Chuck Lauer: The Shameful State of Our Hospitals

I just finished reading the book, "Unaccountable," and I have got to say, I was blown away. Written by Marty Makary, MD, this is an incredibly powerful indictment of hospitals and the doctors who work in them. It presents a stark portrait of a healthcare system that has clearly lost its way.

It's a book that should have a great deal of impact, because its author is a surgeon with a sterling reputation. On staff at Johns Hopkins Hospital in Baltimore, Dr. Makary is a dedicated proponent of patient safety and helped develop a widely used a patient safety checklist.

For more than a decade, ever since the landmark 1999 "To Err is Human" report from the Institute of Medicine, hospitals have talked a lot about instilling a "culture of safety." With all the activity that has taken place, it's a real shock to see that error rates have not budged for the most part.

The book presents some bleak statistics. One in four hospital patients is the victim of a medical mistake. Thirty to 40 percent of our healthcare dollars pays for fraudulent or unnecessary care. Ten to 15 percent of patients are not given all their options for care. And a surgeon operates on the wrong body part 40 times each week. A Harvard study published in The New England Journal of Medicine in 2010 found that as many as 25 percent of all patients are harmed by medical mistakes. These mistakes are the fifth leading cause of death in the nation.

A culture of silence

Stubbornly high error rates, Dr. Makary submits, are the result of unbridled arrogance and a lack of transparency in our healthcare system. "Healthcare's closed-door culture feeds complacency about its problems," he writes.

In stunning detail, he takes on a tour of incompetent surgeons, unnecessary surgeries and a culture of silence that punishes staff who speak out about patient safety. Dr. Makary notes that some of America's most prestigious hospitals have worse patient outcomes than many community hospitals.

We meet a Harvard teaching physician from many years ago called "Dr. Hodad" — not his real name, but one given him by his residents, as shorthand for "Hands of Death and Destruction." Dr. Makary, a medical student at the time, recalls that Dr. Hodad's operating skills were "hasty and slipshod," and his patients often had complications, but his bedside manners were impeccable. "Celebrities requested him for operations," he writes. "His patients worshiped him." He believes there are Dr. Hodads at virtually every hospital across the country.

It is not easy to report someone like Dr. Hodad. Had he done so, Dr. Makary believes he would have been ostracized. There was — and still is, to a great extent — a code of silence against reporting physicians' mistakes. Furthermore, a physician can be excellent at doing one type of procedure and awful at another, but colleagues will cover up for him because of his fame. The book reports that Michael DeBakey, MD, the world-class heart surgeon who died in 2008, was a miserable stomach surgeon. When he performed spleen surgery on the Shah of Iran, Dr. DeBakey mistakenly cut the Shah's pancreas. The shah's death from complications of that surgery at the start of the Iranian Revolution changed the course of history.

'Fred Flintstone care'

The book presents some alarming oversights in hospital ORs, which are especially frightening for those of us intending to have surgery in the near future. Dr. Makary introduces us to "Fred Flintstone care" –– outdated medicine performed by older, often highly respected physicians. These grey eminences haven't kept up with a recent breakthrough like minimally invasive surgery, which is incontestably safer than the old way of open surgery. But because these doctors are so beloved, so well protected and so hungry for more income, their patients will likely never know they had another option.

Dr. Makary tells us of a politician who had a small abdominal tumor and was under the care of the chief of surgery emeritus at his hospital. The surgeon, who had never learned minimally invasive surgery, took out the tumor the old-fashioned way. This no doubt forced the patient to suffer more pain, have a longer hospital and go home with a bigger bill, and all the while face a higher risk of infections and possible follow-up surgery.

Covering up mistakes

Rather than own up to medical errors, hospitals and practices seem to have become more proficient at covering them up. For example, the book says the patient form we fill out in the waiting room increasingly has a "gag order" in it. That is, we agree never to speak about a medical mistake, if one occurs. Dr. Makary thinks gag orders should be banned. "They are utterly contrary to a patient's right to know and to the concept of learning from our errors," he writes.

The book also targets misleading quality claims made by some hospitals, which can ensnare unsuspecting patients in nightmarish medical complications. Hospital marketing departments can make even wildly over-the-top claims vague enough to escape violation of truth-in-advertising laws. Dr. Makary recalls a young patient who was treated in a hospital that had designated itself a "Comprehensive Breast Cancer Center," even though it lacked necessary equipment and skilled surgeons. The result was her reconstructed breast was permanently disfigured.

