The surgical consent

This picture has been used for representational purpose

You'll have to sign here," I instructed a chubby patient of mine, after I had explained to her the risks of undergoing surgery for a brain tumour. She had come in complaining of an unremitting headache, and the MRI revealed a tumour the size of a tennis ball in her right frontal lobe. She was 23 years old. After explaining the need for an operation, I began talking to her about the possibility of death, paralysis, seizures, infection, or a postoperative haemorrhage requiring a redo surgery, wanting to give her a full disclosure of the possible complications any brain surgery can entail. "Will you shave my whole head?" she asked, combing her hands through her pink highlights. I remembered George Eliot: Our vanities differ as our noses do.

"We usually don't, but if you insist, we will!" I teased, and was rewarded with a priceless expression as her fair complexion turned ashen. I hastened to comfort her. "We'll make a tiny incision behind your hairline," I pointed to where we would cut, "and a few weeks later, no one will know you've even had an operation, which is the beauty of modern medicine," I said, and watched as her face regained colour.

I later pondered upon what gets patients to agree to have surgery. Are they concerned about the part of their body being operated upon, the probability of a mishap, or the intentions of their doctor? Do they rely on their intuition or who they've been recommended by? Do they want to ensure that their expectations match what the surgeon is able to deliver?

When I trained at the Christian Medical College in Vellore, we treated a sizable portion of Bengali patients having large brain tumours, and their primary complaint - obviously unrelated to the tumour - was constipation. It's the problem of all of East India. It didn't matter to them if we performed the finest operation to remove the most complex tumour from deep-seated cervices of their cranium; surgery was deemed a complete failure if we were not able to solve their ‘gas problem'. "Aye bodo operation toh theek aache kintu aami paikhana korte paachi na, ki kori?"

On one end of the spectrum are patients who don't want to know of all that can go wrong; they will stop you in the midst of an explanation of the risks involved. "We have complete faith and trust in you. Please do whatever you deem fit." These are patients who, in my experience, sail through surgery like a breeze. On the other end of the spectrum are patients who want to know details down to the bone: they want to know numbers, statistics, how our complications match up with what's published in the literature, and everything else one can possibly ask their surgeon. When I trained in the United States, one such patient who had an issue with her spine and needed a complex procedure, asked my boss how many of these operations he had performed. "I invented this procedure!" he proclaimed. He really did.

The latter set of patients want a minute-to-minute low-down on what's going to happen, from the time of admission to the time of discharge and then every day thereafter as well. While I treat the entire spectrum without judgement, I (and most surgeons) can almost intuitively predict that something is likely to go wrong in this group, and it does, but thankfully, it's almost always something minor. But it is also often something you haven't spoken about while taking consent for surgery - like a fall in the washroom, diarrhoea from outside food sneaked in by a relative, or a rash from a medication they didn't know they were allergic to.

And then there is the patient who complains about something post-surgery that you don't know how to respond to. A zesty young patient of mine had come to me for decompressing her trigeminal nerve (responsible for facial sensations) from an artery that was deeply indenting it, causing an electric shock to her jaw every few seconds. "The pain has gone, but I can't feel sufficient sensation over the left half of my lips," she complained. "Every time I kiss a guy it feels so strange - and you never mentioned a word about it before surgery!"

The surgical consent form is now a medico-legal document. There are lectures conducted on how consent should be well-informed, the importance of the legibility of what is written down as risks, and the alternate options to surgery. It is signed and sealed by the doctor, the patient, and a witness. It is ceremonial. Even a marriage certificate is not this intense - and surgeons have to do this every day. It may also be heartening for a patient to learn that consenting to every single risk of surgery and signing the paper doesn't absolve a doctor in the court of law if something does go wrong.

In his book Blink, Malcolm Gladwell analyses why highly skilled doctors get sued much more than those doctors who make a lot of mistakes. Patients file suits not based on shoddy medical care alone, but something else that happens alongside that. And that something is how they were treated by their doctor on a personal level when something goes wrong. After a successful operation, most patients thank the surgical team for taking such good care of them. In return, not only do we acknowledge the gratitude, we also thank them back for allowing us to operate on them.

The cumulative risk of any untoward occurrence in most standard brain and spine operations is less than 5 per cent. While we're explaining the risks of a surgery, patients' relatives often ask, "What if he is paralysed or comatose after surgery?" or "What if she doesn't wake up?" Even though with practice I've mastered the art of not letting a reaction show on my face, my response varies every single time. Sometimes I reiterate that it's an extremely unlikely possibility. Often times I say, "We'll do whatever it takes to resolve it." If I've had a really long and exhausting day, I simply peer through the concrete ceiling of my office into the sky above and point my finger to the big guy in the sky. And then exhale deeply.

American author Henry David Thoreau said, "In human intercourse, the tragedy begins not when there is misunderstanding about words, but when silence is not understood." Surgical consent is like that.

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals.