Raising the Alarm

Some say that high blood pressure is a silent killer. However, a surgeon and author of a newly released book believes that your doctor may be the real silent killer. The prescription? Transparency.

Pay close attention to that man behind the curtain. He may be your doctor. He’s as powerful as a wizard, and more dangerous.

That is the opinion of Marty Makary, M.D., MPD, surgeon at Johns Hopkins Hospital and associate professor of health policy at the Johns Hopkins School of Public Health, in his book “Unaccountable.” If the title isn’t enough to scare you (clue – he’s referring to doctors when he uses the term), this story on page 1 will be:

“As a third-year medical student, I quit medical school in disillusionment – modern medicine seemed as dangerous and dishonest as it was miraculous and scrupulous. The crowning moment came when I saw a sweet old lady I cared a lot about die after a procedure she didn’t need and didn’t want. Her doctors had pressed her to do it. I expressed my concern to them that she really didn’t want this procedure and was frightened by the picture her doctors painted of what would happen to her if she didn’t go through with it. Despite my protests to senior colleagues that the patient was misinformed and wanted to decline her the operation, surgeons persuaded her otherwise. They operated. She developed a tragic painful complication and died three months later. That was it.”

And that was it for Makary’s medical schooling, at least for a while. He left, pursued a degree in public health, then returned to medical school, as he longed for direct patient contact. Since then, he has taken it upon himself to sound the alarm on one of America’s most trusted professionals – your doctor.

Silence perpetuates the problem
And an alarm should indeed be raised, says Makary. He tells the story of a Harvard surgeon at a national surgeons’ conference, who instructed his audience to do the following: “Raise your hand if you know of a physician you work with who should not be practicing because he or she is dangerous.” Every hand went up.

“Every day, people are injured or killed by a medical mistake that might have been prevented with a modicum of adherence to standardized guidelines,” Makary writes. “The silence about the problem has paralyzed efforts to address it – until now.”

“The problem” is multifaceted. It’s part incompetence, part arrogance and part greed. Because of it, people are suffering and dying needlessly…and expensively. “Most medical school applicants would detest a career goal to overtreat patients or prescribe expensive interventions,” he writes. “But this is how doctors are socialized. We’re subtly taught a bias toward treatment rather than restraint. And while we don’t like to admit that the almighty dollar can influence our medical decisions, we all readily concede it does – for other doctors.”

If only patients knew. “A hospital is no longer the community pillar I knew growing up, with its altruistic mission guiding its decisions,” writes Makary. “Hospitals have merged and transformed into giant corporations with little accountability – and they like it that way. Patients are encouraged to think that the health care system is a well-oiled machine, competent and all-wise. It’s not. It’s actually more like the Wild West.”
The results are mistakes…lots of them. Carefully guarded mistakes. “Medical mistakes are but one costly example of how health care’s closed-door culture feeds complacency about its problems.”

That closed-door culture, or cult of unaccountability, is at the core of healthcare’s problems today, to the detriment of patients and providers alike, maintains Makary. “Just as the financial crisis was incubated when unaccountable bank executives created a culture of rewarding short-term profits without wanting to know the ugly details about their mortgage-backed securities, so too does medicine’s lack of accountability create an institutional culture that fosters overtreating and runaway costs.”

The incompetent doctor
Even the nicest doctors can cause irreparable harm, says Makary. Example: Dr. Hodad. Not a real person, “Hodad” (stands for “hands of death and destruction”) was the nickname surgical residents gave to one particularly incompetent surgeon at Harvard when Makary was a resident there. Hodad had a wonderful bedside manner, but patients had no way of knowing what the other surgeons knew – that Hodad was dangerous, had poor judgment and practiced outdated medicine. “[W]atching Hodad in action made me realize that patient satisfaction was only half the story,” says Makary.
The tragedy of Hodad was not only that he harmed patients, but that those around him – colleagues, residents and others – hid these dangers from his patients, to save their own professional skins. For example, what does a surgeon or resident tell a patient who asks about Hodad’s skills? “My way of staying out of trouble was to offer a carefully calibrated answer that did not speak ill of anyone,” writes Makary. “I learned this art form of double-talk from my senior residents, who were masters at it.” Doctors – not to mention residents – who call out colleagues are marked men and women. Meanwhile, patients suffer and occasionally die.

“Goldman Sachs and other investment banks were publicly admonished in a congressional hearing for selling investment products that they internally spoke of as bad deals and were betting against,” he writes. “How much more serious is the problem of hospitals actively selling services that they know are far more unsafe than the national average?” It’s hard to argue the point.

The light of day
The conspiracy of silence and unaccountability that characterizes American medicine today can be eradicated, says Makary. “[D]ata transparency, properly weighted, would empower patients to make informed decisions about where they should spend their health care dollar. If we had more of it, the accountability visited on hospitals would revolutionize the quality of medical care in every city in America, dramatically reshaping our health care landscape.”

