In his New York Times
Bestseller Unaccountable: What Hospitals Won't Tell You and How Transparency Can
Revolutionize Health Care, Johns Hopkins cancer surgeon Marty Makary reveals that the U.S. medical system, in many ways the best in the world, too often allows bad doctors and systemic flaws to go unchecked. A dramatic and
startling video trailer accompanied the book’s September 2012 release. Many of us in the patient advocate community were pleased to see a medical insider publicly validate concerns we'd been talking up for years. But as the book gained media attention, Makary braced himself for pushback
from his medical colleagues.
Marty Makary MD, MPH and me at
the National Patient Safety Congress May 2013
I was introduced to Makary
last year by my friend Patty Skolnik, whose
tragic story of losing her son to medical harm is told in the Unaccountable book trailer. Makary was later kind enough to read
and provide a comment about my book. When we both ended up attending this year’s
annual Congress of the National Patient Safety Foundation, I had a chance to
sit down with him and ask about his work.
I found Makary thoroughly
accessible, genuine, and committed to the ideas he writes about. At times
during our interview, like a surgeon taking a moment to ponder the consequences
of each stroke of the scalpel, he chooses his words with great care. It's a
trait that must serve him well in the OR, commenting on live television (he lends medical opinion to CNN, Fox News and others), and in that tricky
place where challenging the medical profession to which you've devoted your
entire adult life might just harbor consequences.
The following is edited
Mastors: In your
book, Unaccountable, you go public with some of the dirty underbelly
of what happens in
medical care. Was there a tipping point that made you decide to write it?
really a tipping point. The idea goes back quite a while. When I was in school
getting a Masters degree in public health (I took time off during medical
school to get this degree), I was talking with one of my mentors about being a
surgeon, about going through the surgical training. And they said, it’s going
to be rough, and you’ll have no time to do research, and you’ll see a lot of
unethical stuff going on that’s going to bother you. And rather than trying to
change the system as a resident, and risk losing the opportunity to be a
surgeon, do your job, focus on being a good surgeon, write down stories as you
go, and then when you get done, do the research and
pull it together. So that's what I did. As for the timing, when I heard all the demagoguery
going around about the Affordable Care Act, it made me so frustrated to hear
the political pundits miss the boat, talking about how to finance the broken
system. And I thought, you don’t just need to find ways to finance the broken
system, you need to fix the broken system-- the preventable harm, the medical mistakes and
the wide variations in quality.
kind of pushback have you gotten since releasing the book?
doctors wrote me after the Wall St. Journal article appeared. One of them said
he’d never seen a medical mistake in his entire career and he thinks that I
crossed the line and did a big disservice to the general public. I told him if
he’d like to read the book I’d be happy to sit down and discuss the book with
him. And he said, he hadn’t read it. I’ve braced myself for reaction, but by a
ratio of 9 to1, the feedback has been positive. And then right as the book came
out, the Institute of Medicine released its report that up to 30 % of medical
procedures may not be necessary. So that lent some urgency to the message.
Mastors: Are you
comfortable with being so public on this topic?
Makary: I feel
very privileged to have had media outlets come to me over the years for medical
opinion or comment. This developed over time from a lot of my research over the
years, and relationships cultivated. I actually turn down a lot of media
opportunities. It’s just not in-line with what we’re trying to accomplish.
Mastors: In the
book, you talk about a doctor during your training very popular with patients,
but privately referred to by colleagues as HODAD ("Hands of Death and
Destruction"). Have you heard from him?
Makary: Has not
gotten in touch with me.
Mastors: Does he
know who he is?
Makary: We went
through incredible detail to make sure the information in the book was not
Mastors: Is he
I’m not sure if he’s still practicing.
have to be very careful, don’t you?
always hard to challenge assumptions in a very profitable industry. Health care
represents 20 cents on every US dollar. There are many stakeholders. But I
think the only thing that’s really advanced many industries historically to get
better is people questioning what’s going on. I feel privileged just to be a
part of this conversation. Many others have been asking the questions I’ve
asked, but often they’re not physicians or clinicians. They’ve been spot-on,
but have been written off with “well, you’re not a physician”. Maybe it’s the
same message, but from different voice.
