P
Phyllis
From yesterday's NY Times
January 6, 2009
Second Opinion
Should Patients Be Told of Better Care Elsewhere?
By DENISE GRADY
Six years ago, a relative of mine found out that she had rectal cancer and would need surgery, radiation and chemotherapy. She lives in a small town, and she consulted a local surgeon at a community hospital.
He was pleasant and kind, and clearly explained her condition and the operation he would perform. He was also painfully honest, and said that because the tumor was large, he doubted that he would be able to save the sphincter muscles that make bowel control possible. She would very likely need a colostomy, a procedure to divert wastes out through an opening cut in the abdomen, and would have to wear a colostomy bag for the rest of her life.
My relative thought it over. Being treated close to home had seemed so easy and convenient, and she dreaded the thought of shopping around for doctors when she was feeling sick, vulnerable and anxious. It was tempting to think that she would receive first-rate treatment no matter where she went.
But she also recognized that this was a small hospital, and a surgeon who probably spent more time fixing hernias and taking out gallbladders than he did operating on cancer patients. She decided that she wanted a doctor who operated on patients like her all the time, and that the two-hour trip to a cancer center would be worth the trouble.
And so it was: she found a surgeon who specialized in rectal cancer, and today she?s in good health, with no need for a bag. She might have done just as well with the local surgeon, but we both doubt it.
An article published online in October in the journal PLoS Medicine really hit home with me. Noting that the quality of cancer care is uneven, its authors argued that as part of the informed-consent process, doctors have an ethical obligation to tell patients if they are more likely to survive, be cured, live longer or avoid complications by going to Hospital A instead of Hospital B. And that obligation holds even if the doctor happens to work at Hospital B, and revealing the truth might mean patients will take their business someplace else.
?It?s only fair,? said Dr. Leonidas G. Koniaris, an author of the article and a cancer surgeon at the Miller School of Medicine at the University of Miami.
Studies have confirmed the common-sense notion that practice makes perfect, and the medical profession has known for at least 30 years that how well people fare after surgery often depends on where it was performed. For a given operation, outcomes are generally best at ?high volume? hospitals, which perform it often. The difference between high- and low-volume centers is not just the surgeon?s skill, but also the level of expertise in other areas that are crucial after surgery, like nursing, intensive care, respiratory therapy and rehabilitation, Dr. Koniaris said. The same principles apply to treating cancer.
But patients are not often told during the informed-consent process that the results of cancer treatment can vary among hospitals, according to Dr. Koniaris and his co-author, Nadine Housri, a medical student.
?I think it?s sort of starting to happen but hasn?t really become a dialogue yet,? Dr. Koniaris said.
The strongest evidence that volume makes a difference comes from studies of surgery for pancreatic and esophageal cancer, but Dr. Koniaris said the experience of the surgeon and the whole medical team was important in any major cancer surgery.
He was not surprised to hear about my relative. He was an author of a study published in 2007 that found that people with rectal cancer survived longer and were more likely to have operations that saved the sphincter at teaching hospitals than at community ones ? even though the university hospitals were more likely to take on difficult cases with large tumors. Another study in which he participated suggested that women with advanced breast cancer received more comprehensive therapy and survived somewhat longer when treated at teaching hospitals rather than at community ones.
Some medical experts say complicated treatments like surgery for cancer or heart problems should be regionalized ? done strictly at specialized, high-volume centers, not at centers that don?t perform the operations often enough to become really good at them. But Dr. Koniaris and Ms. Housri suggested still another option.
?We brought up the idea that maybe it should just be up to the patient,? Dr. Koniaris said.
Studies have found that some people still prefer to be treated close to home even if the risks are higher there. Maybe they shouldn?t be forced to travel, especially if the difference is not large, Dr. Koniaris said.
Asked if he practiced what he preached, Dr. Koniaris said yes, that as a surgeon he sometimes sent patients to other doctors, especially for pancreatic cancer and liver tumors.
His article pointed out that in a few cases in the United States and Australia, courts have ruled that doctors who had operated on people with poor results should have informed the patients that more experienced surgeons were available.
PLoS Medicine framed the article by Dr. Koniaris and Ms. Housri as a debate, with two other researchers taking different views. Dr. Robert J. Weil, a neurosurgeon at the Cleveland Clinic, argued that although it might seem a good idea to inform patients of differences in outcomes among hospitals, there would be ?a variety of hurdles.?
Which hospitals would be chosen for comparison? And as medicine advances and changes, Dr. Weil asked, ?is it possible to compare hospitals or even recent time periods, especially when faced with disease courses that may extend over years?? He also suggested that if hospitals were forced to give patients comparative information, it might lead some to avoid difficult cases, to make their numbers look better. And he pointed out that patients might have no idea what to make of the information, because most people have a hard time gauging risk or understanding that statistics apply to a population but don?t predict the fate of an individual.
David I. Shalowitz, a bioethicist, said that expecting surgeons and hospitals to disclose information about other doctors and medical centers would create an untenable conflict of interest for them and should be avoided.
The question of what the doctor?s obligation is remains unresolved. People can ask doctors for comparative information, but many patients would fear giving offense. And judging by volume alone may have its pitfalls, because there are bound to be some hospitals that do lots of operations badly and some that perform few but do them well.
(For people who want to find out how a specific hospital performs in treating certain illnesses and performing operations, the government Web site www.hospitalcompare.hhs.gov provides information. In addition, some states require that hospitals publish their infection rates; that information is at www.hospitalinfection.org.)
Some people will try to sort out whatever information they can obtain or, as my relative did, simply figure that the odds will be most in their favor if they can find their way to a doctor or surgeon who takes care of a lot of people who are a lot like them. For now, many patients facing tough decisions are pretty much on their own.
