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Commentary

Grading Surgeons May Be A Healthy Practice
David Wessel, Wall Street Journal, 7-6-06

In this piece, David Wessel argues that "report cards" for surgeons can raise the quality of care for patients and that giving information to consumers is an important part of a free market health care system. While he admits that publicly distributed individual doctor "report cards" encourage doctors who know they are being graded to avoid tough cases or simply move to states without such systems, he advocates the use of these report cards to reform the health care system. But it is important to note that anonymous or privately reviewed "report cards" can also be easily accessible for consumers and health care officials, without the damaging effects that Wessel has pointed out.

For more than a decade, a handful of states, notably Pennsylvania and New York, have been issuing public report cards on individual surgeons that show the rates of death and complication of their heart–bypass patients. After all, practicing doctors and nurses know which surgeons are good, and which are to be avoided. Shouldn't the rest of us know, too?

But report cards remain surprisingly controversial, and not only among doctors being graded. Daniel Kessler, a Stanford University economist, divides the debate into three camps. One says report cards boost the quality of health care. A second says they don't have much effect, good or bad, because ordinary patients ignore them.

And a third group, to which Mr. Kessler belongs, holds that report cards may have some beneficial effects, but those could be outweighed by unwelcome, unintended consequences—such as encouraging doctors and hospitals to game the system by avoiding sicker patients, thereby reducing the overall quality of health care. [States attempt the tricky technical task of adjusting data so doctors who take tougher cases are compared meaningfully to those who take easier cases. Surgeons and other skeptics often criticize the precision of such adjustments.]

Now come a couple of Harvard School of Public Health physicians, firm adherents to the view that report cards do lead to better medicine, with an intriguing observation: Cardiac–bypass surgeons who get bad marks are more likely to give up practice than their peers. "These are cardiac surgeons, the best students in med school, residency, fellowships—they've always been the stars. It's psychologically difficult to have spent 15 or 20 years training and practicing and then to be identified publicly as one of the worst in state," speculates Ashish Jha, one of the Harvard researchers.

More than 20% of the surgeons who scored in the bottom quarter of the New York state grades stopped practicing cardiac-bypass surgery in the state within two years after the report was issued, Dr. Jha and colleague Arnold Epstein report in the journal Health Affairs. Only 5% of surgeons who scored in the top quarter, and fewer than 7% of those with middling grades, dropped out.

The researchers tried to query all the surgeons who have dropped out. "Some, when they found out what we were trying to do, were upset and didn't want to talk to us," Dr. Jha says. "A few surgeons were very honest and said they felt constant pressure from their colleagues and department chairs to get better, and they decided it wasn't worth it."



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