LAUSR

The best meal I ever ordered at a restaurant was hardly ordered at all. The occasion: a birthday celebration of a good friend. The setting: Royal Sushi & Izakaya in Queen Village, Philadelphia, PA, USA. The meal was served omakase style, that is, “chef’s choice.” I was asked to state some general preferences—likes, dislikes, and allergies—but beyond that, the meal was going to be composed by the chef, using his experience, expertise, and best judgment. I was not disappointed. That restaurant visit made me wonder if there is a role for surgical informed consent, omakase style as well. In this model, patients can state some general preferences—a willingness to take some risk for a faster recovery, say, or a particular dislike of immobilization—but beyond that, the details of the care are left to the surgeon’s experience, expertise, and best judgment, just as they’d be used in an emergency setting [4]. I am not suggesting a return to the days of old, when some physicians did not even share the diagnosis with a patient [9]. Nonetheless, the pendulum might have swung too far in the direction of patient involvement, far beyond what patients want themselves. A few years ago, I had a patient considering an ACL reconstruction. I presented him with three graft options: his own patellar tendon, his own hamstring, or an allograft Achilles tendon. I drew some Caves-ofAltamira sketches, recited the statistics, and reviewed the relative advantages and disadvantages of all three choices. I then asked him what he wanted. His reply: “Doc, give me the one that works.” My patient’s glib response may reveal what patients intend when they consent to treatment. They are not so much consenting to treatment, they are “consenting” to the cure, with the former merely tolerated as means to the latter. For some, making decisions is a cognitive and emotional burden they’d rather foist on others. Furthermore, truly unbiased informed consent can be elusive, and maybe impossible. Surgeons inevitably will influence patients’ decision-making. That’s because the language used by the surgeon framing a decision [2] inherently affects how the choices are perceived and in turn which option is selected. This framing effect was demonstrated by Tversky and Kahneman [11]. In a replication study I conducted with my colleagues Eli Kupperman, Ari Kandel, and Jaimo Ahn (the birthday boy, above), we confirmed that these phenomena permeate surgical informed consent as well [3]. We presented clinical scenarios to 131 volunteer respondents and asked them to make choices as if they were the patient described.We then repeated the presentation a month later, with identical facts but different wording, aiming to trigger some of the biases identified by Tversky and Kahneman. In one example, we twice asked respondents to choose between surgery and physical therapy to address a postfracture 40° flexion contracture of the knee. In the first presentation, they were told that therapy offered a certain gain of 10° of motion relative to the current 40° contracted state, whereas surgery offered a 25% chance of a 40° gain and a 75% chance of no gain at all. In the second presentation, the patients A note from the Editor-in-Chief: We are pleased to present to readers of Clinical Orthopaedics and Related Research the next Not the Last Word. The goal of this section is to explore timely and controversial issues that affect how orthopaedic surgery is taught, learned, and practiced. We welcome reader feedback on all our columns and articles; please send your comments to eic@ clinorthop.org. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. J. Bernstein ✉, University of Pennsylvania, 424 Stemmler Hall, Philadelphia, PA 19104, USA, Email: [email protected] Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA