Are Patients Entitled to Know Doctor’s Record of Competence? Debate Simmers

Seventeen of every 100 patients who had coronary bypass surgery last year at the hands of “Dr. X,” a New York heart surgeon, never made it out of the hospital alive.

That is not a good record.

By contrast, some of that surgeon’s colleagues have mortality rates for the same operation of less than 5%. This means that Dr. X’s patients could have cut their risk of dying on the operating table by more than two-thirds if they had been able to find a better doctor.

Unfortunately, it is not as easy as that. The New York Health Department, which compiled Dr. X’s statistics, will not reveal his identity.

In the past few years, researchers have shown that significant differences exist in the quality of care offered by individual doctors in everything from complicated life-saving procedures to delivering babies. And consumer advocacy groups have urged that patients be given information about the performance records of doctors to guide their choice of physician. But deciding how much of this information to release to patients, and how to release it, has proven difficult and controversial.

Dr. X’s statistics, for example, were said to have been adjusted to account for the possibility that his patients were generally sicker than the patients of his peers. But that adjustment is only an estimate. And the statistics do not indicate whether he is incompetent or simply inexperienced, in which case he may improve with time. Nor do they make clear whether he is entirely at fault or whether he is plagued by incompetent nurses, poor anesthesiologists or a badly run hospital.

Is it really fair, in other words, to represent a complicated procedure like coronary bypass surgery with one statistic?

“I think it’s important for patients to have enough information about their doctors to be comfortable,” said Nancy Dickey, a board member of the American Medical Assn. “But at this point we’re not in a position to suggest that there are magic numbers that can be plugged into a formula . . . . It is inappropriate to mislead patients into believing that there are quick and easy answers to their questions.”

“I think ultimately we are headed toward a full disclosure situation,” said Howard Hiatt, a researcher at Harvard University’s school of public health. “But unless this kind of information is handled with great care and a lot of understanding, to have it leak out can be very, very unfortunate. It has to be done in a framework that helps people understand how it fits into general practice.”

The push to collect and release quality-of-care statistics has come, in part, from health insurers who want to make sure that the escalating amounts they pay for health care are being well spent. Beginning in the late 1980s, for example, the Department of Health and Human Services began issuing a list of the mortality rates of every hospital in the country for Medicare patients undergoing any of nine common procedures or suffering any of eight common medical conditions. Other states, including New York, have followed suit with more targeted studies of high-cost procedures, and some private insurers have attempted to measure differences in quality among the doctors.

The cause also has been taken up by consumer advocates, who have argued that as a matter of principle patients should be informed about everything from how good their doctor is to whether he or she has ever been penalized or disciplined.

“There is no one--short of a spouse, lover or family--with whom a patient will have a more intimate relationship with than a physician,” said Sidney Wolfe, who has been in the forefront of the patient’s right-to-know movement for 20 years. He is the director of the Health Research Group, a branch of the consumer advocacy group Public Citizen.

“I don’t see where there should be any limitation on information given to patients about their doctors, so long as it doesn’t constitute an unwarranted invasion of personal privacy such as something about the doctor’s sexual preference or religion,” Wolfe said.

Wolfe and others argue that there is a whole range of clinical data about physician effectiveness that would be easy to collect and of great relevance to consumers as they make decisions about their health care.

One example is death rates. In generating numbers for bypass surgery, New York’s health department took the medical records from every operation performed by each heart surgeon in the previous year and estimated, based on an analysis of how sick each patient was, how many of those patients should have survived a bypass if their surgeon had been fully competent.

Another possibility is information on how the percentage of deliveries that an obstetrician performs as Caesarean sections. In the United States, about 25% of all babies born are delivered by Caesarean. Yet, according to the Health Research Group, if “C-sections” were performed only when they were absolutely necessary, the national rate would drop to about 12%.

Since the chance of dying during a Caesarean is two to four times greater than during a vaginal delivery, and the chances of complications are greater, unnecessary C-sections pose an additional health threat to women. As a result, at least two states, New York and Massachusetts, have passed laws requiring hospitals to inform patients of their C-section rates, and efforts are under way to prompt similar laws in other states.

A physician’s experience also is relevant because in medicine, practice makes perfect. Studies have shown that for cardiac bypass, intestinal operations, total hip replacement, cardiac catheterization, abdominal aortic aneurysm and biliary tract surgery, the more procedures a surgical team or a hospital perform, the more successful they are.

A group of 12 large private health insurers has begun developing a quality-of-care report card to rate the hospitals and doctors they use. Working with the RAND Corp., a think tank, the group is examining each institution’s record in performing procedures in which a wide variation in quality typically occurs, such as in treatment of heart attacks or prenatal care. The report will attempt to summarize all the criteria related to quality of care: mortality rates, rate of complication, infection rates, appropriateness of treatment decisions for various types of patients and so on.

Some argue that not all information is truly useful. In the case of mortality rates, for example, many experts argue that the usual adjustments for differences in the patient mix are not good enough. As a result, they say, the statistics penalize those physicians who take on the sickest patients or attempt the most difficult operations.