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BOOK REVIEW: Hospital Negligence: Legal and Administrative Issues by Arthur S. Shorr, FACHE

Edith Rodriguez entered Martin Luther King Hospital in Los Angeles on May 8, 2007 and was misdiagnosed as suffering from gallstones.  She returned the next day complaining of severe abdominal pain. The triage nurse refused to assess and prioritize her condition, and so Edith could not be placed in line to be examined by a physician.

In an effort at fairness, this could be understandable, don’t you think?  Lots of people use the ER for non-emergency purposes, because they are lonely, hypochondriacs, have mental issues;  or they use the ER as a substitute for seeing a doctor.

But not this time.  The hospital’s surveillance camera shows Edith lying on the floor “writhing and screaming in pain while the janitor mopped around her.” Other patients in the ER asked the nurse to help Edith Rodriguez, but these requests were ignored.  Someone called the police, but even they could not persuade the nurse to triage Mrs. Rodriguez, so the police decided to take her to a police facility where she could be treated.  Unfortunately before that was possible, Edith Rodriguez suffered a cardiac arrest secondary to a perforated colon, and died.

This happened less than five years ago, here in America.  The county settled with Edith’s family for $3 million.  Would you call this a malpractice litigation problem, or a malpractice problem? Read more..

My question is not what is the magic dollar amount of appropriate compensation for Edith’s family, but how can something this barbaric happen?  Can refusing treatment to a patient writhing on the floor in pain be considered just a lapse in judgment?   Can healthcare practitioners become this fatigued, indifferent, or callous to their power of life and death over a suffering patient?  The obvious answer is yes, and not infrequently.  Edith Rodriguez’ case can be found on page 290 of Arthur Shorr’s book Hospital Negligence Legal and Administrative Issues.

If you are interested in a movie developed around this type of flagrant and catastrophic medical malfeasance, watch The Confession, starring Alec Baldwin, Amy Irving, and Ben Kingsley.  If you are interested in an exhaustive (but not exhausting) treatment of current patient care in American hospitals, and the efforts of the courts to establish accountability, read Arthur Shorr’s book.

As those of you who have been faithfully following the thread of this blog over the last few months know, I have been heavily engaged in a research project on the subject of medical malpractice.  Not, mind you, the subject of medical malpractice litigation, but the subject of malpractice itself.  The objective has been to get past the defensiveness, angry bombast, propagandizing, and frequent intellectual dishonesty of vested interests, and discover what is really going on in the arcane, veiled world of healthcare in America.  Admittedly there is a bias to what I report, and that bias is that I am very pro-patient.   I have been a patient  many times, and as I approach the geriatric years, I want to know what to expect, I want to better understand the mysterious inner workings of the healthcare universe and how to survive in it.  Statistically, all of us will spend more time in the hospital during the last year of our life than the total of all our prior hospitalizations combined.  This is even true of doctors and nurses.  We are all going to die, and about half  of us are going to die in a hospital.  Would you like to get better acquainted with the place now, while you are well?  Then take this journey with me through Arthur Shorr’s book.

The 5% Who Maim and Kill

If you have been reading my previous book reviews, you cannot possibly have any doubt that to enter the doors of a hospital in calm confidence that your best interests will be tended to competently and professionally is not only naïve, but to play the part of the fool.  No one disputes the Institute of Medicine’s conclusion that between 100,000-200,000 people are killed in hospitals every year due to preventable error, carelessness, negligence, whatever you want to call it.  What most people don’t know, as Arthur Shorr, the author of Hospital Negligence Legal and Administrative Issues reminds us, is that 5% of all physicians create 54% of all malpractice litigation.  (See National Practitioners Data Bank, 2001 Annual Report: www.npdb-hipdb.com/pubs/stats.2001HIPDB_Annual_Report.pdf )  The National Practitioner’s Data Bank is the central repository for all major physician disciplinary actions, loss of privileges, etc.

You say you didn’t know that such a fount of valuable information existed?    Ever wondered what your doctor’s  cumulative professional history looks like? Would you be interested in knowing if s/he made the honor roll of healthcare practitioners whose  competence is open to question?  Now that you are educating yourself about the very real perils of healthcare  in America that one day could conceivably impact your life or prematurely end it, would you like to take a peek at this repository of reportable events created by the federal HCQIA law?  Well, so sorry, but the same law says you and I  aren’t allowed to see it.  In what is apparently a flagrant and obsequious concession to physician and hospital political lobbies, we, the patient population, are not permitted to identify and avoid the 5%ers.  In the healthcare game, the patient is the patsy, the powerless constituent who continues to have sublime faith that the system is going to take care of him (us).

