Logo of brjopthalBritish Journal of OphthalmologyVisit this articleSubmit a manuscriptReceive email alertsContact usBMJ
Br J Ophthalmol. Aug 2006; 90(8): 990–993.
PMCID: PMC1857200

Effects of presentation method on the understanding of informed consent



Knowledge of which presentation methods impart the most information to patients can improve the informed consent discussion. The purpose of this study was to determine if the comprehension and recall of the informed consent discussion varied with presentation method.


Randomised, prospective study at the University of Arkansas for Medical Sciences. 90 freshmen medical students were randomly assigned to one of three groups and separately went through an informed consent on cataract surgery. Group A heard an informed consent presentation. Group B was shown diagrams while hearing the same presentation. Group C heard the consent and then watched an informational video on cataract surgery. A 10 point multiple choice quiz was administered after the presentation and repeated again 1 week later.


Scores from each group were averaged as number correct out of 10 questions. For same day scores, group C scores (7.70 (SD 1.24)) were significantly higher than group A (6.39 (1.63)). One week testing revealed that group C (6.96 (1.62)) recalled more between the two time periods and scored significantly higher than groups A (5.15 (2.11)) and B (5.54 (1.64)).


This study found differences in the participants' ability to recall facts based on the manner in which the material was presented. It clearly demonstrated that the use of visual aids improved the ability to remember facts and risks associated with cataract surgery beyond a verbal presentation alone. It also showed a benefit of the repetition of information as provided by audiovisual presentations that can be used in conjunction with the physician‐patient discussion.

Keywords: informed consent, cataract surgery

Informed consent represents a significant portion of physician‐patient communication. An active surgical ophthalmologist may engage several patients a day in the informed consent process. This can often lead to a discussion that is mechanical and far removed from its actual intent of educating the patient regarding the important facts and risks of their particular surgery. To emphasise the importance of the informed consent discussion, one need only survey current malpractice claims to see that informed consent is second only to documentation as the most frequent risk management issue for physicians.1 Sources agree that better communication increases patient satisfaction and in turn can decrease the number of malpractice suits.2,3,4,5,6

To gain a better understanding of what patients learn from the informed consent discussion, Priluck et al performed a survey of patients undergoing retinal surgery. Their study revealed that while 97% of patients thought the informed consent was satisfactory, only 57% passed a post‐informed consent quiz.7 Furthermore, despite being given the information beforehand, 75–86% denied ever hearing the information reflected in the questions that were missed.

Are there methods of presentation that can improve informed consent? The literature has numerous studies which have attempted to answer this question by looking at variables such as the consent form's reading level, the amount of written detail presented, the length of the form, whether the information was presented verbally or in a written form, the age of subjects, etc.8,9,10,11,12 Our study specifically asked if there was a difference in a person's ability to recall information concerning the informed consent for cataract surgery between a verbal presentation alone and a verbal presentation with visual aids or a verbal presentation followed by an audiovisual aid.


After obtaining approval from the University of Arkansas for Medical Sciences institutional review board, 90 volunteers from the University of Arkansas for Medical Sciences freshmen medical school class were randomly assigned to one of three groups by colour coded cards. To avoid issues of coercion in this population, no identifying information was collected. This particular group was selected to ensure a homogeneous educational background with little to no prior knowledge of cataract surgery. All three groups were presented with the same scripted verbal presentation of informed consent for cataract surgery. The presentation described the definition and effects of cataracts. It also presented the risks, benefits, and non‐surgical options of cataract surgery as well as a detailed description of the procedure.

Groups A and C heard the verbal presentation without the use of visual aids (fig 11).). At the completion of the talk, group A was excused from the room, and group C was shown a 13 minute video presentation produced by the American Academy of Ophthalmology entitled “Understanding Cataract Surgery.”13 The informational content of the video presentation covered the same information as the scripted talk.

figure bj92650.f1
Figure 1 Presentation methods. Group A heard only the verbal presentation; group B heard the presentation while being shown visual aids; group C heard the presentation without visual aids, then saw the informational video concerning cataract surgery. ...

In a separate room, group B was exposed to the same scripted verbal presentation, but were also shown diagrams during the talk. To avoid providing unequal amounts of information between groups, no questions were entertained from the participants.

To assess the effectiveness of the informed consent process, we developed a 10 item, multiple choice quiz (appendix). To access the validity of the questions before the study, the quiz was administered to ophthalmologists and non‐ophthalmologists without any pre‐quiz presentation. Questions answered correctly by non‐ophthalmologists were rewritten and administered to other non‐ophthalmologists until the questions could only be answered correctly by chance alone. These results ensured that the items could discriminate between those with and without knowledge about cataract surgery. Care was also taken in the development of the quiz to ensure that the content of all questions was separately covered in the verbal presentation and in the video presentation.

