At a medical conference Dr. Marty Makary saw one of his Harvard professors who "looked out at a room of 2,000 doctors and asked 'How many of you know of another doctor who should not be practicing because he is too dangerous?' Every hand went up." Yet few report bad doctors and those that do often get fired.
In fact, unlike repeat offending criminals who get caught, many doctors can keep making similar, even mortal, mistakes on different patients and get away with it.
Hospital staff knows they are practicing bad medicine and mostly do nothing. In Makary's provocative book, Unaccountable, he describes one Ivy League-trained doctor who's popular with patients yet dubbed 'Hodad,' by his colleagues, for his continuing string of patient deaths. 'Hodad' is their dark humored acronym for "hands of death and destruction."
Alarmingly, medical errors are the third leading cause of death in this country. "As many as 25 percent of all patients are harmed by medical mistakes" reports Makery. Going into a hospital, we have no way of knowing if we will get good care or be one of the 100,000 patients killed or nine million Americans harmed each year by medical mistakes.
I was surprised to learn that many of the hospitals that did not keep up with modern procedures were big academic medical centers. They are most likely to be led by what Makery dubs an "old-guard patriarchy." They aren't required nor motivated to learn modern, less invasive procedures from which recovery is higher, or to support programs that increase transparency with patients. Plus they resist instituting evidence-based medical practices. Thus they "tend to be more behind the times than some large, non-university hospitals," Makery discovered. Across the board, many hospitals and doctors lag behind most other industries and professions in serving us, their "customers."
One of Makery's colleagues said you could find more information about toothpaste or a car you are buying than you can have about the healthcare you get. The "raging" interest in reform has even sparked creation of a documentary, Escape Fire, and a film in the making, Informed Consent.
1. While the code of silence and cloak of secrecy around patient survival and recovery remains the norm in most of the country, there are ways you can increase the chances that you will get better care, according to Makary, a surgeon at Johns Hopkins Hospital in Baltimore and a professor at Johns Hopkins School of Public Health.
2. If you don't know if your doctor is competent for the kind of care you appear to need, ask one or two medical professionals at the hospital to give their personal recommendation of a doctor in that field.
3. No matter what your current doctor's hospital affiliation may be, look online for unbiased sources to compare hospitals and doctors, and to learn more about your condition and your options. Start with these websites: Vitals.com, PubMed.gov, and HospitalCompare.
When a doctor proposes surgery, ask:
- What happens if I don't do this?
- What other options do I have?
- What are the risks and the benefits for each alternative, based on statistical outcomes?
- How many times have you performed that procedure, and how recently?
- Is there is a minimally invasive alternative (if it is not suggested upfront)?
4. Ask a nurse or other medical professional, to recommend another doctor, to get a second opinion, even if your insurance does not cover it.
How Strong is Your Hospital's Performance Accountability?
Has your doctor's hospital adopted a system for nurses to independently monitor infections? If so, the quality of care and follow-up will probably be much better. Currently, for example, Makary says that hospitals that "do a poor job of self-monitoring their infections get rewarded for having low rates and conversely hospitals with close patient follow-up and independent nurses to monitor infections are punished for capturing more infections via higher reported rates."
Hospitals, like functioning democracies, depend on transparency and check and balances. The Association of periOperative Registered Nurses are strong backers of this approach and can be experienced, real time guardians of our health care, when given the power to independently enforce and verify that patient safety systems are followed. We need to support them in securing this role in more hospitals.
Bottom Up: We Can Create Collective Clout for Better Medical Care
As individuals we have little power over health care reform. et, if enough of us possible patients demand comparison shopping for the best performing hospitals we can nudge hospitals -- and the doctors on which they depend -- to become more accountable and transparent. When we ask, collectively and publicly, for national standards of accountability we can hasten hospital reform.