Clearly, in actual malpractice litigation is the part of the malpractice iceberg that shows above the surface; the vast majority of mistakes go undiscovered, are concealed from patients and their families, or for various reasons never make it to the courtroom.

Where and how do these 5% hide out?  What (and why) hospitals permit them to admit and treat patients within their institutions?  How are doctors screened, or in the argot of the medical world, credentialed and privileged?  How reliable and trustworthy a process is this?  Why is the profession so notoriously lax in disciplining its own members?  When you enter a hospital, it all appears vaguely chaotic, with all these people in uniform running here and there.  Who are they, what are they doing, and who’s in charge here?  How do you know if these people are doing what they are supposed to be doing, especially when it’s your turn?  Mistakes and even negligence are a frequent part of life, in every profession and occupation.  Mistakes and negligence kill 50,000 on the roads of America every year, yet we don’t bat an eye.  But when an accident happens, there is an investigation, there is accountability, there are consequences.  Depending on the circumstances and intent, when a driver kills someone, it may be called accidental death, or involuntary manslaughter, or vehicular homicide.  What happens when a doctor kills someone?  What is it called?  Oops?  (And dispose of the evidence?)

In other words, the issue is medical malpractice or institutional negligence  or both, and this does not mean mistakes, which are inevitable to all aspects of the human experience.  It is important for readers to appreciate that outcomes are not guaranteed, but this should not be confused with medical malpractice or institutional negligence. Malpractice in Shorr’s book means administrative negligence; in other words, outcomes (often catastrophic) that with customary professional care should not have happened.  And so Mr. Shorr wrote a 600+ page tome that takes us on a guided tour into the bowels of the hospital organization, explaining the interrelationships between all levels of the institution, including the responsibilities, conflicts, egos, frustrations, and humanity of all the players, from the governing body to the newest certified nursing assistant.  He elucidates the processes, regulations, policies, and system redundancies that must, or should, be in place to prevent disaster, and what happens when they fail.

Cooking Patients

Considering his subject material and the human carnage involved, the author is remarkably sanguine as he calmly marches through the records and elucidates what actions can and should be taken to improve patient safety.  Take for example his treatment of surgical fires.  I had never even heard of surgical fires, and perhaps, dear reader, you haven’t either.  These occur when something combustible, such as oxygen catches fire on, or even worse, inside the patient on the operating table.  The Joint Commission, the organization that develops minimum safety oriented community standards for hospitals issued a Sentinel event bulletin alerting hospitals to the issue of operating room fires.  Arthur Shorr lists the nine inexpensive  measures recommended by the Joint Commission to take so that a surgical fire never occurs.  Sometimes the fires occur because ointments or gels on the patients face have not fully dried yet, and when an electric tool is used to cauterize, it ignites the ointment.  The solution is very simple; either wait until the ointment thoroughly dries, or make sure you wipe excess ointment that may be hidden in the folds of an obese patient’s skin before you proceed.  Surgeons do not operate alone in the operating room.  They have nurses and assistants and anesthesiologists working with them.  How could all of these people not think of taking simple and necessary precautions to prevent a disaster?  Too often the answer is, they all defer to the surgeon, the commander-in-chief in the operating room.

When a surgical fire occurs, it is usually around the face and neck, and often part of the patient’s face can get severely burned, on the inside as well, including the mouth, airways, esophagus, etc.  The treatment of these burns often causes infections and other complications, leading sometimes to the death of the patient, and most certainly to grotesque scarring.  Imagine going into what you expect to be a routine surgery, and, as reported by MSNBC,  waking up in recovery with ‘your chin gone, your nose deformed, your mouth virtually melted—so damaged that after a dozen reconstructive surgeries, you still have difficulty eating, drinking, and breathing?’

If you are having difficulty imagining this, look at this.

How Many Does It Take?

