Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"'Surgery Is Certainly One Good Option': Quality and Time-Efficiency of Informed Decision-Making in Surgery"
by Clarence Braddock III, MD, MPH, et al.

Commentary & Perspective by
Judith F. Baumhauer, MD*,
Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York

Posted September 2008

This prospective cross-sectional descriptive study examines the quality of the informed decision-making process in orthopaedic practices. It was performed by evaluating 141 audiotaped patient-physician discussions regarding the option of surgery, and it was scored with use of a modification of a previously published informed-consent model1. The prior consent-model elements were defined as the nature of the decision, the patient's role, alternatives, risks and benefits, uncertainties, the patient's understanding, receiving input from others, and exploring the patient's preferences. In addition to total quality score, the inclusion frequency of each of these elements and the relationship between visit duration and a quality score were explored.

The authors concluded that the major deficiency for orthopaedic surgeons in the informed decision-making process was the patient's involvement—more specifically termed the patient's role and understanding. Only 14% of the discussions included the topic of the patient's role, and only 12% of the discussions included an assessment of the patient's understanding. The amount of time spent with the patient did not correlate with an improved quality score.

Informed consent is defined by as a "patient's consent to a medical or surgical procedure or to participation in a clinical study after being properly advised of the relevant medical facts and the risks involved." As Braddock et al. discussed in their prior paper in JAMA, "Many clinician-authors have called for a shift toward a view of informed consent in which the emphasis is on a meaningful dialogue between physician and patient instead of a unidirectional, dutiful disclosure of alternatives, risks, and benefits by the physician. This expanded view is termed informed decision making."1 This is an extremely important topic. In a MEDLINE search with use of "Informed Decision Making" as a title, only seventy-eight articles were found to be published on this topic, and none had reference to orthopaedics. This study attempts to measure the ability of the surgeon to communicate with the patient with use of a validated tool. This has implications to the training of our residents and the 360-degree feedback evaluations of our peers and other health providers.

A related but different type of decision-making is shared decision-making, in which patients are given the current best evidence on a topic and in which patients can decide on the best treatment options2. This process has a somewhat different agenda. Shared decision-making has focused on influencing the rates of surgeries through communication of the evidence-based outcomes and has been shown to influence the procedure rates of prostate and spinal surgery through video education of patients. The limitation on our current advancement in educating our patients is the paucity in the orthopaedic literature of evidence-based outcomes and high-level research publications.

The limitations of the current study include the narrowly focused patient population—74% were women of sixty years of age or older. It is unclear if the same findings would be present irrespective of age and gender. The physician practice was 40% academic and 56% community based. The other 4% were not defined in the paper. It was unclear how many visits the patient had with the surgeon prior to these audiotaped conversations and what had been previously discussed. The amount of patient understanding based on this informed decision-making discussion was not assessed. Previous studies have reported that the amount of information a patient retains during the informed consent process is quite limited3. Finally, the prior published validated model was modified for use with this paper, and this brings into question the ongoing validity of the instrument and subsequent results.

In summary, this paper attempts to quantify a pivotal communication between the surgeon and the patient and provide examples of high-quality conversations. It appears that this may be a "first step" toward objectively assessing this process of informed decision-making for surgery.

*The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of her immediate family, is affiliated or associated.


1. Braddock CH 3rd, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282:2313-20.
2. Weinstein JN, Clay K, Morgan TS. Informed patient choice: patient-centered valuing of surgical risks and benefits. Health Aff (Millwood). 2007;26:726-30.
3. Turner P, Williams C. Informed consent: patients listen and read, but what information do they retain? N Z Med J. 2002;115:U218.