Immediately following the conclusion of each group's initial presentation, students received the 10 item quiz (immediate post test). Each student retained the colour coded card for later group identification. One week later, without any presentation, the same quiz was re‐administered (delayed post‐test) to all three groups. The cards were then collected with the quiz to identify the original group of the student. The students were informed that a second quiz would be given 1 week after the first quiz and instructed not to discuss the quiz with their classmates. However, they were not told the second quiz would be identical to the first.

The individual scores for each subject were added together by group and an average group score was obtained for both the immediate and delayed post‐tests. The group results were then analysed using two one way analysis of variance for the immediate and for the delayed scores. Significant one way results were followed with a Tukey HSD post hoc test with p set at 0.05.


Scores from the test given immediately following the presentation and 1 week later are shown in table 11.. We were able to follow up all but seven (7.8%) of the students. Overall, there was a significant difference among the three groups on the immediate post‐test (p = 0.006). Post hoc tests indicated that for same day testing, the verbal only group (A) had significantly lower scores than the group receiving verbal and video (C). Results of the 1 week later, delayed post‐test indicated a significant difference across groups (p = 0.001) with post hoc tests indicating that the students in verbal only (A) and verbal plus diagrams (B) scored significantly lower than those students in verbal plus video (C). The students in the verbal plus video (group C) dropped less than a point between the two quiz administrations while the other groups dropped more than a point, indicating that group C had statistically forgotten less between the two time periods than did the other two groups.

Table thumbnail
Table 1 Results of the quiz after the presentation


Obtaining informed consent is a common procedure in all ophthalmology offices. Although all consent processes have a verbal component, in a busy clinical setting, finding visual aids or diverting patients into another room to watch an informational video can be time consuming. However, patients anxious about surgery may not fully process the information they hear. Aside from the legal ramifications, a poor understanding of the procedure can lead to unrealistic expectations or feelings of anger if complications should occur. Clearly, learning which methods of informed consent provide higher levels of patient understanding and recall is helpful.

Previous studies have examined many variables in an attempt to improve informed consent. Our study is unique in its design to expose a group to three methods of presentation, including an audiovisual aid. It is also unique in that our subjects were a homogeneous group of equally educated participants.

When applying our findings to patients, one must apply caution as the learning abilities and preferences of medical students may be different from those of a diverse group of patients. Further study in this area to explore the ability to generalise our data to patients is warranted. Our study also has other limitations. The students were grouped randomly and not separated to equally account for age, sex, educational record, or other factors in each group. Although this was necessary to avoid any suggestion of coercion in this unique, vulnerable population, the results could have been affected by these differences. Additionally, since the students were identified only by group affiliation, we were unable to match individual student scores for the two administrations. Also, we did have some attrition from the study, but the numbers were relatively small. We do note, however, that the largest number of non‐participants on the delayed post‐test were from the verbal only group. And finally, it should be noted that the quiz was derived from points that a physician would want the patient to remember. These may not be the same points that a patient, or our participants, would view as the most important, which could have had an effect on the results.

Our study indicates that there were differences in our participants' ability to recall information based on the manner in which the material is presented. It clearly demonstrated that the use of visual aids improved the ability of our participants to remember facts and risks associated with cataract surgery beyond a verbal presentation alone. It also showed a benefit to the repetition of information as provided in our study by an audiovisual presentation. It can be reasonably argued that the group watching the video had better information retention not only from the audiovisual method , but additionally from exposure to the information twice. This is an area that warrants further study. However, from a clinical recommendation standpoint, obtaining repetition by allowing the patient to view a video before sitting down with the physician for a one on one discussion makes practical sense.

Although we acknowledge that no method can reasonably discuss every conceivable complication of a surgical procedure, we believe that increasing a patient's understanding of a procedure with the use of diagrams or with the repetition provided by an audiovisual presentation will not only allow for a more informed decision concerning surgery, but will also relieve anxiety and improve overall satisfaction with the physician.


This work was supported in part by unrestricted grants from Research to Prevent Blindness and the Pat & Willard Walker Eye Research Center.


A 10 item multiple choice quiz concerning cataracts and cataract surgery. The quiz was administered immediately after each group was presented the information and again 1 week later. Correct responses are highlighted in bold.

