Informed Consent: Is It Accompanied by Full Disclosure?

Abstract

Informed consent assumes full disclosure has been discussed in its entirety. However, is full disclosure ever really achieved? This column discusses how lifestyle medicine, both philosophically and ethically, must be a standard component of informed consent. Yet despite unequivocal evidence regarding the efficacy of lifestyle medicine, few physicians even consider lifestyle medicine as a viable option in the informed consent process. Reasons for the lack of lifestyle medicine considerations are postulated and a potential solution through education of trainees is suggested. How one medical school is addressing the need for lifestyle medicine education through several initiatives is discussed. Last, we expect that trainees educated in lifestyle medicine will push the momentum forward toward the “tipping point” where lifestyle medicine will be a viable option in the informed consent process—only then will full disclosure truly be achieved.

‘We spend a significant amount of time educating trainees on how to appropriately communicate and document informed consent.’

Full disclosure, informed consent . . . what images pop into your mind? We typically see a patient in the office (ideally >24 hours), prior to a procedure and sign a document that explains how even the most benign procedure possible, perhaps removal of a precancerous mole, still has risk of infection and ultimately death. The other option available is to “wait” or “do nothing.”

In the world of medical care, the ethics of providing full disclosure in the informed consent process is drilled into practitioners early on and continuously throughout training. We spend a significant amount of time educating trainees on how to appropriately communicate and document informed consent. The idea that all patients have a right to be informed about their options and potential outcomes is foundational to the contractual relationships that we have with our patients and is underpinned by the respect that we extend to our patients as participants (and ideally leaders) in their own care decisions. Yet much like the fine print on a website user agreement or the quickly spoken disclaimers on radio advertisements, the idea that patients understand all their options and the relevant outcomes is frequently glossed over and minimized.

Despite the emphasis on providing informed consent with full disclosure throughout medical training with reams of paper and massive amounts of electronic medical record space designated for this documentation process, all too often medical professionals do not provide full disclosure about all the options available to patients. Notably absent is a regular consideration of how lifestyle medicine adequately treats and even reverses the underlying disease process. This is unacceptable and yet understandable. Due to a lack of education and knowledge of the powerful dose-dependent effect of “treating the cause” of the patient’s disease within mainstream medicine, relatively few physicians even consider listing lifestyle medicine as a viable alternative to surgery, procedures, or medications.

Although not every practicing physician is convinced of the utility of lifestyle medicine, we would argue that the philosophy and ethics of providing informed consent must include the options inherent in lifestyle medicine. Many physicians have made ineffective lifestyle recommendations to patients by failing to match the intensity of lifestyle medicine intervention with disease severity, offering recommendations to patients who were not ready to change, failing to consider how determinants of health affect behavior change, or simply having an authoritarian versus health coaching approach. The physician then concludes that lifestyle medicine is ineffective or that patients are not compliant. Of course, we have abundant evidence to the contrary but the problem remains . . . many physicians are not convinced of the power and effectiveness of lifestyle medicine as a viable treatment option. This is where we would argue that every practitioner, whether or not a lifestyle medicine specialist, should be educated in 2 areas: (1) the evidence behind lifestyle medicine interventions and (2) the ethics of providing informed consent for all possible modalities, including lifestyle medicine—the one treatment option that has little to no side effects or adverse events and a host of benefits. Practitioners, professional societies, and medical schools should make it their business to ensure that their members and trainees know all the options available to patients.

We recognize that training physicians who will enter the workforce over the coming years in basic lifestyle medicine skills is vital.^1,2 Thus, all trainees must be educated on the effectiveness and benefits of this treatment paradigm. At our tertiary care center and medical school, we have been tackling the problem of how to build lifestyle medicine into the medical school curriculum over the past several years. Prevention and lifestyle medicine focused faculty have formed collaborative relationships with like-minded practitioners across campus and nationally. Our Preventive Medicine Department, Family Medicine Department, and School of Medicine have been incredibly supportive in hiring faculty with this passion and providing time and resources to allow for curricular development and student education. In addition to emphasizing the underlying determinants of chronic disease in our second-year preventive medicine course, we piloted and are now implementing an integrated lifestyle and preventive medicine course during the third-year clerkship rotations that is on every student’s transcript. During this course, every student will document lifestyle medicine recommendations for patients throughout 6 of their clerkships (family medicine, internal medicine, pediatrics, obstetrics and gynecology, psychiatry, and surgery).

Additionally, our department was recently awarded an Innovation Funding Grant to take a comprehensive look at the current curriculum for obesity and lifestyle medicine over the 4 years of medical school with the intent to implement improvement where needed. One early change in the works includes increasing the amount of teaching time in the fourth year on obesity and lifestyle medicine as well as culinary medicine. In addition, a competitive lifestyle medicine track for first- and second-year students is being initiated that includes culinary medicine and an active mentoring program to raise the level of competence early in training. The students who are chosen to participate in the lifestyle medicine track will be seen as leaders by their colleagues and worthy of emulation. As a harbinger of change, some of our third- and fourth-year students have taken active leadership roles in our Preventive and Lifestyle Medicine Interest Group and are actively spreading the knowledge and skills of lifestyle medicine modalities to their colleagues. We hope these medical students will influence future training and practice sites as they matriculate into primary care and other specialties.

Malcolm Gladwell³ describes the “tipping point” as the point at which something becomes normative. We believe that lifestyle medicine will gather momentum to reach the tipping point so that it becomes unconscionable to exclude lifestyle medicine treatments as a viable alternative to medication or procedure informed consent discussions. The evidence for lifestyle medicine is clear, the tipping point is upon us . . . let the lifestyle medicine discussions commence as trainees push the momentum forward—only then will full disclosure be truly achieved.