Mastors: How has
your life changed since the book came out?
physicians groups and hospital ratings agencies have invited me to speak to
them, and members of Congress have said some of this stuff makes so much sense,
can you help us figure out how to discuss legislation. Since the book came out
I get an invitation a day to speak somewhere. I probably do one a week, and
squeeze in another in the same area if it works.
you like to do more of it?
Makary: I love
being a doctor more than anything else in the world. And I want to be a good
role model for the students and the trainees. And also it’s fun and rewarding
and exciting, and it’s what I trained to be. I’ve had many opportunities, and
it would be easy just to “give it all up”, now that every hospital wants a
chief quality officer, and I’ve had many requests to consider that. But for
now, I enjoy being very clinically busy. And it gives me credibility in talking
about complex cases and differences in patient populations in different
hospitals, because the most common reflex people have when they know public
reporting is on the horizon is they say “my patients are sicker and our
problems are more complex”. So I can speak to that notion with credibility.
Mastors: We come
to conferences like this, collaborating on quality improvement…but does our
work really seem to be moving the dial on quality? What is it really going to
take for there to be significant culture change?
excited to see some small steps in changing the culture. Behaviors that were
acceptable when I was a resident are no longer acceptable today. And
unfortunately when hospitals allow one bad behavior to go without
accountability, it sets the standard for accountability for the entire
organization, and says “that’s what you can get away with.” It’s very
disruptive for culture. So there are some good changes in the culture of what’s
acceptable and what’s not.
then you see these studies that show we were only looking at the tip of the
iceberg with medical harm, and there haven’ been noticeable improvements, and I
couldn’t agree more. And I think taking care of patients on a regular basis has
taught me that there’s talk and there’s action in safety. And we’ve suffered
from bad science in safety. And now that we’ve learned how to measure it, we’re
asking now what do we do? And I think we need to do something highly innovative
and highly disruptive from an innovation standpoint in the same way other
industries have done it.
Mastors: Can you
give me an example?
education, we’ve got this horrible burden on society which is the tremendous
cost of higher education. You need a quarter of a million dollars now to send
your kid to many of the good schools out there. Well, this one guy at Stanford
is making his classes totally available to the public, all the course and tests
and feedback, and he got 160,000 students to sign up for it, this class that he
just made freely available. He didn’t recruit those people, they saw the
opportunity. He’s now talking about reducing the cost of higher education by 90
percent over the next 10 years. That’s a highly innovative and disruptive
intervention. We need something like that in health care. We need a whole new
look at transparency that measures, captures, and feeds the data back. We need
external peer review, something I wrote about in JAMA last week. We can’t rely
on internal peer review because it’s contaminated by the local politics of an
organization and a department. If you only have one surgeon that does chest
surgery, how are you going to internally provide per review of those
complications? You need external peer review. External peer review might have
prevented these instances of egregious overtreatment, like hundreds of patients
getting unnecessary stents, and other things.
Mastors: What do
you think you uniquely bring to the dynamic of quality improvement and culture
change in health care?
I see myself as an observer of a movement. Of people that are on the front
lines of health care saying “this isn’t right…we need to do something
differently”. And in Unaccountable, I almost present myself as a journalist sharing
first-hand accounts. I don’t claim to be the leader in this effort to make
health care more honest and transparent. But I think we in the medical
profession should be very proud that doctors are stepping in to say we are
over-treating patients so frequently...that we’re seeing these exciting things
like Choosing Wisely, where physicians are coming up with a list of treatments
that we need to warm patients about if they’re recommended to them. The
external peer review process I wrote about in JAMA is being modeled in a few
places. All these steps help.
that the wisdom to make health care safer exists; we’re just not listening to
it. And I say we as doctors and nurses…we all say we all know how to make
health care safer, but our wisdom is not being solicited. We know what to do,
we just don’t feel management and people at the policy level are empowering us
to re-design care. We feel that that we only own a small piece of the care
process, whereas we used to own the entire delivery of the care.
