In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Martin Makary, MD.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
What we need is a Sarbanes-Oxley for medicine, so reporting can be standardized and there can be accountability."
Martin Makary, MD, is a prominent Johns Hopkins pancreas surgeon specializing in minimally invasive surgery and eyelet transplants.
He's also an outspoken surgical quality advocate who wants "trust restored to healthcare through public reporting and transparency," and for healthcare "to move to more transparency, from the bedside to the hospital's performance."
He's pushing for the use of video cameras in operating rooms to better monitor quality and technique, and for standardized national requirements for hospitals to report adverse events resulting from surgery. This way hospitals can learn from their mistakes using peer review and video-based coaching for quality improvement.
Hospitals should also be required to make available the data on their adoption of best practices, such as procedures done with minimally invasive laparoscopic methods that are associated with lower infection rates, reduced pain, and better outcomes, versus open surgery.
And he wants registries that now collect quality and outcomes statistics from surgical and other hospital procedures—especially those registries that receive taxpayer support—to be available to the public.
"Making public access a condition of taxpayer funding" of national outcome registries "is one simple reform which would allow the free market to identify and eliminate waste in healthcare," he said in his April testimony before the House Oversight and Government Reform Subcommittee on Energy Policy, Healthcare, and Entitlements. Another strategy is to provide more federal funding of those registries to ensure independence and transparency.
"The procedure for reporting measures [in these registries] needs some oversight," he says.
"We have a Sarbanes-Oxley law for business, where a CEO can be accountable for misstating the company's earnings to the public; what we need is a Sarbanes-Oxley for medicine, so reporting can be standardized and there can be accountability. Does the public have a right to know about the quality of their hospitals? Many of us have said, 'Yes.' "
One area of particular interest is appropriateness of care and overtreatment, especially in surgery. Makary serves as director of quality and safety for the Johns Hopkins Hospital Department of Surgery, and leads his own research team exploring the widespread problem of overtreatment, which he called "the next big frontier in quality."
"About $750 billion, or one-third of healthcare expenditures may be going to things that don't improve health outcomes at all, and they're attributed to fraud, opportunities for overtreatment, and unnecessary tests," he says. "We focus on things that are easy to measure, like patient satisfaction. But you can have a totally satisfied patient who had unnecessary surgery. Patient satisfaction is an important measure, and it should be publicly reported, but we shouldn't be fooled into thinking it's a comprehensive measure."
Makary is an author of the 2012 book Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care and more than 150 scientific papers on topics including technical improvements in surgical techniques and physician behaviors, such as how often they acknowledge errors and report adverse events.
He's accomplished all this since he realized during graduate school 15 years ago—where Harvard patient safety advocate Lucian Leape was his professor—that quality and honesty in healthcare needed scrutiny and improvement.
Arriving at Johns Hopkins in 2004, he watched colleague Peter Pronovost, MD, now senior vice president for patient safety and quality, develop a checklist for the intensive care unit that reduced hospital-acquired bloodstream infections associated with placement of central line catheters.
"Based on Dr. Pronovost's experience with checklists in the ICU," Makary says, "he suggested we develop a checklist for general surgical procedures in the OR," which started with just a few key items to prevent errors.
By allowing all members of the surgical team to introduce themselves before the procedure and indicate their roles, "we could create a sense of dignity" and empower anyone on the team to "speak up when they see something that doesn't look right." Also in the checklist is a pause or a time-out, a period for discussion about expectations and potential problems that might be encountered, and at the end of the surgery a time for debriefing to discuss lessons for future cases.
The checklist took off, was adopted by the World Health Organization, and was lauded in a book, The Checklist Manifesto by Atul Gawande, MD.
"That's the one achievement I'm most pleased with," Makary says.
One area Makary plans to work on is the improvements in the nation's traditional peer review systems, "in ways that remove the politics of the local referral practice system," so poor performers are identified and dealt with.
For example, he says, "having one chest surgeon at your hospital, and having them present morbidity and mortality that they review themselves, alone, or by their brand new junior partner, or a referring pulmonologist—you can not really have regular, fair, standardized peer review when it's knit so tightly in local referral patterns. Medicine is a referral business, especially the high-ticket items like surgery."
Expanding healthcare systems and networks can provide what Makary calls "a tremendous opportunity for hospitals to draw on a broader group of physicians to weigh in on peer review."
Makary also speaks out about the need for hospitals to report data in standard ways so it is reliable and comparable. All too often, for quality indicators that are available for performance programs, "we just rely on hospitals to just send a number in, on their own good faith, using their own internal method of reporting that nobody has audited, with the exception of a few programs from the American College of Surgeons' National Surgical Quality Improvement Program.
"And we've created a perverse incentive, which rewards hospitals that are less vigilant or poor at capturing their complications. So why do we think hospitals are uniformly applying aggressive standards to their reporting?"
For any other industry, he adds, "we have checks and balances."
Makary frequently travels to give talks about surgical improvement, performs pancreas surgeries three days a week, and has time for ambitious research projects and weekend golf.
"I love being a doctor," he says.