Patients trust their physicians. They trust that hospitalists will provide the best advice and make recommendations with their interests at heart. To not do so violates the public trust in physicians as patient advocates. Required by law, transparency of hospital quality data is the basis of a truthful relationship between the healthcare system and the public.
HM’s reputation will be tarnished if patients perceive that the physicians are more interested in the well-being of the hospital than the well-being of the patients.
- Kowalczyk L, Smith S. Hospital halts heart surgeries due to deaths. Boston Globe Web site. Available at: www.boston.com/news/local/articles/2005/09/22/hospital_halts_heart_surgeries_due_to_deaths. Accessed March 31, 2009.
Outcome disclosure is impractical, unnecessary
At first glance, disclosing information about better outcomes at another hospital seems reasonable—even ethically obligatory. However, there are several competing interests, and in the end, the existing precedent for requiring reasonable disclosure in informed consent makes more sense.
The first issue is practicality. How much is a hospitalist obligated to know, and what degree of difference must be disclosed? In the case example, the hospitalist knows better outcomes are available at a nearby facility. However, if a duty to disclose this information exists, it can’t be limited to the information that an individual hospitalist has available to them. If such a duty exists, there is a corresponding burden on providers to have consistent and accurate information to disclose. If disclosure of differing outcomes is the ethical standard, then the reasonable disclosure needs to meet some uniform criteria for when a differing outcome rises to the level that the disclosure is compelled.
Data exist for pneumonia outcomes, readmission rates, and medication errors, as well as data for physicians relative to their colleagues. The fact that a hospitalist might have incidental knowledge of differing outcomes is not sufficient to create an ethical obligation, but there must be some uniformity to a disclosure requirement.
It is easy to envision a hospitalist spending as much time disclosing outcomes data as disclosing medical information and prognosis in the process of obtaining informed consent. Hospitalists can’t be expected to manage all of that information, much less make a meaningful disclosure. Physicians’ information-management skills should focus on medical knowledge—not outcomes data.
The test case has more implications for the professionalism of the hospitalist. Ultimately, they should act in the best interest of the patient. The recommended course of treatment should maximize benefit and minimize harm. Enough information should be provided that the patient can participate in weighing risks and benefits. The hospitalist needs to decide if it is unsafe to perform the procedure at their institution, and if so, the patient should be referred out. If there is a small but real benefit to having the procedure done elsewhere, the hospitalist cannot be responsible for determining what threshold of incremental benefit warrants disclosure. Existing ethical responsibilities to protect the patient and act in their best interests already addresses the issues of disparate outcomes more effectively than a blanket disclosure policy. Patients need to trust their hospitalists, and we need to be worthy of that trust.
Mandating disclosure of better outcomes would create a conflict of interest for physicians and hospitals. This conflict would be difficult to manage. Large referral centers exist because physicians recognize their own limits and act in patients’ best interests. Requiring a new level of disclosure would mean that many hospitals (save for an elite few) would recommend patients go elsewhere a substantial part of the time.