Medical Teacher

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Twelve tips for teaching the informed consent

conversation

Asha Anandaiah & Laura Rock

To cite this article: Asha Anandaiah & Laura Rock (2018): Twelve tips for teaching the informed
consent conversation, Medical Teacher, DOI: 10.1080/0142159X.2018.1426844

To link to this article: https://doi.org/10.1080/0142159X.2018.1426844

Published online: 23 Jan 2018.

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MEDICAL TEACHER, 2018
https://doi.org/10.1080/0142159X.2018.1426844

TWELVE TIPS

Twelve tips for teaching the informed consent conversation

Asha Anandaiah and Laura Rock
Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA

ABSTRACT
Obtaining informed consent has been traditionally viewed as a mundane task, learned on the job and often relegated to an
inexperienced member of the healthcare team. In reality, the process of obtaining informed consent is complex, challenging,
and warrants focused teaching, observation and feedback. There are few published standards for what should be included
in a high-quality informed consent conversation, and little or no guidance regarding how to best teach the process of con-
ducting this type of shared decision-making conversation. The following twelve tips provide a roadmap for teaching the
essential components of how to obtain informed consent, including both content and communication skills, with a focus on
common pitfalls for trainees, and strategies to address them.

Introduction that best practices for informed consent conversations will

Growing emphasis on patient-centered care has shed new
light on the significance of informed consent conversations
(Longo and Grady 2015; Spatz et al. 2016). While long
viewed as a mechanism of preserving patients’ legal rights
and autonomy, they are now additionally recognized as an
opportunity for patients to learn about their disease, reflect
on personal goals and values, and engage in meaningful
shared decision making with their health care providers
(Barry and Edgman-Levitan 2012; Spatz et al. 2016). Recent
advances in medical education assessment have accord-
ingly highlighted informed consent conversations as an
important skill for trainees to master; indeed the ability to
obtain informed consent is now listed as an entrustable
professional activity (EPA) for medical school graduates
entering residency in the United States (Cate 2014).
However, available studies suggest that there has been lit-
tle formal training about informed consent in medical edu-
cation; rather, trainees report they have primarily learned
informally through peer observation (Nickels et al. 2016).
Given the marked variability in how physicians approach
informed consent (Falagas et al. 2009), it is not surprising
that trainees report varying levels of comfort and familiarity
with what constitutes informed consent, and how to best
conduct consent conversations (McClean and Card 2004;
Gaeta et al. 2007; Eftekhari et al. 2015; Nickels et al. 2016).
Formal training, observation, and feedback in informed
consent represent an unmet educational need with import-
ant clinical ramifications. Furthermore, the consent conver-
sation is an opportunity to teach, observe, and give
feedback on core skills that are essential for effective and
empathic communication in any specialty. We therefore
propose the following twelve tips as a framework for teach-
ing informed consent conversations in the clinical setting.
Incorporating both content and relevant communication
skills, we attempt to focus on basic principles that may be
adapted for a wide range of encounters, acknowledging
vary based on clinical context as well as local legal and
professional standards.
Tip 1
Choose a time and place for the consent conversation
that emphasizes its value
In clinical practice, consent conversations often take place
just before the procedure is scheduled to occur. Elective
procedures are often preceded by informal discussions
about the procedure during office visits, which often do
not meet the standards of shared decision making, which
include interactive communication, discussion of best clin-
ical evidence, and integration of the patient’s values and
preferences (Braddock et al. 1999; Spatz et al. 2016). For
inpatient semi-elective or urgent procedures, time con-
straints frequently lead to conversations that are rushed
and often lack sharing of even basic relevant information
(Brezis et al. 2008). The consent conversation is, therefore,
often treated by both patient and clinician as a formality,
with the goal reduced to simply signing a form for med-
ical-legal purposes (Habiba 2004). The hidden curriculum is
powerful, and when trainees observe consent conversations
in this context, they are likely to come away with the same
impression of informed consent conversations: as manda-
tory paperwork, rather than an opportunity to engage
patients in their medical care and tailor decisions to their
needs and goals (Waisel et al. 2009; Gaufberg et al. 2010).
When working with medical students and junior doctors,
thoughtful selection of the timing, location, and context of
the consent process will provide an important contrast to
the rushed, one-sided process promoted through the hid-
den curriculum and teach trainees that obtaining informed
consent is an important opportunity to encourage patients
to ask questions, discuss their goals, and participate in deci-
sion making.