Now that you’ve looked at some pictures, maybe, like me, you have a problem with comments such as from Karen Weiss, M.D., M.P.H., program director of the Safe Use Initiative in FDA’s Center for Drug Evaluation and Research, that ‘these fires are small in number compared to the millions of surgical procedures performed each year.’  How many is this small number of surgical burn victims?  The same article estimates 550-650 each year!  Entirely preventable except  that the others in the operating room are too intimidated by the surgeon to speak up when the situation is unsafe!  We know this number must be understated because there are many more surgical fires that go unreported or are covered over to preclude malpractice litigation.  As Arthur Shorr reflects, “Both plaintiff and defense attorneys should recognize that the theory of the surgeon as “captain of the ship” has given way to the concept of the surgical team in which everyone  in the operating room has a duty to maximize the patient’s safety.”

The sad plight of children shot and killed in our schools and malls recently has dominated the attention of the media.  So how is it that five or six hundred patients have been burned on the operating table, and it doesn’t even make the news?  And since this conservative estimate of the number of victims is so small, according to Weiss of the FDA, how many victims do there have to be before it deserves comparable outrage?  The MSNBC article quoted above downplays the severity of the situation, in my opinion, by noting that 500 incidents out of 50 million surgeries per year is not that big a deal (unless it’s you, or a member of your family, of course).  Well, let’s see, 89 million passengers fly out of Atlanta airport every year, so I guess if five or six hundred a year catch fire, are disfigured or killed getting off the ground, that’s not such a big deal, right?

Who Authorized this Doctor to Practice?

Author Shorr divides his time equally between the top and the bottom of the hospital hierarchy, but always his focus is on patient safety.  It is obvious he knows from 40+ years of personal experience where the land mines are.  He gives a superb and constructive critique of the credentialing process, which is how hospital governing boards decide whether to grant hospital privileges to a physician after evaluating his performance record.  He points out the turf wars and ego conflicts that can (and do) occur between the administrator and the powerful, leading figures in the medical hierarchy of the hospital.  The CEO, in the incredibly delicate position of having  nondelegable accountability for whatever occurs in the institution,  also knows that if and when he challenges or countermands the medical leadership, those who recommend clinical practice privileges to the governing body, he places himself at the risk of jeopardizing his own employment and career.  How do you exercise principled leadership in such a situation?  Shorr points out the powerful personal incentives for administrators to avoid confrontation with the medical staff leadership and stick to issues with less personal risks such as the politics of  hospital systems, finance, equipment purchases, etc. and not to push issues that could create unpleasant blowback from the medical hierarchy.  Everyone likes to stay employed.

The Administrator’s Catch-22

The catch-22 for the CEO/administrator is that when malpractice occurs in his hospital by a member of the medical staff, the buck stops with the administrator if the credentialing process was compromised when that negligent physician was screened and accepted.  In other words, if a doctor’s professional history gives reason to doubt his competency and he is credentialed and granted practice privileges at the hospital anyway and then later is found guilty of malpractice, the CEO/administrator and the governing body have a serious problem.  The hospital may likely share liability for negligent credentialing and privilege granting.

Shorr focuses on not only ineffective credentialing and weak peer reviews, but he turns his laser on the opposite: sham peer review; the removal from the medical staff of otherwise qualified clinicians for political or economic reasons.  The most dramatic example might be of powerful physicians basically ganging up on a whistle blower in their midst and maliciously driving him/her out of the hospital:  “One of the most profound unintended consequences of HCQIA (a 1986 law designed to improve accountability of physicians)  is the emergence of “sham peer review,” the willful misapplication of HCQIA’s intended  protections refocused to persecute, punish, and otherwise penalize competent physicians.  This cynical and abusive practice is often employed by politically powerful physicians or groups of physicians to advance their own economic, social, or political agendas in the hospital setting.”  It’s hardly a quantum intellectual leap to go from understanding the existence of sham peer review to a profession that tightly closes ranks around its members and resists efforts at transparency, a threat to their control.

Registered Nurses as the Patient’s Advocate

My favorite part of Hospital Negligence is the section on nursing.  Nurses spend by far the most time in actual patient contact, and it is the nurses who generally define a patient’s experience during a hospital stay.  It is obvious that author Shorr has a special empathy for the nursing constituency.  He emphasizes their unique responsibility as patient advocate:  “Registered nurses are the full-time guardians of the patient, and function as patient advocates as defined by the American Nurses Association (ANA) Code of Ethics and most state licensure laws.  Their role as patient advocates should be recognized in their job descriptions as well.  It is understood that although the nurse will principally discharge physician orders consistent with their professional assessment of patients, professional nurses are also expected to utilize their independent  professional assessment and evaluation skills, and communicate relevant observations and concerns to the physician in a timely manner.”