Researchers have proven that once hospitals are required to publicly report outcomes, their outcomes improve rapidly, says Makary. He recalls the work of Dr. Mark Chassin, health commissioner of New York State, who decided to make heart-surgery death rates public. The results were startling.
“New York’s transparency program changed the way heart hospitals compete,” says the author. “No longer were they competing over highway billboards and valet parking. Suddenly they were competing over good outcomes.” Statewide, deaths from heart surgery fell 41 percent during the first four years of the program, and have continued to fall ever since.

It’s sad but true: Public reporting spurs hospitals to do things they should have been doing anyway. “Like Gulf Coast oil-spill cleanups…hospital crackdowns are rarely altruistic,” he writes. “They are commonly triggered by fears of a tarnished public image.” When rumors circulated that Medicare would publish hospital infection rates, hospitals quickly installed handwashing dispensers everywhere.

“Sunlight, it is often said, is the best disinfectant,” writes Makary. “But under our current, largely unaccountable system, hospital problems out of sight and out of mind just pile up until they get so out of hand, only a major, punishing scandal can hope to remedy them.”

Greed and ignorance aside, arrogance accounts for a good deal of the misery visited upon American patients today, maintains Makary. The code of silence in the typical operating room, for example, discourages nurses and other caregivers to speak up when they see something that might harm the patient. And despite the existence of published and established guidelines of care, doctors continue to practice medicine their own way.
“Ever since I’ve been in medicine, I’ve been amazed that each doctor has their own personal threshold to give a blood transfusion to patients with anemia, or low blood level, despite established guidelines,” he writes. And by no means is this disparity of care limited to blood transfusions. As a result, some patients get good care, others get poor care. And some doctors and hospitals overtreat, to the detriment of the patient – and at great cost. “The only reason for massive expenditures in one city and relative economy in the other was that some doctors just do more stuff, and so do entire hospitals,” he says.

Unfortunately, patients usually don’t know whether they will get the good kind of care or the bad kind. Makary tells the story of one patient, Gretchen, a breast cancer patient, who checked into one hospital after seeing its advertisements for its “comprehensive breast cancer center.”

“What? ‘Comprehensive’? ‘Center’? I was shocked at the fancy branding, since I worked there and knew it was little better equipped than a school nurse’s office.” Just a few miles away was a true breast cancer center, with properly trained radiologists, oncologists, breast surgeons, genetic counselors, and the right equipment. Gretchen survived the surgery, but with a permanently botched reconstruction job. “When I asked her if she was pleased with the result, she said, ‘I don’t really know what to compare it to, but yes, I feel very blessed.’

“Gretchen’s story taught me a personal lesson. When choosing a hospital, beware of clever marketing.”

Then there was Ronald, who came to the ER one night with what Makary referred to as a “chip shot,” a common complication following abdominal surgery. There is an easy, minimally invasive fix for the procedure. But unfortunately, the physician on call that night didn’t know how to do it, and so performed an open procedure. Ron ended up enduring a month-long recovery marked by pain, complications, inactivity and lost time at work. “Ron…would never know that if only he had come to the hospital on a different night of the week, he would have had a complete different operation and his recovery would have been radically different. But how could he know about the different ‘styles’ of practicing medicine?”

And Makary was silent. “As I changed the open wound that spanned Ronald from stem to stern, I peeled off the gauze from the beefy, red wound, cringing a little at his clearly excruciating pain. It seemed so wrong. I felt frustrated, demoralized and completely powerless. What could I do?…I knew saying anything to our chief was political suicide, and that calling the hospital president was a stunt that would haunt my career. Washington’s surgical community was small; if I was labeled as a whistle-blower, my career would be shot.”

Complicating all this is the current reimbursement system, which rewards doctors and hospitals for doing more, rather than better, procedures, says Makary. For patients with back pain, surgery is much more profitable for surgeons than neurosurgery. That leads to more back surgical procedures, at greater cost to the system.

In a transparent system, patients would know which hospitals perform the greatest number of a certain kind of procedure, and which get the best outcomes. Further, they would know which doctors to seek out. That’s a far cry from today, says Makary, who writes, “Historically, knowledge of who the best and worst doctors are has been confined to doctors’ lounges and closed risk-management meetings.”

Little oversight
State medical boards are responsible for policing medical care in America, and they’re doing a lousy job, says Makary. It’s relatively easy to get a license to practice, but difficult to get it taken away. “Unbeknownst to the public, surgeons can be arrested for driving drunk or stoned, and then go into surgery the next day. A doctor might be unable to legally drive his car to the hospital, but once he gets there, he can open up your chest for surgery.” State medical boards are lax in investigating doctors who have moved to their state from another one, where they might have been suspended, disciplined or lost a lawsuit.

Standards for airline pilots are national; they should be national for doctors as well, Makary argues. “Imagine if an airline pilot who was fired from one airline for flying while drunk could simply get a job with another airline without any other consequences. Or that a pilot who was barred from working in one state for endangering passengers could just get a flying license in another state. Would you feel comfortable getting on a plane?”

