Words Matter: The Operative Request

Surgeons understand the importance of having patients sign a "permit" prior to any procedure. This piece of paper is signed because if you touch someone without their permission, you can be sued for assault. If you have ever had this experience, you want to avoid it ever happening again.
The problem is, however, that the word "permit" is destructive to the relationship between the patient and the physician.

Words matter! They influence our understanding and perception of anything that we describe. Isn't a "previously owned" car much different that a "used" one? "Permit" or "consent" are no exceptions. These words come from the legal arena, and not from medicine. Legal encounters are frequently based on adversarial interactions, and not on relationships of "shared decision making based upon mutual respect and consideration." Medical relationships are a different arena, and we should use appropriate words to describe them.

Surgeons know the law. When we see a patient, we evaluate the patient's history, examine the patient and documentation of tests, and then we suggest a treatment. We describe the risks, benefits, potential complications, and alternative procedures. Once that is done, we ask the patient if she would like to have the suggested procedure. The patient either says "yes" or "no." Either way, we are not getting "permission" to operate, but, if the patient says "yes," the patient is actually "asking" us to do the procedure. There is an important distinction here that places the patient, linguistically, in the appropriate venue. The patient is now out of the adversarial arena of a legal interaction, and in the venue of a "shared decision, based on mutual respect and consideration."

Having the patient sign a "request for surgery" actually implies a greater respect for the patient's rights! The patient is now an active participant is the decision, not just a passive object that we must get permission from to touch. A surgeon is under more obligation to inform completely when the patient must "request" surgery, because the patient in now an active participant in the decision.

This concept was originally started in the VA hospitals in the United States in the late 1970's, by an OB-GYN surgeon named Lindon Lee. He understood these concepts, and spent eight years getting this concept approved in the VA system.

Importantly, there is no legal difference between these terminologies. It accomplishes the same goal in a more "medically" appropriate manner. Lawyers do not, understandably, like it because it does not represent their understanding of the situation.

Surgeons should stand their ground in this battle, and insist that their forms read "Request for Surgery" for it is an important gift to medical students and residents to understand their appropriate relationship with their patients. Give it to your students for their future.

James P. Weaver, M.D.