The ANA Code of Ethics, in application, means that a registered nurse will advocate for the patient, even in the face of incompetent or compromised physician oversight.  This puts the registered nurse in the same precarious employment position as the hospital administrator.  If she advocates for the patient, she may open herself up to retaliation from those higher up on the food chain, but if her failure to act courageously results in harm to the patient, she exposes her hospital to liability and probably the termination of her employment.  I have to wonder how many of either hospital administrators or nurses would pass that test?  In my experience, survival instincts trump all other considerations, including violations of the training manual.  As Shorr points out “The administration must continuously reinforce senior management’s commitment to support nursing advocacy”—but how many of them will do that in actual practice?  To his credit, Shorr gives practical examples of how a nurse can question without seeming to challenge authority.

Following a sub-theme of protecting the patients from the very human natures of their caretakers, Shorr gives examples of patient chart notes appropriately done, but no one reads them, and hospital or nursing home records that are falsified by nursing staff, attesting to their having timely turned their patients to prevent pressure sores, when the patient in question had been transferred or even died, or the individual  who falsified the record was not even at work on the days or shifts indicated on the turning logs.  This would be almost funny were it not for the fact that patients needlessly die because of such negligence.  Shorr says:  “Although turning the patients is highly effective, the unreliability of nursing assistants coupled with inconsistent supervisory follow up can place patients at risk.”

Shorr maintains that while physician negligence is by far the most expensive per case in human suffering, death, and malpractice litigation, the mistakes of nurses and other caregiving hospital staff are greater in number, but generally cost far less per incident.

The New Healthcare–a Different Paradigm

The lesson for the patient:  “Until the 1970s the relationship between doctors and patients was highly paternalistic, based upon the premise that “the doctor knows best.”  Today, the concept of patient rights is based on the principle that patients are self-reliant and should exercise the greatest degree of influence possible on the decisions that impact their health and well-being.  Thus, this principle has re-defined the relationship between the patient and the caregivers.  It is the hospital’s responsibility to ensure that this dynamic is respected.”

To which I would add that it is our individual responsibility as patients to insist on this, or find better  caretakers as soon as the opportunity presents itself.  The paternalistic (and sometimes narcissistic) physician model who dictates rather than invites patient participation is being replaced by a new patient activism aided and abetted by the Information Age.  Our becoming a more-aware consumer of healthcare will raise the bar for our providers, as they realize they have a better educated, more observant and involved patient.  Some of them will become better doctors because of us.  That’s good for everybody.

The 5-percenters?  I can’t help wondering, of the five or six hundred people who are victims of surgical fires each year, what happens to the sloppy surgeons who wreck their lives or kill them? Presumably we only know about these five or six hundred cases each year because the doctors are  sued.  Are they still practicing medicine?  Was there disciplinary action?  Even a slap on the wrist?  How would we even know?  I have to ask you, my reader, if you or one of your children needed surgery, and you saw pictures like these of what your intended surgeon had done to one of his/her previous patients, would it influence your decision to have him operate on you or your child?  Would you be inclined to blow it off with an “Aw shucks, everybody has a bad day?  He deserves another chance.”  How would you feel if you knew, not only that he withheld this information from you, but that his entire profession conspired to prevent it from becoming known in order to protect him, a member of the Hippocratic brotherhood?  With improved and accessible performance metrics and much greater transparency,  dangerous physicians should be encouraged to  find something more suitable to do for a living.

Who Should Read This Book?

Who should read this book?  I did, but I am researching the subject.  But I found myself enjoying it, and I learned a lot.  I feel slightly less like a potential victim, and slightly more empowered knowing how a hospital is organized, the relationships, the conflicts, the dangers, the pressure points.  Just as with prior books where I have learned to pay attention to such things as whether or not my doctors or nurses wash their hands (most don’t), Shorr’s book has helped me learn what I have a right to expect in the hospital, and when I have the right to object or insist, strenuously if necessary.  This book has contributed to my self-confidence when I am in a very intimidating hospital environment where you are vulnerable both mentally and physically, are unceremoniously pushed, pulled, and poked, and I am less inclined to passivity the more I learn.  I think it will be a little bit harder for a careless provider to bluff or blast their way past me.

