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

J. OAKLEY. Cambridge: Cambridge University Press, 2007. 316 pages. Paperback. ISBN 978-0-521-68778-2. Price: $USD48.00. This book had its origins in a 2004 Melbourne workshop convened by the editors to debate the contentious issue of publication of performance data for individual surgeons, known colloquially as ‘report cards’. First trialled with New York State cardiac surgeons 20 years ago, the idea has since aroused intense and heated debate. The Royal Australasian College of Surgeons, while strongly supportive of personal surgical audit, which is mandatory for Fellows, is opposed to publication of individually identified data, as are other Royal Colleges and the American Medical Association. The book is divided into three parts, with the headings accountability, informed consent and reporting clinician performance information. There is considerable overlap in the subject matter of each section. Although Clarke and Oakley, both ethicists, are noted advocates of report cards their book provides a wide range of opinions. They set out their ethical arguments for surgical report cards in an introductory chapter, claiming that they will improve patient choice of surgeon, satisfy the community demand for accountability, and improve the quality and safety of care. In the succeeding chapter Michael Parker, an Oxford bioethicist, points out the vulnerability of these arguments to empirical and ethical challenge, a vulnerability that is exposed effectively by several other contributors. Merrilyn Walton, a one-time Health Care Complaints Commissioner, points to evidence that although report cards have been available for decades, patients rarely use them to choose their surgeons or hospitals, in part because they cannot interpret the information. Silvana Marasco, a cardiac surgeon, and Joseph Ibrahim, a physician, make a good case for considering the risks to the doctor–patient relationship posed by report cards, which generate surgeon anxiety and risk-avoidance behaviour. Yujin Nagasawa from Birmingham University documents the widespread anxiety among UK and American cardiac surgeons subjected to report cards, but astonishingly considers that ‘surgeons’ anxiety is not harmful per se’. Someone should tell him about the causes and prevalence of surgical burnout and its harmful effects on patient safety. Many other important issues, such as how to provide for surgical training and innovation within a reporting framework, the probable adverse distributive effects of surgical ‘league tables’, which would almost certainly lead to higher fees for good performers, thus denying their services to lower socioeconomic groups, and the many biases inherent in the collection and interpretation of performance data are discussed well in the book. The difficulties of collecting appropriately risk-adjusted data are well covered. Touched on in several chapters, although not explicitly described as such, is recognition of the ‘fundamental attribution error’ risk in report cards, which focus attention on the individual surgeon, who just happens to be the closest person to an adverse event, such as the death of a patient. Adverse surgical outcomes, like clinical successes, are almost invariably the product of a team and a hospital system and the arguments in the book for public reporting of institutional, rather than individual, outcomes are therefore compelling. What is missing in the book is adequate recognition of the fundamental importance of the ‘discretionary space’, which surrounds the interaction between surgeon and patient. What happens definitively within that space influences the outcome for the patient and is (and must be) determined by the surgeon. This is not to revive the paternalistic/autonomy issue, because a properly functioning surgical decision-making process should incorporate the autonomy of the patient, but should weigh that appropriately to achieve the best patient outcome, something that must have primacy in the whole debate. Mandatory surgeon report cards are an ever-present silent intrusion into the discretionary space, exerting an insidious and sometimes only partially conscious harmful effect on surgical decision-making – ‘How will taking on this case affect my stats?’ Clinicians who already receive, for example, routine Medicare feedback on their service and test-ordering profile will recognize the reality of that effect, which is not always to the benefit of the patient. Clarke and Oakley freely acknowledge that even if their ethical arguments for the introduction of report cards were accepted ‘we have not shown how our proposal could be turned into sound policy – that would be a major undertaking’. In the reviewer’s opinion, that would be a major understatement! Their book, nevertheless, is an invaluable reference source. It is a handy paperback size and deserves a place on the shelf of every surgeon who wishes to participate in the inevitable continuing debate on this subject.