Most Americans have been a hospital patient—probably more than once. Very few have any awareness of the fact that entering a hospital is one of the most dangerous actions of a lifetime. Not because there are a lot of bad people in there with the intent to harm us—quite the opposite is true. The vast majority of those people are in their professions for the best of reasons. But consider:
- We are about to enter an environment where every single customer is sick; where pathogens and contagion abound.
- Dozens of professionals will participate in our care, and the failure of any one of them to wash their hands before tending to us can contaminate us with infection other than what we brought into the building ourselves.
- Dozens of professionals will participate in our care, and the means of communicating is often chaotic, fractured, and prone to error.
- If we are there for surgery, someone is going to cut us open, and we most likely have no idea how many times s/he has done this particular operation before, nor do we know what his/her success/failure rate has been.
- What facilities, staff, and equipment are available in the event something goes wrong with our procedure?
- What if there is a better way to perform this procedure, but it is one that our surgeon is not very familiar with, and s/he doesn’t want to refer us to a colleague or institution more skilled in the better techniques? Because of pride, ego, or compensation?
- Do all these people participating in our care communicate openly with each other? They are human like the rest of us: what happens if someone is about to make a mistake, and everyone aware of it is afraid to speak up?
- When someone comes in our hospital room and hands us medications, or hooks up an IV for us, how do we know they are giving us the right stuff? Does anyone ever get killed in here because someone got the prescription wrong, the dosage wrong? What happens to the patient when staff members can’t read the doctor’s handwriting?
- Are any of our attending healthcare practitioners sloppy, incompetent, or under the influence of alcohol or other substances? How would we know? Were any of them C- students in med school? Every profession has its underperformers. Is the person beside my bed one of them? Doctors have more access to controlled substances than anyone in our society. How would we know if our doctor abuses drugs?
- What happens when any one of these practitioners is overly tired, isn’t feeling well themselves but came into work anyway, are troubled with serious personal problems at the moment, are forced by staffing shortages to care for a larger patient load than is safe?
- What if the hospital we have been admitted to puts their doctors under pressure to recommend or prescribe procedures or therapies we don’t really need, subjecting us to unnecessary unpleasantness and possible complications in order to enhance billing? Is my doctor a commissioned sales person? Does s/he receive kickbacks/bonuses from pharmaceutical drug companies for prescribing, or worse, meeting sales quotas?
- Obviously all hospitals are not equal, nor are all departments within any given hospital equal. What if we are in the wrong hospital, or about to be operated on by the wrong surgeon? How would we know? Would the people who work here willingly choose our doctor, our surgeon, to make life or death decisions on their own behalf?
- Who tells these people when to retire? What happens when their memory starts to fail, or they begin experiencing tremors in their operating hand?
If you’ve never wondered about any of these things, it’s time for you to wake up to the realities of healthcare in America. In his book, Dr. Makary, a surgeon and researcher at John Hopkins University School of Medicine, exposes the inner workings of the system, identifying the various stakeholders, from the medical colleges to doctors, national doctor associations, hospitals, Medicare, the American Board of Medical Specialists, state medical boards, insurance companies, and most important of all, you, the patient.
His main point is that the medical culture for centuries has been a closed society and very resistant to reporting incompetence among its peers. We as patients make huge assumptions about how the profession functions and are blissfully unaware of the perils that await us when it’s our turn to enter its doors. The numbers are more than sobering. Take for example his very conservative estimate that 2% of the physician population is impaired, either through substance abuse or burnout and psychological problems, which amounts to 20,000 doctors treating approximately 10 million patients on an annual basis.
Dr. Makary makes us aware that technology has made possible the accurate metrics for evaluating health care providers and institutions and particular procedures, but that participation so far is voluntary and sporadic. Many hospitals have adopted the exit patient survey as a relatively meaningless metric, while the survey that really matters, which is the opinion of the individual staff members of the institution as to the safety culture they work in, either doesn’t get done or the results are locked up tighter than Fort Knox. These are, after all, the only people who really know what goes on inside the walls of the palace.
The most sobering statistic of all, for me, is that according to Dr. Makary, virtually every doctor out there knows a doctor who for one reason or another, is unsafe or downright dangerous. The only ones who know the identity of these unsafe practitioners are their colleagues, the doctors and nurses who work with them and who feel sorry for the malfeasants’ patients. The professional code of silence doesn’t allow them to speak up, but published performance metrics, appropriately adjusted for the nature and severity of the patients’ pre-existing conditions, would speak for themselves.
Until such metrics are made available to patients on a national basis, every one of us needs to become an amateur sleuth before making our healthcare choices. To his credit, Dr. Makary does not demonize any of the stakeholders, nor does he lobby for any political viewpoint. His solution is simple: Insist on transparency, make information about hospital performance metrics universally available to patients, and the free market will get the job done very efficiently, because informed patients will be free to choose.
Along the way, Dr. Makary gives us some delicious little bits of trivia. For example:
- Who is Dr. Hodad? (Hint: S/he works in a hospital near you.)
- What occurrence of medical malpractice, although never litigated, influenced U.S. foreign policy for over 30 years?
I highly recommend this book for anyone and everyone. Besides opening a rare window into a profession known for its obscurantism, Dr. Makary presents detailed practical suggestions on what each of us, as a patient, can and should ask our healthcare providers before making choices. I for one would never have thought of some of these. And when it comes to saving our own lives, every one of us needs to become a passionate activist—at the very least about our next doctor visit or hospital stay.
Note: Stay tuned for the release in the Spring of 2013 of a book demythologizing medical malpractice. A rational, ethical, and non-polemic guided tour by a prominent insider to both the medical specialty practice of medicine and plaintiff law. Read about it here first!