A lot of quality concerns have to do with greed, such as when hospitals routinely pressure doctors to perform more procedures so they can make more money. Doctors often get bonuses for productivity, but not for quality, the book reports. It's an "eat what you kill" approach — the more procedures you can churn out, the more you're paid. One of Dr. Makary's physician colleagues got a note from his hospital saying: "As we approach the end of the fiscal year, try to do more operations. Your productivity will be used to determine your bonus." Performance, in this case, was "certainly not based on improved patient outcomes and lower rates of medical errors," Dr. Makary writes.

Bloated salaries

The book shows that children's hospitals make a great deal of money pulling the heartstrings of donors, and much of it goes into the pockets of their executives. Some CEOs of children's hospitals make more than $5 million a year and have perks like their own company cars, first-class travel, country club memberships and retirement packages worth millions, according to the book.

Dr. Makary writes that while the CEO of National Children's Hospital in Washington, D.C., cut the budget, he increased his own salary to $2.1 million, plus benefits. "This small, 300-hundred-bed hospital was paying its CEO far more than the CEO of our mammoth, 2,000-plus-bed John Hopkins Health System," he states.

Mind you, these are non-profit institutions that don't have to pay any taxes and continue to tug at donors' sleeves for donations. The book points out that the millions earned from these fundraising drives could be used to address mistakes in medications, which disproportionately affect children and are very expensive to fix. This cache of donations might also go toward raising the salaries of pediatrics caregivers, who are at or near shortage because they are paid relatively little. Pediatricians have a starting salary of around $110,000, compared with $500,000 for orthopedic surgeons, and the average pediatric nurse at one children's hospital gets 40 to 50 times less than what its CEO gets, the book says. What kind of message does that send out?

The solution is transparency

The best way to tamp down all the greed and improve healthcare outcomes, Dr. Makary maintains, is to end the secrecy at U.S. hospitals. Rather than micromanaging with excessive regulations, the simple act of transparency would revolutionize our whole healthcare system. If hospitals had to prove their claims of superior outcomes with real data, they would have to be more serious about meeting higher standards, and the healthcare system would be well on its way to recovery.

Dr. Makary wants hospitals to keep precise records on a variety of measures, including surgical outcomes, hospital-borne infections, readmission rates, payments to doctors, patient volume for each condition and clinicians' use of best practices.

The message is simple: When hospitals have to provide solid outcomes data, their performance improves. The book notes that when New York State began requiring hospitals to disclose death rates from coronary artery bypass surgeries, the ones with high mortality rates suddenly felt the pressure to make improvements.

The results of the New York program are remarkable. Statewide deaths from heart surgery fell by 41 percent in the first four years of the program. When leadership at one hospital saw that the mortality rate of a particular surgeon was bringing down its score, he was ordered to stop doing heart surgery. The Dr. Hodads were no longer protected.

Dr. Makary is taking further steps toward transparency in his own practice. He has started asking patients to review the notes he took on them on their office visits. Patients began correcting important data that he had gotten wrong in the interview.

He also recommends what is perhaps the ultimate form of transparency — recording medical procedures on videotape and playing them back for the surgical team to evaluate. He adds that installing cameras at hand-washing stations in North Shore University Hospital on Long Island improved hand-washing compliance by more than 90 percent.

Signs of hope

There are signs of hope that Dr. Makary's vision could yet become reality. The book says young physicians, medical schools and medical societies seem less willing to protect their poorly performing peers, and some hospitals have even taken a pledge of transparency.

Trust, integrity and forthrightness all go hand in hand, and they should be the basis to revive our great American healthcare system. Transparency "can restore the respect of the public in what many perceive has become a secretive, even arrogant industry," Dr. Makary writes. "With accountability, medicine can address the cost crisis, deliver safer care, and earn once more the trust of the communities we serve."

Chuck Lauer (chuckspeaking@aol.com) was publisher of Modern Healthcare for 33 years. He is now an author, public speaker and career coach who is in demand for his motivational messages to top companies nationwide.


More Articles by Chuck Lauer:

Chuck Lauer: Keep it Simple
What Makes a Great Mentor: 10 Traits of True Leadership
Chuck Lauer: What's Really Happening to Healthcare?


