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Hopkins Surgeon Blasts Healthcare Safety, Ethics

 |  By cclark@healthleadersmedia.com  
   September 13, 2012

In three decades of writing about healthcare, a couple of tragic medical errors still haunt me. One is a series of "awake" surgeries traced to a malfunctioning anesthesia machine at a California hospital. The other is the story of a man whose surgeon had left a 14-inch metal retractor in his groin for three weeks.

But I've never been so petrified of entering a hospital or a doctor's office as I am now, since reading the excoriating book, "Unaccountable," by Martin A. Makary, MD, MPH. It is set for release Tuesday.

I think anyone who reads it, providers and consumers of healthcare alike, will be too.

A Johns Hopkins pancreatic cancer surgeon, Makary portrays an industry operated by a money-grubbing, deceitful, and dangerous cabal of over-worked, sometimes drug-addicted, charlatans who frequently profit from unnecessary and unsafe procedures, and commit malpractice even as they hide behind their mistakes.

They market non-existent excellence, take kickbacks on the side, and perform surgery even when they lack adequate training, Makary asserts.

The next time I see a surgeon, I will look for any hint that he or she is a so-called "Dr. Hodad," physicians nicknamed by their peers as having "Hands of Death and Destruction." Every hospital has at least one, and they turn surgical instruments into "wrecking balls," Makary says.

I imagine that people who read his book will fret that their doctor is among those surgeons prone to perform procedures "as medically unjustified as injecting Botox into a furry dog."

Or that they are laggards who will use more dangerous, more invasive techniques simply because they lack the training to perform minimally invasive, safer procedures, and—out of greed—won't refer patients to a more competent provider who is better trained.

Makary's desire is for patients to be more skeptical and curious, to find out more about their providers, their hospitals, and their doctors.

"As a homeowner, you wouldn't hire a plumber to fix your fuse box," he writes. "The plumber's error could easily cause a spark that could burn your house to the ground. Yet every day there are patients sitting in waiting rooms waiting for the wrong doctor to treat their condition."

Makary, 40, is not your average doctor. He is a frequent contributor on CNN, and once was reportedly under consideration to be President Obama's Surgeon General. And he worked with Johns Hopkins' intensivist Peter Pronovost, MD, to reduce central line bloodstream infections through the well-known "checklist."

In an interview this week, I asked Makary what prompted him to write this horrifying "doctor-tells-all" book, and what he expects to accomplish with it.

The idea came four years ago, he says. That's when laparoscopic removal of the tail of the pancreas to remove cysts or tumors became the standard of care. It is vastly safer and better than the traditional "open" incision operations, he explains.

"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.

He was further prompted to write the book, he explains, by the healthcare reform bill debates, because absent from the discussion was the imperative to "empower patients to make informed decisions, just like we do for consumers for other goods and services."

With an insider's perspective, Makary paints a picture of a secret society, zealously unwilling to be transparent and whose members are unaccountable to anyone but themselves, and certainly not their peers, regulators, payers, or their patients.

The breadth of the issue is such that many hospitals have started to ask their own employees whether they would dare undergo treatment in their own units, and whether their organization's doctors and nurses "do what's in the best interests of their patients," he says.

At about half of the hospitals where at least 70% of the employees participated in the survey, fewer than half answered yes. Scary.

"I am often bewildered at the ethics of a corporation that is aware of a dangerous product, yet continues to sell it," he writes in the book.

While most of Makary's book focuses on perverse incentives in healthcare, and how they influence quality. But, good things are happening in isolated pockets.

He writes that groups are developing quality metrics that rate how hospitals perform, often with real-time data, but the industry needs to figure out how to best use the information for consumers and providers to see how they're doing.

Nancy Foster, Vice President for Quality and Patient Safety for the American Hospital Association, hadn't finished the book when I asked her to comment. But she agrees with its theme, that hospitals have tough problems, and that "clinicians' openness about the issues they perceive is important to solving safety problems."

Foster says, however, that hospitals struggle with a tough challenge, which is getting the right culture for their organizations. Even in other fields, she says, executives have to "work hard to communicate their desire for a safety culture and create the opportunity for it to exist.

Makary tells me he sees glimmers of hope, but also obstructions that need to be overcome.  For example, The American College of Surgeons and the Society of Thoracic Surgeons, laudably, have started to collect patient procedure outcomes in national registries. But that's for physicians and hospitals, "not for the public," Makary says.

"The data is locked and sealed tighter than Fort Knox. Hospitals don't want [patients] to see it. In hospital-speak, we call it 'sensitive data,' available only with hospital names removed."

That's a shame, he says. Because some hospitals, even among the most prestigious, have complication rates four to five times those at other hospitals, even after adjusting for patient disease severity, he says.

Of course, what Makary says isn't all that new. As he points out, scholarly articles document harm in roughly one in four patients due to medical mistakes. We know this from recent reports issued by the Institute of Medicine, the Office of Inspector General, and the New England Journal of Medicine.

What we don't know is which doctors and hospital teams are causing them. And that's what Makary wants to find out.

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