A few bad apples

CMAJ 1999;160:693-4

© 1999 Canadian Medical Association

Some of her suggestions to increase accountability are controversial. She advocates public disclosure of postoperative complication and death rates with respect to individual surgeons and hospitals, routine competency testing for physicians, and a minimum volume requirement before physicians can perform a given procedure. Her book is well written and has many strengths. Priest makes her case for greater public disclosure of information with a good mix of anecdote, evidence and illustrative quotes from experts. Each chapter features a list of questions to be directed at individual surgeons, hospitals or government. She also proposes "things you can do to help," although often these are variants of "lobby the government."

How will Canadian physicians react to this book? I suspect that many will speak out against it without reading it. Surgeons may be annoyed to find themselves a clear target of her arguments, while anesthetists and others will be happy to hide below the parapet. Many will be affronted that their competence is being called into question and that the book calls for more public accountability. There will be bluster about the erosion of trust in the physician­patient relationship. Others will dismiss much of the evidence Priest offers by claiming that her data are flawed. Some will see the move to greater openness as a way to improve the quality of care; others will be much more cautious, judging that the public will become unnecessarily worried and that their faith in the medical profession will erode. For the issue at the heart of this book is whether it is better to allow public access to imperfect data with caveats, or to rely on professional self-regulation.

There are many problems associated with publishing performance indicators. Although Priest cites evidence that the publication of hospital death rates in the US has led to a decline in those rates and that poor surgeons have been encouraged to move on, she fails to discuss whether the reported improvement in hospital performance is real, or whether in fact it resulted from other strategies. It would be relatively simple for a hospital to "doctor" its performance indicators, by relaxing the coding criteria for diagnosis (for instance, assigning the same code to cases ranging from severe angina to mild heart attack would have the effect of increasing the number of patients with heart attacks seen in hospital) or by discharging patients earlier so that they die at home rather than in hospital. These methodologic issues are more likely to be resolved, as has been argued in the research literature, by publishing data than by censoring it.

A more fundamental issue, which is not really addressed in her book, has to do with the practical implications of what Priest proposes. For example, what would happen to the provision of care if every informed patient sought the "best" surgeon or the "best" hospital (hardly an option for many Canadians)? My main criticism of Priest's account is that it does not acknowledge that most care received in Canadian hospitals is of high quality and provided by conscientious and skilled doctors. This point could have been made without any damage to the case for greater accountability.

The reality is that only a few bad apples spoil the barrel. Consider the case of the Bristol heart surgeons. In a case strikingly similar to that of the Winnipeg Health Sciences Centre pediatric cardiac surgery program, two surgeons in the UK were found guilty last year of serious professional misconduct in connection with the deaths of twenty babies who underwent heart surgery. This case is different, however, in its far-reaching consequences. Richard Smith, editor of the British Medical Journal, invoked W.B. Yeats in lamenting that medicine in Britain is "All changed, changed utterly." Indeed, the very issue of self-regulation by the General Medical Council is being called into question. A public enquiry is currently hearing submissions; its recommendations will likely contain suggestions similar to those put forward by Priest. In anticipation of the council's findings, the senate of the Royal College of Surgeons of Great Britain and Ireland has already recommended that surgeons undergo professional review every five years.

Most physicians will recognize some legitimacy in what Priest preaches. They may disagree on the extent of the problem and on whether the solution lies in self-regulation or in public disclosure. Where you stand on this issue rather depends on where you sit. Nevertheless, we only have to look at the far-reaching impact of similar cases in the UK to realize that this issue will not go away. Public disclosure is coming to Canada. Hospital performance report cards will soon be published in Ontario. This is a book that deserves to be widely read.

Duncan J.W. Hunter, PhD
Director, Health Information Partnership
Eastern Ontario Region
Kingston, Ont.

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