Good luck!
By Sharon Begley
When Dr. Marty Makary
was a medical student, staffers at the Boston hospital where he was
training had a nickname for one of its most popular surgeons: Dr. Hodad.
"Hodad" is an
acronym for "hands of death and destruction": Despite his Ivy League
credentials and board certification, the surgeon had an unfortunate
tendency to botch operations so badly that patients often suffered
life-threatening complications.
But he was also one of the surgeons most requested by
patients, including celebrities, thanks to his charming bedside manner
and their lack of understanding about what caused their post-op
problems.
Makary, 42, aims to
end the professional code of silence that allows colleagues like Dr.
Hodad to thrive. Now a cancer surgeon at Johns Hopkins Hospital in
Baltimore, Makary
has just published the book "Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care."
It outlines the extent to which doctors and hospitals suppress objective data about how patients fare in their hands and
argues for clear, publicly accessible statistics to help people make the
best choices when it comes to treatment. Hospitals and physicians, he
argues, should collect "outcomes data" on everything from how many
knee-replacement patients walk without a limp to how many prostatectomy
patients become incontinent.
Without that,
"patients are walking in blind" every time they choose a hospital,
Makary said in an interview. With rare exception they have no way of
knowing whether they will receive appropriate care or be one of the
100,000 patients killed or 9 million harmed every year in the United
States because of medical mistakes.
"There is terrible
guilt about keeping quiet, but there are strong social forces against
speaking up when you think something doesn't look right: It can get you
fired," said Makary. (HealthGrades, a Denver company that develops and
markets quality and safety ratings of healthcare providers, rates Makary
a "recognized doctor" based on his training and record of no
disciplinary actions or malpractice claims.) "You realize as a young
doctor that you've walked into an industry with a very dark side."
CLEAR AS MUD
In no U.S. state can patients find out what a surgeon's
rate of complications is, how many mistakes a hospital makes, how many
avoidable deaths it has or almost anything else about a provider's
record of care.
Most ratings, from
magazines to websites, reflect softer metrics. In the closely watched
hospital rankings issued by U.S. News & World report, "reputation,"
or what specialists think of a hospital, counts 32.5 percent toward
overall scores. Patient volume, number of nurses, use of advanced
technologies and 30-day mortality rates also count.
The federal
government collects and makes public some measures, such as hospitals'
rates of complications and mortality after certain procedures, on the
Hospital Compare website. About half the states require hospitals to
make public what percentage of patients develop infections. While that's
better than nothing, says Dr. John Santa of Consumers Union, publisher
of Consumer Reports, providers have largely succeeded in hiding their
records.
"Despite the best efforts, if hospitals don't have to report something they don't," said Santa.
For example, a
regular survey by Johns Hopkins asks staffers at 60 hospitals about
safety and teamwork. Studies show that hospitals scoring high on the
surveys have fewer surgical complications and better patient outcomes.
But hospitals participate "under the condition that the results remain
top secret," said Makary.
Specialist groups also gather data, including the
Society of Thoracic Surgeons, which tracks national heart-surgery
outcomes. Only one-third of hospitals have agreed to post their results
on the society's website.
Santa believes patients should have far more data on
outcomes, such as what fraction of hip-replacement patients develop
infections and what fraction of heart-bypass patients survive, not just
currently available information on whether providers follow medical
guidelines.
The reason? Good practices may not be a reliable proxy
for good safety. A hospital's rate of providing antibiotics after
surgery, for instance, does not always correlate with patients'
infection rate, said Santa.
The Joint
Commission, an independent non-profit that certifies and accredits
hospitals and other providers, last week released its annual report
summarizing how well 3,300 hospitals did on measures of quality and
safety.
Patients can see that a particular hospital was a "top
performer" in pneumonia care, meeting criteria such as taking blood
cultures in the intensive care unit. But unless a hospital was
specifically cited for exceptional care, patients have no way of knowing
how good or bad relative to others it is.
More outcomes
measures - whether that knee replacement patient walks again, or even
dies on the operating table - will be made public in coming years, said
Nancy Foster, vice president for quality and patient safety policy at
the American Hospital Association. Patients typically choose a hospital
based on what their doctor or friends recommend, she notes, adding, "I
think there is a lot of opportunity to enrich that process with hard
data. The measures currently available are not as consumer-friendly as
most of us would like."
THE EXCEPTIONS
Makary notes several models of transparency that have
shown promise. New York, Oregon and California require hospitals to
report death rates from heart bypass surgery, adjusted for how sick
patients were and other factors to make the comparisons fair.
Transparency has benefited patients. After New York
made its data public in 1989, hospitals scrambled to improve, and death
rates from heart surgery fell 41 percent in four years.
Vitals.com, a
doctor-reviews site launched in 2008, recently began incorporating
outcomes for cancer and orthopedic surgery from a number of large
hospitals into its ratings, said chief executive and co-founder Mitch
Rothschild.
"Individual
facilities recognize that if they don't weed out bad practitioners,
they'll get creamed as Medicare starts penalizing hospitals for poor
performance, so they collect these metrics and share them with us," he
said.
For other outcome data that hospitals chose not to
share, Vitals filed a Freedom of Information Act request to access the
government's Medicare health program for the elderly.
"After a year and a half, as legal fees mounted, we
gave up," Rothschild said. The government maintains the data cannot be
made public for reasons of privacy and others.
In the meantime,
the pitfalls for patients are many. When Makary looked Dr. Hodad up
years later, he was still thriving and had a five-star rating on a
popular review website.
Makary regrets
keeping quiet during a residency at a university-affiliated community
hospital that boasted of its "comprehensive breast cancer center" and
"No. 1 ranking."
Both statements
were inventions of the hospital's marketing department, which can make
all sorts of claims as long as they are vague enough not to fall afoul
of truth-in-advertising laws. The assertion that patients "may" or
"often" do better at a particular hospital is allowed, for instance, as
are subjective terms like "comprehensive."
Based on such
claims, a young patient Makary calls "Gretchen" who needed breast-cancer
surgery believed she would get superb care.
In reality, the small hospital did only a few dozen such surgeries per year compared with hundreds at major hospitals.
It did not have the expertise to do breast-conserving and
-reconstruction surgery, nor were its surgeons adept at the latest
procedures.
Makary said he was
bothered at the time by the hospital's disingenuous claims and worried
for Gretchen, though he did not warn her. He did ask if she'd considered
other hospitals, but even that placed him "on thin ice with my own
job."
The operation was
horribly botched, leaving Gretchen deformed. Not knowing any other
outcome was possible, Makary said, she considered herself "very blessed"
just for being alive.
"Why
do students cheat?" is a silly question, because the answer is obvious:
to pass the test. Indeed, a lof of kids cheat because they couldn't pass
the test otherwise, no matter how hard they study, but that's not the
case in New York City's flagship public school Stuyvesant, where most
kids are already very, very, very smart.
