Hospital informed consent for procedure forms: facilitating quality patient-physician interaction.

BACKGROUND: Informed consent forms should document and reflect the goals of informed consent and shared decision making. We conducted this study to examine the extent to which informed consent for procedure forms meet accepted informed consent standards, how well state informed consent statutes correlate with these standards, and whether existing forms can enhance the interactions between patients and physicians or other health care providers. HYPOTHESIS: Informed consent forms do not meet accepted standards. A different format may be more useful for patient-physician interactions. DESIGN: A content analysis was conducted of hospital informed consent for procedure forms from a random selection of hospitals in the 1994 American Hospital Association membership directory. Forms were examined for evidence of the basic elements of informed consent (nature of the procedure, risks, benefits, and alternatives) and items that might enhance patient-physician interactions and encourage shared decision making. UNIT OF ANALYSIS: From 157 hospitals nationwide, 540 hospital informed consent for procedure forms were examined. MEASUREMENTS AND MAIN RESULTS: Ninety-six percent of forms indicated the nature of the procedure, but risks, benefits, and alternatives were found less often. Only 26% of forms included all 4 basic elements, 35% included 3 of 4 elements, 23% had 2 of 4 elements, 14% had only 1 element, and 2% had none of the elements. Forms appear to authorize treatment (75%) or protect hospitals and caregivers from liability (59%) rather than clarify information about procedures (40%) or aid patients in decision making (14%). Forms from states with statutes that require that all 4 elements be provided were no more likely than other states to include them (Fisher exact test = 1.000). Fewer than 40% of forms supported models of shared decision making. CONCLUSIONS: The content of most forms did not meet accepted standards of informed consent or patient-physician interactions. We propose a form that more fully supports the models of ideal informed consent and shared decision making to enhance the applicability of informed consent in the clinical setting.

Part I. "Behind every problem lies an opportunity": meeting the challenge of diversity in medical schools.

The authors describe the historical evolution and present status of affirmative action in medical school admission policies. The demographic transformation of the medical student body between 1965 and 1998 from a homogeneous white and male group to one that includes a significant number of women and minority students is presented. Challenges to affirmative action are outlined. In addition, the authors note the increasing diversity of the general population and discuss the benefits of diversity to medical practice, research, and education. However, the upper ranks of professors and administrators remain white and male. The rationale for an innovative course on the history of bias in medicine and the benefits that diversity brings to the medical enterprise are presented.

Part II. Educating for diversity: a decade of experience (1989-1999)

In response to tensions created by a racial misunderstanding, the authors developed a course for first year medical students entitled Race and Gender in Medicine. The course, presented in a seminar format, enables the participants to discuss openly their concerns about diversity and its impact on their institution and the medical enterprise. Physician speakers describe their experiences with gender bias, racism, and other discriminatory practices and then present strategies they used to overcome these obstacles in their career path. Given the increasing heterogeneity of the population, the authors advocate integrating a course such as this one into the curriculum that will help prepare students to practice humane medicine in the multiracial, multiethnic, and multicultural society of the 21st century.

Domestic violence and mental health: correlates and conundrums within and across cultures.

Gender-based violence, only recently emerging as a pervasive global issue, contributes significantly to preventable morbidity and mortality for women across diverse cultures. Existing documentation suggests that profound physical and psychological sequelae are endemic following intimate partner violence. The presentation of domestic violence is often culture specific. A new lexicon, prompted by the expansion of human rights analysis, describes particular threats to local women including dowry deaths, honor murder, saiti, and disproportional exposure to HIV/AIDS as well as globally generic perils including abuse, battering, marital rape, and murder. While still fragmentary, accruing data reveal strengthening associations between domestic violence and mental health. Depression, stress-related syndromes, chemical dependency and substance (ab)use, and suicide are consequences observed in the context of violence in women's lives. Emerging social, legal, medical, and educational strategies, often culture specific, offer novel local models to promote social change beginning with raising the status of women. The ubiquity, gravity, and variability of domestic violence across cultures compel additional research to promote the recognition, intervention, and prevention of domestic violence that are both locally specific and internationally instructive.

Patient-physician communication when blindness threatens.

The threat of blindness creates a difficult and challenging environment for communication between patients and their ophthalmologists. This study examined concordance between what patients want to know from their physicians about their eye condition and what physicians believe their patients need to know. Eight retinal specialists and 24 of their patients with proliferative diabetic retinopathy and at risk of blindness were interviewed using parallel-constructed instruments. Although all recognized that blindness was the patients' greatest concern, disparities were noted that involved the desire/need to know about the possibility of vision loss, the causes of the eye condition, the results of each eye exam, and the extent of patient confusion. Physicians, while conscientious about informed consent, described various communication behaviors to avoid discussing bad news.

The patient and practitioner as co-authors of the medical record.

Health care professionals traditionally have resisted patient access to medical records. There is evidence, however, that the patient's medical record can promote improved communication between patient and practitioner. In an exploratory study, patients in a primary care office practice collaborated with their health care professionals in the authorship of their records. Co-authorship was effective in conveying more complete, accurate, and mutually understandable information. The patient-held copy of the record served as an adjunct to this collaborative process. The potential problems and prospects arising from this strategy are discussed.