Mastors: You said
you see yourself as an observer. But are you also a catalyst? Do you think this
book has changed the dialogue?
Makary: I’ve been
very pleased that a lot of doctors have come up to me and said thank you for
speaking up about what I’ve been watching as a disparity “in our local area”
for decades. I’ve had hundreds of nurses contact me saying I was fired or let
go or threatened because I spoke up about somebody who was doing unethical
things. I don’t condemn many things in life but I have come out very strongly
against hospitals for firing nurses for speaking up about safety…and doctors
too. And that’s the whole problem, is there’s been almost a gag on the whole
subject. When one nurse gets fired for speaking up, it sends a message out to
every nurse around the country: speak up and run the risk of losing your job.
It’s an intangible risk, but it sends a horrible message. And we need to be
moving the other way. We need to be saying “tell us your stories”. We need to
create a safe place and give you counseling to help you with the trauma of
seeing this harm.
Mastors: So are
you shaping up to be a champion of nurses?
Makary: I’m a big
believer in peer-to-peer champions. But it’s been a very nice privilege to be
welcomed into their [the nurses’] circles.
thing that brings me the most joy is watching the light bulb go off with
medical students…challenging things that don’t look right. Improving the poor
communication that leads to harm. The lack of humility. It’s hard to measure in
databases but can have huge impact with younger students.
about Marty Makary personally?
busy, because I’m still trying to find time to operate 2-3 days a week, and see
patients in the clinic another day a week, and work with students and research
fellows and projects that will have high-impact value in medical literature.
But the thing I love most about traveling outside is what I learn. I find out
which hospitals are using best practices and learning a lot. If I were to
re-write the book today it would probably be a bit different because I learned
so much from the feedback from the book. You realize, for instance, sometime a
small hospital in the middle of nowhere has completely different struggles, and
things we talk about don’t always apply to them.
Mastors: What is
the next step?
Makary: Right now
I’m just trying to learn about day-to-day struggles, and find out why doctors
are burning out. I’m also learning more about frail patients and why their
conditions don’t tolerate many medical procedures due to this frailty. This is
a big area of opportunity to learn about.
Mastors: Will you
write another book?
thinking about it.
We'll keep you updated on Marty Makary's endeavors.
|Marty Makary MD, MPH and me at|
the National Patient Safety Congress May 2013
In his New York Times Bestseller Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care, Johns Hopkins cancer surgeon Marty Makary reveals that the U.S. medical system, in many ways the best in the world, too often allows bad doctors and systemic flaws to go unchecked. A dramatic and startling video trailer accompanied the book’s September 2012 release. Many of us in the patient advocate community were pleased to see a medical insider publicly validate concerns we'd been talking up for years. But as the book gained media attention, Makary braced himself for pushback from his medical colleagues.
I was introduced to Makary last year by my friend Patty Skolnik, whose tragic story of losing her son to medical harm is told in the Unaccountable book trailer. Makary was later kind enough to read and provide a comment about my book. When we both ended up attending this year’s annual Congress of the National Patient Safety Foundation, I had a chance to sit down with him and ask about his work.
I found Makary thoroughly accessible, genuine, and committed to the ideas he writes about. At times during our interview, like a surgeon taking a moment to ponder the consequences of each stroke of the scalpel, he chooses his words with great care. It's a trait that must serve him well in the OR, commenting on live television (he lends medical opinion to CNN, Fox News and others), and in that tricky place where challenging the medical profession to which you've devoted your entire adult life might just harbor consequences.
The following is edited for length.Pat Mastors: In your book, Unaccountable, you go public with some of the dirty underbelly