The Surgical Consent

While surgeons subscribe to full disclosure so that their patients are aware of any risks involved post-surgery, it’s not always an easy position to be in.

“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 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%. While we’re explaining the risks of a surgery, patients’ relatives often ask, “What if he is paralyzed 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.

19 Comments on “The Surgical Consent
  • Dr. Vishnu Mulchandani says:

    Well explained and documented consent pays a rich dividend. That comes from communication too with the patient honestly. Post operative period is the most challenging. If the risk is amply explained DEATH is accepted as No life is immortal. REGARDS .

  • Mahashweta Biswas says:

    Wow Mazda what a beautifully worded article with your impeccable English. Not to forget the humourous bong sentence about “Paikhana” problem which is the talk around the dining table of a bong house🤣
    Super article

  • Dr Vineeta goel Radiation oncologist says:

    Enjoyed reading

  • Manoj MALKAN says:

    In almost 40 years of Family practice, I have observed VIP SYNDROME. Whatever the best surgeon does, VIP patients tend to have most post op problems, many of them unexpected.

  • Bikram Dr. Shakya says:

    Informed Consent… a good trend!!!
    Nice reading …

  • Rita singh says:

    As usual very interesting doctor patient relationship. I too was operated by u for a front lobe brain tumour.But I had such a fine surgery plus the most fulfilling experience a patient can have from her doctor.I am sure most of ur patients will say this .Thank for being a gem of a doctor that u r.

  • Clera Menezes says:

    Lovely and a beautiful Artical Sir…
    What is the sadest part is still some of the surgeons dose not understand the concept and leagal issues of consent .When we audit or check the consent papers,can find incomplete documentation .When we ask them complete it ,they feel we point them out and show their fault.
    Aldo there are few Surgeons who listen to us and understand the importance of consents .
    This is my personal experience.

  • Navzer Irani says:

    The best combination would be God operating through you.

  • Avinash Karnik says:

    Dear Mazda,
    As usual your article took me through the paces of experience that your mind would get under the virtual knife by most of your patients while explaining the risks of operation. The delicate parts of a human body such as brain and spine having vital responsibility for a healthy body and to dabble with such parts to ease a patient from his/her life challenging issues is indeed a task that is almost like offering a new and healthy life to your patients.
    Hence I truly admire your skills of not only your hands but also your temperament while explaining the risks.
    I wish all the success as a neurosurgeon and also to all your patients for healthy lives post operations

  • Shashank Joshi says:

    It’s worth reading your mind. I had similar situation through which i am still going. Even if one conveys all possibile complications and risks, still it is very difficult for patient or relatives to digest them. We can’t predict to which patient and at which hospital and at what time the catastrophe strikes. Retrospective allegations are difficult to face. It’s nice write up. Thanks.

  • Hitendra says:

    One more very important point is that.
    Consent can not be pre printed for all. It has to be written by someone. Surgeon or assistant. Printed consent is not valid in court of law. Individual patient. Different surgery. So. Different complications.
    Ideally. Consent. Should have details of.
    1) current problems with timeline
    2) associated other diseases and their duration with control of them with medication.
    3) Options of different modalities of treatment.
    And reason for, why surgical option was selected
    4) Risks related to all possible Anaesthesia complications. These are common to all. Except few related to position and type of anaesthesia
    5) Complications related to the disease patient having if Left for natural course of disease.
    6) Complications related to the type of surgery patient undergoing
    7) other general complications realated to drug reactions and related to long bed rest and nutrition , many catheterization.
    8); All possible Post operative complications including redo surgery for CSF leak or bleed or brain oedema or
    fresh infarcts or recurrence or bone flap preservation and surgery to replace it, etc etc etc.
    Down the it appears that it’s next to impossible to write down all the possible complications.
    Law and lawyers will keep on finding loop holes every where.
    That may lead to over protective medical practice. Which is leading to more expenses for extra investigations and cross references.
    In all this. Means. Patient as a consumer and CPA ( Consumer Protection Law) applied to our profession has ruined the previous faith based relationship between doctors and patients.
    All Think that health is also a commodity. Can be bought with money or Law ?
    ( If we dig deep. It’s a failure of Government to give health care to all at affordable cost. )

  • Monika Naiknimbalkar says:


  • Dr Dara Engineer says:

    I remember at the time of my interaction with my Cardiac Surgeon, a very young man, before my Bypass surgery I
    remember what he said “Dr, everything will be OK but there is a chance you may die on the operation table”
    Any lay person would think “how can a Dr talk like that”
    But I immediately reassured him and said” Yes of course anything can go wrong at any time during operation”
    Dr’s trained abroad do say this without hesitation because this is what is done abroad.

  • Anjali Patki says:

    Simple, clear but important observations on all aspects of taking informed consent. Laced with subtle humour in your impeccable style. Great read.

  • Cashmira Sethna says:

    Very well explained and enjoyed reading it.
    All decisions are best left in the Dr hands.

  • Supriya Correa says:

    Interesting behind-the-scenes post, Maaz…good stuff

  • Chandan Sanjana says:

    Another great piece of writing. Every surgery comes with a risk. I know for sure every doctor does his best as he does not want to loose a patient, especially one who passes away on the OT.
    I did not ever think that Bongs are so constipated and this topic forms a part of their daily convo and even table talk. Yuk!

  • Vipul Shah says:

    Hello Dear Mazda Sir

    Very well explained piece of Article on Consent

    The most important phrase I like is ‘“ THE BIG GUY UP THEIR “

    I trust Him & I trust U

  • Dr Shivkumar V Dalvi says:

    Very nicely explained simply complex aspects of patient consent.There r 2sets of patients, those with total faith in their doctor n those who want to know pros n cons.One really cant blame either.Dr Turel puts both sides very nicely n dilemmas faced by doctors and patients r pointed out in very open manner.Nice reading doctor


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