Unaccountable: What Hospitals Wont Tell You and How Transparency Can Revolutionize Health Care by Marty Makary

Unaccountable: What Hospitals Wont Tell You and How Transparency Can Revolutionize Health Care Reviews

• 
  Malin Friess

  When Dr. Makary MD (general surgeon) told his friends he was going to write this book they said, "Your colleagues will hate you." But after publication, Dr. Makary found just the opposite, as physician after physician told me this story needs to be told. I agree.
  
  Dr. Makary quit medical school as third year intern after he watched a sweet elderly lady die after a procedure she didn't need. He enrolled in the Harvard School of Public Health; to study the science of measuring quality. After 6 years Dr. Makary found he missed patient care and came back and finished a residency in general surgery and now specializes in patients with pancreatic surgery.
  
  This book is fabulous. Physicians should read this book. Health Care administrators should read this book. Politicians need to read this book. Anyone who has been hospitalized or is about to undergo (or have family undergo) surgery should read this book. Besides Atul Gwande (Complications, Better) I have found no other book that clearly articulates how we can all be better health care consumers. I learned so many things...
  
  - 25% of patients are harmed by medical mistakes. There are doctors unfit to practice. Makary had a surgeon in his residency known as HODAD (Hands of Death and Destruction), but the patient's loved his bedside manner, celebrity good looks. The nurses and aneshetiologists feared him. There was another doctor called the RAPTOR..patient's feared this doctor's cold bed side manner and disheveled appearance. But Residents, and nurses loved him because his surgical outcomes were exceptional. How can patient's know who the good doctors are? Ask the nurses, residents who would they chose for their operation. Makary also wonders how could they could be if they worked as a team and HODAD learned his limits and RAPTOR learned better beside manner? But that is against medical culture.
  
  How do you find a good hospital? Outcomes really do vary. Some Hospitals in New York have a CABG mortality rate of 18%, where as others are as low as 9%. Also publicity matters (remember the moldy patient rooms at Walter Reed?)..when these results hit the press..hospital administrators scrambled to make changes and yield to the physicians requests (more specialists in aneshesiology and nurses). Mortality rates declined to 2%. How does a patient avoid a chop shop? Ask doctors and nurses in your community where they would have their heart sugery performed?
  
  14.7 Percent death rate in Surgeons who perform fewer than 2 operations per year..
  8.5 Percent death rate in Surgeons who perform 2-4 operations per year
  4.6 Percent death rate in Surgeons who perform more than 4 operations per year
  I remember sadly when a dental front office person I worked with years ago died after what it seems should have been a routine thyroidectomy. Did a medical error occur? Did my friend know the risks of the surgery (her lump was benign and more a nuisance). The procedure was done in a large City hospital perhaps by resident General Surgeons. How many had they done? Ask your doctor how many of these operations have you done..and find the super-specialist. If you are incontinent find a urogynecologist. If you break your hand find a hand surgeon. Repetition produces better results.
  
  Medical decision vary widely. Patient A goes in with a sore knee and one office recommends a NSAIDS and the other office recommends knee surgery. I see it in dentistry all the time...Dr. A recommends RCT, and crown. Dr. B recommends a limited occlusal adjustment. Makary would say seek the most conservative approach. Can the procedure be done minimally invasive? Is the surgeon comfortable using scopes? Are there other options? Should I be referred to someone with more experience? Patients that are offered minimally invasive procedures: Prostrate (90%), Appendectomy (60%), Hysterectomy (50%). Some doctors don't offer because they were not trained.
  
  Policing doctors is hard. No one wants to do it. AMA has declined to 15% of US doctors. Doctors don't like to retire. Nurses have a hard time speaking up in Operating Rooms for fear of reprisal.
  Find a hospital with good communication (Read Gwande's Checklist Manifesto) where all the people in the O.R. know each others name. Lets move past a culture where doctors could throw instruments and scream and berate nurses with obscene language.
  