CONTACT Asha Anandaiah aanandai@bidmc.harvard.edu Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical
Center, 330 Brookline Avenue, KSB 23, Boston 02215, MA, USA
ß 2018 Informa UK Limited, trading as Taylor & Francis Group
2 A. ANANDAIAH AND L. ROCK
Tip 2
Emphasize the importance of first making a
connection and establishing trust
Trainees are often task-oriented when they approach
patients to obtain consent, which may lead them to skip
initial verbal and nonverbal gestures that are essential to
establishing rapport with patients and families. Efforts to
convey compassion and empathy, even for as little as 40
seconds, can substantially reduce patient anxiety and pro-
mote a positive doctor–patient relationship (Fogarty et al.
1999). Trainees will learn that taking the time to connect
with a patient is not only good clinical practice but an
investment that will pay future dividends in the form of
reduced patient anxiety, improved clinical outcomes (Blasi
et al. 2001; Kelley et al. 2014) and decreased risk of litiga-
tion (Levinson 1994; Ambady et al. 2002).
The beginning of the interaction should involve basic
social etiquette, such as introducing oneself, smiling, and
asking about how they are doing. Simple gestures, such as
sitting down rather than standing (Swayden et al. 2012)
and making eye contact, have been shown to increase
patient satisfaction with physician encounters. Importantly,
trainees engage in these trust-building behaviors much less
frequently than they think they do (Block et al. 2013).
Tip 3
Counsel the trainee to assess for barriers to discussing
informed consent
The beginning of the consent conversation is also a time to
ensure that the conversation the trainee is about to have
will be effective, in that the patient has the capacity to par-
ticipate in shared decision making. While engaging in an
initial informal conversation does not represent a formal
assessment of medical decision-making capacity, it may
reveal a need for specialized assessment. While a discussion
about the approach to assessing capacity is beyond the
scope of this article, it is worth noting that there are sev-
eral validated mental capacity decision support tools avail-
able for use by clinicians (Sessums et al. 2011). If
interactions with the patient or review of the medical
record suggest impaired capacity, the trainee should be
instructed to seek further guidance regarding how to pro-
ceed with a formal assessment of capacity or alternative
avenues of discussing procedural consent.
Another common barrier to effective consent conversa-
tions is a language difference between the clinician and
patient. Because trainees may be tempted to proceed with
an informed consent conversation despite a partial lan-
guage barrier in order to avoid delays, it is important to
remind them of the critical nature of meaningful communi-
cation during the informed consent encounter. Even
patients who speak the clinician’s language proficiently as
a second language may benefit from an interpreter when
faced with complicated medical decision making.
Often family members will offer to translate for a
patient. Although this may seem helpful, one should
remind the trainee that family and other “ad hoc” inter-
preters are not equivalent to professional interpreters with
respect to comprehension and errors (Karliner et al. 2007).
While family members may participate in the conversation
at the discretion of the patient, they should not be used in
place of a trained interpreter for important encounters
such as informed consent.
Tip 4
Reinforce principles of effective communication
The consent conversation is an opportunity to teach or
reinforce key communication skills that will promote trust
and allow for care that is both more empathic and efficient.
Given that patients and families frequently demonstrate
poor comprehension following consent conversations
(Falagas et al. 2009; Dathatri et al. 2014), one skill we rec-
ommend explicitly reviewing for consent conversations is
known as “Ask—Tell—Ask”, which focuses on iterative
assessment of the patient’s understanding when sharing
complex information (Back et al. 2005).
1) ASK. Trainees should explain the rationale for asking
and then ask an open-ended question meant to elicit the
patient’s understanding of the medical situation and the
planned procedure: “Just so I know where to begin, please
tell me what you have been told about this procedure?”
They may also use this opening inquiry to ask about the
amount of information and level of detail the patient
would like to hear, as patients will have a wide range of
preferences (Jenkins et al. 2001; Levinson et al. 2005).
2) TELL. They should tailor their initial sharing of infor-
mation to what they heard from the patient about their
understanding, expectations, and informational needs. In
our experience, trainees often struggle with providing
clear explanations in simple, easy language. They should
be taught that it is most helpful to start with a simple
small chunk of information, always offering to give more
detail.
3) ASK. The second “ask” represents an opportunity to
check in and assess for understanding and concerns as
information is shared. An example of this type of check in
is “I’ve shared a lot of information. How are you feeling
about what we’ve discussed? What questions do you
have?”
The trainee should be prepared to truly listen at this
point, and to answer the patient’s concerns. Furthermore,
the trainee should be taught to then explicitly check for
understanding, an important step that has been endorsed
repeatedly by patient safety organizations as a priority for
reducing medical error (Agency for Healthcare Research
and Quality (AHRQ) 2013). One useful and evidence-based
technique we recommend is the “teach back” method,
where patients are asked to restate in their own words
what was told to them during the consent conversation
(Fink et al. 2010). This is a simple and revealing way that a
trainee can be taught to assess and then improve his own
effectiveness at communicating with patients.
Finally, it is important to teach trainees to anticipate
that consent conversations often evoke emotions, and to
recognize and respond to those emotions with patience
and empathy. It may be helpful to provide examples of
simple phrases that trainees can use to respond to
patient cues for emotional support. An example of this
might be: “I can see this is hard to discuss. It’s normal
to feel anxious before a procedure. Tell me what’s scar-
ing you the most?”

