Module 3.

3: The foundations of communication - 4

Background
Communication is a fundamental prerequisite of the medical profession and beside skills is crucial
in ensuring professional success for doctors. This module continues to provide an emphasis on
effective communication skills. The emphasis is on administering informed consent during
professional year III.

Competency addressed
The student should be able to: Level
1. Demonstrate ability to communicate to patients in a patient, respectful, SH
nonthreatening, non-judgmental and empathetic manner
2. Identify, discuss and defend, medico-legal, socio-cultural and ethical issues as KH
they pertain to consent for surgical procedures
3. Administer informed consent and appropriately address patient queries to a SH
patient undergoing a surgical procedure in a simulated environment

Learning Experience
Year of study: Professional Year 3
Hours: 5 hours (1 + 2 + 2)
i. Introductory Small group session- 1 hour
ii. Focussed Small group session - 2 hours
iii. Skills Lab Session – 2 hours

Contents:
1. Introductory small group session on the principles of communication with focus on
administering informed consent.
2. Focused small group session with role play or video where students have an opportunity to
observe, criticise and discuss common mistakes in administering informed consent.
3. Skills lab sessions where students can perform tasks on standardised or regular patients with
opportunity for self critique, critique by patient and by facilitator.

Assessment
1. Formative: Participation in session 2 and performance in session 3 may be used as part of
formative assessment.
2. Summative: A skill station in which the student may administer informed consent to a
standardized patient.
Resource:
1. Makoul G. Essential elements of communication in medical encounters: the Kalamazoo
consensus statement. Acad Med. 2001; Apr; 76(4): 390-3.
2. Hausberg M. Enhancing medical students' communication skills: development and evaluation
of an undergraduate training program. BMC Medical Education 2012; 12:16.
Source: AETCOM Module of MCI 2018

AETCOM Module 3.3: Teaching Learning Guide Draft Outline – Drs. Animesh Jain, Sharada Rai, Sheetal
Ullal and Pratik Chatterjee 1
 Outline of the TL Module and Faculty guide
Competency addressed
The student should be able to: Level
Demonstrate ability to communicate to patients in a patient, respectful, non-threatening, SH
non- judgmental and empathetic manner
Identify, discuss and defend, medico-legal, socio-cultural and ethical issues as KH
they pertain to consent for surgical procedures
Administer informed consent and appropriately address patient queries to a patient SH
undergoing a surgical procedure in a simulated environment
PE2.3 Counselling a parent with failing to thrive child
PE10.5 Counsel parents of children with SAM and MAM
SU8.2 Demonstrate Professionalism and empathy to the patient undergoing surgery
SU10.2 Describe the steps and obtain informed consent in a simulated environment
OR14.2 Demonstrate the ability to counsel patients to obtain consent for various orthopedic
procedures like limp amputation, permanent fixations etc.

Specific Learning Objectives:

At the end of the module, the student shall be able to:
1. Describe the types of informed consent in health care with appropriate examples for their
use.
2. Explain the basic elements for informed consent in clinical practice.
3. Identify, discuss and defend medicolegal, socio-cultural and ethical issues in consent for
surgical procedure.
4. Administer informed consent and appropriately address patient queries to a patient
undergoing a surgical procedure in a simulated environment
5. Reflect, describe and paraphrase the learning and the way forward in terms of doctor
patient communication.
No. Session Hours Date Signature of Faculty
1 Introductory small group session 1
2 Focussed small group session 2
3 Skills Lab session 2

Teaching Learning Methodology/Implementation

1. Introductory small group session on the principles of communication with focus on
administering informed consent. – 1 hr
Learning Objective:
Identify, discuss and defend, medico-legal, socio-cultural and ethical issues as they pertain to
consent for surgical procedures

AETCOM Module 3.3: Teaching Learning Guide Draft Outline – Drs. Animesh Jain, Sharada Rai, Sheetal
Ullal and Pratik Chatterjee 2
Lesson plan outline
Set induction – 3- 5 min
Case of Jerry Watson Canterbury which led to informed consent before surgery becoming a
norm.
Brief discussion on Importance of informed consent. (5 min)
Video: 'Informed Consent: in a patient's shoes' (2.48 min). (3 min)
https://www.youtube.com/watch?v=g_LEAp7_isU
Group work: (35 min – 10 min to brainstorm and then 5 min for each group to share)
The small group may be divided into smaller groups and asked to come up with content and
answers for the following.
Types of Consent in medical practice – Implied, Expressed (verbal, written).

