Factors Affecting Risk Recall in Open Carpal Tunnel Release Surgery

Objective of this study The investigators' study objectives are to see if additionally providing a written document along with the discussion of surgical risks improves risk recall for patient seen in consultation for open carpal tunnel release, and if this has any effect on overall satisfaction after the procedure.

To accomplish this goal, the investigators intend to provide patients with a written document outlining the same risks as are discussed in consultation and investigate if their recall of the risks is improved compared to patients who receive discussion alone. The investigators will also see whether risk recall is affected if patients participate in a group format informed consent discussion compared to a standard individual discussion. The investigators propose to do this as a two-part prospective randomized control trial of patients who are new referrals to the Halifax Infirmary Plastic Surgery Clinic.

Background The informed consent process The risks and benefits of an operation or procedure are typically discussed as part of the informed consent process for an initial surgical consultation. Informed consent is a legal requirement for surgery and is based on the components of disclosure, comprehension, competence and voluntary choice. Despite this, patients are often unable to recall the specific risks that were reviewed. Additionally, failure to understand the possible risks and failure of communication are more common reasons for patients to seek legal action. Patients have historically reported that they wished they had received more information about their operation prior to surgery.

Increased understanding of a procedure and its risks has been shown to give patients more realistic expectations, increase cooperation and result in higher satisfaction. Traditionally, obtaining informed consent for surgical procedures has involved an oral discussion, but this may be insufficient as oral information tends to be poorly retained.

Previous research in the field of otolaryngology has shown that written documentation in addition to oral discussion increases recall of both general knowledge of a procedure and of the specific risks of a procedure. Siau et al. (2010) found that this effect was even more pronounced for recall of the risks associated with the operation and that subjectively patients were found to be happy to have received a pamphlet and found it helpful. Early research into this subject in general surgery suggested that the optimal time to provide additional information regarding a procedure is at the time of the initial consultation or at least one week prior to surgery.

The investigators' research is important as it could show that providing a written document in conjunction with the standard oral discussion improves patients' risk recall in the informed consent process for open carpal tunnel surgery. In addition, the investigators wish to look into whether this in turn increases satisfaction with the procedure. Though past research has drawn a link between comprehension and satisfaction, very little research has been conducted specifically on this topic. In the future this research could be extended to other surgical practices.

Due to large volumes of patients requiring open carpal tunnel release, wait times following referral can vary from 30 to 151 days in Nova Scotia, with an average wait time of 59 days (Patient Access Registry NS, July-September 2013). While open carpal tunnel release surgery is a very brief procedure with an extremely low rate of post-operative complications (Ono et al., 2010), the presurgical consultation with each patient takes a large proportion of the time spent by both patient and surgeon addressing the disease. To address a similar problem involving extensive information required prior to surgery, the UHN breast reconstruction program in Toronto is in the process of piloting an educational group intervention, which includes seminar-style lectures and group discussion, in order to improve shared decision making in women undergoing post-mastectomy breast reconstruction (Platt et al., 2013). We seek to implement a similar program for patients scheduled to undergo open carpal tunnel release.

According to the Weiss model of medical stigma (Weiss et al., 2006), Carpal Tunnel Syndrome could be considered a disease with minimal stigma attached. As one would correspondingly expect, when offered the opportunity to participate in a group seminar style presurgical consult, many patients have expressed a positive opinion and willingness to participate.

If there are no differences between risk recall or general satisfaction in patients who are part of a group consultation compared to a traditional consult, group consultation may be a viable tool to shorten wait times for patients undergoing specific kinds of medical and surgical procedures.

Hypothesis The investigators are testing whether providing a written document in conjunction with the standard oral discussion improve patients' risk recall in the informed consent process for open carpal tunnel release and increase patients' subjective satisfaction with their operation. In addition, the investigators will test whether a group consultation format provides a model for large-volume, low-variation, low-urgency surgery without reducing ability to recall risks of surgery or overall satisfaction.

Patient Selection

The investigators study will be a two-part prospective randomized study, each of 100 consecutive patients being seen for open carpal tunnel release consultation at the Halifax Infirmary. Inclusion criteria will be:

The sample size was chosen based on previous studies investigating risk recall and a power calculation with the hypothesis of a mean of 4 items recalled, a standard deviation of 2.5 (alpha 0.05, beta 0.95), giving us a sample size given our hypothesis (n = 40 per study group).