In response to my last post about informed consent in my Medicine and Law series, several commenters made the point that informed consent is more than just getting a form signed. That ideally it should involve a dialogue between patient and doctor. That the burden of trust is on the doctor to inform the patient so that the patient actually understands what the risks and benefits are. That the doctor should empower the patient to make the choice.

These are all great points and I couldn’t agree more that informed consent does involve all of the above. It does involve trust and building of it in a patient-physician relationship. There is the medicolegal aspect that I have outlined in the Medicine and Law series, but there also is the real relationship that goes on between the patient and doctor.

Despite all these ideals that physicians strive for, the circumstances are not always conducive to this. For example, when a physician meets a patient for the first time in the Emergency Room and the outcome of the workup is that a procedure will need to be done on the patient, the doctor does not have a long history of rapport with the patient. The patient just met the doctor this visit and doesn’t have a lot to go on other than this limited reaction. Thus for the physician covering the Emergency Department with tons of patients backlogged that he needs to see, he cannot feasibly spend an hour talking with the patient about the informed consent. Generally, informed consent can be as fast as a few minutes and as long as an hour conversation that is unresolved and carries over to the next day.

To make matters worse, if the patient requires surgery, the surgeon must schedule the surgery when the operating room has availability, must find an anesthesiologist to do the anesthesia, and must make sure the patient has not had a meal in the 6 to 8 hours prior to surgery. Thus, when a patient wants to delay surgery to decide and think things over in the emergent or semi-emergent situation, then he is delaying his care.

The other issue comes with choice and empowerment. Many patients act surprised when you ask them what they would like to do. They often want the physician to decide what is best. They are not physicians and do not want the responsibility to make the decision. Often when given power to make the decision, they choose the one that the physician does not think is the best idea and leads to a worse outcome.

Physicians strive for the ideals above and that informed consent where the patient is on board and also feels empowered to control the destiny of his own health. However, from a medicolegal standpoint, at the end of the day, it is the physician that is responsible for the patient’s care, not the patient.