Implied Consent
Much of physicians work is done on the basis of consent, which is implied either by the words or
behavior of the patient or by the circumstances under which treatment is given, e.g. it is common for
a patient to arrange an appointment with a Doctor, to keep the appointment, to volunteer the history,
to answer question relating to the history and to submit without objection to physical examination.
In these circumstances consent for the examination is clearly implied. An implied consent is a consent
which is not written, that is, its existence is not expressly asserted, but nonetheless, it is legally
effective. It is provided by the demeanour of the patient and is by far the most common variety of
consent in both general sense but not to procedures more complex than inspection, palpation,
percussion, and auscultation.

Expressed Consent
An express consent is one the terms of which are stated in distinct and explicit language. It may be
oral or written.
Oral Consent
For the majority of relatively minor examinations or therapeutic procedures, oral consent is employed
but this should preferably be obtained in the presence of a disinterested party. Oral consent, where
properly witnessed, is as valid as written consent, but the latter has the advantage of easy proof and
permanent form. It is advisable to document that the verbal consent was taken.

Written consent
It should be obtained when the treatment is likely to be more than mildly painful, when it carries
appreciable risk, or when it will result in diminishing of a bodily function. Consent may be confirmed
and validated adequately by means of a suitable notation by the treating physician in the patient’s
record.
When is it needed to have a written informed consent?
Expressed consent in written form should be obtained for surgical operations and invasive
investigative procedures. It is prudent to obtain written consent, also whenever analgesic, narcotic
or anesthetic agents will significantly affect the patient’s level of consciousness during the
treatment.

Blanket Consent
It is a consent taken on a printed from that covers (like a blanket) almost everything a doctor or a
hospital might do to a patient, without mentioning anything specifically. Blanket consent is legally
inadequate for any procedure that has risks or alternatives
AETCOM Module 3.3: Teaching Learning Guide Draft Outline – Drs. Animesh Jain, Sharada Rai, Sheetal
Ullal and Pratik Chatterjee 3
 Who can give informed consent?
Legally valid consent for medical examination, interventional procedure and treatment:
In our country only a person who is a major by law i.e. above the age of 18 can give valid consent for
the treatment. Hence any person who is a minor, cannot legally give consent.
Anyone above the age of 12 years can give consent for general physical examination.
Additionally, the person giving consent must be conscious and mentally sound
If not or if the patient is unconscious, the consent must be given by the parent, guardian or close
relative or a legally authorized representative. In such circumstances consent give by parent, guardian
or close relative is known as “substitute or proxy consent”.

Who should administer and take informed consent?

 Operating surgeon or the person performing the procedure/investigation
 In case of a team, member of team who is actually involved in the procedure can take.

NOTE: If a proper consent is not obtained the doctor/heathcare worker is liable for legal action.

Contents of informed consent documents – information sheet and consent form.

All information should be explained in comprehensive, non-medical terms preferably in patient’s own
language about the:
i. Context of the consent (viz., nature of the illness, reason for the procedure/investigation)s
ii. Nature of the proposed treatment or procedure
iii. Alternative procedure
iv. Risks and benefits involved in both the proposed and alternative procedure
v. Potential risks of not receiving the treatment
vi. Relative chances of success or failure of both procedures. Yet, in practice this is not always so
simple. Because in certain situations the patient may be in dire need of treatment, but
revealing the risks involved (the law of full disclosure) may frighten him to refusal.
The doctor may not reveal the risks involved, if—
a. Patient prefers not to be informed
b. When complications are trivial
c. When revealing complications is likely to have a gross impact on psychology of the patient
(a close relative of the patient can be informed of the complications and a colleague should
be consulted, preferably patient’s family physician for the treatment of the patient). This is
known as “Therapeutic privilege”. But the doctor should note his decision and reasons for the
same in patient’s case record6. The informed consent when expressed by the patient in
writing is termed as, “informed expressed written consent.”
vii. Follow up required, if any.

