"Eventually you could die"
Makary confesses that as a trainee, he engaged in a practice he called "patient manipulation" as a survival mechanism.
"I was under pressure to get [patients] to sign surgical consents. If a patient asked, 'What if I don't have this done?' I would cut right to the chase and say, 'Eventually you could die.' That was a phrase that circulated a lot among residents."
The idea to get patients to consider their own unique health status before making a decision is, in part, the brainchild of James Weinstein, DO, a spine surgeon and former head of the Dartmouth Institute. He is now President and CEO of Dartmouth-Hitchcock healthcare system.
Just in his field of spine surgery, he says, "we know that in shared decision-making models, when patients are given good information, 30% choose not to have surgery."
Some versions of the concept have been rolled out at Dartmouth for a variety of orthopedic procedures, Weinstein says. All take the surgeon out of the decision-making equation because of obvious conflicts of interest they may have, conscious or unconscious.
Decisions about non-emergent surgeries "should be made at the primary care doctor level. That's what we at Dartmouth do," he says.
Naturally, the idea will get the best reception in healthcare systems with salaried surgeons, like Dartmouth-Hitchcock or Makary's Johns Hopkins.
Several systems, like Intermountain and the Mayo Clinic, are rolling out versions of this model soon. At Mayo Clinic, it's being adopted to help patients choose how to choose medications for their diabetes.