Monday, September 24, 2012

On The Promotion of Hospital-Based Killing

It's an interesting world in medicine these days.  What I read in papers and see in flashy professionally-produced book trailers about hospitals as killing fields boggles the mind.  Imagine: there are even full page spreads in papers as influential as the Wall Street Journal carrying headlines like "How to Stop Hospitals From Killing Us."

It is, of course, nothing more than a book promotion for "Unaccountable," written and heavily promoted in the main stream media and TV circles by the surgeon Marty Makary, MD from Johns Hopkins, who's parlayed his public policy interest in safety into a money-making PR campaign based on fear.

There is no question that there are issues in major medical medical centers with preventable mistakes that can lead to patient death.  I would be a fool to think that the pharmaceutical and medical device industries haven't used shady marketing techniques to sell their products in our very lucrative growth industry called health care.  (I would also be a fool to think it hasn't happened with the Electronic Medical Record industry or on Capitol Hill, either).  And I would be a fool to think that we shouldn't always be striving to avoid any patient errors.

But when we see book trailers with fancy aerial shots flying above big cities, close-up cameos of doctors doning face masks, and gushing teaser quotes from provosts of the very university where Mr. Markal practices, editors of the New England Journal of Medicine, a medical journalist, and even the President of the Institute of Medicine (none of whom actually cares for patients), we should ask: Why now?  Why here?  Who paid for this?

There is money in fear.  Big money. 

And one hell of an industry that caters to safety training.

But these fear tactics are not without their costs to our patients and health care system.  When we pull back the cover on what Dr. Mackary's solutions for our "current crisis" are, we see that the solutions he proposes are actually quite thorny.

We once again see the number "98,000" touted as the number of deaths each year at hospitals when the actual value is unknown. The number came from The Institute of Medicine's 1999 report on medical errors which estimated the number from 44,000-98,000. But this is unimportant.  Big death numbers sell.

Data dashboards are heavily promoted as one of Dr. Mackary's paths to transparency, but we should ask ourselves how much this data collection costs.  We should ask if it has affected outcomes.  As Dr. Mackary acknowledges, patients make decisions on which hospital to go to based on personal choice, not data.  Since we've been collecting these data on quality, has it impacted costs one bit?  The answer, actually, is no.

And then there's Dr. Mackary's idea of using cameras in hospitals to improve transparency.  In his article in the Wall Street Journal, Dr. Mackary justifies this approach by telling us an anecdote about a gastroenterologist who filmed his colleagues doing colonoscopies "without telling his partners."  (I'm not kidding).  There was no attempt at education between colleagues.  There was no attempt at professional discourse.  Just a camera secretly filming colonoscopies.  Images of the Orwellian book "1984" flashed in my head when I read this.   How much time might I soon be required to review the films we make of our colleagues if we chose such a path?  How much time will it take from me seeing patients?  Who will own the films?  Where will they be stored?  Who will pay for the filming?  And let's not even speak of the liability implications to physicians when these films are discoverable.  It is hard to see how this will constructively correct patient safety in hospitals and won't further add to doctors' burnout with the system.  Is this now going to be our path to patient safety salvation, fear-based medical practice?

Not all of Dr. Mackary's ideas are crazy: his idea for Open Notes and lessons about the importance of transparency in medicine are valuable.  His ideas of cherishing the input of every member of the care team in a patient's care is spot on.  But if we are going to be fully transparent, then we should be transparent about costs at all levels of patient care.  We should recognize that there large hurdles to accomplish transparency and accountability in medicine when the legal risks of slander and libel can be so easily invoked when a junior physician dares to buck a financially-flush system hell-bent on maximizing revenues.  Yes, we have problems, but the solutions are complicated and risky for those already ultimately legally on the line for every patient who enters our health care system.

Finally, we should ask how our younger doctors (who are training and more likely to make mistakes) how they would feel practicing in such a Orwellian, fear-based system.  Might we be compromising our ability to recruit new doctors? 

From a business sense, I wish Dr. Mackary all the best in the sales of his new book.  No doubt his sales will soar thanks to the cleverness of this sales campaign. 

I just hope that the Grand Thinkers in our legislative and health policy circles have enough marbles in their heads to not be influenced by all of Dr. Mackary's proposed grand schemes for improving our patient's safety.

If they do, they may be causing more harm than good.  Then who will be accountable?



Monica said...

Hi Dr. Wes,

Another fantastic article, thank you for addressing this topic! Too often people react to an ad or sound clip and don't investigate who is behind it and what type of agenda is being promoted. Yet another round of proposed changes that will result in higher healthcare costs. Unfortunately, I think many politicians and policy makers these days aren't capable of making policies that genuinely help the public, just ones that cost more money and create more red tape.

Anonymous said...

His name's actually Makary but you're otherwise dead on. He is a fame hound to an absurd extent. Why has nobody asked why a pancreas surgeon was interjecting himself on CNN about Michael Jackson? It's almost funny if it wasn't so bizarre.

And he claims to have been "on the list" for US surgeon general as an unknown assistant professor? Someone should probably examine his CV closely to see whether he's a serial exaggerator.

Anonymous said...

From the pharmacy standpoint, I agree entirely. I studied those five years in pharmacy school, balanced those chemistry equations, titrated acids for pH curves, attended every lecture, worked up every case, and presented every care plan, passed tests, performed the labs and experiments, memorized structures along the way, and for the most part it all has been built on as a body of knowledge. Then, along comes some dietician that writes articles discussing drug side-effects based on abstracts, abstracts mind you!, to bring a new dimension to daily gossip in the 'health' sections of popular journals (guess they cannot afford to pay a registered pharmacist for their knowledge base) to set to people that no nothing on edge. Worse, yet are the folks with degrees in pharmacology and anthropology or 'naturopaths' advising patients on using 'natural foods' (foods, as such because the products have not been researched nor tested as 'drugs') and the people that know nothing lap it up for excitement and forget the gist tomorrow.

Vaccinations, raw milk, ketone diets, asafoetida, turn around and throw salt over the left shoulder, pay for bogus drugs over the internet, but don't see a regular doctor because it's too expensive, MRSA, VRSE running rampant, and pass the extra ciprofloxacin left-over from the 'free' supply at Wal-mart and Publix along to the next-door, to use for a while.

Bizarre is an inadequate adjective because it doesn't include damage to reputable healthcare professionals, nor does it propel those ill to see the doctor.