Eyeworld

13 EW NEWS & OPINION January 2015 by J.C. Noreika, MD, MBA Care," Christakis showed that physi- cians' prognostic accuracy can be as low as 20%. Claude Shannon, who labored in the Bell Laboratories in the 1940s, is known as the father of informa- tion theory. In groundbreaking work, he demonstrated that the human brain's attention limit is around 120 bits per second. In 1977 in the Journal of Marketing Research, Jacoby reported not only do con- sumers have finite limits as to how much information they can absorb, but found they made poorer choices with additional information. This is called the "load effect." It was thought that 10 al- ternatives were the maximum a brain could handle. Contemporary research puts the upper limit at 5. In fact, more information is det- rimental; humans cannot ignore information that is irrelevant. Each bit of information imposes an equal neural-processing tax. Statistical risk of endophthalmitis after cataract surgery less than 0.15%? In "Think- ing, Fast and Slow," psychologist Daniel Kahneman wrote "our intui- tive system is not well configured to understand statistics." So what is the ethical physician to do? I'm not an attorney, not even an attorney's spokesperson. But I urge physicians to browse the requirements stipulated in the Federal Code (Title 42 C.F.R. § 482.51 (b) (2)) Interpretive Guide- line A-0392, and the guidelines of obligation that risks, benefits, and alternative treatments be discussed. In 1998, the American Medical Association (AMA) codified 6 broad criteria of true informed decision. The AMA specified that "the phy- sician, not a delegated representative (my italics), should disclose and discuss" these elements. Current studies in the neurosci- ences propose that: Patient compre- hension of true informed consent is not possible; the decision-making process is asymmetrical by definition and favors the physician; given the complexity and vicissitudes of the human body, no list of risks and complications can be inclusive; and how the problem and treatment alternatives are framed contort choice. This is especially relevant as physicians market "premium" procedures commanding extra dollars to offset decreasing insurance reimbursement. Physicians may take no solace in their performance. In "The Organized Mind," Daniel Levitin stated that in decision-making, physicians provide better knowledge of efficacy than risk. If doctors think a treatment should work, they come to think it will work even when evidence is lacking. Examples are the conundrums of cardiac bypass and angioplasty showing no long-term survival benefit and the fact that more men die with prostate cancer than from it. In "Death Foretold: Prophecy and Prognosis in Medical S teve Jobs was a brilliant visionary. When diagnosed with pancreatic cancer, I suspect he sought advice from renowned authori- ties, researched the world's medical literature, and could reel off all pertinent statistics. He reportedly chose acupuncture, dietary sup- plements, and juices as his initial treatment protocol. Was his choice "informed"? Informed consent is both ethical obligation and legal construct. It is defined by requisites so broad that warnings listed in the PDR seem laser-specific. Like pornography, judges and juries seem to know it when they see it. This essential responsibility is cloaked in language inferring what the "reasonable physician" would report and the "reasonable patient" requires to choose appropriately. The qualifica- tion, "reasonable," is interpreted locally. Not only is informed consent a misimpression, but like multiple universes, the human brain is incapable of processing its complexity. Its construct grew out of legal precedent established in the state of New York in 1914. A judge ruled that a surgeon was guilty of battery because he had violated an "indi- vidual's fundamental right to decide what is being done with his or her body." The principles of informed consent weren't adjudicated until the late 1950s. Each of the 50 states has enacted legislation defining its requirements. With narrow excep- tion, a physician can be held liable for battery and/or malpractice if she fails to obtain informed consent. All parties agree that patients are entitled to receive information about therapeutic options that are understandable and promote shared decision-making with their doctors. The Federal Code lists 11 requirements for which caregivers are responsible. These include the Of unicorns, tooth fairies, and informed consent the AMA (1998). Informed consent should be provided conceding that the American patient has a remark- ably low health literacy quotient. High-risk groups include ethnic minorities, the elderly, the unem- ployed, the lower educated, and the poor. These are the same folks who cull information from television, the medium favored by trial lawyers. The Institute of Medicine found that lack of health literacy skills impeded half the patient population in their understanding of informed consent forms. A generic informed consent form without individually targeted education is not sufficient. The 2003 National Assessment of Adult Literacy showed that 30 million American adults have below basic (BB) prose literacy, 27 million have BB document literacy, and 46 million have BB quantitative litera- cy. A physician's erudite command of academia's statistics will not help these patients choose wisely. In 1981, Kahneman and Tversky proposed that perception of gains and losses are non-linear. The iden- tical amount of gain in different individuals does not result in equal happiness and satisfaction. Surgeons know experientially that a patient who cannot read prior to cataract surgery is apt to be happier with her result than the functioning presbyope who opts for multifocal lens implantation. Management of expectations is foremost. Inquire of them, assess whether they can be met, and then shape the discussion of risk and benefit. Highlight no more than 4 or 5 critical points and confirm the patient's comprehension. Document "more and still more." And comply with the legal mandates demanded of our profession. You'll sleep better. EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com Insights J.C. Noreika, MD, MBA

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