Tip 5
Review the core elements of an informed consent
conversation
It is a mistake to assume trainees are familiar with what a
consent conversation must include. Lack of formal training
in informed consent has led to peer observation as the pri-
mary modality by which trainees learn to conduct these
conversations (Gaeta et al. 2007; Nickels et al. 2016). Given
the low rates of meeting basic standards of informed con-
sent in observational studies (McManus and Wheatley
2003), it is unlikely that trainees are reliably learning these
core elements. Therefore, it is worthwhile to briefly review
the essential components of any informed consent conver-
sation prior to involving a student or junior doctor in this
task. These components include indication, risks, benefits,
expected outcomes, and alternatives (Murray 2012).
To promote the inclusion of these essential elements
of the consent process, there have been proposals for
routine adoption of informed consent checklists in clinical
practice (Krumholz 2010; Ripley et al. 2015); these can be
a resource for teaching informed consent as well.
Developing procedure-specific checklists tailored to your
own common procedures can provide a clear structure
for trainees who conduct consent conversations with
your patients.
Tip 6
Ensure the trainee is knowledgeable about the
procedure
In addition to not assuming trainees know the elements
of informed consent, one should similarly not assume
that they have the requisite knowledge about any given
procedure to accurately review those core elements.
Because students and junior doctors frequently rotate
among different clinical services, they may be asked to
obtain consent for procedures with which they have little
familiarity. When supervising a trainee in this context, it
may be helpful to simply have a trainee first observe
how you describe a procedure and its standard indica-
tions, benefits, risks, expected outcomes, and alternatives
during several interactions early in a rotation. The trainee
will not only learn this specific information, but import-
antly also how to explain it in clear and simple terms.
Alternatively, if a trainee indicates she is experienced
with a given procedure, you may instead ask her to
describe to you how she would review the core elements
of informed consent for the procedure. Of note, while
trainees can often quickly gain the knowledge necessary
to describe a procedure and its benefits, the ability to
discuss risks and answer questions about expected out-
comes and alternatives is often more challenging
(Eftekhari et al. 2015; Nickels et al. 2016). To comprehen-
sively assess a trainee’s knowledge of all aspects of a
procedure, it may be helpful to conduct a mini role-play,
where you play the role of the patient or family
(Thompson et al. 2015).
However assessed, it is important to ensure a trainee
has an adequate knowledge base before allowing him
to obtain informed consent from a patient for any
procedure.
MEDICAL TEACHER 3
Tip 7
Specify how to discuss risks
Trainees report being less comfortable discussing risks as
compared to benefits (McClean and Card 2004; Nickels
et al. 2016), and surveys of patients suggest that risks are
less well discussed by physicians at large (Brezis et al.
2008). Therefore, special attention should be paid to
reviewing procedural risks and how to best discuss them
with patients.
While there are no absolute universal standards for
which risks to disclose, legal precedent generally espouses
the disclosure of risks that a “reasonable doctor” would
provide and a “reasonable patient” would want to know
in order to make an informed decision (Spatz et al. 2016).
In addition, all “material risks” should be disclosed, with
“material” generally defined as those risks which are ser-
ious or frequent (Raab 2004). While trainees may readily
discuss procedural risks that are frequent, such as infec-
tion or bleeding, serious risks may be underreported or
not mentioned at all due to a lack of knowledge or dis-
comfort with saying out loud things like “loss of limb” or
“death.”
To facilitate patient understanding and satisfaction, avail-
able evidence suggests it is best to express probabilities
quantitatively, using event rates (5%) or natural frequencies
(5 in 100) and absolute terms (i.e. absolute risk reduction
rather than relative risk reduction). Wherever possible, the
use of visual aids to quantify risk (icon arrays or bar graphs)
is also helpful (Zipkin et al. 2014). Discussing methods of
risk communication with trainees and providing relevant
data and/or visual aids will enhance both their confidence
and accuracy when discussing procedural risks with
patients.
Tip 8
Teach the trainee to discuss the procedure in the
context of the individual patient’s circumstances
While all informed consent conversations should
include the core elements discussed above, trainees must
further learn to adapt the conversation to the individual
patient’s circumstances. In addition to adjusting the
amount of information provided, trainees should learn to
tailor their discussion of the procedure itself to the spe-
cific attributes of their patient (Murray 2012). The risks,
benefits, expected outcomes, and alternatives to a pro-
cedure will vary depending on a patient’s health, age,
values, goals, and other individual factors. Therefore, it is
crucial to teach trainees that they should not begin an
informed consent conversation without knowing the
details of the specific patient’s medical situation. They
should refer to those details when discussing the proced-
ure, and further ask questions probing the patient’s atti-
tudes about medical care, side effects, and recovery
times. All of this patient-specific information will be
necessary to fulfill their role in shared decision making,
as together with the patient, they decide whether the
procedure is indeed the most appropriate next step in
