“Informed consent wasn’t being assessed systematically; it wasn’t being taught effectively – we identified this as a gap. When we reviewed the literature, we found that there was no published tool available,” Dr Ian Incoll says.
Incoll and his co-author, Jodie Atkin, are piloting a new formative assessment tool, in which trainees are observed performing informed consent in the workplace.
This pilot project has recently received a funding boost from an Avant Foundation Grant.
Dr Penny Browne, Chair of the Avant Foundation Board, says Avant is thrilled to get behind this historic step forward. “Deeply rooted in providing patients the very best care, we look forward to seeing how this tool can be used in surgery and perhaps beyond,” Dr Browne says.
It is one measure the Australian Orthopaedic Association (AOA) will introduce for targeting learning as part of their redesigned ‘AOA 21’ curriculum.
Experts join forces to enhance trainees’ 'soft’ skills
AOA undertook a strategic education review beginning in 2012, performed by experts from the Royal College of Physicians and Surgeons of Canada. This report prompted the curriculum redesign project, named ‘AOA 21’. It places more emphasis on non-technical or ‘foundation’ competencies such as communication, teamwork, leadership and professionalism.
Atkin was engaged by the AOA to work with surgeon members to improve the orthopaedic training program. This included a revised, competency-based curriculum, workplace-based assessment tools, a process for monitoring and reviewing performance, as well as a review of the accreditation process for hospitals involved in training.
“It’s marrying up my educational expertise with surgeons’ experience to improve training,” Atkin says, who holds degrees in psychology and adult education. She is currently completing a qualification in applied law.
Atkin says it was her passion for improving patient care that drew her to the role. “Patients like to see an ‘all-rounder’; a doctor who is not only medically and surgically competent, but also has effective communication skills and helps them to make decisions that are in their best interests. It’s the teaching of those latter skills we hope to target a little more,” Atkin explains.
Dr Incoll, an Orthopaedic Surgeon and Clinician Educator with a Master of Surgical Education, has been engaged in surgical education since 2003. He has designed and provided teaching for undergraduate and post-graduate doctors. Currently Dean of AOA, he is the lead or 'Goal Champion' for the AOA 21 project. He cites the AOA 21 project as one of his proudest achievements. “It’s certainly been challenging, as with any culture change,” he says, adding, “However, we’re starting to see tangible benefits”.
Consent process is a complex procedure in itself
Studies have demonstrated that surgeons often overestimate patient literacy when obtaining informed consent, and fail to dedicate enough time to ensuring the patient understands the benefits and material risks of their surgery. This poses a demonstrated medico-legal risk.
“Until recently, it’s just been expected that the surgeon would tell a patient about the procedure, about all the risks and then get them to sign on the dotted line. We understand now there are more aspects to consent than that,” Dr Incoll says.
Atkin points to patient needs as an example, “One patient may have the goal to walk to the letter box, and another patient may be intending to return to elite sport. The surgeon listens to the patient in terms of what quality of life means to them and then the surgeon offers treatment options, which could include no surgery, to help the patient achieve their goal,” Atkin says. She adds that the informed consent process should be a two-way conversation.
Current training works on the assumption that trainees will learn foundation competencies from role modelling. “We found, however, that trainees don’t often observe their senior colleagues taking informed consent or, if they do, it might not be a demonstration of best practice,” Atkin explains. “In the training program, we need to teach some aspects a little more explicitly,” she adds.
Dr Incoll says that, “Within the AOA training program, there was actually no explicit teaching of informed consent beyond role modelling'. Dr Incoll’s and Atkin's literature review also revealed that neither was there a recognised assessment tool for clinicians to use to rate an informed consent interaction.
The Informed Consent Observation Tool
“We started looking at all the components of medically, ethically and legally valid informed consent, then designed an assessment tool for an observer to use,” Atkin explains.
This innovation, the Informed Consent Observation Tool, is currently being validated and will then be trialled with doctors in training. The tool will help identify any deficiencies and prompt the provision of targeted feedback on areas for improvement.
Improving standards early on in the training program
The team hopes this study will produce a reliable and valid tool that can be used to assess informed consent skills in surgical trainees and consultant surgeons. Ultimately, it could have the flow-on effect of improving patient outcomes in surgical procedures in Australia, by improving the standard of informed consent early in the training program and establishing proficiency.
Dr Incoll is optimistic the tool will be useful beyond the surgical realm. “If we find that the tool works and achieves the goals hoped for, it should be a useful addition for any procedural specialty training requiring informed consent,” he says.