In Box 12.3, we examine a case in which a patient experiences complications known to the surgeon yet surprising to the patient and her husband. It represents a miscommunication between patient, the patient’s family, and the treating surgeon. Although the informed consent form for surgery explained the possibility that additional surgery would be needed, the reasons for such additional surgeries were either not heard or not understood by the patient and her family.

Box 12.4 examines how shared decision-making, informed consent, and patient education can reduce the need for patients to seek post-surgery second opinions. In this case study, a known complication occurs, leading the primary surgeon to request a second opinion to ensure patient understanding.

The consulting surgeon must make an individual decision as to whether he will assume the care of the patient who is seeking a second opinion. It creates an ethical dilemma for the surgeon when the driving force behind such consultation comes from a surgical colleague. Under such circumstances, professional courtesy necessitates discussion of such options with the primary surgeon. This dilemma is further muddied when the opinion is sought in the midst of treatment when a complication or adverse development has necessitated such opinions. Here, surgical advice is being sought. Assumption of care by the second surgeon may be perceived as threatening the integrity or skill of the primary surgeon. Ideally, in such circumstances, seeking another opinion is a shared decision process between the patient and the surgeon. The best interest of the patient addresses the physical, psychological, spiritual and emotional needs for each particular patient . Such solutions may differ from one patient to the next as cultural, social and economic factors become part of the decision making process. Ideally, involving the primary surgeon in such decision pathways maintains working relationships that will facilitate present and future care of this and other patients.

As the United States continues the implementation of the Patient Protection and Affordable Care Act (PPACA), we hope to see the health care delivery system move toward sustainability.

In part, the PPACA attempts to redefine the economics of health care by changing the financial incentives to providers—substituting volume of service with value of service. The PPACA demands that providers justify care using an evidence-based perspective. Physicians and institutions will be measured, scrutinized, and judged for their outcomes of care. Care providers will be paid for better performances, as determined by the payer, and outliers may face significant penalties. Certain complications will no longer be reimbursed; however, physicians and institutions remain responsible for the cost, care and treatment of the patient for complications deemed “avoidable” by the payer.