I just finished reading the book, "Unaccountable," and I have got to say, I was blown away. Written by Marty Makary, MD, this is an incredibly powerful indictment of hospitals and the doctors who work in them. It presents a stark portrait of a healthcare system that has clearly lost its way.
 
It's a book that should have a great deal of impact, because its author is a surgeon with a sterling reputation. On staff at Johns Hopkins Hospital in Baltimore, Dr. Makary is a dedicated proponent of patient safety and helped develop a widely used a patient safety checklist.
 
For more than a decade, ever since the landmark 1999 "To Err is Human" report from the Institute of Medicine, hospitals have talked a lot about instilling a "culture of safety." With all the activity that has taken place, it's a real shock to see that error rates have not budged for the most part.
 
The book presents some bleak statistics. One in four hospital patients is the victim of a medical mistake. Thirty to 40 percent of our healthcare dollars pays for fraudulent or unnecessary care. Ten to 15 percent of patients are not given all their options for care. And a surgeon operates on the wrong body part 40 times each week. A Harvard study published in The New England Journal of Medicine in 2010 found that as many as 25 percent of all patients are harmed by medical mistakes. These mistakes are the fifth leading cause of death in the nation.
 
A culture of silence
Stubbornly high error rates, Dr. Makary submits, are the result of unbridled arrogance and a lack of transparency in our healthcare system. "Healthcare's closed-door culture feeds complacency about its problems," he writes.
 
In stunning detail, he takes on a tour of incompetent surgeons, unnecessary surgeries and a culture of silence that punishes staff who speak out about patient safety. Dr. Makary notes that some of America's most prestigious hospitals have worse patient outcomes than many community hospitals.
 
We meet a Harvard teaching physician from many years ago called "Dr. Hodad" — not his real name, but one given him by his residents, as shorthand for "Hands of Death and Destruction." Dr. Makary, a medical student at the time, recalls that Dr. Hodad's operating skills were "hasty and slipshod," and his patients often had complications, but his bedside manners were impeccable. "Celebrities requested him for operations," he writes. "His patients worshiped him." He believes there are Dr. Hodads at virtually every hospital across the country.
 
It is not easy to report someone like Dr. Hodad. Had he done so, Dr. Makary believes he would have been ostracized. There was — and still is, to a great extent — a code of silence against reporting physicians' mistakes. Furthermore, a physician can be excellent at doing one type of procedure and awful at another, but colleagues will cover up for him because of his fame. The book reports that Michael DeBakey, MD, the world-class heart surgeon who died in 2008, was a miserable stomach surgeon. When he performed spleen surgery on the Shah of Iran, Dr. DeBakey mistakenly cut the Shah's pancreas. The shah's death from complications of that surgery at the start of the Iranian Revolution changed the course of history.
 
'Fred Flintstone care'
The book presents some alarming oversights in hospital ORs, which are especially frightening for those of us intending to have surgery in the near future. Dr. Makary introduces us to "Fred Flintstone care" –– outdated medicine performed by older, often highly respected physicians. These grey eminences haven't kept up with a recent breakthrough like minimally invasive surgery, which is incontestably safer than the old way of open surgery. But because these doctors are so beloved, so well protected and so hungry for more income, their patients will likely never know they had another option.
 
Dr. Makary tells us of a politician who had a small abdominal tumor and was under the care of the chief of surgery emeritus at his hospital. The surgeon, who had never learned minimally invasive surgery, took out the tumor the old-fashioned way. This no doubt forced the patient to suffer more pain, have a longer hospital and go home with a bigger bill, and all the while face a higher risk of infections and possible follow-up surgery.
 
Covering up mistakes
Rather than own up to medical errors, hospitals and practices seem to have become more proficient at covering them up. For example, the book says the patient form we fill out in the waiting room increasingly has a "gag order" in it. That is, we agree never to speak about a medical mistake, if one occurs. Dr. Makary thinks gag orders should be banned. "They are utterly contrary to a patient's right to know and to the concept of learning from our errors," he writes.
 