  Be careful what you contribute to? Have you ever noticed how nice the lobbies of Children's Hospitals seem to be (Doernberchers, Cleveland Heart?) The CEO at Akron Children's Hospital (Meredith spent 6 weeks here at the ICU) made a fine salary of 5.132 million dollars. While the pediatricians earn less than 110k. That's not right! Children's Hospital fund-raisers are huge businness. I would suggest charitites like Samaritan's Purse, PACCS, Post-Residency program. Some of the administration funds its own position.
  
  Medicare pays out only about 5k for a complicated 9 hour brain surgery. But Medicare can pay out 10-15 k for a short back surgery (that seems is moderatly effective to treat back pain). Its no surprise that neurosurgeons are leaving brain surgery to pursue spinal surgery. Spinal fusions are a gray area in medicine.. Medicare alone paid out 2.3 billion for this procedure. Hospitals are rushing to find spinal surgeons where the outcomes are ill-defined. Whereas the general surgeon who gets called in the middle of the night for an appectectomy gets reimbursed by medicaid $600.
  
  The DaVinci Robot costs 2 million dollars. My wife uses it for minimally invasive surgeries. Makary is decisively against this expensive tecnhology. He feels the Robot is mostly a hospital advertising mechanism. The surgeries are long and costly. The robots maintenance is 140 k per year which Makary says could cover patient co pays. He claims the studies do not show conclusive benefits. Anesthesisologists say the large robots gets in the way if they need to provide emergency CPR. 41 percent of US hospital websites advertise the Robot with words like improved outcomes (where is the evidence?). It costs 4k more per operation and more time under anesthesia for the patient. The DaVinci stock price has been soaring since 2000.
  
  We need a culture of speaking up. Bostonians pick up trash. Southwest airlines crew are funny on the intercom. A Toyota belt can be stopped by the lowliest employee if their is a problem. Makary claims Mayo Clinic does it right...team work. Multidisciplinary care. A culture where a Nurse can stop an operation.
  
  Makary wants cameras everywhere; OR, washing hands, colonoscopies. When doctors who did colonoscopies knew their procedures were being recorded they spent 50% longer inspecting every fold of the colon for polyps. Dr. Makary wants open chart that patients can see. Makary dictates in front of a patient and he feels that mistakes are corrected (Doctore, my MI was in 2002, not 2008). Makary wants complication rates for hospitals on the web for patients to see. The consumer will make informed decisions...and poor hospitals will have to improve.
  
  5 stars for Makary! I'm less moved by his arguments about dangerous care (I think doctors do their best and mistakes are still extremely rare. When mistakes do occur Doctors take it very personally). But I think medicine should be more transparent with costs, results, complications. Sometimes the best care is no care. Dr Makary (pancreatic surgeon) says if he got pancreatic cancer..no chemo/radiation for him. he would spend his final months on the beach. I also believe overtreatment in medicine and dentistry needs to be curtailed.
  
  
• 
  Bernard Farrell

  Reading this book helped me better understand that surgeons aren't infallible and suggested questions to ask before undergoing any procedure. Marty Makary's book is gripping reading, and the anecdotal stories are outrageous.
  
  I'm hoping enough people will read this and demand hospital produces statistics on surgical outcomes (both good and bad) so we can decide with real information to back our decisions.
• 
  Kevin

  I met Dr. Makary at the HIMSS 2014 Conference in Orlando last week where he spoke on this topic (and held a book signing). His speaking is just as engaging and motivating as his writing. Overall, transparency, I agree, is a good thing and will go a long way toward improving patient safety.
  
  One of the things to look out for: gaming the system. Dr. Makary makes the point in the last chapter (p. 213) that "Doctors understand the science and have developed non biased methodologies for tracking quality, and a younger generation is already expressing a distaste for the old way of doing things." Unfortunately, there are "bad actors" in every organization, health care systems not excluded. In fact, this book is chock full of examples of them. These "bad actors" have that same understanding, and non-patient-safety-related motives by which to attempt to bias results. Safeguards will have to be built in to detect such tampering.
  
