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 BOOK REVIEWS

Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care

Richard Balon, MD

Wayne State University, Detroit, Michigan, USA

By Marty Makary; Bloomsbury Press, New York, New York; 2012; ISBN 978-160819-836-8; pp 243; $17 (paperback).

It seems that medicine in the United States has been in a perpetual crisis, from managed care to the Affordable Care Act, and further on. I actually have been worried that the entire health care system is going to follow the pattern of other industries and that after the dot com, finance, and real estate bubbles we will see a health care bubble (and health care constitutes about one-sixth of our economy!). The costs have been skyrocketing and with the increases in obesity, diabetes, and other maladies related to lifestyle, the price will keep rising. However, the cost has been just 1 part—although the biggest part—of the crisis. Medicine also has become quite corporate, less personal, fragmented, and, as the author of this book, Marty Makary writes, “littered with perverse incentives” (p 2). Hospitals and medical centers “have merged and transformed into giant corporations with little accountability” (p 3). Lack of accountability “creates an institutional culture that fosters overtreating and runaway costs” (p 5). Hospital bailouts have been perpetual.

The author Marty Makary, a cancer surgeon at Johns Hopkins Hospital and an associate professor of health policy at the Johns Hopkins School of Public Health, took his frustration farther than most of us. He has tried to analyze what is wrong with the system, what should and could be improved, and wrote (among other things) a book with a telling title, Unaccountable, about it. The book deals mainly with issues related to surgery and cancer treatment (understandable, considering Dr. Makary’s specialty), yet it touches upon many general issues applicable to other areas and of interest to all of us.

The book consists of 3 parts: “Some random doctor,” “The Wild West,” and “Transparency time.” Part I focuses mostly on problems with physicians and what possibly to do with them, such as in chapter 4 “The supersurgeon and the Shah.” When the late Shah of Iran became ill, 2 prominent physicians were summoned to treat him. One of them was Michael DeBakey, probably the most famous surgeon of the time. He correctly recommended and performed the Shah’s spleen removal. Because the pancreas could be injured during splenectomy, a standard, good practice calls for placing a drain in the area of the pancreas to prevent pancreatic fluid accumulation if the pancreas is injured during the surgery. DeBakey refused to use this drain, as he was confident that he would not touch the pancreas (although, being a cardiovascular surgeon, he had little experience with this type of surgery). Surgery went well, DeBakey was celebrated, yet the Shah got worse because there was build up of fluid from leaking pancreas in his abdomen. Makary uses this example to emphasize that volume matters (DeBakey had not done splenectomies routinely) and that “it is better to learn from the wisdom of others than by making mistakes practicing on patients” (p 54). He also writes that teamwork is a marker of good medical care (p 23), that the public demands to see the results of the safety culture surveys (p 27), and that “people are angry with being ping-ponged from doctor to doctor and from test to procedure, not knowing how to discern whether their care is of good quality” (p 27). He reminds us that hospital administrators are increasingly being removed from daily hospital care and that modern medicine has a growing appetite to over-screen, over-diagnose, and over-treat. (Who has not heard of emergency department patients being ordered all possible tests prior to even being seen by the doctor?) The discussion also mentions hospital marketing and advertisement (which costs a lot of money that could be better spent!) and the widespread financial conflict of interest many physicians have. The financial conflict of interest meant here is not so much getting money from the pharmaceutical companies, but rather the under-referring to others, incentives for the number of procedures (some unnecessary), payments per procedure, selection of procedures (physicians who bought radiation therapy equipment, and make profit from each treatment—mostly recommending radiation to their cancer patients, no matter what). Makary also writes about how the patient should navigate through the system and how to select a doctor—proceduralist vs diagnostician. In case of selecting a proceduralist, one wants a person with the most experience in treating his condition. When looking for a diagnostician, one should look for a compassionate listener who will let the patient talk. One should also look at hospital stats and patient outcomes.

In “Part II: The Wild West,” Makary continues in his criticism of the health care system, starting with a chapter on impaired physicians, noting that medicine is poorly policed. With regard to monitoring impaired physicians he notes, “The lack of cooperation between hospitals and state medical boards resembles the problems of the Roman Catholic Church—another nontransparent and unaccountable system—which failed to remove dangerous child molesting priests, opting instead to reassign them to other parishes” (p 106). He touches on issues such as the unwillingness of physicians to retire (more problematic for surgeons) and that we start failing to monitor “bad apples” already at medical schools (everybody graduates). In the following chapter on medical mistakes, he mentions the numerous mistakes made even with prominent and famous patients. Did you know that the comedian Dana Carvey had open-heart surgery on the wrong vessel or that John Wayne’s fatal colon cancer was missed because his doctor did not want to inconvenience him with a rectal exam? The author then turns to the hospitals and their greediness, such as in children’s hospitals. Many of their CEOs make more than $5 million per year and have special packages (retirement worth millions, country club memberships), yet their hospitals organize collecting pennies from other children (eg, Boston Children’s Hospital, while having a surplus and paying its CEO millions) and are subsidized by the government. Reading these facts one realizes that the system is really perverse. The analysis continues to bring further examples, such as the unnecessary number of back surgeries (a profitable procedure), while conservative back surgeons maintain that physical therapy and pain medication is an effective approach to degenerative disc disease. Makary reminds us that we are obliged to say no to some treatments at times and we have to learn that. We treat too much, as that is what we are taught at medical school. The last chapter of this part reviews the enormous expansion of robotic surgery, although it is not clear whether it is more beneficial than regular surgery (except in several studies paid by the makers of robots).

The last part, “Transparency time,” suggests some solutions to the problems of our health care system. As to the fragmentation and lack of immediate help, Makary provides the amazing example of the Mayo Clinic, where the coordination is perfect and patients are seen, examined, and treated almost immediately. No wonder as the system was designed by physicians. Makary suggests that hospitals need to change their culture. Physicians and systems have to become more open and transparent. He emphasizes “Anonymity fosters incivility” (p 177) and “Transparency builds trust” (p 183). He also emphasizes the importance of family-centered care (critical component), the involvement of the patient’s family in the treatment and follow-up. Another of Makary’s suggestions is the “online dashboard” for tracking hospital performance, which would include readmission rates, complication rates, reporting of events that should never happen but do happen, safety-culture scores, hospital volumes, and transparent records with open notes and even videos of procedures such a colonoscopy and others.

Reading this book one wonders, What is happening to the system we are (maybe) so proud of? What has happened to properly communicating with our patients? Has greed taken over medicine? Why have we allowed the corporate makeover? One wonders whether this change is permanent or whether the new generations will be able to change these flaws and make the system more transparent, accountable, and mainly human. The book is intended mostly for patients and the general public, but every physician will benefit from reading it and using it for some self-reflection. Psychiatrists should wish that we get a similar book addressing similar and other problems in the care for the mentally ill, such as expensive medications of questionable efficacy, lack of access to psychotherapy modalities namely cognitive-behavioral therapy, insufficient insurance coverage for mental illness, just to mention a few.