The book also targets misleading quality claims made by some hospitals, which can ensnare unsuspecting patients in nightmarish medical complications. Hospital marketing departments can make even wildly over-the-top claims vague enough to escape violation of truth-in-advertising laws. Dr. Makary recalls a young patient who was treated in a hospital that had designated itself a "Comprehensive Breast Cancer Center," even though it lacked necessary equipment and skilled surgeons. The result was her reconstructed breast was permanently disfigured.
 
A lot of quality concerns have to do with greed, such as when hospitals routinely pressure doctors to perform more procedures so they can make more money. Doctors often get bonuses for productivity, but not for quality, the book reports. It's an "eat what you kill" approach — the more procedures you can churn out, the more you're paid. One of Dr. Makary's physician colleagues got a note from his hospital saying: "As we approach the end of the fiscal year, try to do more operations. Your productivity will be used to determine your bonus." Performance, in this case, was "certainly not based on improved patient outcomes and lower rates of medical errors," Dr. Makary writes.
 
Bloated salaries
The book shows that children's hospitals make a great deal of money pulling the heartstrings of donors, and much of it goes into the pockets of their executives. Some CEOs of children's hospitals make more than $5 million a year and have perks like their own company cars, first-class travel, country club memberships and retirement packages worth millions, according to the book.
 
Dr. Makary writes that while the CEO of National Children's Hospital in Washington, D.C., cut the budget, he increased his own salary to $2.1 million, plus benefits. "This small, 300-hundred-bed hospital was paying its CEO far more than the CEO of our mammoth, 2,000-plus-bed John Hopkins Health System," he states.
 
Mind you, these are non-profit institutions that don't have to pay any taxes and continue to tug at donors' sleeves for donations. The book points out that the millions earned from these fundraising drives could be used to address mistakes in medications, which disproportionately affect children and are very expensive to fix. This cache of donations might also go toward raising the salaries of pediatrics caregivers, who are at or near shortage because they are paid relatively little. Pediatricians have a starting salary of around $110,000, compared with $500,000 for orthopedic surgeons, and the average pediatric nurse at one children's hospital gets 40 to 50 times less than what its CEO gets, the book says. What kind of message does that send out?
 
The solution is transparency
The best way to tamp down all the greed and improve healthcare outcomes, Dr. Makary maintains, is to end the secrecy at U.S. hospitals. Rather than micromanaging with excessive regulations, the simple act of transparency would revolutionize our whole healthcare system. If hospitals had to prove their claims of superior outcomes with real data, they would have to be more serious about meeting higher standards, and the healthcare system would be well on its way to recovery.
 
Dr. Makary wants hospitals to keep precise records on a variety of measures, including surgical outcomes, hospital-borne infections, readmission rates, payments to doctors, patient volume for each condition and clinicians' use of best practices.
 
The message is simple: When hospitals have to provide solid outcomes data, their performance improves. The book notes that when New York State began requiring hospitals to disclose death rates from coronary artery bypass surgeries, the ones with high mortality rates suddenly felt the pressure to make improvements.
 
The results of the New York program are remarkable. Statewide deaths from heart surgery fell by 41 percent in the first four years of the program. When leadership at one hospital saw that the mortality rate of a particular surgeon was bringing down its score, he was ordered to stop doing heart surgery. The Dr. Hodads were no longer protected.
 
Dr. Makary is taking further steps toward transparency in his own practice. He has started asking patients to review the notes he took on them on their office visits. Patients began correcting important data that he had gotten wrong in the interview.
 
He also recommends what is perhaps the ultimate form of transparency — recording medical procedures on videotape and playing them back for the surgical team to evaluate. He adds that installing cameras at hand-washing stations in North Shore University Hospital on Long Island improved hand-washing compliance by more than 90 percent.
 
Signs of hope
There are signs of hope that Dr. Makary's vision could yet become reality. The book says young physicians, medical schools and medical societies seem less willing to protect their poorly performing peers, and some hospitals have even taken a pledge of transparency.
 
Trust, integrity and forthrightness all go hand in hand, and they should be basis to revive our great American healthcare system. Transparency "can restore the respect of the public in what many perceive has become a secretive, even arrogant industry," Dr. Makary writes. "With accountability, medicine can address the cost crisis, deliver safer care, and earn once more the trust of the communities we serve."
 
Chuck Lauer (chuckspeaking@aol.com) was publisher of Modern Healthcare for 33 years. He is now an author, public speaker and career coach who is in demand for his motivational messages to top companies nationwide.

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