  Dr. Makary used an example in his talk that is not in this book that I think wonderfully sums up the value of open feedback from customers (patients): TripAdvisor. He related a recent conference he attended in Azerbaijan (I think) where the quality of the hotels was exceptional. He was informed by staff there that it was always so good. TripAdvisor.com, and more specifically the candid (if sometimes rude and snarky) customer reviews (like this one? I hope not...) really lit a fire under the management of the hotels in Azerbaijan, and they really upped their game. Suddenly, the managers and staff were being held accountable, even after the guest was gone, and that unhappy guest had the ability to negatively affect the opinions of potential future customers. I know I personally used TripAdvisor.com to help plan my upcoming trip to Ireland, and I'm definitely looking at what folks who have experienced the services in the places we want to eat, play, and sleep, and it's definitely affecting my decisions. I seen no reason why this model shouldn't or couldn't extend to healthcare, and Dr. Makary makes a good case in this book on how and why it would work.
• 
  Dan Drake

  This book does a great job of describing the dysfunctional reality of hospital health care -- and also working as a bit of consumer's guide. Recommended for anyone dealing with a complex health condition or surgery.
  
  The author did a very long, very interesting interview on the Peter Attia podcast that I also recommend:
  https://peterattiamd.com/martymakary/
• 
  Logan Smith

  Great book overall. Provides a picture of what medicine could be if transparency is encouraged. A recommended read for anyone in healthcare.
• 
  Vertrees

  I am completely appalled at the section on Walter Reed. The gross inaccuracies, misleading information, and lack of attention to detail of that section casts the entire book in doubt.
  
  See for yourself- search for the Washington Post article (search Google for 'Walter Reed Washington Post 2007'- I found it in under a minute). If you *read* the article, you will see that there were two major problems reported- the *offpost* housing and overly bureaucratic process.
  
  My second problem- Dr. Marohn was assigned to Andrews AirForce base. He would come to Walter Reed very infrequently (I saw him there in a case in 2003) to help with a case. How could he have even known about building 18- an *outpatient housing which was offpost* when most people who worked there full time did not know about it? And he was supposed to have complained about it? I call Bull.
  
  I looked up that survey (searched 'hospital safety culture survey' on Google). There is no way that the problems in *outpatient housing* and a stalled checkout process could have been identified by the survey he mentions. One thing we can agree about- I wish the survey had been completed. I worked there from 2003-2010 except for the time i was deployed to Afghanistan. Morale was good, and the actual impatient care (what would be tested by the survey) I am sure would have been rated highly. I am proud of the work that we did there. There was truly first-rate medical care for our soldiers.
  
  I am also grateful that the problems of *outpatient housing* and overly bureaucratic process were highlighted, addressed, and punished. But unlike the article, I recognize that those problems are beyond the scope of this book and would not be addressed by his referenced survey.
  
  What I took away from that section is that he jumped on the bandwagon of a sensationalized story without doing adequate research. Did he even read the article? He then takes a statement from a colleague at his workplace - as he notes, down the street from Walter Reed- rather than asking someone who works at Walter Reed. Shameful.
  
  He flippantly says that this magical survey could have fixed bad hospitals like Walter Reed. Check the details- it took me a couple of minutes using his information to completely discredit his argument. After such sloppy work- how can we believe anything else? It's too bad bc I think the point of transparency in healthcare is an excellent one, and needs to be accurately addressed in a manner we can trust has been researched with attention to detail rather than sensationalism.
• 
  Andd

  Transparency in government needs to be accompanied by transparency in the medical field. There are certain things a patient needs to know, such as was your surgeon on call the night before, and did he or she get enough sleep.
  I would never think of asking that if I were going in for elective surgery. But maybe if I read the book again, I'd be more savvy.
  I recall when my mom was hospitalized for surgery to correct a surgeon's inexpertise in setting a collarbone. Mom looked at the new surgeon's name tag. Same surname as the first surgeon. Turns out he was the son. Mom got up and left that hospital in a hurry.
• 
  Missy Caulk

