The estimated number of doctors working in the surgical units at the three teaching hospitals was 214 which was the number of questionnaires handed out. A total of 132 (62.1%) out of 214 questionnaires were completed and returned which is better than a 52% recorded in a previous related study . Another related study gave a response rate of 63% . This also highlights the fact that staff at university teaching hospitals in Uganda tend to be reluctant to respond to surveys.
The average age of the surgeons was 33.1 years. The average age was low because many of the respondents were either doctors doing their internship or graduate students pursuing their masters degree training. In addition, the majority of the employees at the university and associated teaching hospitals are actually in the age group 30–40 years . Medical doctors in Uganda are usually at least 25 years of age at the time of qualification if trained in Uganda. However, since the surgical units have clinical officers who participate in surgery, the four respondents with a diploma also contributed to the younger age of 22 and these are clinical officers who participate in surgical procedures at the hospitals.
The 60.2% of respondents with Bachelor’s degree was high because many of the respondents were either intern doctors or postgraduate students who tend to respond to surveys better than their senior counter parts. In addition, they all perform surgery and contribute to teaching of medical students in our setting. There were no significant differences in obtaining informed consent among doctors among the different specialties, levels of education or experience as shown in Table 1.
Obtaining informed consent among respondents was seen improving among those from internship to those in general practice but then went down during graduate training. Also specialists were more than 20% less likely to obtain informed consent as compared to intern doctors (Table 1).
There were more males than females which are a reflection of the fact that most of the surgery based clinicians are actually male. There are relatively fewer females in the surgical specialties in Uganda.
The average number of patients operated per week was 10.4 and this is because of the high burden of disease and low numbers of doctors in our setting, hence increased work load for the few available doctors at public hospitals [23–25].
Almost all, (99.2%) of the respondents agreed that informed consent is necessary though only 48.8% reported obtaining consent all the time surgery is done. Despite the fact that emergency surgery occurs at these hospitals, the magnitude of such operations with no next of kin available to give informed consent cannot be as high as 51.2% meaning that sometimes doctors do not obtain informed consent from their patients with no genuine reason (Table 1). It is also true that for emergency surgery with no available next of kin, the senior hospital administration should consent on behalf of the patients. In this study, 88.6% of the respondents said they had obtained informed consent at their last surgical operation. However, the quality of such consent may be lacking since no adequate documentation of informed consent was available from reviewed patient records.
There was a big variation among respondents as to when consent should be sought (Table 2) indicating a discrepancy in the knowledge and practice of informed consent by surgeons. The responses are quite different from the expected practice where informed consent is a process of dialogue between the patient and the provider [26–28]. Hence the need to address these differences with a focus on streamlining the informed consent process in the country.
In response to how informed consent is obtained, 34% of the respondents described it as follows; consent is got by the admitting nurse/doctor; by signing the consent form; obtained verbally; and implied consent. This highlighted the fact that knowledge and practice of informed consent were not well appreciated. A number of other respondents indicated that informed consent is usually obtained by the anesthesiologists or anesthetic clinical officers.
Additionally, many of the respondents interviewed said that nurses are used to obtain consent for surgery from patients. The respondents reasoned that sometimes the patients are so many and the nurses would help in consenting while the doctors did the operating which is a form of task shifting. All the above responses indicate the lack of appreciation of what constitutes adequate informed consent.
It should be stressed that informed consent should be obtained by the surgeon who is going to operate and it is a continuous process that starts as soon as the doctor meets the patient and should continue after the operation to facilitate the patient’s understanding of the procedure, benefits, anticipated risks of the operation and the post operative follow up period.
Despite the fact that there are many deficits in the informed consent process highlighted by this study, challenges associated with obtaining consent during clinical care are not limited to our setting but affect other parts of the world though the reasons could be different .
The magnitude of this problem thus calls for a more comprehensive approach to obtaining informed consent by development of an informed consent template that has adequate information and room for modification to facilitate the informed consent process. Additionary, refresher training and continuing education with focus on medical ethics can be made mandatory for all medical practitioners.
Self reporting bias may affect the outcome of the study since some respondents may not report what they actually practice.
The high level of non-response may give a different interpretation of the findings
The alternatives in the questionnaires were not mutually exclusive which could have caused confusion to the respondents.
Informed consent administration and documentation for surgical care is still inadequate at University teaching hospitals in Uganda. Surgeons need to be educated into what constitutes informed consent and the importance of adhering to such requirements.
There is need for development of an informed consent template with adequate information and room for modification to facilitate the informed consent process.