Makery worked with Atul Gawande in ardently advocating The Checklist approach (read The Checklist Manifesto: How to Get Things Right) that requires doctors, like pilots, to follow specific steps and permits, and even requires the rest of the medical team in attendance to speak up if they do not. Change comes slowly to most hospitals. Faster than most hospitals, in even informing their workers about the Checklist Manifesto approach, Twitter and Square founder Jack Dorsey gives a copy of the book to everyone he hires. Makery and other daring medical leaders advocate hospital data "dashboards": that we as patients, as well as medical professionals can view and -- finally -- do comparison shopping. After all, our lives may well be at stake.
Your Life May Depend on Knowing This
Does the hospital where your doctor practices have a system of tracking patient outcomes that is available to the public and easy to understand? Few do. According to Makary, hospitals should track meaningful data on a dashboard, for six vital performance factors that directly affect your safety. Consider this the new checklist, this time for hospitals:
1. Bouncebacks: Patients who have to be readmitted within ninety days after discharge.
2. Complication Rates: "Unexpected adverse effects" that can be complex in nature yet sufficient algorithms have been developed to compare and report hospital performances in language that we lay people can understand. "The shocking truth is that some prestigious, large hospitals have four to five times the complication rates of other hospitals in the same city, wrote Makery.
3. Never Events:Gross errors such as leaving an instrument in a patient, or performing the wrong operation, or other gross errors that should never happen.
4. Safety-Culture Scores: Hospital administrators ask medical staff three questions in a survey that is made public and is a highly accurate way to assess safety:
- Would you have your operation at the hospital in which you work?
- Do you feel comfortable speaking up when you have a safety concern?
- Does the teamwork here promote doing what's right for the patient?
Imagine! Only an estimated 1,500 U.S. hospitals dare to follow this practice.
5. Hospital Volumes:Report the number of patients with a particular medical condition and how many of each type of surgery do they perform each year. Makary lauds Minnesota and Massachusetts which have "begun to require hospitals to reveal how many procedures they perform, by type, each year for the public to use in deciding where to go for care." As well, how many minimally invasive surgeries do they perform as compared to traditional open surgeries, which are much more fraught with danger yet some doctors refuse to learn how to do them? The shocking truth is that some prestigious, large hospitals have four to five times the complication rates of other hospitals in the same city."
6. Transparent Records, Open Notes, and Video Recording: We should be able to find out whether a hospital participates in a program by which, "we can easily view our written and video medical records" according to Makary. To buttress that benefit for all parties, a recent study shows that we, as patients, are more likely to understand our condition and comply with our doctor's instructions when they share their clinical notes with us, Christine S. Moyer of American Medical Newsreported yesterday:
"I want [doctors] to be enthusiastic about this prospect," said study co-author Tom Delbanco, MD, an internist at Beth Israel Deaconess Medical Center in Boston, one of three sites where the study was conducted. "I think that once [open notes] become part of standard practice and we learn how to use these well, it will enrich the doctor's experience and the patient's experience."
The Veterans Administration has been an early adopter of the "open notes" movement, and the positive reaction from patient's family members has been an added boost according to Dr. Sue Woods with the VA in Portland, Ore., Forbes contributor Dave Chase reports.
Let's Save Lives by Seizing This Possible Healthcare Accountability Opportunity
Of course a national standard for such public dashboards will have an effect similar to when, despite initial resistance, all football players were required to wear helmets. When all players must follow the same rules, the dramatic difference in safety is clear and obvious to everyone. Such a standard creates the rising tide that raising all boats. Doctors may have a stronger motivation to learn from each other for us.
We have an opportunity to participate in improving care for us all. It is hidden within this wrenching time of healthcare reform, where many doctors are selling their practices to work for someone else, because they cannot afford to buy the required electronic medical record systems. Let us strongly urge our doctors, the administrators of the larger practices many of them are rapidly joining, and their affiliated hospitals to attract us as patients and as referrers for our loved ones and friends.
How? Because they offer the best care for our condition, as the user-friendly data they provide us proves. Perhaps you, too, might want to learn directly from some of the best doctors and others covering patient-centered care.