  1. The best time to remove cataracts is when:
    1. The doctor tells you the cataract is ripe
    2. Your vision is not 20/20 with your new glasses
    3. You cannot see road signs with your new glasses
    4. You can no longer read without your glasses
  2. Cataracts can cause all of the following except:
    1. Sensitivity to sunlight
    2. Glare at night
    3. Yellow‐tinted vision
    4. Difficulty reading
  3. All of the following are true concerning cataracts except:
    1. Cataracts may be treated with glasses for a while
    2. Cataracts may make it seem you are looking through a smudged window
    3. Cataracts may make objects appear much smaller than before
    4. Cataracts may make it very hard to tell colours apart
  4. All of the following are true concerning cataract surgery except:
    1. If cataracts do not run in your family, then your risk is low
    2. Cataracts always worsen over time unless treated
    3. Improved vision is obtained after cataract surgery in most cases
    4. Improves vision by removing the lens inside the eye
  5. Which of the following concerning artificial lenses is true?
    1. They may cause clouding of the cornea
    2. They may cause a retinal detachment
    3. You may need a more powerful artificial lens as you get older
    4. It may cause an infection even years later
  6. During cataract surgery:
    1. A small incision is made in the centre of the clear part of the eye
    2. The front clear part of the eye is removed, then replaced after the surgery
    3. The cataract is removed after inserting an artificial lens
    4. The artificial lens is placed inside a capsule in the eye
  7. Which of the following statements about cataract surgery is false?
    1. Once inside the eye, a laser scalpel is used to properly shape the lens to the correct power
    2. A small incision is made in the front part of the eye
    3. During the operation, a hole is made in the front portion of the lens capsule that holds the lens
    4. During the operation, the cataract is gently vacuumed out of the eye
  8. All of the following are risks of cataract surgery except:
    1. Regrowth of the cataract
    2. Clouding of the cornea
    3. Retinal detachment
    4. Glaucoma
  9. Which of the following could you have after cataract surgery?
    1. Droopy eyelid
    2. Crossed eyes
    3. Strain on the other eye
    4. Infection on the white part of the eye
  10. Which of the following statements is correct?
    1. Vision can become blurry even 1 year after surgery
    2. Although 20/20 vision after surgery is not guaranteed, vision better than before surgery is guaranteed
    3. Once the operation begins, cataract surgery usually takes 1–2 hours
    4. Cataract surgery is routinely performed with a laser


Conflict of interest: None of the authors have any financial interest in this manuscript.


1. Weber P. Malpractice: the lessons in other surgeons' woes. Rev Ophthalmol 2001. 824–26.26
2. Beckman H B, Markakis K M, Suchman A L. et al The doctor‐plaintiff relationship: lessons from plaintiff depositions. Arch Intern Med 1994. 1541365–1370.1370 [PubMed]
3. Hickson G B, Clayton E C, Githens P B. et al Factors that prompted families to file malpractice claims following perinatal injury. JAMA 1992. 2871359–1363.1363 [PubMed]
4. Levinson W, Roter D L, Mullooly J P. et al Physician‐patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997. 277553–559.559 [PubMed]
5. Mavroforou A, Giannoukas A, Michalodimitrakis E. Medicine & Law. 2004;23:479–488. [PubMed]
6. Shapiro R S, Simpson D E, Lawrence S L. et al A survery of sued and nonsued physicians and suing patients. Arch Intern Med 1989. 1492190–2196.2196 [PubMed]
7. Priluck I J, Robertson D M, Buettner H. What patients recall of the preoperative discussion after retinal detachment surgery. Am J Ophthalmol 1979. 87620–623.623 [PubMed]
8. Langdon I J, Hardin R, Learmonth I D. Informed consent for total hip arthroplasty: does a written information sheet improve recall by patients? Ann R Coll Surg England 2002. 84404–408.408 [PMC free article] [PubMed]
9. Shurnas P S, Coughlin M J. Recall of the risks of forefoot surgery after informed consent. Foot Ankle Int 2003. 24904–907.907 [PubMed]
10. Stanley B M, Walters D J, Maddern G J. Informed consent: how much information is enough? Aust N Z J Surg 1998. 68788–791.791 [PubMed]
11. Dresden G M, Levitt M A. Modifying a standard industry clinical trial consent form improves patient information retention as part of the informed consent process. Acad Emerg Med 2001. 8246–252.252 [PubMed]
12. Kruse A Y, Kjaergard L L, Krogsgaard K. et al A randomized trial assessing the impact of written information on outpatients' knowledge about and attitude toward randomized clinical trials. The INFO trial group. Control Clinical Trials 2000. 21223–240.240 [PubMed]
13. American Academy of Ophthalmology Understanding cataract surgery: an educational DVD for patients. American Academy of Ophthalmology, 2004

Articles from The British Journal of Ophthalmology are provided here courtesy of BMJ Group
PubReader format: click here to try


Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...


  • Cited in Books
    Cited in Books
    PubMed Central articles cited in books
  • PubMed
    PubMed citations for these articles

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...