Pre-Surgical Appointment Mandate to Ensure Informed Consent
Insurance companies need to allow two appointments for pre-surgical consults. Currently, insurance companies allow one pre-surgical consult to occur expecting the patient to fully comprehend the surgery they will be undergoing. However, from my experience, as an advocate working with patients, one appointment is not enough to discuss and understand the full scope of surgery.
Pre-surgical appointments go over the patient’s treatment findings, the surgery, and the expected outcomes. In speaking with patients I found they are often scared, confused by medical lingo, and misinformation. Their doctors will ask if they understand what will happen and most patients will say yes, but once a patient is home, they often find they can’t remember all of the information or have questions.
A second appointment ensures the patient and the doctor engage in a comprehensive discussion regarding the patient’s care, the expectations of the surgery, and any confusion or misgivings the patient has regarding surgery. During the time between the appointments, the patient may take time to gather additional information, read over the surgery explanation, post-surgery care, and write down questions. Without two appointments, it is difficult to know if a patient is able to give informed consent.
In discussions with breast cancer patients, I found the amount of information, the time in which to make decisions, and the understanding patients had regarding their care ranged from minimal to strong. Patients recalled their appointments with their doctors as overwhelming because of the diagnosis they were given and the intricacies of their treatment, which included surgery. They felt they needed an extra appointment with their doctors so they may have time to absorb the enormity of their situation, how the surgery will affect their lives and the process in which their type of surgery was decided. Many of the patients could not recall how a modified radical mastectomy differed from a radical mastectomy, why they were having a mastectomy versus a lumpectomy, and why other surgical options weren’t available to them. The majority of the patients agreed a second appointment would help them understand their surgery better.
Based on my discussions with breast cancer patients, my recommendation to cancer centers and insurance companies is to put in place a two-appointment pre-surgery mandate. Informed consent cannot be given if a patient has not been granted the opportunity to absorb, research, and ask questions after the initial visit.
The reason insurance companies limit the time spent in a doctor’s exam room and the number of appointments they deem necessary before surgery is linked to insurance companies adopting Medicare guidelines called Relative Value Unit (RVU)1. The relative value of a doctor’s time is calculated to reflect the fee allowed by an insurance company. Insurance companies look for a way to save money, but the savings can lead to lower quality of care. Patients who can not give informed consent because they weren’t allowed extra time to sit and discuss their misgivings, ask questions, and clarify any confusion are not able to give informed consent. The two pre-surgical appointment mandate is not about the cost and time needed to implement this protocol but instead is about the ability to build doctor-patient relationships while cementing informed consent.
American Medical Association, “Medicare Physician Payment Schedules”,2018. https://www.ama-assn.org/practice-management/medicare/medicare-physician-payment-schedules.