Information on duration and cost of procedure may also be informed/discussed.

This must be signed by both the patient/representative and the doctor.

Special situations: Emergency, Mental illness, Children.

Consent in special circumstances
1. If the patient happens to be a child below 12 years of age, consent from the parent or guardian is
taken.
2. In emergency, involving child when parents and guardians are not available consent can be taken
from the person who is in charge of the child (Loco Parentis).
AETCOM Module 3.3: Teaching Learning Guide Draft Outline – Drs. Animesh Jain, Sharada Rai, Sheetal
Ullal and Pratik Chatterjee 4
 3. Consent given for an illegal act is not valid.
4. In case of emergency where the patient is unconscious and incapable to give consent, emergency
doctrine is applicable.
5. Consent of spouse for operation and treatment in the routine course is not necessary. But consent
is required if the operation or instrument involves danger to the life or impairment of sexual functions.
6. Consent of both the spouses is essential for an operation which involves reproductive and sexual
organs e.g. sterilization. For artificial insemination donor the consent of both the recipient husband
and wife and that of the donor and his wife is obligatory.
7. Under Medical Termination of Pregnancy Act 1972, for MTP the consent of pregnant woman is
sufficient if she is above 18 year of age and has sound disposing mind. In case, if she is below 18 years
of age, unconscious or insane consent of parent or legal guardian is essential.

Summary and wrap up (6-7 min)

Informed consent in healthcare (5.11 min)
https://www.youtube.com/watch?v=mJ2GgOjatCA

2. Focused small group session – 2 hrs

Role play or video may be used where students have an opportunity to observe, criticize and
discuss common mistakes in administering informed consent.
Some videos of doctor patient interactions can be shown and the students are asked to critique
them and discussion follows to bring out the important points and elements of informed
consent process.
Students are asked to do role play for specific senarios. Students may be assessed based on
their participation. To make it more interesting a Google form may be devised where the
students are supposed to log in their answers for the video critique.

Active Participation in group work in Session 2

Exceeds expectations Meets expectations Below expectations
Took an active part in the Took part in the discussions with some Hardly took part in the
discussions in a encouragement from other team discussions in spite of
constructive manner and members/facilitator and was receptive encouragement
was open to ideas to ideas from other team members

Obtained Grade

Feedback

3. Skills lab sessions where students can perform tasks on standardised or regular patients with
opportunity for self critique, critique by patient and by facilitator.

Topics for role play

Informed Consent to be administered to a patient scheduled for Appendicectomy.
Informed consent for a biopsy, Informed consent for laparoscopic surgery.
AETCOM Module 3.3: Teaching Learning Guide Draft Outline – Drs. Animesh Jain, Sharada Rai, Sheetal
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Points to look out for:
 Information being provided in detail and in simple language without jargons.
 Patient’s understanding being checked.
 Patient and relative being given the opportunity to clarify and ask questions.
 Verbal and non-verbal communication
Log book entry and signature (in case a physical hard copy log book is used).
Background reading and reference material for facilitator:
Jerry Watson Canterbury (1939-2017) was an F.B.I. clerk who suffered a ruptured disk in
1958.He was operated on by Dr. William T. Spence, a well-known Washington neurosurgeon,
and as a result of the surgery, and a subsequent fall from his bed while hospitalized, he ended up
paralyzed below the waist and incontinent. Canterbury sued for malpractice on the grounds of
negligence. It established the idea of "informed consent" to medical procedures.
https://www.nytimes.com/2017/05/16/us/jerry-canterbury-medical-consent-paralysis.html
Informed Consent. Includes some MCQ questions.
https://www.youtube.com/watch?v=RWL2enliFgY
Informed consent checklist (7.02 min)
https://www.youtube.com/watch?v=AN8CdzQj6xk&t=55s
Surgery informed consent with Dr. Choll Kim
https://www.youtube.com/watch?v=_o6R01ghcSo

AETCOM Module 3.3: Teaching Learning Guide Draft Outline – Drs. Animesh Jain, Sharada Rai, Sheetal
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