Often, mistakes are made not through incompetency or impairment, but through overwork. Despite new work rules for interns, hospitals continue to rely on interns to do too much. Makary tells of the night he had 12 trauma patients to care for; two died. “For Americans who don’t believe in rationing care, I have news for you. I was rationing care that night. It was absolutely impossible for me and one other student to give all 12 patients the attention they required…As interns covering vast numbers of complex patients at night, we were well aware that calling a senior doctor was like walking into a minefield. And as burnout intermittently burdened our lives, the art of not getting yelled at sometimes superseded the goal of providing good patient care.”
Sometimes providing too much care is as bad – or worse – than providing too little care, he says. Yet doctors do it all the time. “Treating patients is what we are taught, and many times expected, to do as doctors,” says Makary. “It’s very easy for treatment to become overtreatment. We are wired early in medical school to do things because we can.” In school, medical students learn to connect diagnoses with treatments. “As I participated in this mass-memorization game, I realized that what got lost was the appropriateness of when to treat.”

The last straw leading Makary to leave medical school for awhile was an incident involving an 82-year-old woman diagnosed with ovarian cancer. She didn’t want a biopsy, but she was pressed to have the procedure by her doctors. “She was a courageous lady, but she finally succumbed to the strong push of her doctors. The informed-consent process was pathetic, and hardly informed. I could tell she didn’t really know why she was having the biopsy. I knew this because her doctors couldn’t even tell me why she needed it. But the drive for the doctors to react reflexively to her tumor by ordering a biopsy was like a train no one could stop.” The result was unnecessary pain and suffering for the woman in her final weeks of life.

“We had foisted an unnecessary, unwanted, and ultimately harmful procedure on our patient. This was no longer a debating point to me. It harmed someone I cared about.”

The profit motive
“Even though doctors by and large are good people, they live with the many forces pulling at them amid the day-to-day grind of practicing medicine,” writes Makary. “One of those forces is their boss or hospital administrator keeping a close eye on how many dollars the doctor is bringing in. Can we be surprised if they advocate therapies that offer more income for themselves with a marginal gain for the patient?”

And of course, there is the pull of personal gain. Doctors who are incentivized by pharmaceutical companies for meeting prescribing targets, for example, tend to prescribe more pharmaceuticals.

And there is the pull of modern technology, such as surgical robots (which Makary believes offer few if any advantages over manual procedures). “Looking to technology for hope is part of the culture of medicine. But in these days when draconian cuts in health care are being considered, we need to judge technology on the basis of outcomes, not on its coolness factor.”

It’s a bleak picture Makary paints. But it’s not hopeless. Outcomes reporting and measurement systems are becoming more sophisticated. Patients are becoming more discerning. And healthcare providers are changing their internal processes. Rather than keeping “family secrets,” many providers are working on creating cultures in which speaking up is encouraged. In those situations, teamwork among staff is improved, to the ultimate benefit of patients.

“There is one common thread among hospital mishaps: poor communication,” Makary writes. “Medicine is highly complex, and there are countless ways to make mistakes, large or small. Most can be easily and quickly corrected – when people work as a team and speak out without hesitation….Nurses often have safety concerns. Whether they feel free to voice those concerns depends on hospital culture.”

Something as simple as introducing all the team members in the OR prior to a surgical procedure can enhance teamwork and communication.
In the end, transparency works, because it leads to buy-in on the part of all involved in the care process, including the patient, says Makary. That’s why he dictates notes while his patient is still in the room, to reinforce what occurred during the visit and to let the patient correct him if necessary.

“Transparency builds trust. Being able to review your doctor’s notes in writing might be even better, particularly if you could add your own comments, perhaps via the web. Transparency plus collaboration puts patient and doctor literally on the same page, so people no longer have to wonder what their doctor is thinking or whether it radically diverges from what they understand. As many as half of all medical records have been shown to contain mistakes in medication lists and other key elements of background information.”

And there is hope. Doctors who throw temper tantrums in the OR, and hence, shut off communication, are increasingly seen as old school. “Thankfully, there is a new generation of doctors and nurses moving up through the ranks with little tolerance for the immature behavior once modeled by the surgical elite,” Makary writes. They also want more humane schedules, and they want to be more honest with their patients.

“They also take a more holistic approach to healing; they are more attuned to the connection of mind and body, and willing to suggest nontraditional therapies. They’re more forthright with patients about what they know and don’t know. They believe in full disclosure and shared decision-making and are more accepting of patients who refuse treatment.”

They’re older, more diverse, more often married and less male-dominated; and there are more second-career students entering medicine after spending some years as a teacher, businessperson, nurse or other professional. “They are more mature and are ready to object to things that just don’t seem right, whether that is surgeons throwing temper tantrums or doctors withholding information from patients.”

The culture of medicine is changing rapidly, says Makary. “Medicine is an institution as old as humanity. Its traditions are as hierarchical as those of the royals. And for centuries, doctors have enhanced their authority with mystery, keeping the workings of their profession opaque. But I am convinced that the new generation of doctors is poised to usher in a revolution of transparency, open-mindedness and honesty. This generational shift may be just what is needed for medicine to end the secrecy that has historically permeated our profession.”

Here’s hoping.

About the Author

Mark Thill
Mark Thill is the Editor of The Journal of Healthcare Contracting and has been reporting on healthcare supply chain issues since 1985. He is a graduate of Dominican University in River Forest, Ill., and he received a master's degree in journalism from Northwestern University in Evanston, Ill.