medical care.
4 A. ANANDAIAH AND L. ROCK
Tip 9
Explain how to articulate an informed decision
After discussing the rationale, benefits, risks, outcomes, and
alternatives to the proposed procedure, a decision must be
made. Trainees will realize that sometimes this is simple,
and in other circumstances quite complex. It is important
that trainees learn to summarize and reflect back what they
have heard and offer support in the decision making itself,
if desired by the patient. For example, “I’m hearing you say
that you are willing to go through the risks I have
described if it means we will be able to remove the cancer.
Is that right?”
Sometimes patients ask, “What would you do, doctor?”
We recommend teaching trainees to answer honestly and
use this question as an opportunity to reflect back on
what is important to the patient. “Based on what you
have told me, it sounds like being very active is
extremely important to you. Because this surgery will give
you the best chance of returning to running and biking, I
would recommend that we proceed” or “With your busy
job and caregiving responsibilities, it sounds like the bur-
dens of time off for recovery and physical therapy would
be too much for you right now, so I would recommend
holding off on surgery until a time when you can balance
it more easily with your life.” Learning to make recom-
mendations based on one’s knowledge of both the pro-
cedure and the patient is an important advanced skill
that junior doctors should develop as they approach inde-
pendent practice.
Tip 10
Adapt your teaching to the clinical context
Consent conversations must occur across a wide range of
clinical environments, and the time available may not per-
mit as comprehensive and reflective a process of discussing
consent, and teaching about it, as we might prefer. It is
better to acknowledge the time constraint and openly dis-
cuss how to adapt the conversation than to risk simply
modeling an inadequate conversation. For example, most
trainees are aware that the informed consent process can
be waived entirely in the setting of an emergency.
Explicitly stating when the emergency exception is being
invoked, rather than simply omitting any mention of con-
sent, will help trainees understand when it is appropriate
to waive consent. For urgent procedures, the essential com-
ponents of informed consent must still be reviewed (Moore
et al. 2014). Demonstrating how one includes all those
components into a brief conversation while exhibiting effi-
cient trust-building behaviors can be an invaluable lesson
for an observing trainee.
We are often teaching in unpredictable, suboptimal
settings and being transparent about how we balance
what may be best for patients with the reality of our
day to day work pressures is a critical lesson that is
rarely discussed. Discussing how you modify the consent
interaction under time pressure offers that valuable learn-
ing opportunity and may help trainees develop better
habits.
Tip 11
Discuss and review documentation
It is self-evident that the consent form must be signed prior
to the procedure, and the forms are typically worded to
address the legal requirements related to informed consent.
However, when done properly, the informed consent dis-
cussion should reveal far more information about a patient
and his or her priorities, concerns, and goals as they relate
to medical care than what is reflected by a simple signature
on a form. Encourage trainees to document not just that
they obtained a signature indicating consent, but also the
details of the shared decision making conversation that led
to the consent, in narrative form. This type of thorough
documentation is valuable for both meeting legal require-
ments and providing optimal patient care (Moore et al.
2014).
For example, it is logical that an informed consent con-
versation about central line placement in the intensive care
unit with the family of a patient who has developed refrac-
tory shock might lead to conversations about how long the
patient might wish to undergo the type of resuscitative
efforts for which the central line is being placed. Although
preliminary, documenting the thoughts shared by the fam-
ily during the consent conversation would be incredibly
valuable to the care team as they prepare for future con-
versations regarding the most appropriate medical care for
the patient. Alternatively, if a patient consenting for ortho-
paedic surgery is particularly anxious about the risks of
nerve palsy, documenting the extra time spent providing
details about risks and prognosis may be valuable should
the complication arise and there are concerns regarding
potential litigation.
Tip 12
Observe and debrief the experience afterwards
The consent conversation provides an opportunity to teach
and observe a wide range of skills in a common medical
conversation that is integral to the practice of medicine in
any field. Observation of a consent conversation allows for
assessment of the trainee’s knowledge in a variety of
domains (the disease, the procedure, and the individual
patient’s case) as well as the trainee’s communication skills
and capacity for patient-centered care.
The trainee’s growth from the experience will depend
on the quality of the feedback that is subsequently pro-
vided. A detailed guide to effective debriefing or feedback
is beyond the scope of this article, but some brief sugges-
tions follow:
 Tell the trainee in advance that feedback will occur fol-
lowing the conversation.
 Ask if there is a particular skill or aspect of the
conversation the trainee would like to practice or
discuss.
 Utilize a brief checklist to record observations of major
communication skills: building trust, eliciting patient
concerns and providing information (Ask—Tell—Ask),
and articulating a decision.
 Choose one or two points to discuss, and provide spe-
cific, actionable feedback.

