Book review: Unaccountable by Marty Makary

It was one year ago that my father was severely burned, and his transfer from a local hospital to a burn center delayed for about 15 hours. I marked the occasion by reading Marty Makary’s book Unaccountable.

I have been researching medical errors for over ten months now, and this book is a summary of nearly everything I have learned about errors and the U.S. healthcare system. It is horrible, depressing, and maddening. And I am so glad that Dr. Makary has written this book.

Dr. Makary describes how his “premed ideals” to work in the best interest of patients clashed with the reality of the hospital environment he saw in medical school. He left medical school and enrolled at the Harvard School of Public Health, where he learned about measuring quality in healthcare. He went back to complete medical school then began a six-year residency to train as a cancer surgeon, once again experiencing the reality of hospital environments. “I took my medical-school graduation oath to ‘do no harm’ seriously, so I was internally ashamed at how far I’d come from the days of telling my medical-school interviewer that I wanted to be a medical missionary.” Today he is a oncology surgeon and patient safety researcher at Johns Hopkins University School of Medicine.

These are some themes of the book:

  • Physicians are aware of other physicians who do not have the appropriate skills or knowledge to practice medicine, but remain silent. “I even noticed that my favorite professors kept the code of silence. When they were told about atrocious care at their hospital, they would refrain from comment, or on occasion express disgust, whispering under their breath—but never take action. (p. 17)
  • There is little standardization in treatment for a given disease or condition. The treatment a physician recommends is likely to be influenced by their own preferences and skills (and potentially paybacks from drug and device manufactures).
  • Patients have very little information available for making decisions about where to seek healthcare. Therefore they make decisions based on factors such as slick advertising campaigns and the availability of convenient parking—not the quality of care at the institution.
  • The people who work in hospitals know whether their unit has a culture of safety and teamwork. A simple way to measure this culture of safety and teamwork is to ask the healthcare workers if they would feel comfortable receiving care in their own unit. “At over half the hospitals we surveyed, half of the health care workers said no. At other hospitals, as many as 99 percent said yes.” (p. 26) This question is part of Hopkins Safety Culture Study. The hospitals that allowed their employees to respond did so on the condition of anonymity, so the public has no way of learning where any particular hospital ranks.

The issues of transparency and accountability underlie all these themes. Information is hidden from patients. People on the inside of the healthcare system know the information, but people on the outside do not. Dr. Makary proposes transparency is the answer to solving a large number of problems in the US healthcare system: the high rate of errors, over-treatment, inappropriate treatment, and poorly performing healthcare institutions or departments.

Here is one piece of evidence in favor of transparency: Beginning in 1989, all hospitals in New York state that performed heart bypass surgery were required to publicly report their heart-surgery death rates. They ranged from 1% to 18%. “With each passing year of public reporting, the state’s average death rate went down. In addition, bad outliers, like the hospital with the 18 percent mortality, were reigned in.” (p. 37) The underlying idea is that if patients have data about outcomes of specific procedures for specific hospitals, patients can make informed decisions about their care—and few people would intentionally choose to have low-quality care.

The last five chapters of the book describe how transparency and accountability can become a part of the US healthcare system. Here are the big ideas:

  • A hospital must be committed to a culture of safety, transparency, and patient-centered care. This commitment must be fundamental to the administration of the hospital. Instead of sitting behind a desk, administrators must spend much time in the clinical units, listening to concerns and soliciting ideas from staff.
  • Information must not be withheld from patients. For example, patients should have online access to their doctor’s notes, and for any procedure that involved video (such as a colonoscopy) the video should be available to the patient.
  • Treatment decisions should not be made by the physician. A patients should be provided with appropriate information about their choices (perhaps as brochures or videos), and the physician acts as a guide to explain the options. The choice is then made by the patient after they have had time to think through their options. (See for more information about shared decision making.)
  • People behave better when they are on camera. Cameras in operating rooms reveal if the pre-surgical checklist that was required by the hospital was actually done, and whether the surgeon had another fit of disruptive behavior.

The most hopeful part of Dr. Makary’s book is chapter 16, “A New Generation for Honest Medicine.” One paragraph reads, “Medicine is an institution as old as humanity. Its traditions are as hierarchical as those of the royals. And for centuries, doctors have enhanced their authority with mystery, keeping the workings of their profession opaque. But I am convinced that the new generation of doctors is poised to usher in a revolution of transparency, open-mindedness, and honesty. This generational shift may be just what is needed for medicine to end the secrecy that has historically permeated our profession. With younger doctors taking the lead, the culture is ripe for transformation if we can capitalize on this moment and push for reform from within.” (p. 206)

It sounds like the time is right for change within the healthcare system. It is time for accountability. It is time for transparency. It is time for honesty. If a new generation of doctors will embrace transparency and accountability—and the public demands it—surely we can make it happen.


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