Besides everybody like me, patients or might-be-patients-someday, who else should read this book?  The first thing that comes to mind is every single Congressman and all their staff assistants.  It is the staff assistants who write healthcare legislation, and no one should be permitted to do that without reading this book first.  If this book has an ideology, it is patient safety.  If the staff aides are only concerned about satisfying their lobbyist campaign donors, they might conclude that this book would be of little practical value to them.  This, in my opinion, would be a mistake.  Health, and healthcare, are the great equalizers of us all.  Sooner or later, with very few exceptions, we are all going to need a hospital, and no matter which side of the ideological aisle we hail from, when that day comes, we are going to be better prepared if we have read Arthur Shorr’s book.  There should be a copy of this book in every Congressional office.

Graduate students enrolled or majoring in hospital administration should read this book, and learn about hospital accountability from someone who knows it from the inside out.

Key hospital administrative, nursing, and physician staffs should read this as a reminder of why they chose their respective professions to begin with, and who have a greater interest in raising the bar of their profession than they do in evading the plaintiff’s bar.  By paying more attention to the former, they can minimize danger from the latter.

Defense attorneys:  This book creates a clear picture of the standards and expectations against which your client will be measured.

Plaintiff attorneys who screen potential clients, to appreciate where the community standards and the bar of accountability  are set in order to assess whether the client’s situation is actually worthy of legal pursuit. Shorr makes it clear that there are no guarantees for outcomes in the practice of medicine or patient care services.  As such, the author makes it clear that less than desirable outcomes aren’t necessarily worthy of lawsuit, and draws a clear line between medical and ministered cases of negligence and bad outcomes.

Anyone involved in the education of future generations of hospital administrators should have this book as a resource.

Patient safety advocates of every stripe need to read this book.  Hospital Negligence Legal and Administrative Issues is an invaluable  desktop encyclopedia of patient safety case law.

Why am I promoting Arthur Shorr’s book?  Because nothing in this world moves unless someone or something is pushing it.  If we want our hospitals to become safer places, we have to participate at some level.  This book is a great combination of academic excellence without being afflicted with ivory tower isolation.  It is reality-based, not rhetoric.  This man obviously didn’t spend his many years of hospital administration hiding in some corner office.  He knows hospitals where it really counts most–at the intersection of the hospital and the patient.

You can reach the author through his website here.




Book Review: The Life You Save . . . Nine Steps to Finding the Best Medical Care—and Avoiding the Worst by Patrick Malone

As my regular subscribers know, I have been involved as a researcher and ghostwriter for a fabulous (of course!) book due to be released in the Spring of 2013 that for the moment we’ll just call Inside Medical Malpractice.  In that role, over the last eight months or so I have become something of an expert on the current literature on the state of American healthcare.  So for my busy readers, let me cut to the chase and simply say, get out your credit card and order The Life You Save . . . from Amazon or Barnes & Noble or your favorite bookseller, but do it now.  Get a copy for yourself, and get a copy for your grown children with a mandate to actually read it.  It will make a superb Christmas gift for anyone you care deeply about, including any who are healthcare practitioners themselves.  And no, I’m not connected to any of the beneficiaries of this enthusiastic endorsement, including the author. Read more..

So what’s this all about?  It is not my nature to gush or engage in hyperbole.  What’s up with my enthusiasm for  The Life You Save . . . ?  The shortest and straightest answer is in the title itself—this book is about saving your own life when it comes your time to enter the healthcare system for anything more serious than the common cold.

A few weeks ago I recommended How We Do Harm—A Doctor Breaks Ranks About Being Sick in America, by Dr. Otis Brawley, Executive Vice President of the American Cancer Society.  In my review of Dr. Brawley’s excellent book (you can read it here: https://www.financialliteracysource.com/money/book-review-how-we-do-harm-a-doctor-breaks-ranks-about-being-sick-in-america-by-otis-webb-brawley-m-d/#more-354) I recommended this book as a wake-up call to naïve Americans who enter the healthcare system with an unwarranted confidence that they will be treated competently and with reasonable expectations of a happy outcome.  Dr. Brawley lays it all out with well-documented information about how broken, chaotic, and fragmented our system is, and how frequently patient safety is the last priority of the stakeholders in the system.

