient. Utilizing teach back methods can be one avenue for determining patient awareness in such situations. Of note, culture can also refer to the culture of one’s family. Family dynamics are another instance in which care must be taken to ensure a patient understands, rather than defaulting to familial pressures. A high level of emotional intelligence is required by the radiologist to read the room in such situations when cultural background is influencing the consent process.

While the previous points have mostly focused on the patient, a key partner in the process, and one that can just as easily contribute to a poor consent, is the physicians and their biases. A great deal has been discussed in recent years about unconscious bias and its effects in medicine. As radiologists will, most of the time, be far more educated than their patients, the questions must be asked: Does this affect the way radiologists interact with their patients? Are patients seen as less capable, less intelligent? While these are difficult questions, they are important ones to consider in self-reflection. Biases, whether conscious or unconscious, are proven to affect the way physicians interact and treat patients. The consent process is not immune to these effects, and may well be a time when they are most at work.

It is crucial for radiologists to recognize these confounding factors of the consent process. It is their duty to recognize them, and adjust accordingly, so as not to compromise the ethics of patient care: autonomy, beneficence, non-maleficence, and justice. Radiologists must ensure that the patients are educated to the best of their ability regarding the proposed procedure, the risks, benefits, and alternatives. The radiologist’s duty is to help the patients navigate decisions regarding their care just as radiologists do on a daily basis with other physicians. As consulting physicians, radiologists are in a perfect position to be the most skilled at consulting the patients during the informed-consent process. This does not require multimillion-dollar machines, or years of advanced imaging training. It is an art rather than a science. As providers learn to excel at it, they will be fulfilling the most noble of roles of the physician. From tissue biopsy to TIPS, every procedure is an opportunity for radiologists to hone their skills as educators and consultants to guide patients through the decision-making process and the art of the consent.

References:
1. Walsh TM1, Volsko TA. Readability assessment of internet-based consumer health information. Respiratory Care 2008; 53(10):1310-5.
2. Hedman, Amy S. Using the SMOG formula to revise a health-related document". American Journal of Health Education 2008; 39(1):61–64.

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Radiologists are in a perfect position to be the most skilled at consulting patients during the informed-consent process

David Gage

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The Art of the Consent