Martin Makary discusses how to improve healthcare in his book,
Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care. I excerpted some useful parts in the remainder of this post.
Internal peer reviews are a little like the Russian parliament under Stalin. No matter how much discussion there is, the result seems foreordained. At these internal peer-review conferences, complicated cases are reduced to biased two-to-three-minute summaries, and doctors who might raise probing questions are well aware that they can pay a heavy price for challenging their peers. Like many health professionals, my friend didn’t like the safety culture in his unit, but he was no dummy. He knew that whistle-blowing could not only hurt his career but also fail to accomplish any meaningful change. At most institutions at which I’ve worked, I’ve witnessed the rare occasion of a doctor bravely challenging another doctor about substandard care only to later face major internal political blowback. I’ve even seen a few vocal doctors leave a hospital under pressure by the “incumbent” doctors in power there.
It’s easy to say that doctors should speak up, but being overloaded with work and performing complex surgery is stressful enough. When it comes to peer-to-peer confrontation at the workplace, our survival instinct guides us to retreat to a haven of neutrality: We don’t need partners’ anger and resentment to boot. Hospitals sometimes fire doctors who speak up, sending a powerful warning to the medical community at large to stay in line. As I wrote this book, I learned of another whistle-blower sacked by her institution. Kiran Sagar, sixty-five, a prominent cardiologist who has trained hundreds of doctors in reading echo (ultrasound) studies of the heart and who was one of the first female cardiologists in Wisconsin, was studying an issue she is passionate about: misinterpretation of heart-echo tests by doctors, a problem endemic in many U.S. hospitals.
By formally studying procedures at her own hospital, she found that the quality of the interpretation of echocardiograms varied widely depending on the doctor reading them. At a national cardiology conference, she presented her findings that in total 29 percent of heart-echo interpretations are incorrect. She concluded with a suggestion to develop more standardized methods to interpret echos and to initiate a quality-control mechanism to prevent this important heart test from being misread. You would think that a patriot who brings attention to an important medical problem would be rewarded for being a patient advocate. Exactly the opposite happened. She was instantly fired by her hospital (Aurora St. Luke’s Medical Center in Milwaukee) despite a long, prominent career. Tragically, her highly publicized firing over her study sent yet another shock wave reminder to medical professionals everywhere: Expose medicine’s dark side of doing business and risk your own career.
Doctors and nurses know of docs who are reckless, but it takes moving a mountain to do something about it. Not reporting incompetence among peers is part of medical culture and has been for centuries. Medicine is poorly policed. Getting fired takes an action so egregious or offensive to hospital administration that I have only seen it happen twice among all the hospitals in which I’ve worked and trained. How about the national doctors’ associations? Can they police their own kind? As a member of several, only once have I ever heard of a program that tried to address impaired physicians, and that effort never picked up steam.
After asking around, it became clear that the only time that a doctors’ association would ever consider taking action against a doctor was if a state medical board had already done so. Hungry to grow their membership and collect annual dues, doctors’ associations are historically passive when it comes to policing doctors (the AMA is actively recruiting to increase its membership, which has now declined to 15 percent of U.S. doctors; membership costs $420 a year). Policing doctors is a job so messy, no one wants to do it. Except, of course, in sending out dunning notices for thousands of dollars in membership dues each year. So who is in charge of policing medical care in America? Not the FDA—they approve medications and devices as safe. Not Medicare—they just pay the bill for seniors and police billing fraud. Not hospitals—they profit from incompetent medical services that only breed more hospital services….
Every organization, institution, medical association, and hospital administrator that I have asked has told me that policing physicians is the real responsibility of state medical boards. So let’s examine the role of state medical boards in American medicine.
Alan Levine is a soft-spoken gentleman with a big smile who worked for the inspector general of the United States, overseeing medical boards. “They vary widely,” he says, referring to the state boards, “mostly serving the interests of their stakeholders—doctors.” Some states let you look up a doctor’s disciplinary record. Other states don’t. If a medical board ever conducts an investigation—a relatively rare event—it tends to be weak. And I have never heard of a state board making a call to a witness, let alone conducting an on-site hospital investigation. Boards do publish lists of doctors who settled a lawsuit out of court. Of course this is distorted data, because unfounded lawsuits can be common.
Nearly all doctors will experience a lawsuit at some point in their career, and teasing out the ones with merit can be difficult. Some lawyers seem to encourage any patient who becomes disabled to sue, hoping they get lucky with an empathetic jury. Even a life-saving amputation by a good doctor can prove difficult to defend for hospitals. Juries sometimes will hold a subpar hospital against the individual doctor, even if this is unjust in the particular doctor’s case. Hospital lawyers therefore tend to settle before entering a courtroom stacked against them. Given the risk of a large potential payout, hospitals also calculate that it’s cheaper for them to settle these types of cases out of court. In fact, hospital lawyers go to court on average only once for every ten to twenty lawsuits brought, opting to settle the rest….
I routinely witness young medical students interested in fields such as brain cancer doing amazing research in residency. These talents have very promising careers in brain cancer, but as they proceed through their training, they see the high-dollar rewards for sidetracking their cancer research to become back surgeons. Dr. Michael Lim, a neurosurgeon at Hopkins, told me that for a complex brain-cancer surgery taking twelve hours, Medicare pays him about $5,000. But a short two-hour back operation pays a lot more. That’s a powerful incentive. Stacking two or three back operations in a day instead of performing a long, delicate brain-cancer surgery would allow him to earn between $15,000 and $20,000 in a day. It’s no surprise that each year, an increasing number of neurosurgery graduates are going into back surgery exclusively….
I ask my orthopedic-surgeon friends and colleagues every time I run into them if it’s true that there’s too much back surgery going on. They insist it is true, and it’s driven by money. When I ask colleagues in my own field, oncology, about the markup of chemo drugs and the lack of transparency to patients, they agree it is prevalent, profitable, and wrong. When I ask cardiologists about too many stents and devices being put in people, many, though not all, will agree that some cardiologists are doing too many procedures. My hunch about those who don’t is that they’re being discreet out of reluctance to go against their own.
Usually, whenever I ask doctors to comment about these matters, I am mightily impressed by how outraged they are, angry that such things should go on in their field—a field they are proud of, and want to be proud of rather than ashamed of. Doctors overall do care about patients’ well-being and are well aware of the perverse incentives that drive good doctors to do questionable things. But is it only orthopedics, cancer, and cardiology that overtreat? As an exercise, I began to ask specialists the question, “What is the most overutilized thing in your field?” Pediatricians said, “Antibiotics.” Radiologists said, “CAT scans.” Obstetricians said, “C-sections.”