  I just finished this book and I commend the author for writing it. I'm sure he had a lot of his fellow physicians up in arms. I recommend it to everyone before going into the hospital for surgery, as it contains the right questions to ask, who to ask and who to look for for second opinions.
  Dr Makary has great ideas on how to make Dr.'s and hospitals more accountable for their outcomes. It will be interesting to see if any hospitals adopt "any" of the suggestions.
• 
  Wendi Lau

  Alarming. Clear. Many stories of bad practices. Too many. Yay Mayo. Boo children's hospitals. Surprising how little power doctors felt they possessed to affect change that would benefit the patient within their own workplace. Avoiding hospitals like the plague does not sound so crazy after all. Author makes good recommendation to demand transparency from hospitals and also from legislators if the medical institutions are receiving federal funds.
• 
  Christy

  Definitely opened my eyes. It's imperative to inquire and question when it comes to your health - no more blind trust in doctors (or anyone). Transparency would be transformational for our healthcare system. If only that was the topic being debated right now.
• 
  Marks54

  Another excellent book by Dr. Makary focusing on how to improve the accountability of doctors and other health care providers. This is a loving concerned look at med students, doctors, nurses, and hospitals and presents much that is reassuring. The details of what can and does go wrong in the hospital, however, should catch everyone’s attention and are not reassuring. It turns out that accountability problems are difficult even for those who know and practice medicine. What does that say for the rest of us? I would rather know than not know, however.
  
  There is much talk about the role of the “market” in health care. This has not really been possible in terms of conventional economic markets because of huge discrepancies in information between health care providers and patients who wish to purchase health care. Specialty areas in medicine have become so complex that few individuals are sufficiently expert to navigate such a system on their own. ....and yet information, through research and “evidence based” medicine has transformed the sector dramatically. The problem, as anyone facing major health crises knows, is how to make good decisions about prospective care, what to do, where to go for care, and who is to treat you. The unfortunate truth is that despite the gains made by medical research, patients face a minefield in trying to find out their options for care. Makary considers multiple aspects of this problem in terms of medicine being unaccountable. His book explains what he means by this, including poor treatment climates, excessive or inappropriate care, medical mistakes, and even the wide variety of approaches for treating conditions that can range from major surgery, to less invasive surgery, to non-surgical and lifestyle options.
  
  What can patients do to improve the odds that their treatment choices are well considered and not the result of a crap shoot, a bad time of day, or even a scheduling issue that has not doctors out of the hospital on the days when surgery is sought? Of course one can ask about these issues, and many more, that are detailed in the book. The trouble is that, even if one asks, the information even if available is not available to patients or to the general public. It is difficult to tell whether the hospital you wish to go to or the physicians you want to patronize or more or less skillful and careful. It is difficult to find out what is what. This is a scary condition to read about and it is ongoing today.
  
  Dr. Makary is wonderful and noting and explaining the issues and in informing readers what they can do to try to prepare themselves for care. Part of the recommendations require doing one’s homework - and using the Internet. But part of the answer lies in patients being their own manager for their own care, even if that involves asking lots of questions to intimidating looking health care professionals and administrators. But if a patient or family member does not do this, it is hard to see how someone else will do it for them, short of some amazing good luck.
  
  Everyone who anticipates personal contacts with the healthcare system but either themselves or their family members should read this book, even though it is not necessarily a feel good message. The idea of “caveat emptor” (let the buyer beware) takes on added urgency when contemplating major medical care. This is a great book that will assist people in figuring things out.
• 
  Lilly B

  This is a very interesting book in terms of the cases it discusses and the issues affecting american healthcare more generally - but ultimately it’s totally useless in terms of offering solutions because it fundamentally doesn’t see an issue with the profit-motivated privatised healthcare model. In fact it actively endorses it and discusses how patients would actually pay more for transparency in healthcare and that the free market actually benefits healthcare!!!
  
