Informed Consent and the Physician-Patient Relationship

Patients who experience a decrease or disturbance in their visual acuity look to their ophthalmologist for answers to questions such as “What is wrong with me?” “Why did this happen to me?” “What is going to happen to me because of this illness?” and “How can you help me?” When an ophthalmologist sees a new patient with macular degeneration or a retinal detachment, as part of the informed consent he or she discusses the facts about the condition and the treatment options. If the ophthalmologist then asks the patient how he or she would like to proceed, it is not uncommon for the patient to point out, “You are the doctor!”

Perhaps the patient is simply stating the obvious. But could there be something more to it? Do we respond by providing a more detailed explanation of the risks, benefits, and alternatives? What is the most skillful and thoughtful response to this statement? This article takes a deeper look at the informed consent process and offers a potentially better way to go about it.

THE FOUR MODELS OF THE PHYSICIAN-PATIENT RELATIONSHIP

Ezekiel and Linda Emanuel described four models of the physician-patient relationship: paternalistic, informative, interpretive, and deliberative.1

In the paternalistic model, the physician articulates and implements what is best for the patient.

In the informative model, the physician aims to provide patients with all relevant information, including risks, benefits, and alternatives, and then asks them to select their own medical intervention.

The intent of the interpretive model is for the physician to determine the patient’s values and what he or she actually wants, then to help him or her select the medical intervention that realizes these values.

In the deliberative model, the aim of the physician-patient interaction is to help the patient determine and make the best health-related decision that can be realized in the clinical situation.

INFORMATIVE IS ADEQUATE

Many of us begin our careers patterning ourselves after our teachers. Many of us also begin in an atmosphere of trepidation due to legal concerns, and we find ourselves outlining every possible risk and quoting statistical outcomes. However, despite our best efforts, few patients really comprehend what we are saying. We cannot expect them to understand terms such as high pressure and corneal swelling, let alone realize the long-term significance of these complications, or know the treatment options and variable outcomes should complications occur. It is also sometimes challenging for patients to understand statistical outcomes. Furthermore, most patients are unaware that when we are explaining their situations we are also building their legal informed consent.

Over the past several decades, many retina specialists have adopted the informative model of the physician-patient relationship described above. We might find ourselves using it when selecting an anti-VEGF treatment or when deciding whether to remove an epiretinal membrane. Although the informative model provides patients with all of the facts and the physician with a legal document, it lacks a caring touch.

In his book The Healer’s Art, Eric Cassell explains that an individual’s thought patterns change when he or she is sick.2 He writes:

“While the sick may think rationally when they are able to consider the Presidency, their thoughts about themselves or their illness appear to be purely emotional. … [I]n emotive thought, feeling deeply influences the way in which new information is perceived. A new piece of information does not float freely in our heads; it is assigned to some category or frame of reference that already exists within the mind. Experience, education, social background and other factors contribute to the mind’s decision as to where to assign incoming information. In the sick, feelings such as fear greatly influence this process.”

GO AHEAD, GIVE THEM GUIDANCE

What patients want from their physicians is much more than just facts or the freedom to make their own decisions. They want a partner, teacher, and friend who understands their values and will help guide them through their illness. When patients remark, “Well, you are the doctor,” they are really asking you to help them get through whatever it is they are facing. As their physician, you can offer a great deal of relief in this situation simply by replying, “I understand why this is so frightening and confusing. I have dealt with this condition numerous times, and, given what I know about you, this is the course of action I would recommend. It is the same treatment I would recommend if you were my mother.”

The interpretive and deliberative models of care aim to allow the physician to understand the patient’s values and choose the best health-related values that can be realized. The physician not only indicates what the patient can do, but, knowing the patient and wishing what is best, the physician can and should indicate what the patient should do. Unfortunately, with limited time, we must be careful not to unwittingly impose our own values on patients who may be overwhelmed by their medical conditions or uncertain of their own views, making them too easily accepting of this imposition, which would fall in line with the paternalistic model.

CONNECT ON AN EMOTIONAL LEVEL

We listen to patients and try to understand their fears, and, when we do understand and address these fears openly, patients then realize that we are on the same team. This, in turn, allows them to listen better to us, which ultimately benefits both parties. Sometimes patients freeze up when we explain that they have a serious condition, such as retinal detachment. They are so fearful of their assumed outcome (usually pain and blindness)—which they base on their limited understanding or on what happened to a neighbor with a retinal problem—that they are no longer capable of listening to the physician.

In this situation, providing patients with more information will not be useful. I have found it best to acknowledge their fears and use an emotive response: “I understand why this must be very frightening to you.” This simple sentence conveys to patients that you understand them. Once this sinks in, most patients will be able to continue to participate in the discussion. Thus, in the informed consent process, knowing your patients’ emotional state and, in particular, their fears, will go a long way in enabling you to tweak your approach when necessary and ensuring a better overall physician-patient relationship.

DELIBERATIVE IS BETTER

As our confidence and understanding of what patients really want out of their relationships with us has evolved, we have changed our emphasis from simply dispensing information and asking patients to make their own decisions (informative model) to trying to understand their needs, fears, and values. Doing so allows us to be our patients’ partners in their eye care. By aligning our knowledge and skills with what we know about our patients, we can recommend the appropriate course of action (deliberative model) for each individual. This approach appears to inspire more confidence, greater patient satisfaction, and better outcomes. n

1. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992;267(16):2221-2226.

2. Cassell EJ. The Healer’s Art. Cambridge, MA: MIT Press; 1985.

Mya Aung, MBS, DO, MMed, Sc(Ophth)
• professor, Yangon University, in Yangon, Myanmar
• financial interest: none acknowledged

Arun Patel, MD
• retina specialist at Retina Consultants of Sacramento, Calif.
• financial interest: none acknowledged
• medicinewithcompassion@gmail.com