Stephen Bolsin, the anaesthetist who raised concerns about paediatric heart surgery services at the Bristol Royal Infirmary (27 November, p 1387), told a BMJ conference on whistleblowing that all doctors should be given regular anonymous feedback about their performance so that they can "blow the whistle on themselves" before serious errors occur.
"Risk adjusted measures of performance can be achieved," he said, "and these need to be anonymously fed back to the people carrying out the treatment. All medics will want to improve their performance once they have seen the data."
He argued that this type of feedback could be an important mechanism of quality improvement, citing its success in improving outcomes of coronary artery bypass surgery in New York (JAMA 1994;271:761-6).
The New York state cardiac surgery reporting system collected data on all patients undergoing such surgery between 1989 and 1992, including preoperative risk factors, postoperative complications, and mortality. After the analysis and dissemination of the data, there was a two fifths reduction in risk adjusted mortality.
This professional monitoring needs to be placed within a changing societal and legal framework, he suggested, in which "we need to share our uncertainties with our patients, and we need to do this in a systematic fashion." Before an operation, he said, doctors should have detailed communications with patients and their relatives to explore these uncertainties.
Dr Bolsin, who is now director of anaesthesia at Geelong Hospital in Australia, discussed recent Australian legal cases which highlight this changing framework.
In the case of Chappel and Hart, in New South Wales, the court ruled that a doctor must inform a patient when he or she knows of the better success rates of a different doctor. In the case of Metaxis versus Western General Hospital, in Victoria, the court itself felt that it should decide what constitutes an important medical treatment, and not the doctor. These cases, said Dr Bolsin, mark "the end of benevolent paternalism."