Psychiatric Residents Lax on Informed Consent


NEW YORK – Psychiatric residents may have learned a good deal about diagnosis and dosage, treatment options, and side effects in their training. But they are not eager to share this knowledge with patients, judging by the results of a study designed to assess compliance with informed consent criteria.

However, the same group of residents would quite readily provide appropriate information in response to patients' queries, Dr. Bret R. Rutherford said in a poster presentation at a meeting sponsored by the American Psychoanalytic Association. “They knew what they were supposed to say, but they weren't proactive.”

A relatively modest educational intervention aimed at informing residents of their responsibility to initiate informed consent discussions might have a substantial–and lasting–effect, he suggested.

The study used a questionnaire with vignettes describing initiation of treatment with three hypothetical patients with diverse diagnoses: an episode of major depressive disorder treated with medication, borderline personality disorder treated with psychotherapy, and psychotherapy for neurotic character traits.

Respondents were asked to say what they would tell patients spontaneously about various aspects of their disorder and its treatment, what they would tell patients if asked, and what they would refuse to discuss altogether.

The questionnaire was distributed to 220 residents at the seven largest psychiatric residency programs in the New York City area and returned by 108 (49%), of whom 27% were postgraduate year (PGY)-2, 42% were PGY-3, and 29% were PGY-4.

“We set a bare bones set of criteria of what would constitute informed consent,” said Dr. Rutherford of the Columbia University Center for Psychoanalytic Training and Research, New York. This included information about diagnosis and prognosis, treatment options, details of recommended treatment, side effects and logistics of treatment, and their own educational and personal background.

Eight of 324 responses to vignettes (2.5%) met these criteria; six residents accounted for all of them, and only one resident's responses met criteria for all vignettes. In general, residents were more forthcoming with depressed patients than with others, at least with regard to diagnosis and prognosis, recommended treatment, and side effects. They were best overall in giving information on treatment alternatives and costs, and worst in disclosing appropriate information about themselves.

Residents performed considerably better in answering hypothetical patients' questions: 173 (53.4%) of responses met a priori criteria. Again, a higher proportion of residents (71.2%) met criteria in dealing with the depressed patient than the borderline (42.6%) or neurotic patient (46.3%). The responses of one-third (36) of 108 residents met criteria for all three hypothetical patients.

In general, Dr. Rutherford observed, responses to patient queries suggested that participants knew what information should be provided for informed consent and what not to reveal, he said.

But they provided less information on diagnosis and prognosis, the ways treatment would help, and side effects to patients in psychotherapy than to those receiving medication. In fact, “most residents didn't seem aware that psychotherapy could have side effects; they wouldn't even answer questions if asked about them,” he said.

Residents aren't alone in their deficiencies in this area, according to other surveys, which have found that less than 50% of psychiatrists in community practice believe informed consent is important.

“We suspect that if they don't learn this in residency, the odds on learning it later are low,” Dr. Rutherford said. The topic seems to receive little attention in residency training, he said. “There needs to be more emphasis on the responsibility to tell patients things even if they don't ask.”

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