Often it takes someone working inside an industry to bring to light its flaws and pose solutions. Surgeon and New Yorker correspondent Atul Gawande has become famous for such system change via his The Checklist Manifesto, which details how simple hospital safety fixes can radically improve patient outcomes.
Now there’s Dr. Marty Makary’s New York Times bestseller Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care. Makary, a surgeon at Johns Hopkins Hospital and an associate professor of health policy at the Johns Hopkins School of Public Health, helped create the surgical checklist described in Gawande’s Manifesto, and is a medical commentator for CNN and Fox News.
Makary has worked at “about a dozen” hospitals, and much of that personal experience with good and bad doctors informs the book. For a nonfiction medical advocacy book, it’s a rather gripping read because Makary is passionate about fixing the modern healthcare system.
Recently, Aging Today spoke to Makary about how his push for transparency in medicine could change the culture of healthcare, and what impact that might have on elders.
Aging Today: You write about the financial incentives behind a modern tendency to overtreat. How might that tendency play out with older patients, and how it might be prevented?
Marty Makary: Overtreatment is one of the great epidemics in modern healthcare. Our system has created this problem—with good people working in a bad system. The most vulnerable patients are at the highest risk, and older adults are one of those populations.
Thirty percent of all healthcare expenditures are due to overtreatment. And medical mistakes are more common in elders. We’re talking about the problem so we can recognize it and fix it.
AT: What advice might you give an older adult seeking care?
MM: In the book I tried to give patients tools. One of those big tools is a set of questions to ask so they can navigate a system where 30 percent of second opinions are different than the first.
One of the book’s messages is that doctors are, in a sense, the heroes of the healthcare system, but new studies are telling us that 46 percent of doctors are burned out. Any time you have an industry where 46 percent of employees are burned out, there are going to be major problems with overuse, abuse, overtreatment—mistakes generated from not feeling a sense of ownership.
AT: What causes the burn out?
MM: Doctors feel they’re under pressure to produce. Part of it is a change in culture where hospital managers and executives are saying, ‘We’re seeing a 10 percent profit, and we want that up to 20 percent, so we’ll be tracking your progress carefully—we want you to be more productive.’
Doctors are saying, ‘We feel like the hospital is our landlord and we’re its tenants; we don’t feel we own delivery of care.’ It’s very difficult for them to speak up about it. We know how to make it better (say the doctors), but we feel disempowered.
AT: What causes the mistakes and overtreatment?
MM: Last year, there were a record number of mergers and acquisitions in hospitals and healthcare companies. It’s a corporatization phenomenon. Targets are given. It’s one of the great tragedies, and it’s fueling an epidemic of mistakes and overtreatment. Well-intended health providers are working in a system very different from what it was 20 years ago. The Institute of Medicine says 30 percent of procedures may be unnecessary; medical mistakes and preventable infections constitute the number three cause of death.
AT: What can doctors do to fix it?
MM: Already we’re seeing doctors rise up to say we need more accountability, we need to make outcomes transparent. There are now doctor-authored, doctor-endorsed ways to measure quality and track infections. And they’re approaching Medicare saying, ‘You should make how well a hospital does publically available.’
Nothing brings together hospital executives and doctors and nurses like the public reporting of outcomes. The hospital is then very interested in making corrections. They don’t want to be a bad outlier in the public eye.
AT: Do you find the same reasons that doctors tend to over-recommend surgeries also explain a tendency toward overmedication? Especially in elders?
MM: There are slightly different reasons, but it’s a similar concept. Overtreatment is an epidemic, and the elderly are the most vulnerable. They often experience polypharmacy, where they’re on so many meds that the meds are interfering with one another. It’s confusing to patients. Some meds are prescribed for long-term health prevention and may not be applicable to elders. Doctors are increasingly saying they don’t like the pressure they’re under to see more patients in the same amount of time. When doctors are rushed, there’s less time to counsel patients about prevention or behavior modification.
There is also a patient expectation that you go to the doctor to get meds. And there’s a public perception that there’s a pill for everything, which is fueled by direct-to-patient marketing.
AT: We’ve written about transitions of care and how they can be a dangerous time, especially for older patients. Communication is a big part of the problem. Could your push for transparency also help with this issue?
MM: The issue of breakdowns in communication and hand-off failures is creating a culture of safety, a culture of teamwork and communication. There are good ways now to measure these, with hospital surveys on patient safety culture. Many hospitals use such surveys, but don’t disclose those scores. If hospitals released them, it would add accountability, and facilities would need to put resources into making the culture safe.
AT: What about electronic record keeping as a way to help with safety and hand offs? Why is it so slow to implement?
MM: The market tends to respond to demand. There have not been the advocacy groups and consumer demand to say, ‘Hey, this isn’t right that you get treated at a hospital and can’t see your records.’ We’re talking about sensitive information that could be used to save a life, or to not repeat tests.
Society is in a dilemma right now. Do we think the public has a right to their health records? Some medical centers are charging $200 to $300 through third-party record dispensers. Some are saying, ‘Here, these are yours, take them, use them for your own personal health records.’ Keeping personal health records is important.
MM: There are a whole bunch of these third-party companies doing personal health records online, in the cloud. For me, personally, I also keep my records on my hard-drive on my computer, password-protected. You could have them in a folder and put them in a safe deposit box. It’s important to have copies; it helps put things in context when someone gets sick. Doctors love to see old health records. Someday we’ll be able to have videos of procedures we’ve had done.
AB: In the book you mention Johns Hopkins’ new family-centered care program. What have been the barriers to such care in the past and why is it still not the norm?
MM: I think, the incentives have not been aligned to make patient satisfaction the ultimate priority. Now that patient satisfaction is being shared online, and patients are writing comments online, patient satisfaction surveys at hospitals are no longer being kept private. This progress all speaks to how an increased focus on patient satisfaction could improve care.
When you ask people what’s not working well when a loved one is hospitalized, they often say the same things: there’s nowhere to sleep, there’s no access to records, the food stinks, there’s no Internet access. For a long time it’s been like the aviation industry—the safety’s good, the quality’s poor, there’s very little incentive to make it different. Hospitals are now making patient satisfaction a top priority.
AT: You mention the idea of running medicine more like we run the aviation industry. Is that a real solution to our healthcare issues?
MM: There’s a lot we can learn from the aviation industry. When you talk to doctors and nurses about safety and quality, and overall patient experience, you will know how it’s not good, and how to make it better. But doctors don’t feel empowered— their input is not solicited. Many answers and solutions lie within these frontline doctors and nurses. As more hospitals are held accountable for their performance, the more they will go to frontline doctors and nurses and listen to them.
AT: What has been the feedback on the book from peers in the medical industry?
MM: By and large doctors like the message, they feel that they often have local wisdom to make healthcare better, but they’re not being heard. The book’s main message is that if you listen to doctors and nurses you will hear many pearls that can make healthcare better. There’s been a tremendous response. I’d say 90 percent of the feedback is positive.
There’s a small subset of the old guard that say, ‘Why are you writing about “50 shades of healthcare”?’ That’s part of the problem. I think the new generation of doctors is a completely different breed. There’s a new generation of students and residents who feel very strongly that we shouldn’t be keeping any secrets. If a problem is endangering the public, we should speak up about it.
AT: There’s also a movement to change the culture of medical schools. Do you find this is also changing?
MM: Absolutely. The way we teach, the behavior we model, the way we call things out, we are now insistent that we give patients all the options. This culture is changing quickly within this new generation.
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