The concepts and processes of consent have changed considerably over recent years.
Checking for patient understanding
If we take into account the clarification of patients’ rights under the Health and Disability Commissioner (HDC) legislation, and the practice standards required by the Dental Council, the process of arriving at a decision about treatment is a core component of a dental clinician’s work.
The emphasis is now on the sharing of decision making with the patient or their carer. It requires an understanding of patient expectations (especially those that are unrealistic) and a requirement for patients to share in the ownership of treatment choices.
The question is how we can be sure that patients understand what we have told them. Treatment options may be many and often complex and expensive. Risks and benefits need to be communicated to our patients in a way that enables them to make a meaningful decision about the treatment programme they want to take. Home care is fundamental to successful long term treatment outcomes and a patient who has an understanding and sense of ownership of their treatment is more likely to adhere to an ongoing care programme.
A study compared different methods for checking for patient understanding with respect to their preferred option. Three options were demonstrated:
Tell Back. Patients were asked if they understood what they had been told with an expectation of a Yes or No answer
Tell Back—Directive. Patients were asked to repeat back what they had been told. This can sometimes be perceived as intimidating or threatening.
Tell Back—Collaborative. This is a patient-centred approach and is phrased to allow the clinician to accept responsibility if there has been any misunderstanding. Useful phrases in this technique include: “It is important for me to understand that I have communicated the information correctly so could you share your understanding about what we have discussed?”
The conclusion was that patients strongly prefer the Tell Back—Collaborative approach when assessing their understanding.
The paper noted there is considerable evidence that many patients leave medical encounters with a poor understanding of their disease and the recommended treatment. In one study when patients were asked to explain what they had been told, their explanations included so many gaps and errors that half of the information they had been given was lost. Several early studies substantiated poor understanding of medical information, with reports of lost information ranging from 46 percent to 63 percent.
More recently, a study of 20 general practices in England reported that misunderstandings associated with actual or potential adverse outcomes occurred in 80 percent of consultations.
There can be a high cost for inadequate understanding of dental information for the patient and the clinician. For patients, misunderstanding can lead to failing to follow treatment recommendations with consequential adverse outcomes, as well as decreased satisfaction of the clinician. If we, as clinicians, fail to check for patient understanding of dental information we have an increased risk of complaint or notification.
Perhaps as part of our “safety netting” approach to review our diagnosis and treatment recommendations we should include a conscious step to be absolutely sure patients understand what we have communicated to them. This could include ensuring we use the Tell Back—Collaborative technique to assess patient understanding before agreeing on a treatment programme.
 Patients Prefer the Method of “Tell Back-Collaborative Inquiry” to Assess Understanding of Medical Information.” Evelyn C. Kemp, Michael R. Floyd, Elizabeth McCord-Duncan, Forrest Lang. Journal of the American Board of Family Medicine January-February 2008 vol.21 no.1.