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March 22, 2020 by Matt Bivens, MD | NEJM

The Dishonesty of Informed Consent Rituals

The patient was moaning and swearing, his emergency visible from across the department: the flattened shoulder, the dent where the humeral head used to be, the yurt-shaped bulge below the clavicle where it was now.

The paramedics had made a sling from a triangular muslin cravat, but he wasn’t using it: with his good left hand, he clutched his right to hold that injured arm in elbow flexion, a little away from the body with the forearm internally rotated. He was locking this shoulder dislocation in place — it wasn’t going anywhere on his watch.

The patient told me what he’d done, and I told him what he already knew.

“Looks like you dislocated the shoulder,” I said.

He and I quickly agreed we should put it back.

Enter the ritual paperwork.

“So we have a formal consent process — ”

“I consent,” he replied.

The nurse offered him a form and a pen. He gave her an exasperated look, nodding at his whole situation.

“Sure, we’ll sign it for you.”

As I spoke, we cut off the sling, I sat down on the edge of the bed facing him, cajoled him into releasing that left hand’s death grip on the right — “Wait, wait, wait!” he yelped, but I kept talking over his refusal.

“I’m just going to put your right hand on my right shoulder, and I’ll stop there,” I said.

He watched wide-eyed as I transferred his hand to my shoulder, locking it there with my left hand, and then draped my right forearm in the crook of his elbow as a hanging deadweight.

“I’m not doing anything,” I lied. I was already into one of my favorite reduction techniques.

“Don’t do anything yet, doc!” he said. “I’m going to need something for the pain!”

“Sure, we’re not going to do anything crazy,” I replied evasively.

EMS had given him IV fentanyl, but the agony of a dislocation is merely blunted by opioids; it is cured by a reduction. Some dislocations do require a wrestling match with an unconscious patient; most respond easily to a gentle touch. Patients who want sedation often don’t know what they’re asking for: that requires nurses, monitors, extra paperwork, medications from the dispenser — all of which takes time to organize. So the patient sits in excruciating pain for at least an extra 15 minutes. If a more critically ill patient arrives or decompensates in the interim, that purgatory stretches far longer.

Since medicine is all about customer service now, we’ll justify the delay by ordering an x-ray in the meantime. It’s often of questionable value, runs up the bill, and increases the discomfort involved (the x-ray techs have to move the arm to get the pictures; many shoulder dislocations “spontaneously reduce” at x-ray). But patients see it as progress. They return from x-ray even more uncomfortable and wait again, until the care team can recoalesce and rally for the final effort. After sedation, patients are groggy, foggy, and often nauseated and generally lose at least an extra hour lying in an ED (and tying up a bed).1 So it’s better for everyone if the shoulder can be coaxed home up front, without drama.

“We’re just going to rest here like this” — facing each other, his right hand gripping my shoulder, the bent elbow like a hammock for my lazy arm — “and I’ll tell you what happens next.”

Enter the informing and consenting: I don’t think the shoulder’s broken, though it could be, but even if we x-rayed it and found a fracture we’d try to reduce the dislocation the same way; we might succeed, we might fail; if we pull too hard the arm might fracture (that never happens, but I have to mention it), the nerves might get injured or even already be injured, and if we can’t reduce it easily, you might need sedation —

“Great, knock me out!” he interjected.

— with a sedative, you might have an allergic reaction or get oversedated and stop breathing, although we know how to handle all that and it never happens, though it might, just like it’s theoretically possible you could die (which also never happens) —

“I get it, no guarantees,” he said.

Against his will, he was starting to relax, overcome by my droning. I reminded him to sit up … I let gravity pull steadily down on my arm draped over his elbow … I massaged his trapezius, deltoid, and biceps muscles ….

“It’s not like I have an option anyway,” he said. “What am I going to do, walk around hunched over like an ape, with my arm dragging on the ground — ” and then he sighed in relief, as the shoulder clunked into place.

* * *

Some time later, a new patient popped up on my computer. Even as I clicked on her name, the chief complaint of “Seeking prescription refill” was amended to “High blood pressure.” During her 45-minute wait, she’d had blood pressures of 210/105, 190/100, 200/95.

Her chart said she was in her 50s with no medical history and no primary doctor. The only notes were from an encounter a month ago, for a foot injury, when my ED colleague had noted similar high blood pressures and referred her to a new PCP.

I assumed she’d been unable to keep the appointment and was back hoping we’d prescribe blood-pressure medication. I was half right. She still had no health insurance or PCP, but she’d just been to an occupational health clinic, which had prescribed Hyzaar DS, an antihypertensive combining losartan 100 mg with hydrochlorothiazide 25 mg.

Then the pharmacy told her a month’s supply would cost $90.

Or $1,080 a year, out of pocket.

She was not optimistic I could help. But in despair, she’d paid for one more $150 ED visit to find out.

I returned to my computer and called up a website that has coupons for prescriptions at big chain pharmacies. By splitting the losartan–HCTZ pill into its components, I got the monthly price down to $6. I printed two generic prescriptions, with the associated coupons, and returned triumphantly. I expected a hero’s welcome but wasn’t surprised to find her mostly just indignant. How could a medication that cost $90 a month now suddenly cost $6? How did that make sense? What was wrong with doctors?

Well, I explained lamely, everybody has different insurance, so we doctors don’t always know the cost … and maybe the other doctor assumed a combination pill would be convenient ….


So the first doctor didn’t inform her she could pay $6 a month and assumed she’d find the dubious convenience of two pills pressed together into one worth an extra … $84 a month? “You don’t think she should have told me my options?”

Actually, I do. In fact, I believe that any physician who wants to prescribe any combination medication should have to obtain the patient’s formal, written consent.

Once a pharmacy asked me to pay $800 for a family member’s acne medicine, Onexton, which combined a topical antibiotic, clindamycin 1.25%, with benzoyl peroxide. A similar-sized jar of generic topical clindamycin 1% was $10. I changed the prescription, paid $10 — instead of $800! — and picked up a benzoyl peroxide face wash on my way out. It felt like cheating, that I could so easily fix this.

We claim to have such deep respect for patient autonomy that we ritually inform people with acute orthopedic injuries of the obvious: that the injury and stabilization efforts may have consequences. We delay their treatment for this celebration of the self-evident, culminating in the ceremonial signing of a document no one has read.

But in an era when medical bills bankrupt hundreds of thousands of families each year2 — when Nobel laureates sell their medals to pay their doctors,3 and young people die trying to ration their insulin4 — we still routinely prescribe combined medications that we must know by now will cost patients 10 times as much as the separate components. And when patients ask, “What will this cost?,” we shrug helplessly. This happens every day throughout the country — doctors mocking the very idea of informed consent, as we inflict avoidable and potentially catastrophic financial harms. It gives the lie to our sworn pledge to do no harm.

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