  I originally read this cause The Resident is based on this book which is one of my fave TV series and it was pretty weird being able to pick out bits of a nonfiction book being story lines in a massively over-dramatised tv show. Would recommend the first half of the book, especially the chapter on children’s hospitals, but I think anyone who is British and has a experienced healthcare in the NHS/ lives anywhere else that has nationalised healthcare will think the conclusions in this book are frankly ridiculous lol
• 
  Akshay Dusad

  If you or your close ones have ever been to a hospital, or have had a surgery or are planning to have one, or might need one, then it is very important to listen to what Marty Makara has to say.
  
  Dr. Makary has tried to do his best to give the readers an insider view of what goes behind the curtains in the health care industry and to shed light to all it’s problems. I would be interested in a follow up considering this book was released more than 10 years ago and the healthcare sector have changed a lot since.
  
  4/5.
• 
  Tiff

  Extremely well-written and informative. Glad to have read this!
• 
  Shreya

  Yet another text that should be required reading at health professional schools. Highlighted throughout
• 
  Jerry

  This book is well worth reading to learn about some very sensible proposals for improving and reducing the cost of health care. The key point is transparency.
  
  “Congress should make transparency a condition of Medicare reimbursement and other funding.” Transparency includes “public reporting of outcomes, disclose all conflicts of interest, streamline patient access to records, and disclose mistakes as soon as they learn about them... By doing so, it will unleash the power of the free market to create positive change. When hospitals have to compete on a level playing field, all of them will be forced to improve how they serve their patients.”
  
  Hospitals should publish patient outcome metrics: bouncebacks (% readmitted within 90 days, categorized by discharging diagnosis), average length of stay for each medical condition category, complication rates by treatment or procedure and by type (respiratory, cardiovascular, bleeding, wound/infectious, gastrointestinal/malnutrition, kidney, and neurologic), risk-adjusted mortality statistics, never events, safety-culture scores (would you have your care here?, are you comfortable speaking up about safety concerns?, does teamwork promote doing what's right for the patient?), hospital volumes (by medical condition they treat, by type of surgery), percent of operations using minimally evasive surgery versus traditional open surgery, and transparent records (access to written and video records, disclosure of drug and device-related conflicts of interest).
  
  “For far too long now, the payment system we have has rewarded spending more money even if there's no benefit. As a result, expensive gadgets that may have no clinical benefit can be rapidly adopted. In the case of surgical robots, its an arms race.”
  
  “Health-policy professors are unanimous that the number-one driver of rising health care costs in the United States is new technology. The surgical robot perfectly symbolizes how our widespread adoption of new, high-tech solutions without proper evaluation of their benefits is breaking the bank.”
  
  50% of cardiac catheterizations are done for uncertain or inappropriate indications. 20% of implantable heart defibrillator patients do not meet guidelines to have them placed. The maker of Lucentis (price $2000 per dose) injected for wet age-related macular degeneration, secretly pays doctors an incentive of up to $58,000 for meeting prescribing targets. The drug Avastin (price $40 per dose) has been shown in two studies to be equally effective.
  
  Many chemo or radiation treatment patients “are never informed that the outcome will be a meager one-to-two month added survival benefit... One highly cited study showed that approximately half of all cancer patients received chemo or radiation treatment the same week as their death... Cancer centers have become profit centers for hospitals, thanks to the increasing number of services they prescribe and the surcharges added to the price of chemotherapy drugs... Whenever confronted with a decision about your medical care, inquire about the difference in average outcomes and the quality of life among the options.”
  
  “The complication rates a doctor will quote out of textbooks and the medical literature are generally two to three times higher in the real world. This is a well-known bias in the literature that in the medical community is called publication bias. It refers to the fact that only doctors with low complication rates dare submit their results to medical journals... Even though patients are often quoted a pancreas-surgery mortality rate of 1% based on published studies, the real-world mortality rate is closer to 7%.”
  
• 
  Dan

  Dr. Makary says that transparency is the key to reducing the cost of health care in the US and improving the areas in which US health care has results worse than many other countries. Driven by the profit motive and free from any scrutiny by patients or the general public, hospitals have reacted to maximize profit rather than patient welfare. He cites such problems as incompetent doctors (all medical students pass medical school regardless of grades), impaired doctors (those under the influence of drugs or alcohol or suffering from senile degeneration of various kinds), and the atmosphere of covering up for other doctors' mistakes as being prevalent in all hospitals. These sections of the book serve to educate the patient as to what to expect and ways to become informed before blindly submitting to prescribed treatment.
  
