In 1908, Mary Schloendorff was admitted to a New York hospital and diagnosed with a fibroid tumour. She adamantly refused to undergo tumour resection, but consented to an examination under anesthesia. During the examination, the treating surgeon proceeded with resection of the tumour despite her wishes. Her post-operative course was complicated by gangrene requiring amputation of several digits. Legal action ensued, culminating in 1914 with a decision by the New York Court of Appeals establishing consent as a requirement for surgical procedures (1914).

Today, this requirement has evolved into informed consent, where the physician has a “duty to disclose to the patient all the facts which affect his rights and interests, and of the surgical risk, hazard and danger, if any” (as cited in Mulsow et al., 2004). Ideally, informed consent adopts a patient-centered approach and focuses on maintaining patient autonomy (Mulsow et al., 2012). 

            Despite the requirement of informed consent, only 57% of orthopaedic consultations meet the minimum requirements for informed consent (Braddock et al., 2008). Obtaining surgical consent is often treated as a ritualistic legal procedure; patients sign the consent form without truly understanding the procedure or potential complications (Habiba et al., 2004, McCormack et al., 1997, Lavelle-Jones et al., 1993). Surgeons rarely assess patient comprehension and often overestimate their patients’ understanding (Waitzkin, 1984, Falagas et al., 2009). This results in poor patient understanding throughout the process despite a strong desire to be adequately informed (Braddock et al., 2008, Braddock et al., 1999, Mulsow et al., 2012, Larobina et al., 2007). 

 

Information leaflets have been the most widely adopted type of decision aid, likely due to their simplicity (Mulsow et al., 2012). The majority of randomized studies have shown a small benefit to using information leaflets in addition to the typical verbal consent discussion. Although improved, patient understanding remained unsatisfactory even within groups who received the leaflet (Mulsow et al., 2012, O'Connor et al., 2009). 

Multimedia resources, which convey information in multiple forms, may improve knowledge transfer and improve understanding (as cited in Mulsow et al., 2004). Randomized controlled trials evaluating the effectiveness of multimedia resources as decision aids reveal a significant improvement in patient recall as assessed by questionnaire (Mulsow et al., 2012).  However, whether increased information recall translates into improved understanding and decision making remains unclear. 

Due to a lack of effective decision aids directly provided by their surgeon, patients have begun to rely on the Internet; one third of patients seek information on the Internet prior to routine surgical procedures (Murphy et al., 2003). However, the information available is often of poor quality and leads to increased confusion and anxiety in one third of these patients (Murphy et al., 2003, Tamhankar et al., 2009)

            The origins of surgical simulation are unclear, but records indicate that simulators were in use over 2,500 years ago. These early simulators consisted of wooden bench-top models, live animals, and human cadavers (Owen, 2012).  The field of surgical simulation remained relatively static until the second half of the 20^th century. The recent introduction of computerized simulators in the 1980s and virtual reality (VR) simulators in the 1990s has revolutionized the field (Cooper and Taqueti, 2004, Badash et al., 2016). VR simulators, in particular, offer significant possibilities (Badash et al., 2016). 

Throughout its history, access to surgical simulation has been restricted to experts and trainees within the surgical field; patients and their families have been persistently excluded. In a recent publication, Kneebone recognizes this barrier and proposes a “democratization” of surgical simulation (Kneebone, 2016). He argues that eliminating this barrier to access between experts and non-experts is necessary to expand the applications of simulation. His paper focuses on the potential for simulation to become a means of communication between individuals in vastly different fields, with the primary goal of improving medical techniques and practice. My proposition, although implied as a possibility by Kneebone’s paper, steers simulation in a slightly different direction. It involves repurposing surgical simulation to improve communication between surgeons (experts) and patients (non-experts) in clinical practice, with the primary goal of improving patient education. Specifically, it involves using simulation as a decision aid when obtaining consent for surgery. This novel application of surgical simulation has the potential to improve patient understanding, facilitate decision making, and assist the surgeon with the difficult task of obtaining informed consent. 

            Unlike more familiar forms of surgical simulation, the objective in this context is not to transform the patient (a non-expert) into a capable surgeon (expert). Instead, the goal is to foster a deeper understanding of the surgical experience as a whole from a patient’s perspective. Surgical simulation geared towards patients must encompass the salient aspects of pre-operative, operative, and post-operative care including evidence-based information about their medical condition, treatment options, potential complications, and post-operative rehabilitation. As Kneebone acknowledges, simulators must be designed for the specific purpose of each encounter (Kneebone, 2016). For example, a high-fidelity arthroscopic simulator used to train orthopaedic residents would be ineffective and inappropriate for patients contemplating arthroscopic knee surgery. 

            Some authors have reported on the use of simulation, including computerized simulators, in the context of patient education (Phillips et al., 2001, Lefevre et al., 2017). However, there is a paucity of studies evaluating the use of simulation as a decision aid in the context of informed consent. Further research is necessary to explore this potential application. Researchers should focus their efforts on low-cost simulators that are remotely accessible by patients. As one third of patients already search the Internet for information prior to a procedure, web-based simulators are likely to be more acceptable to this population as they offer more flexibility (Tamhankar et al., 2009). From prior research conducted on novice surgical trainees, low-fidelity low-cost simulators are likely to be adequate, and possibly preferable, in a lay patient population (Munshi et al., 2015). Simulators should also avoid medical jargon and match patients’ level of health literacy (Fransen et al., 2013). Lastly, simulations should be customizable and reflect the salient aspects of each individual patient’s values, basic characteristics such as age and sex, medical history, the medical condition of interest, as well as the proposed procedure(s). With recent technological advances, the feasibility of this notion is becoming less of a concern. 

Prior to the widespread adoption of web-based simulation as a decision aid, high-quality randomized controlled trials are necessary to confirm the benefits of such an endeavour. Of particular concern is the dissemination of non-validated simulators that do not rely on evidence-based information, which would be comparable to the vast amount of erroneous information presently distributed to patients through the Internet (Murphy et al., 2003). One solution is to entrust the development of web-based simulators to non-governmental specialty associations, such as the Canadian Orthopaedic Association.  For example, in response to the distribution of erroneous Internet information, the British Orthopaedic Association has taken the initiative to develop websites that provide standardized information and consent forms to patients and health professionals (www.orthoconsent.com) (Atrey et al., 2008).