 End by setting a goal together for the next encounter,
with a plan to follow up, if possible.
Conclusions
While at first glance informed consent can seem like a
straightforward and mundane part of the practice of medi-
cine, dissecting the process of obtaining high quality
informed consent through a shared decision-making con-
versation demonstrates that it is in reality a complex and
nuanced skill that requires training and practice. The avail-
able literature demonstrates that this training has not trad-
itionally been provided to the majority of medical students
and junior doctors; it is our hope that these twelve tips
provide a practical and realistic structure for medical educa-
tors to use when considering their practice of teaching
effective and patient-centered informed consent in the clin-
ical setting.
Disclosure statement
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of this article.
Notes on contributors
Asha Anandaiah, MD, is a pulmonary and critical care physician at
Beth Israel Deaconess Medical Center; associate program director of
the Harvard Pulmonary and Critical Care Medicine Fellowship;
Instructor of Medicine, Harvard Medical School; and a graduate of the
Rabkin Fellowship in Medical Education, Harvard Medical School,
Boston, MA.
Laura Rock, MD, is a pulmonary and critical care physician at Beth
Israel Deaconess Medical Center; Instructor of Medicine, Harvard
Medical School; a graduate of the Rabkin Fellowship in Medical
Education, Harvard Medical School; and faculty at the Center for
Medical Simulation, Boston, MA.
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