  Fortunately, Makary does not stop with pointing out the problem. He goes on to propose a solution--transparency. He advocates that all hospitals publish their "dashboard" with six statistics: (1) bounce backs: the percentage of patients readmitted within ninety days; (2) complication rates; (3) never events--events that should never happen, e.g. sponges left in a patient or operations performed on the wrong side of the body; (4) safety culture scores--obtained by asking hospital staff three simple questions, e.g. "Would you have your surgery done here?"; (5) hospital volumes--how many of key types of medical problems do they handle each year; (6) transparent records, open notes, and video recordings to allow patients to be partners in the decision-making process regarding their treatment. He cites examples of successful use of each of the six steps he recommends.
  
  I highly recommend this book to everyone affected by the US healthcare system regardless of your views on the role government should play in healthcare. The measures Makary advocates can be administered and overseen by healthcare industry organizations. He is not pushing government regulation.
• 
  Rachel

  On hearing that 20% or more of patients encounter complications caused by their medical treatment or hospital stay, one might wonder how individual hospitals and the medical-industrial complex could afford to ignore the statistic--and why more patients aren't up in arms about the obstacles to evaluating the quality of their treatment. In fact, as Dr. Makary discusses, this is one logical consequence of a system that makes up a fifth of the nation's economy yet goes largely untaxed and unregulated, and sees profit from every procedure undertaken, necessary or not. Advocating for transparency in data such as doctor ratings, number, type, and outcomes of procedures performed, and safety indicators such as employee perceptions of teamwork, comfort level bringing up problems to superiors, and percentages of hospital staff who would want their own treatment administered at the facility where they work, he makes the argument that patients will have to wield their power as consumers to demand accessible and decipherable information enabling them to take more control of their own care. It's a grand vision for a complicated system, but one Makary argues an up-and-coming generation of doctors themselves are getting behind.
• 
  Ariadna73

  The author is an oncologist at John Hopkins. He talks about dr. Hadad (Hands of Death and Destruction) there are quite a lot in our system. It tells horror stories of doctors that are reckless and treat their slept patients as garbage. They rely on the blissfulness amnesic powers of the anesthesia and know that the patient won't remember a thing of the mistreats they are subjected to. Doctors have no heart. They have big wallets in the middle of their chests; but sometimes the system starves those wallets so badly that they keep no feelings at all. They keep prescribing expensive treatments and surgery necessary only to put more money in those wallets; but not for the well being of the patients. And the worst of all is that when the patient wakes up; he or she is so grateful with the doctor; that sends the physician flowers and thank you cards. Even the author; mr Hopkings confesses to these flaws. It is not because they are bad persons; it is because they are human and they need to eat and also pay for a few toys; so they really need to make money by using all that new and expensive technology... and on and on it goes.
• 
  Ethan

  Compelling - if occasionally disjointed - case for how transparency of hospital quality and outcomes metrics could greatly improve health care in the USA.
  
  Skirts any mention of cost transparency, also omits describing how most doctors are not actually employees of the hospitals he proposes making more accountable.
  
  But the descriptions of nascent efforts in quality reporting are powerful, along with the idea that health care can only get better - and quickly! - when consumers are empowered with information.
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  Emily

  Between my summer experiences and this book, my med student idealism has been thoroughly and vitally smashed. But from the pieces, I find myself now able to better construct a new and realistic outlook on the current state of medicine as well as where I'd like to take it in my future practice. This is an important book for anyone in the medical profession, as well as anyone interested in having the tools to be their own best advocate as a patient.
  
  
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  Geoffrey Rose

  A call to arms for greater transparency in health care. A solid primer on the importance of better patient safety culture for the health care professional and general reader alike. Strongly recommended.
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  Megan

  Fascinating read about hospital culture and the need for change.
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  Elise

  Excellent......everyone should read this.....