Health care’s reformation

“We are experiencing a healthcare reformation,” writes Joanne Shaw this week (doi:10.1136/bmj.b1080). Like the Catholic church in 16th century Europe, which threw away its Latin texts interpretable only by the priesthood, medicine is being transformed. With varying degrees of enthusiasm, acceptance, and resignation, doctors are interacting with an increasingly web enabled laity.

Some of you may think the reformation is complete or at least has gone far enough. But anyone who has been or supported a patient in the past few years will know that medicine finds it hard to shake off its paternalistic tendencies. There is a long way to go before patients truly control the important decisions about their health care. Mohammed Keshtgar and colleagues provide a potent example (doi:10.1136/bmj.b630). They question the well established practice of screening tissue removed during breast reduction surgery without discussing possible outcomes with the patient. In linked commentaries, a surgeon, an ethicist, and a lay person all agree that full consultation and consent are essential. It’s worth noting, as Peter Lewis does in a letter this week, that the same failure to consult can afflict participants in research (doi:10.1136/bmj.b1059).

Shaw concludes; “Not only is the demand for online health information unstoppable, it should be welcomed and encouraged as good for patients and doctors alike.” Does this statement apply to US style doctor rating sites? Writing in this week’s head to head debate, Neil Bacon believes it does (doi:10.1136/bmj.b1030). His conflict of interest, as founder and majority shareholder of the doctor rating site iwantgreatcare, is obvious and stated. Done properly he believes such sites “can bring together a critical mass of real time, granular, qualitative and quantitative feedback, providing new insights on the perceptions and needs of our patients.”

Since Deborah Cohen reviewed the site last year (http://blogs.bmj.com/bmj/2008/07/25/deborah-cohen-i-want-great-care) it doesn’t seem to have taken off substantially. Now a non-commercial competitor is set to join the fray. The publicly funded health website NHS Choices, which already allows patients to rate hospitals, will soon be encouraging patients to post feedback about their GP surgeries. The BMA is against the idea. So too is the Medical Protection Society, as Rebecca Coombes reports (doi:10.1136/bmj.b1102). She also tells us that some doctors in the United States are getting patients to agree not to post comments on the web without their permission.

Is this just a sign of medicine’s priests clutching their robes around them, or are there real reasons for concern? Writing on the other side of our head to head debate Margaret McCartney, a GP and journalist, says that this untested, unsystematic approach will provide meaningless and potentially harmful data. It will waste public money which would be better spent on interventions that we know will improve patient satisfaction, such as continuity of care and longer consultations.

Doctor rating sites in their current form are not the answer, but nor can we resist the reformation’s incoming tide. We serve patients and health care best by making health care accountable. This means putting our energies into ensuring that the public has reliable, objective, accessible data on doctors’ performance, including how well they interact with patients.