What Hospitals Won’t Tell You and How Transparency Can Revolutionize Healthcare
Medical errors are one of the leading causes of death in the United States, and what’s even more shocking is that the harm often is preventable.
Hospitals often make egregious errors ranging from minor mistakes to treating the wrong patient, leaving behind surgical tools in a person after surgery, or operating on the wrong body part.
According to the 2011 Health Grades report,1 the incidence rate of medical harm occurring in the United States is estimated to be over 40,000 harmful and/or lethal errors DAILY!
Dr. Martin Makary is the author of The New York Times bestselling book Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Healthcare, which is a story about the dangerous practices and mistakes of modern medicine. He’s a practicing surgeon at Johns Hopkins Hospital and an associate professor of public health policy at the Johns Hopkins School of Public Health.
As a busy surgeon, he’s worked in many of the best hospitals in the country, and can testify to the amazing power of modern medicine to cure. But he’s also been a witness to the medical culture that routinely leaves surgical sponges inside patients, amputates the wrong limbs, and overdoses children because of sloppy handwriting.
Healthy eating, exercise, and stress management can help keep you OUT of the hospital, but if you do have to go there, knowing your rights and responsibilities can help ensure your hospital stay is a safe and healing one.
Variations in Quality Medical and Safety of Health Care Driven by ‘Perverse Incentives’
One in four patients in a hospital is harmed in some way from a medical mistake, according to the New England Journal of Medicine. Many doctors have been concerned about the quality and mistakes in healthcare, but the culture has been such that it dissuaded open discussion and transparency.
“We’re really at a very exciting time in medicine,” Dr. Makary says. “For the first time, we’re speaking up openly and honestly about this problem. We’ve got research now that supports it.
…[W]hen I was at a major medical conference once, I heard a surgeon at the podium ask the audience of thousands of doctors, ‘Do you know of somebody out there in practice who should not be practicing because they are too dangerous?’ And every single hand went up. Everybody seems to know about this problem. Everybody even knows of somebody who’s too dangerous to be in practice. Yet for a long time, we haven’t been honest about the problem.”
Dr. Makary goes on to tell a story from his days as a medical student. A young man came to the emergency room with a fractured humerus, and the doctor told him he needed an MRI, an X-ray, and a CAT scan. The young man replied he didn’t have health insurance, at which point the doctor suddenly changed his tune, telling him to just stay off his arm, wear a sling, and all would be fine.
“I thought about it,” Dr. Makary says, “The doctor was right; all those tests don’t really change what we do, because the treatment for that type of fracture was just a sling and to rest it. So, we see these wide variations on what we do. And when you ask the doctors, ‘Look, what’s going on? Why do we have so much variation in quality and safety in America?’ they point out things like ‘Look at our perverse incentives that promote bad care among as subgroup of doctors out there.’”
Is Your Surgery to Satisfy Your Doctor’s Quota?
Doctors are under tremendous pressure these days. Not only are they asked to see more patients per hour, many surgeons even have surgery quotas to meet.
“They’re told they need to do so many operations in a month,” Dr. Makary says. “Sometimes doctors tell me they get text messages and emails, saying, ‘You need to do so many operations by the end of the month.’ They’re expected to do more, often with less resources.”
Quotas aren’t the only symptom of a major disconnect between healing a patient’s problem and running a for-profit disease management scheme. As discussed by Dr. Makary, sometimes a computer software program will order tests and studies automatically, and the doctor just has to sign off on them.
“Doctors don’t like blind triggers that result in overtreatment. They want to practice medicine the way it was intended to be practiced – individualized in care,” he says.
While computers can help with some standardization in medicine increasing dependence on computerized diagnosis and even treatment is an issue that needs to be seriously considered and discussed. We’ve had a continually evolving improvement in artificial intelligence, so much so that in the next 20 to 30 years computers will be able to interview a patient and then spit out an entire battery of recommendations. However, the recommendations will only be as good as the information it’s based on. What good will it do if all RoboDoc can do is spit out tests and treatment protocols based on biased, inaccurate or fraudulent data at a more efficient rate than human M.D.’s?
