28.4.13

DOCTOR'S ORDERS

(Published in Style Magazine)

DOCTOR'S ORDERS

In his new book, Johns Hopkins surgeon Marty Makary breaks the code of silence, exposes hospital errors and medical mishaps in an effort to better inform patients. By Mat Edelson


As a young medical resident, Marty Makary worked with a surgeon whom hospital staff had tagged with a frightening acronym: HODAD…as in “Hands of Death and Destruction.” Unsuspecting patients, Makary discovered, actually appreciated the doctor for his compassion, especially since his often deadly mistakes were shielded by administrators out to protect one of their own. The situation with HODAD, and the medical system’s general withholding of information vital to patients, upset Makary so much that in his third year he quit medical school to go into public health.

A year later, missing patient care, Makary returned to medicine. And now as a Johns Hopkins surgeon, he’s on a mission: to help reduce the estimated 100,000 preventable deaths that occur each year in the United States because of hospital-based medical errors. To put those numbers into perspective, medical errors are the fifth leading cause of death in America--and the third-leading cause when you include another hospital issue, preventable infections.   

In his new New York Times bestseller, “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care” (Bloomsbury Press), Makary exposes the medical mindset that leads to complacency and errors, and offers both medicine and the public the tools they need to measure the safety of hospitals. In the book, the 45-year-old soft-spoken Makary, once nominated to be on President Obama’s short list for Surgeon General, offers an eye-opening, nuts-and-bolts primer on medical errors. The faults, he shows, lie in systems and culture as much as in people.

In an environment fraught with fear, repercussions, litigation and an often-oppressive hierarchy that controls promotions, Makary says the code of silence on errors is inculcated in medical students from Day One, and woe to those who break it. “Suddenly, whistle-blower doctors notice they are assigned to more emergency-calls, given fewer resources, or simply bad-mouthed and discredited in retaliation,” he writes. “I witnessed several doctors run out of town because their honesty and outspokenness began to poke the bear.”

In his book, Makary points out not just the errors of others, but his own, as well. As an intern, Makary was in charge of District of Columbia General’s intensive care unit one evening. The only physician on the unit, he was 24 hours into a shift and admittedly exhausted when he misread a vital sign and had a patient’s ventilator adjusted according to the mistaken reading. The patient came perilously close to respiratory arrest, developed hospital-acquired pneumonia and died a week later. In keeping with the code he'd been taught, he didn't tell his supervisors--or anyone--about his mistake. Makary still doesn't know for sure what role his error played in the patient’s outcome.

Sitting one fall afternoon in The Daily Grind coffee shop in a baseball cap, Makary says admitting his mistake in print is part of the transparency he feels the medical community needs to achieve to move forward, which includes admitting that physicians, contrary to the image many like to project, are imperfect. “I think it was important to be human [about my mistake], and to show others that if they commit a medical mistake they can realize it’s part of being human,” he says. “But you have to be open and address it and not be silent. If we don’t talk and measure it, we’re not accountable.”

After a year of silence surrounding his mistake, Makary had an epiphany in a bar with two other residents. They all discussed errors they’d made, and went on to partially blame a hospital system that, in trying to turn a profit, put patients in harm’s way every day. Too few doctors and nurses serving too many patients was an equation that could only lead to infection, inconsistent care and inevitably poor—if not deadly—outcomes. But the idea that “the system” was at fault was oppressive and infuriating to some. But it energized Makary.

A man of deep Christian faith, he believed he could change the system, and his timing was spot on: A 1999 Institute of Medicine report entitled “To Err is Human: Building a Safer Health System,” placed patient safety and quality control in medicine squarely in the public eye.

Soon after, Makary would team with colleague Dr. Peter Pronovost to research the causes and potential fixes of medical errors, Pronovost, director of Hopkins’ Armstrong Institute for Patient Safety and Quality, is credited with coming up with a simple-to-use ICU safety and infection prevention “checklist” that’s been adopted across America, saving tens of thousands of lives.

Like Pronovost, whose father died of a medical error, Makary admits to being driven by the medical misfortunes of those close to him: a grandfather who died from a preventable infection following unnecessary surgery, a family friend misdiagnosed with breast cancer who had an unneeded mastectomy, a brother bearing a large scar on his back where poorly-sewn stitches tore apart post-surgery.  Makary’s work measuring such errors might not eliminate all of them, but he argues in his book that the public has a right to know that they’ve occurred.

He notes that the science of measuring errors has come a long way, but methods of getting that information to the public have not.  Hospitals are now required to collect information on so-called sentinel events (defined as a major error, such as a drug overdose), infection rates, complication rates for certain surgeries and readmission rates for incomplete care. And, in fact, there are more than 200 registries that track patient outcomes. But only three make their data available to the public, according to Makary.

Then there are the 28 “never-events,” such as leaving a sponge inside a patient after surgery or setting a patient on fire, which, as the name suggests are never, ever supposed to happen. “Never-events were never tracked," says Makary. "To this day, they’re only for the first time being monitored, and only in some states. I’m arguing that if (never-events) are a high-consensus definition of something that represents quality in hospitals, why not measure it, make it available to the public, and make hospitals accountable for their performance?”

Makary’s ideas for accountability also involve video surveillance to record every operating room procedure, which according to the data he cites would improve both quality of care and patient satisfaction (One leading gastroenterologist found that the quality of procedures jumped by 30 percent after implementing recordings of colonoscopies.  He also noted that 81 percent of 250 patients wanted copies).

With a national movement toward electronic patient records, Makary says it would be beneficial for videos to be part of a person’s permanent medical file. Since the average American is expected to undergo more than nine procedures—including, often, repeat procedures--Makary says videos would give a far more accurate picture of what another doctor has done than a set of (often incomplete) notes. “As a surgeon, I know I’d love to be able to see videos of key past operations before I ‘go in,'’’ writes Makary.

While Makary’s pitch for transparency is persuasive, not everyone is buying it. UCLA OB/GYN clinical professor Dr. Peter Weiss, writing critically in his online blog about Makary’s book, claims that “posting infection rates (and) readmission rates will force hospitals and doctors to refuse care of the very ill. It will happen, mark my word.”

Makary counters that there’s no evidence that infection rate information, which is now public, has affected whom physicians choose to treat. And he says the move for transparency, for allowing the public to judge which hospitals and physicians they wish to engage, is gaining internal advocates. He points out that the Society of Thoracic Surgeons has partnered with Consumer Reports to evaluate hospital performance with a simple five-star rating system that will be available to the public. "They have 40 percent of the hospitals now," he says. "They're pushing for 100."

For Marty Makary, that's the kind of accountability that could lead hospitals back to the place from which they sprang; sanctuaries of care, dedicated to doing no harm.

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