The cab ride from the airport should take about 20 minutes. Bags in the trunk, I flopped into the back seat, fumbling for the seatbelt.
“Here, sign this!” the cabbie spat. Out of character, I paused to read:
“The plan is to get you to your hotel. However, the tires have 50,000 miles on them. The cabbie is still drowsy after the sleeping pill he took last night. About 10% of the other cars have chemically impaired drivers. The route to downtown is pretty sketchy. The occasional car on this highway gets shot at from the overpasses.”
Reprising the risks of surgical intervention can resemble this fictional encounter in a cab. A review of proposed surgical treatment includes discussion of the benefits, risks, and alternatives to the planned procedure. Questions are solicited and answered.
The most awkward aspects of surgery involve the disclosure of the risk of the planned intervention. In that task, the surgeon must balance the rewards of surgical intervention against the adverse events, even catastrophes, which might ensue. The problem with that disclosure is that it can subvert the bottom line, which is the performance of necessary surgical intervention and the achievement of a favorable surgical outcome.
Inexpert disclosure of risk can paralyze necessary action. For example:
CB, a 46-year-old female, sustained an episode of osteonecrosis of the jaw (ONJ) after dental extraction a year ago, after 2 years of bisphosphonate therapy for osteoporosis. Within 6 months, the site healed and has remained asymptomatic, but the patient lost her dentist who refused to continue to see her because she was “too complex.” Consultation with a new dentist for caries control and removable prosthesis resulted in a disclosure of risk causing the patient to refuse care. She fears another episode of ONJ.
Cervical caries are progressing. The patient has lost 20 pounds and has myofascial pain from overclosure and absence of prostheses. While there is no evidence of osteonecrosis, caries and poor nutrition are taking their toll on the patient’s health. She is depressed and has had a recent outbreak of trigeminal distribution herpes zoster.
This is but one of countless examples of when disclosure of risk, inaccurate disclosure of risk, or unwillingness to accept reasonable risk results in inaction and a worse overall outcome. An informed consent that results in the patient refusing necessary care is a failed patient encounter.
Here are some tools to consider that may be useful in prescribing proper treatment. They can help avoid the potential path to inaction in risk disclosure.
•Use evidence-based medicine methods to disclose risk, when availableAssessment of surgical outcomes and quantification of risk is available for most of the procedures performed in oral and maxillofacial surgical practice, although the quality of the evidence varies widely and must be interpreted by using multiple sources along with assessment of the rigor of research design.
•Use JOMS and other contemporary peer-reviewed literature to augment your evidence-based knowledge of riskIn this month’s JOMS, clinical evidence of use to the practicing surgeon is presented in a variety of research design formats from Case Report to Basic and Patient-Oriented Research. Read the patients and methods section carefully to understand the nature of the study. Even a case report or a technical note can provide important clues as to surgical outcome. Single center case series are valuable but require careful interpretation, while the randomized clinical trial constructed according to CONSORT guidelines will provide the highest level of evidence.1 •Never present risk to a patient in a rote mannerDo not rely upon surrogates to disclose risk. While paperwork, brochures or videos are useful adjuncts to disclose risk, they must be augmented by discussion with the treating doctor. Be sure all questions are completely answered using the best evidence.
•Always balance the risk of a procedure against what is to be gained, and the risks of inactionSaid another way, “A ship in harbor is safe—but that is not what ships are built for.”
John Shedd2
•Act in the patient’s best interest and be their advocateYour patient will appreciate that you are only motivated to work in their best interests, that your treatment plan embodies a desire to help them, and that you have taken the time to remain contemporary in your knowledge of surgical outcomes and risk.
As for the cab, “drive on” or take the next cab. It’s your choice. But by all means, don’t fail to enjoy the city.
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