Unnecessary Treatment is a Massive Problem
According to a report by the Institute of Medicine, an estimated 30 percent of all medical procedures, tests and medications may in fact be unnecessary2 – at a cost of at least $750 billion a year3 (plus the cost of emotional suffering and related complications and even death – which are impossible to put numbers on). While overuse and misuse have become a deeply ingrained part of the culture of medicine, there are hopeful signs that things are starting to change. Dr. Makary points out a number of standard blanket recommendations that have been changed in recent years, such as daily aspirin regimen, PSA testing, and annual mammograms.
“[N]ow people are saying, ‘Wait a minute, maybe we’ve gone too far.’ …We told everybody for decades [that] everybody should be on an aspirin once a day. And a lot of people were saying, ‘Wait a minute, do I really need to be taking a pill every day, even thought I’m totally healthy?’ There were studies, and they looked at certain outcomes but a recent large study has shown that the internal bleeding consequence balances out the benefits to your heart. So we’re now pulling back that recommendation. If you have a healthy heart, if you don’t have a history of heart problems, we’re now pulling that recommendation back.
Same thing with PSA testing. You’re seeing the medical community say, ‘Wait a minute, we don’t need to do a PSA test for prostate cancer on every older man in the world.’ We’re also seeing the recommendations on breast cancer screening with mammography in that middle-aged group being pulled back.
We’re seeing a lot of research coming out now that’s saying some of these giant recommendations to do more stuff probably were not based on sound science. When we look at the full gamut of consequences of overtesting, we may be creating too many false-positives and hurting more people then we’re helping.”
More Doctors Beginning to Realize What They Were Taught is Wrong
Many doctors are now beginning to accept that some things they were taught in medical school is simply wrong.
“I was taught, for example, that everybody has one million nephrons (the unit in a kidney). We now know that’s not true. We now know that it ranges from 200,000 to two million, and everyone’s different. If you have a lot, you may have more of a reserve. If you have few, you may be more frail in your ability to withstand an insult to your kidney.
We were taught fat was bad for you. We were taught, ‘Don’t eat fat. Fat is bad. Go low-fat everything.’ That was probably wrong advice that the medical community gave to the general public. We now know that what’s far more important than avoiding fat is limiting sugar, a highly addictive substance, which a driver of obesity and heart disease and has many detrimental effects, mainly the hormonal effect of changing your fat storage balance. Little did we doctors know that by demonizing fat we were encouraging high-carbohydrate foods because they are notoriously ‘low-fat.’ Obesity surged parallel to the ‘avoid fat’ era of medicine. We are now dealing with a generation addicted to sugar and we’re seeing the largest growth in obesity in the history of the country.
In terms of the percent of our population on disability and the average time on disability, we are now the most disabled country in the world. And one leading driver is obesity-related chronic diseases—a problem burdening our healthcare system. These are lifestyle diseases (medical problems that can be avoided with better behavior). We’re now recognizing that some of the emphasis in the direction that we had in medical school was just not based on the solid evidence that we’re now seeing.”
Helping Patients and Doctors Choose Wisely
For the past two years, the American Board of Internal Medicine Foundation, one of the largest physician organizations in the US, has released reports on the most overused tests and treatments that provide limited or no benefit to the patient, or worse, causes more harm than good. Last year’s report warned doctors against using 45 tests, procedures and treatments. This year, another 90 tests and treatments were added to the list. To learn more, I encourage you to browse through the Choosing Wisely web site,4as they provide informative reports on a wide variety of medical specialties, tests, and procedures that may not be in your best interest. As reported by NPR:5
“The idea is to curb unnecessary, wasteful and often harmful care, its sponsors say — not to ration care. As one foundation official pointed out last year, rationing is denial of care that patients need, while the Choosing Wisely campaign aims to reduce care that has no value.”
Unfortunately, it seems matters will only get worse with the passage of the Affordable Care Act because it’s just a continuation of the same broken process. I agree that people should be covered under health insurance, but they should be covered with appropriate care; not care that perpetuates the same problems addressed in Dr. Makary’s book.
“What we’ve got to do is educate the everyday patient to empower themselves, to understand what they’re having done, and to learn to ask the right questions,” he says. “We’ve put together a list of sort of important questions a patient should ask, and we’ve put it on the book website, UnaccountableBook.com.
