Wouter Leclercq

Challenging the knowledge base and skillset for providing surgical consent by orthopedic and plastic surgeons in the Netherlands: An identified area of improvement in patient safety 61 4 BACKGROUND Each patient is entitled to detailed information prior to an invasive or a surgical procedure. Once properly educated by a surgeon, a shared decision is made whether or not to perform the proposed operation. These basic rights and obligations are incorporated into the surgical informed consent (SIC) process. 1-4 However, daily practice is troublesome as just a minority of patients are offered the opportunity to complete all stages of this SIC process. 3,5,6 General goals of SIC are to anchor the patient’s authority and to enhance safety, satisfaction and compliance. 3,5,6 If the quality of the SIC process is high, patients are better informed and more compliant while results after surgery may be optimized. 3,5,6 Moreover, patient expectations are more realistic, resulting in more trust in their surgeon and/or surgical procedure and eliciting fewer complaints. 3,5,6 Since 1995, the Dutch Medical Treatment Contract Act (WGBO) has provided legal requirements on informed consent in the Netherlands. This act describes the legal boundaries of SIC in a civil law approach – in other words, in a contract that is made between a healthcare provider and a patient. 7 In contrast, other countries may have explored alternative views. For instance, legislation in Scandinavia is based upon a public approach formulating ‘obligations imposed on physicians and other healthcare providers’. Therefore, a private contract between one doctor and one patient is not required in these countries. 7 Although details of legislation differ per country, the three elements of SIC are equal in western countries. Features of consecutive steps of a correctly executed SIC process were previously reported (Figure 4.1). 3,8 Firstly, it should be checked whether patients are competent and free (without pressure) to decide. Secondly, information on diagnosis, prognosis, procedures, benefits, risks and alternative strategies including postponing surgery should be provided. A check on whether the information is understood is also required. The final stage includes adequate recording. Written consent for invasive procedures is strongly recommended, although a patient’s (or representative’s) signature is not obliged in many European countries, including the Netherlands. 7 A recent survey investigating daily practice regarding SIC demonstrated that knowledge of general surgeons (GS) in the Netherlands was inadequate and guidelines were often not followed. 9 Only 55% of surgeons were familiar with the three basic elements of SIC. Daily practice varied widely between surgeons and residents. This practice resulted in 17% of the surgeons facing an SIC-related complaint in the previous five years. Several other Dutch surgical organizations, including the Scientific Association of Orthopaedic