Peter Angelos, MD, PhD

Obtaining informed consent for surgery is one of the most common tasks surgeons perform. Ensuring that a patient has the capacity to make a decision and then explaining the indications, risks, and alternatives to the surgery is something that surgeons do hundreds of times a year. Although the process is routine, it reflects the importance of respecting patients’ autonomy in making informed decisions about their health care. Informed consent has been an accepted practice in American surgery for decades, but questions about the process can arise and elicit varied responses among surgeons.

Recently, an experienced colleague (Dr. S) called me to discuss a case that had been troubling him. A 68-year-old man had been referred to him for a surgical opinion after experiencing recurrent episodes of diverticulitis. He was a former insurance executive, now retired. He was married, but came without his wife to the appointment with Dr. S.

After completing the history and physical examination and reviewing the imaging, Dr. S recommended an elective sigmoid colon resection. He explained to the patient what was involved in the surgery and the expected recovery. According to Dr. S, the patient then stated, "I understand. When can we schedule it?" At this point, Dr. S stated that a few more things needed to be reviewed and began to discuss the potential risks of the surgery. The patient stopped him abruptly, saying that he knew that there were risks, but he preferred not to hear about them.

When Dr. S responded that it is always good to know the risks when deciding to have surgery, the patient stated, "Look, I trust my primary care doctor who sent me to see you. You seem like a good surgeon, and I have confidence in you. I don’t want to hear about the risks, because my hearing them won’t make them not happen and will only make me worry. I’ll sign anything that you want, but I don’t want you to tell me the risks."

Dr. S felt torn. He had always felt that the consent process was primarily about informing the patient of what could happen. Reviewing the potential risks would help the patient to become better informed in making the decision to have surgery. Dr. S felt that his patient’s desire not to be informed had short-circuited the process, and it now seemed incomplete.

Dr. S offered to call the patient’s wife to discuss the risks with her, but the patient said that would not be necessary since he was making his own decisions. Although there was no hostility in the patient’s remarks, Dr. S felt that he had pushed hard enough, so he obtained a signature on the consent form and documented in his note that he had offered to inform the patient of the risks but that the patient had refused to hear them.

In the 3 weeks between this office visit and the surgery, Dr. S related the case to a number of his surgical colleagues and received diametrically opposing views. One group of surgeons stated that as the surgeon, Dr. S had an ethical responsibility to ensure that his patient knew of the risks of the procedure. They felt strongly that unless Dr. S had reviewed these risks with the patient, the consent was not valid because "it was not truly informed." Another group of surgeons felt that the ethical responsibility was not to inform the patient, but rather to provide the opportunity for the patient to be informed. This second group felt that pushing the patient to hear information that he did not want to hear would actually be violating his autonomous choice not to be informed.

These opposing views of what to do in this case help to clarify what I believe is one of the central points of confusion about the informed consent process as it is currently used. Surgeons and patients alike often believe that the information transfer – that is, describing the risks of the surgery – is the central goal of the process. However, many studies have shown that patients do not actually remember much of what they are told by their surgeons. Specifically, few risks are remembered even on the same day that the surgeon has reviewed them and the consent form is signed. These data clearly suggest to me that the more important aspect of the informed consent process is the communication between the surgeon and the patient.

Communication suggests something more than providing a lecture to a patient. It suggests the importance of listening and responding to requests for more or less information. Given that the requirement for informed consent prior to surgery is grounded on the principle of respecting a patient’s autonomy, it seems clear that when a patient does not want to hear the information that a surgeon wants to convey, the surgeon must respect the patient’s choice not to be informed.

Although Dr. S had felt that something was missing in the consent process since it did not include "the usual discussion of risks," the patient’s choices had been respected and Dr. S had fully discharged his responsibilities in obtaining the patient’s informed consent.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief, endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Obtaining informed consent for surgery is one of the most common tasks surgeons perform. Ensuring that a patient has the capacity to make a decision and then explaining the indications, risks, and alternatives to the surgery is something that surgeons do hundreds of times a year. Although the process is routine, it reflects the importance of respecting patients’ autonomy in making informed decisions about their health care. Informed consent has been an accepted practice in American surgery for decades, but questions about the process can arise and elicit varied responses among surgeons.

Recently, an experienced colleague (Dr. S) called me to discuss a case that had been troubling him. A 68-year-old man had been referred to him for a surgical opinion after experiencing recurrent episodes of diverticulitis. He was a former insurance executive, now retired. He was married, but came without his wife to the appointment with Dr. S.

After completing the history and physical examination and reviewing the imaging, Dr. S recommended an elective sigmoid colon resection. He explained to the patient what was involved in the surgery and the expected recovery. According to Dr. S, the patient then stated, "I understand. When can we schedule it?" At this point, Dr. S stated that a few more things needed to be reviewed and began to discuss the potential risks of the surgery. The patient stopped him abruptly, saying that he knew that there were risks, but he preferred not to hear about them.

When Dr. S responded that it is always good to know the risks when deciding to have surgery, the patient stated, "Look, I trust my primary care doctor who sent me to see you. You seem like a good surgeon, and I have confidence in you. I don’t want to hear about the risks, because my hearing them won’t make them not happen and will only make me worry. I’ll sign anything that you want, but I don’t want you to tell me the risks."

Dr. S felt torn. He had always felt that the consent process was primarily about informing the patient of what could happen. Reviewing the potential risks would help the patient to become better informed in making the decision to have surgery. Dr. S felt that his patient’s desire not to be informed had short-circuited the process, and it now seemed incomplete.