Things like: ‘Do I really need to have this done? What if I don’t take this medication? And then, whatever that consequence could be, what are the odds that that could happen? And if it does happen, can we treat it once that happens?’
I remember consenting people for surgery as a resident. I was way over my head. They would ask me, ‘What happens if I don’t have an operation or take a medicine?’ And I just give them a standard answer sometimes. ‘You could die. Something could go wrong.’ And yet, I was rushing. You’re working sometimes for 40 straight hours; you’re working 120 hours a week. As a resident, you’ve got a mission. You get certain things done to get through this little list of things you need to do during the day… Research now shows that most patients are under-informed about the risks of medical tests, procedures and medications, and the benefits are overstated.”
On Referrals, and…
According to Dr. Makary, under-referral is another major issue that leads to improper medical treatment. Some doctors will simply declare that “nothing can be done,” without realizing a specialist may have an entirely different set of tools at their disposal. There are even “micro-specialists” out there specializing in a tiny area within a particular field of medicine. The trick is to find them.
“There are probably not enough referrals to specialists as there should be. I think sometimes you need to take things in your own hand and just ask for one. Or say, you know, ‘Would it help if I spoke with someone who specializes in this?’ Or go to their websites and find the experts. There are some very good websites out there now for patients, [like] ConsumerReportHealth.org. Medicare is now putting a lot of hospital performance up on the web in their website Hospital Compare. It’s HospitalCompare.hhs.gov. So, there are some good resources out there now.”
Dr. Makary suggests asking an emergency room nurse for their recommendations for specialists and doctors well-versed in a particular ailment. Another helpful strategy can be to ask around for alternative practitioners or treatment options. Your local health food store can be a good place to start.
Dr. Makary suggests “For surgery, ask the following questions:
- Do I really need this done?
- When am I going to be back to feeling good?
- What if I don’t have this procedure done?
- Can I wait a year and see if this gets better?
- What if I wait and then something develops in the interim? How do we handle it that at that point and what are the odds of success then versus now?
There’s a movement – a revolution – that we described in the book Unaccountable, which is starting to provide useful information on websites, so that patients can navigate the healthcare system.”
Safeguarding Your Care While Hospitalized
Once you’re hospitalized, you’re immediately at risk for medical errors, so one of the best safeguards is to have someone there with you. Dr. Andrew Saul has written an entire book on the issue of safeguarding your health while hospitalized. Frequently, you’re going to be relatively debilitated, especially post-op when you’re under the influence of anesthesia, and you won’t have the opportunity to see the types of processes that are going on.
Dr. Makary agrees it’s important to have someone there to act as your personal advocate, or to take the time to stay with your loved one who is hospitalized. This is particularly important for pediatric patients, and the elderly.
“Sometimes, we rely on a competent talking patient to help verify what we’re doing before we go in the operating room. But if we got somebody who’s not mentally coherent because they’re elderly or a kid and there’s no family member around, these are danger zones. These are high-risk areas for medical mistakes,” Dr. Makary warns.
“It’s important to ask what procedure’s being done or why is the procedure being done. ‘Can I talk to the doctor?’ You have a right to know about what’s being done to you or your loved one in the hospital. When you’ve got a kid in the hospital, I think it’s particularly important to ask the questions.”
For every medication given in the hospital, ask, “What is this medication? What is it for? What’s the dose?” Take notes. Ask questions. Building a relationship with the nurses can go a long way. Also, when they realize they’re going to be questioned, they’re more likely to go through that extra step of due diligence to make sure they’re getting it right—that’s human nature.
Pushing for Greater Transparency in Healthcare
The issue of transparency is a big focus of Dr. Makary’s book, Unaccountable. In it, he discusses a number of ways transparency can be improved, not only from an organization-hospital perspective, but also from an individual position perspective.
We now have a lot of data metrics to measure healthcare quality, such as different hospital’s infection rates, re-admission rates, patient satisfaction scores, and surgical complication rates. According to Dr. Makary, the ways to measure hospital performance are now maturing to the point where they need to be available to the public, and he’s seeing a “transparency revolution” starting to take place.
