2017 HSC Section 2 - Practice Management

the surgeons included death and tongue/uvular swelling.

The reason for which specific risks and benefits were men-

tioned during consultation is unclear; however, it likely

depends on the experience (eg, recent occurrence of a rare

complication) and training of the surgeon. As well, some of

the benefits of surgery could have been considered to be

intuitive by the provider (eg, ear tubes will improve ear

infections). Although the inconsistencies among surgeons

can be concerning, each interaction between the surgeon

and parent is unique. Thus, it is incumbent on the surgeon

to provide appropriate amount of information for that spe-

cific interaction. For instance, if the surgeon gets an impres-

sion that a parent is anxious and does not want to hear the

details about surgery, then perhaps only the essential infor-

mation should be shared. However, if a parent is asking

many questions and is being inquisitive, the surgeon may

provide more details.

Surgeons must make decisions about what risks and ben-

efits to discuss with their patients. However, mentioning all

possible risks of surgical procedures is not practical or

likely beneficial.

This concept of the ethics of ‘‘everyday

clinical’’ practice—which changes with each clinical

encounter and relationship with patients—is known as

microethics

Microethics is an important concept not tradi-

tionally discussed or taught in medical schools, as most

ethical training involves extreme or unusual cases (eg,

Jehovah’s witness patient refusing blood transfusion).

However, microethics deals with the constant small ethical

decisions that occur every day in the clinical setting, such

as questioning which risks and benefits should be discussed

with the patient/family members.

Further studies in this

area are needed to help clinicians fully recognize that

microethical decisions are important and relevant to every-

day practice.

A number of risks and benefits recalled by parents were

not actually mentioned by the providers during the visit. In

these cases, it may be that parents obtained supplementary

information about the treatment options from sources out-

side the surgeon. In particular, they may seek advice or

information from family members, other parents, their pri-

mary care providers, or the Internet.

6,20,21

All together, the

implication is that parents are actively seeking more infor-

mation beyond what was provided during consultation.

Therefore, health care providers should consider developing

educational tools with accurate information that can be pro-

vided for parents to review at home. As well, surgeons

should emphasize the important and relatively common

risks (eg, bleeding posttonsillectomy) so that parents are

better able to retain information and handle the potential

complications.

Several demographic and contextual factors were

assessed in this study, and none of them (except the deci-

sion on whether to proceed with surgery or not) were signif-

icantly related to the proportion of recalled risks and

benefits. This is in contrast to previous studies showing that

education levels influenced surgical risk recall. Specifically,

research has suggested that patients with higher levels of

education are more likely to recall 50% of the risks,

while patients with lower levels of education tend to recall

50%.

12,23

However, other studies have found a negative

correlation with education levels, where parents of pediatric

patients with postsecondary education had poorer recall of

surgical risks for their children’s surgery.

Similar to edu-

cation, a prior surgical history for any child in the family

did not influence recall rate. It seems that regardless of edu-

cation level and previous experience, some parents will

have less-than-ideal recall and may therefore benefit from

further support during the informed consent process.

This study provides preliminary information about paren-

tal recall of information shared during pediatric otolaryngol-

ogy consultations. Surgeons should be aware that many

parents have poor recall and that they tend to remember

only a few specific risks and benefits. Moreover, parents

were likely seeking additional information from other

sources. Hence, surgeons should emphasize the important

and common risks involved in a surgical procedure, as well

as find ways to increase information retention (eg, via deci-

sion aids

Limitations of this study should be noted. The timeline

of the follow-up phone call may have influenced parental

recall. In this study, the follow-up occurred 2 weeks after

the consultation, and recall may have been different if the

time frame was different. Second, we did not assess for dif-

ferences in recall based on different ethnicity, since the

study sample was homogenous (ie, mostly Caucasian).

Therefore, cultural diversity and its influence on recall of

risks and benefits are unknown in the current population.

Furthermore, it is possible that the results reported in this

study may not be generalizable to other centers that have

demographically different populations. Third, parents were

aware that a phone call would be made by the research

assistant after the consultation visit, which may have led to

recall bias. However, parents were not aware that specific

risks and benefits would be elicited, and thus it is unlikely

that a Hawthorne effect would have occurred. Fourth, the

surgeons did not have a standardized discussion on risks

and benefits. That is, the providers mentioned different risks

and benefits even though they worked at the same center;

nonetheless, this is another novel finding that requires fur-

ther studies to determine why only certain risks and benefits

were mentioned by the providers. Although data were avail-

able on which specific risks and benefits were mentioned by

the participating surgeons, we could not independently ana-

lyze these data since there was too much variability across

and even within individual surgeons. Even though all sur-

geons mentioned the common risks of surgery (eg, postton-

sillectomy bleed), many instances were observed where

other information was mentioned in a tremendously varied

manner (eg, premature tube extrusion, improved quality of

life). Therefore, we could not analyze these data at the level

of which specific risks and benefits were mentioned by the

providers. Finally, a relatively small number of surgeons

were included in this study, thus representing a restricted

range of potential provider influences. A larger number of

Pianosi et al