Informed Consent and Clinician Accountability: The Ethics of Report Cards on Surgeon Performance

The ethical (and legal) standard for informed consent is the complete disclosure of material information. But what is “material” to a decision to undergo surgery? This question is explored in Informed Consent and Clinician Accountability: The Ethics of Report Cards on Surgeon Performance. For surgeons, the take-home message is that it is no longer ethically acceptable to quote textbook morbidity and mortality data to patients prior to elective surgery. Rather, Clarke and Oakley argue that surgeons are ethically obligated to disclose their personal outcomes for a particular operation.

Yet because this book discusses the use of report cards (ie, the public reporting of physician-specific outcomes data) as a source of surgeon-specific information, it should be read by all patients and physicians. For any patient wanting to be truly informed about an operation they might undergo, the book explains the common information pitfalls found in physicians' report cards. Physicians, on the other hand, will want to read the book to understand one of the most significant socioeconomic forces that will shape their careers during the next decade. Patients and physicians willing to wade through this well-written anthology will be rewarded, because Clarke and Oakley present one of the more balanced discussions of report card use.

Key ethical arguments in favor of physician report cards include fostering improvement in patient autonomy though a more informed decision-making process, providing a vehicle through which the profession can fulfill its ethical obligation to be held accountable, and improving quality of care by providing physicians with feedback. This book, however, makes it clear that physician-specific report cards are not a 1-way street to a better health care system or enhanced patient autonomy. Examples of how report cards can have potentially negative effects on patients and the health care system include patient confusion secondary to the injudicious selection of quality metrics as well as the declining quality of medical education.

It is axiomatic that clinical acumen comes from experience and that all patients want the most experienced physician. But if informed consent means that patients can ethically decline care from a physician without report card–proven experience, how are residents to gain experience? Only a few of the essayists in Informed Consent and Clinician Accountability are clinicians. So it is not surprising that the discussion on medical education tends to view the negative effect of report cards on clinical training as solvable by increasing residency time, supervision, or level of resident supervision. (Most physicians will be skeptical of the conclusions drawn about the effect of report cards on medical education.)

The editors likewise tackle the important need for public dissemination of physician-specific outcomes data. The essayists who tackle this subject correctly observe that adverse physician outcomes could be handled privately under the rubric of peer review. However, the private handling of adverse outcomes “works best in circumstances where the public has a high degree of trust in [the reviewing] institutions.” Unfortunately, after a decade of stories from the United States, United Kingdom, and Australia, the ineffectiveness of peer review and government boards to protect patients from incompetent physicians has resulted in the loss of public trust in these institutions.

Readers interested in the politics of the public reporting of physicians' outcomes will find Sorell's chapter on the Bristol Infirmary particularly interesting. After an anesthesiologist exposed the abysmal outcomes of 2 pediatric heart surgeons, Bristol was the subject of an extensive investigation by the Kennedy Commission. Subsequently, the 2002 Kennedy Commission's report was used as a foundation to justify the revamping of operation and oversight of the National Health Service. Sorell discusses the logical disconnect between the negligent supervision of surgeons in a single unit and the Kennedy Commission's recommendation that the National Health Service should moreover overhaul primary care. More generally, if health care services in the 21st century are to be provided by multidisciplinary teams of clinicians (as recommended by the Institute of Medicine), it would appear to be disingenuous to tag one team member with the sole responsibility for an adverse outcome. Such arguments are germane to US readers, because the Center for Medicare & Medicaid services is in the process of applying New York State's cardiac services outcomes report card model to a wide variety of medical specialties to create process-driven report cards under the Physician Quality Reporting Initiative.¹

No book is perfect. Like any focused anthology, Informed Consent and Clinician Accountability contains a fair degree of repetition. Essayists frequently use the same examples (eg, the Bristol Infirmary debacle) to illustrate their points; by the end of the book, these examples have become old friends. More bothersome is the repeated assertion that no evidence exists that report cards place a chill over the practices of medicine. While such a statement may have been true when Informed Consent and Clinician Accountability went to press, it is no longer valid. During the past 24 months, several reports have shown that report cards increase “cherry picking” behavior in surgeons, who feel the need to protect their reputations by avoiding patients in need of certain (high-risk) operations. One report even correlated adverse report card scores with surgeons exiting the market.² Still, because this book provides one of the most balanced discussions of report cards, it will be valuable to patients as well as physicians.