“I believe it’s going to reshape our entire healthcare landscape,” he says. “Instead of choosing a hospital based on a billboard advertisement or valet parking at a hospital, you should be able to look up a hospital’s performance – their quality, their volumes, and their satisfaction [rate]. You know, 60 percent of New Yorkers will look up a restaurant’s ratings before choosing a restaurant. Yet people are walking into the hospitals blind to the hospital’s performance. We’re seeing an exciting revolution now in healthcare. It’s a transparency revolution, and it’s really why I wrote this book, Unaccountable.”
Help for Victims of Preventable Medical Errors
Part of the nature of being human is that we make mistakes. No one is perfect. Mistakes will be made. And with more transparency, these mistakes will be known. So, what can you do should you find yourself a victim of a preventable medical mistake? Dr. Makary suggests connecting with patient communities like:
- Citizens for Patient Safety6
- ProPublica Patient Harm7
Besides that, he suggests:
“Ask to talk to the doctor about that mistake. If you’re not satisfied, write a letter or call the patient relations department. Every hospital is mandated to have this service. They are set up to answer your concerns. If you’re not satisfied with that, write a letter to the hospital’s lawyer, the general council. And you will see attention to the issue, because you’ve gone through the right channels.
We don’t want to encourage millions of lawsuits out there. But you know, when people voice what happened, what went wrong, and the nature of the preventable mistake, hospitals can learn from their mistakes. Sometimes they’re taking a lot of attention now to prevent mistakes from happening again. You should let that mistake be known.”
Dr. Makary co-developed a checklist for surgeons to use before surgery or any other hospital procedure. His research partner, Peter Pronovost, created a checklist in the ICU for patients that are in the intensive care unit. The World Health Organization (WHO) ended up taking an interest in their checklists and used some of their principles to develop the official World Health Organization checklist.
The WHO surgical safety checklist and implementation manual,8 which is part of the campaign “Safe Surgery Saves Lives” that Drs. Makary and Pronovost were a part of, can be downloaded here. If a loved one is in the hospital, print it out and bring it with you, as this can help you protect your family member or friend from preventable errors in care. You can also learn more in Dr. Makary’s book, available on UnaccountableBook.com and other book stores.
Avoiding Unnecessary Medical Care Can Save Your Life
One of the reasons I am so passionate about sharing the information on this site about healthy eating, exercise, and stress management with you is because it can help keep you OUT of the hospital. But if you do have to go there, you need to know how to play the game.
My primary recommendation is to avoid hospitals unless it’s an absolute emergency and you need life-saving medical attention. In such cases, it’s advisable to bring a personal advocate — a relative or friend who can speak up for you and ensure you’re given proper care if you can’t do so yourself. If you’re having an elective medical procedure done, remember that this gives you greater leeway and personal choice—use it!
Many believe training hospitals will provide them with the latest and greatest care, but they can actually be far more dangerous. As a general rule, avoid elective surgeries and procedures during the month of July because this is when brand new residents begin their training. According to a 2010 report in the Journal of General Internal Medicine,9 lethal medication errors consistently spike by about 10 percent each July, particularly in teaching hospitals, due to the inexperience of new residents. Also be cautious of weekends.
Knowing how to prevent disease so you can avoid hospitals in the first place is clearly your best bet. One of the best strategies on that end is to optimize your diet. You can get up to speed on that by reviewing my comprehensive Nutrition Plan. Additionally, knowing what to do to make your hospital stay as safe as possible is equally important if you have the misfortune of being hospitalized. Understand that you, the patient, are the most powerful entity within the entire hospital system. However, the system works on the assumption that the patient will not claim that power. Knowing your rights and responsibilities can help ensure your hospital stay is a safe and healing one.
- 1 HealthGrades 2011 Healthcare Consumerism and Hospital Quality in America Report
- 2 The Wall Street Journal September 21, 2012
- 3 The Wall Street Journal September 21, 2012
- 4 See ref 3
- 5 NPR February 21 2013
- 6 Citizens for Patient Safety
- 7 ProPublica Patient Harm Facebook page
- 8 WHO Checklist for Safe Surgery
- 9 Journal of General Internal Medicine, August 2010: 25(8); 774-779
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