I was tempted to remove the slide on ‘consent and the trainee' in my presentation on informed consent. Too obvious, I thought. Surely everyone knows that consultants should not ask junior doctors to obtain consent for an unfamiliar procedure. All the published guidance states this simple rule. Last week, however, I met several Foundation Year 2 doctors from different teaching hospitals who felt bullied into obtaining consent for complex procedures. They were suffering in silence.

A recent study on the consent practices of senior house officers (SHO) in Ear, Nose and Throat departments in the United Kingdom showed that over 80 per cent of SHOs are routinely responsible for consenting patients. The authors found considerable variation in the complications mentioned by the SHOs for five common operations, including tonsillectomy, septoplasty and total thyroidectomy. It is possible, the authors conclude, that SHOs ‘are not taught about the specific risks of procedures before being expected to obtain informed consent'.

There are two possible solutions to the problem. One is to ensure that junior doctors do not obtain consent for procedures which they cannot perform themselves.  It would be a blanket rule: senior clinicians must obtain consent for the procedures themselves.  Supporters of this argument will say that juniors cannot possibly answer many of the questions posed by patients ("what is the likelihood of this complication happening?", "what are the performance figures here?"). "If I were a patient about to undergo neurosurgery", they might add "I would want the surgeon himself to consent me, not some well-meaning but out-of-his depth SHO". They might also argue that junior doctors' fear of being asked difficult questions may, consciously or not, adversely influence the way in which consent is obtained. They may rush the ethically crucial part "are there any questions you would like to ask me?" or provide evasive, uninformative or even incorrect answers. 

The other solution is to allow junior doctors to obtain consent, but with certain safeguards in place. One may be a preliminary discussion with the consultant, in which the latter would tell the junior doctor about key facts. Another may be the use of standardised, pre-written consent forms, already in use in some trusts, which would clearly mention relevant information about the procedure (visit http://www.orthoconsent.com/ for examples of such forms). Ideally, junior doctors would observe their seniors obtaining consent on several occasions prior to doing so themselves.  Aside from practical considerations of time, supporters of this option will note the importance of getting junior doctors to learn this crucial skill before they become registrars.

Whatever the guidelines say, the reality is that many junior doctors are still asked to obtain consent for unfamiliar procedures. Senior clinicians must appreciate the dangers of this practice, both ethical and legal. Junior colleagues should try to speak out against the most egregious violations, however difficult this may be. They may as a group decide to raise the issue with relevant authorities, such as the Medical Director or Clinical Governance manager. Good patient care is not limited to well-performed medical procedures, but includes obtaining high quality, rather than mediocre, consent. 

Daniel Sokol is a Lecturer in Medical Ethics and Law at St George's, University of London.

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