Dr. S offered to call the patient’s wife to discuss the risks with her, but the patient said that would not be necessary since he was making his own decisions. Although there was no hostility in the patient’s remarks, Dr. S felt that he had pushed hard enough, so he obtained a signature on the consent form and documented in his note that he had offered to inform the patient of the risks but that the patient had refused to hear them.

In the 3 weeks between this office visit and the surgery, Dr. S related the case to a number of his surgical colleagues and received diametrically opposing views. One group of surgeons stated that as the surgeon, Dr. S had an ethical responsibility to ensure that his patient knew of the risks of the procedure. They felt strongly that unless Dr. S had reviewed these risks with the patient, the consent was not valid because "it was not truly informed." Another group of surgeons felt that the ethical responsibility was not to inform the patient, but rather to provide the opportunity for the patient to be informed. This second group felt that pushing the patient to hear information that he did not want to hear would actually be violating his autonomous choice not to be informed.

These opposing views of what to do in this case help to clarify what I believe is one of the central points of confusion about the informed consent process as it is currently used. Surgeons and patients alike often believe that the information transfer – that is, describing the risks of the surgery – is the central goal of the process. However, many studies have shown that patients do not actually remember much of what they are told by their surgeons. Specifically, few risks are remembered even on the same day that the surgeon has reviewed them and the consent form is signed. These data clearly suggest to me that the more important aspect of the informed consent process is the communication between the surgeon and the patient.

Communication suggests something more than providing a lecture to a patient. It suggests the importance of listening and responding to requests for more or less information. Given that the requirement for informed consent prior to surgery is grounded on the principle of respecting a patient’s autonomy, it seems clear that when a patient does not want to hear the information that a surgeon wants to convey, the surgeon must respect the patient’s choice not to be informed.

Although Dr. S had felt that something was missing in the consent process since it did not include "the usual discussion of risks," the patient’s choices had been respected and Dr. S had fully discharged his responsibilities in obtaining the patient’s informed consent.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief, endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Obtaining informed consent for surgery is one of the most common tasks surgeons perform. Ensuring that a patient has the capacity to make a decision and then explaining the indications, risks, and alternatives to the surgery is something that surgeons do hundreds of times a year. Although the process is routine, it reflects the importance of respecting patients’ autonomy in making informed decisions about their health care. Informed consent has been an accepted practice in American surgery for decades, but questions about the process can arise and elicit varied responses among surgeons.

Recently, an experienced colleague (Dr. S) called me to discuss a case that had been troubling him. A 68-year-old man had been referred to him for a surgical opinion after experiencing recurrent episodes of diverticulitis. He was a former insurance executive, now retired. He was married, but came without his wife to the appointment with Dr. S.

After completing the history and physical examination and reviewing the imaging, Dr. S recommended an elective sigmoid colon resection. He explained to the patient what was involved in the surgery and the expected recovery. According to Dr. S, the patient then stated, "I understand. When can we schedule it?" At this point, Dr. S stated that a few more things needed to be reviewed and began to discuss the potential risks of the surgery. The patient stopped him abruptly, saying that he knew that there were risks, but he preferred not to hear about them.

When Dr. S responded that it is always good to know the risks when deciding to have surgery, the patient stated, "Look, I trust my primary care doctor who sent me to see you. You seem like a good surgeon, and I have confidence in you. I don’t want to hear about the risks, because my hearing them won’t make them not happen and will only make me worry. I’ll sign anything that you want, but I don’t want you to tell me the risks."

Dr. S felt torn. He had always felt that the consent process was primarily about informing the patient of what could happen. Reviewing the potential risks would help the patient to become better informed in making the decision to have surgery. Dr. S felt that his patient’s desire not to be informed had short-circuited the process, and it now seemed incomplete.

Dr. S offered to call the patient’s wife to discuss the risks with her, but the patient said that would not be necessary since he was making his own decisions. Although there was no hostility in the patient’s remarks, Dr. S felt that he had pushed hard enough, so he obtained a signature on the consent form and documented in his note that he had offered to inform the patient of the risks but that the patient had refused to hear them.

In the 3 weeks between this office visit and the surgery, Dr. S related the case to a number of his surgical colleagues and received diametrically opposing views. One group of surgeons stated that as the surgeon, Dr. S had an ethical responsibility to ensure that his patient knew of the risks of the procedure. They felt strongly that unless Dr. S had reviewed these risks with the patient, the consent was not valid because "it was not truly informed." Another group of surgeons felt that the ethical responsibility was not to inform the patient, but rather to provide the opportunity for the patient to be informed. This second group felt that pushing the patient to hear information that he did not want to hear would actually be violating his autonomous choice not to be informed.

These opposing views of what to do in this case help to clarify what I believe is one of the central points of confusion about the informed consent process as it is currently used. Surgeons and patients alike often believe that the information transfer – that is, describing the risks of the surgery – is the central goal of the process. However, many studies have shown that patients do not actually remember much of what they are told by their surgeons. Specifically, few risks are remembered even on the same day that the surgeon has reviewed them and the consent form is signed. These data clearly suggest to me that the more important aspect of the informed consent process is the communication between the surgeon and the patient.

Communication suggests something more than providing a lecture to a patient. It suggests the importance of listening and responding to requests for more or less information. Given that the requirement for informed consent prior to surgery is grounded on the principle of respecting a patient’s autonomy, it seems clear that when a patient does not want to hear the information that a surgeon wants to convey, the surgeon must respect the patient’s choice not to be informed.

Although Dr. S had felt that something was missing in the consent process since it did not include "the usual discussion of risks," the patient’s choices had been respected and Dr. S had fully discharged his responsibilities in obtaining the patient’s informed consent.

Dr. Angelos is an ACS Fellow, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief, endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

Dr. Peter Angelos is an ACS Fellow, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago.