‘Let’s Rate Doctors Too’
Dr. Sidney M. Wolfe’s article (Editorial Pages, May 6), “As Hospital Ratings Go Public, Let’s Rate Doctors Too,” although a seemingly attractive proposal, is a simplistic and naive approach to the future delivery of physician services.
Morbidity and mortality rates as well as length of hospital stays and incurred costs are unarguably useful and important data parameters. A valid rating system for physicians, especially surgeons, however, would necessarily entail an extremely complex and expensive multi-variant analysis of each and every doctor’s performance. Surgical morbidity and mortality rates involve far more than the individual skill and knowledge of the operating surgeon, or his particular patient population.
Operative outcomes depend on the accuracy of referring physician’s pre-operative workup such as a cardiac catheterization, the performance of the anesthesiologist, the performance of the operative circulating and scrub nurses, the quality of the adjunctive post-operative care offered by consultant physicians, the level of skill of the assistant surgeon, the quality of care delivered by intensive care nurses in the post-operative period, the availability of laboratory support at any given time during the hospitalization, and the list goes on and on.
Wolfe believes that a rating system would lead to “better regulation of doctors and hospitals.” Medicine is the most tightly regulated group in all of the professions and most of the regulation has been self-imposed. No other group has such stringent requirements for continuing education, no other group has such strict and clear-cut mechanisms for peer review.
Although Wolfe and the general public may or may not be aware, most hospital departments have morbidity and mortality sessions at which complications and deaths are discussed and actions taken when appropriate. I must assume that the regulatory system Wolfe envisions is one based on an arbitrary rating system that may have minimal physician involvement. The results of a statistical rating system are potentially catastrophic. Patients with complex diseases or patients needing high-risk surgery would and in some instances have already become the medical lepers of modern society.
Although it is neither right nor good many surgeons (and some already do) would necessarily avoid cases with high morbidity and mortality risks in order to preserve pristine statistics and potentially their surgical practices. Very few American surgeons perform more than 250 major operations in any 12-month period. If a surgeon with that type of caseload were to assume the care of between 25 and 50 high-risk cases his statistics, no matter how they were analyzed or explained could potentially appear wretched, leaving him a pariah in the surgical community with little hope of every resurrecting his surgical practice.
Before advocating a public statistical rating of physicians and surgeons the American public should sit back and realize that this is an extremely complex issue with no simple answers. Injudicious implementation of such a system could devastate the level of medical care that the American public currently enjoys.
DANIEL P. HARLEY MD
Torrance
Harley is adjunct assistant professor of surgery at UCLA School of Medicine, Harbor UCLA Medical Center.
