"I observed the surgical community demarcate," he says. "The small group of skilled doctors did this (new lap) procedure for all patients," while others did it through an open operation. But there was almost no dialogue about steering patients toward this superior approach.
"Instead, what I noticed was that (these less-skilled) surgeons would not talk about what was in the medical literature. Instead, they would sometimes mock (the lap procedure), and refer to it a 'not as much fun' as the open operation.
"I saw a competitive environment where surgeons were under pressure to generate more revenue and walk home at the end of the year with $1,000 to $2,000 more for each procedure that they did not refer to someone else. Huge financial incentives that lure doctors to offer suboptimal care. And that was just my own little space."
In talking with colleagues, he realized this practice goes on "in almost every specialty." Some do it just for the money, he says, but others do it because of medicine's "grey zone, those situations where it's a borderline call on whether the patient really needs to have something done."
These are "giant financial pushes" that Makary also calls "kickbacks that are not disclosed to patients in the United States from industry and drug device companies" because no one is accountable to anyone.