More recently I recommended Unaccountable—What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, by Dr. Marty Makary, a surgeon at Johns Hopkins Hospital.  You can read this review here:  https://www.financialliteracysource.com/book-review/book-review-unaccountable-what-hospitals-wont-tell-you-and-how-transparency-can-revolutionize-health-care/#more-390. Dr. Makary’s book focuses on the culture of cover-up in the medical profession, and the intentional code of silence about mistakes, negligence, and incompetence.  He talks about how difficult it is for a patient to discover the safety track record of any institution or doctor, and Dr. Makary has excellent suggestions and comments about a ground swell of interest inside and outside the profession to clean it up and make it safer and more honest for the patient.  He makes the profound point that meaningful change will not happen unless we demand it, push for it, insist on it.

Then comes The Life You Save:  Nine Steps  to Finding the Best Care—and Avoiding the Worst.  The author, Patrick Malone, is a very successful medical malpractice attorney who has had clients all over the country.  His book, however, is not about medical malpractice, and his book is not some ill-disguised attempt to promote his legal practice.  This book is very simply a down-to-earth and comprehensive Survival Guide to coming out of the healthcare system unharmed and unscathed.  This book has valuable checklists for everything, from things to ask your family doctor; steps to take to find a competent doctor; checklists for safe surgery; the red flags that tell you to run like hell from someone you thought was a competent physician; how to become better informed about your prescription drugs; how to evaluate recommended treatments, procedures, and tests; how to avoid infection in hospitals; and how to evaluate hospitals, departments in hospitals, and the presence or absence of a patient-safety culture within the hospital or department you will be using.

Believe me, this guy knows what he is talking about.  For those who have a false sense of security by relying on federal and state regulatory agencies, Mr. Malone exposes the limitations and conflicts of interest that can cripple the effectiveness of these organizations.  He gets behind the statistics, and explains in simple street language what those horrifying prognoses really mean—and don’t mean, when the doctor tells you what your survival chances are, or how long you have to live.

Author Malone makes the point that we should not, as patients, have to go to such lengths to assure ourselves of being given competent, attentive care, but unfortunately when it comes to patient safety, American healthcare has only moved the space of a few inches on a journey of miles.  We have to become responsible for ourselves, which from my view on the bench, is not such a bad habit to cultivate anyway.  Because when you are sick it is often beyond your capabilities to be alert and assertive, it is essential that every one of us know someone who can go with us to our appointments, stay with us in the hospital, including overnight, and, oh, by the way, our friend needs to have big kahunas.  The healthcare system is not likely to pay much attention to someone without assertiveness, the ability to speak up and be firm.  The hospital is the last place to be intimidated, or in awe, of your healthcare providers.  These people are made of the same dirt as everyone else.  They have bad days, they suffer lapses of attention, they have other things on their mind, they have egos, they have wrong-headed financial incentives, they have attitudes, some of them are substance abusers, and some of them shouldn’t be practicing medicine at all.  With some of them, that is precisely the problem—they are practicing medicine.  As long as they are practicing, you had better be paying attention.  Caveat emptor.  Translation:  If you’re not being treated like a customer (instead of a patient), go somewhere else.

Malone cautions us that we also need to develop our relationship skills.  If we start acting like we know more than our physician, either we are now part of the problem or we need a new doctor (and maybe both).  Mutual respect is important.  And any good doctor will welcome an involved, educated client.  Yes, client.

A few days after I finished reading this book, I had an appointment with a new doctor.  I brought my checklist (borrowed from The Life You Save) with me.  My new doctor did not wash her hands after entering the examination room, and did not put on a clean pair of gloves.  She did not use antiseptic hand wipes, and she did not clean the head of her stethoscope in my presence before examining me with it.  She did have a bright cheerful smile as she shook my hand.  For the first time ever, I wondered, who else had she just treated, what sicknesses did they have, and did she shake their hands as well?

One more thing I loved about Malone’s book.  He lists dozens of websites where the reader can go for further information.  Unless you are a trained researcher, these websites are a fabulous resource.  Buy this book now, and keep it handy as your most valuable resource when the freight train of health issues is headed down your track.  Be prepared.  The Life You Save??  Let’s put it this way:  Like an ice-cold Budweiser, this book’s for you!

Book Review: Unaccountable–What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care by Dr. Marty Makary


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: Read more..


  • 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!

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