Extremely Disappointing Facts About Doctors

The gist of Unaccountable: What Hospitals Won’t Tell You — and How Transparency Can Revolutionize Health Care (copy sent me by publisher) by Mart Makary, a med school professor at Johns Hopkins, is that doctors have failed to regulate themselves. Nobody else regulates them, so they are unaccountable. In many ways, Makary shows, bad behavior (e.g., unnecessary treatment, understating the risks of treatment) is common. Hospitals hide how bad things are. Makary mostly discusses surgeons — he’s a surgeon — but gives plenty of reasons to think other specialties are no better.

The book is one horror story after another. At one point, Makary quit medical school. He was disgusted and appalled by seeing doctors — his teachers — push an old woman to consent to an operation she didn’t want and didn’t need. She refused, again and again, but the doctors kept pushing. Makary objected. He was ignored. Finally she agreed. The operation killed her.

I know Peter Attia as a co-founder, with Gary Taubes, of the recently formed Nutritional Science Initiative. Makary met him when Attia did a surgery residency at John Hopkins Hospital. Attia had seen a doctor about back pain and had been told he needed surgery. They operated on the wrong side, causing damage that prevents Attia, an excellent athlete, from playing most sports. Eventually Attia left medicine. He felt “modern medicine was too frequently dishonest with patients, at times understating risks and overtreating patients as a matter of reflex” — “as a matter of reflex” meaning “as a matter of course”, i.e., usually. And Johns Hopkins Hospital is one of the better hospitals in America. “Almost everyone I talk to has a story about a friend or a family member who was hurt, disfigured, or killed by a medical mistake,” writes Makary. He has six such stories, including his grandfather and his brother. His grandfather died from unnecessary surgery.

The “when-you’re-a-hammer problem” says Makary, “plagues modern medicine at every level.” He witnessed a case conference where a young otherwise-healthy patient had a small liver tumor. “The transplant surgeons [more than one] in the audience recommended a liver transplant. I was flabbergasted. Why on earth would any doctor recommend a transplant?” Makary asked around. He discovered there was nothing unusual about the transplant surgeons in the audience. He called a friend who was one of the few surgeons trained in both cancer treatment and transplants. His friend said “there was a battle for turf taking place nationwide between transplant surgeons and cancer surgeons. Both claim to be liver experts.”

Makary tells about trying to obtain informed consent for a surgery when he was an intern. He didn’t know much about the surgery. The patient didn’t agree. “It was well-known among interns that if an attending senior surgeon found out that a patient refused surgery close to surgery date, duck for cover. Mine would surely be livid.” Makary spoke to an upper resident. He couldn’t get approval. They went to the chief resident. He got approval. Congratulations all around amongst the doctors, “glad that the wrath of the attending surgeon would be averted.”

Supposedly state medical boards oversee doctors. Makary devotes part of a chapter to describing how they don’t. He asked state medical boards why they don’t search a national database before issuing a medical license. “My favorite excuse was that they could not afford the four-dollar-per-doctor fee.”

In 1978, the Shah of Iran needed an operation. The United States government set him up with a Texan named Michael DeBakey, “considered by many to be the best surgeon in the world.” During the surgery, DeBakey failed to take “a simple standard safety measure.” Due to this failure, the Shah developed a serious complication, became very sick, and died. The Shah and the United States government had failed to realize — and, more important, none of the experts they consulted had told them (I assume) — is that DeBakey was a famous heart surgeon. The Shah’s operation involved his spleen. DeBakey knew little about such operations and had done almost none — but (I assume) didn’t point this out.

A survey done at many hospitals asks employees if they “feel comfortable speaking up when [they] sense a patient safety concern.” At the median hospital, the percentage is about 70%. In the Milgram experiment (where subjects are ordered to give painful shocks), when audiences were asked by Milgram to predict what they would do in that situation almost all said they wouldn’t give the shocks. In fact, most people did give the shocks — indicating that people vastly overestimated their likelihood of resistance and speaking up. So 70% is likely an overestimate. (A study of nurses found that about 95% of them broke safety rules when ordered to do so. Roughly all of them had said they would never do such a thing.) Since talk is cheap, why is the median percentage as low as 70%? No doubt many respondents had seen themselves fail to speak up.

These aren’t the worst stories, these are average, I just opened the book here and there. There are dozens more. No previous book has spelled out so clearly the depth and width of doctor misbehavior, especially how common it is, and the failure of those supposedly responsible, such as hospital administrators and state boards, to do anything about it.

Title from 12 extremely disappointing facts about popular music.

 

 

11 Responses to “Extremely Disappointing Facts About Doctors”

  1. charlie Says:

    You’ve got to separate hospital from doctors. Two very different incentive structures.

  2. Steve G. Says:

    Although much maligned and slandered, medical malpractice lawsuits seek to influence physician & hospital behavior, but it’s a a weak system. Meritorious cases often don’t win; they are extremely expensive to pursue; and most doctors and hospitals will go to extreme lengths to avoid liability. For a good consideration of the topic, consult Tom Baker’s The Medical Malpractice Myth. In the end, doctors more than lawyers need to address this issue. It’s a much greater problem that most realize or (for those who should know), want to admit.

  3. WB Says:

    1. Seth: There is a term for this that I first learned from reading one of Nassim Taleb’s books; a term I’d never heard before: iatrogenic (from the Greek term iatros, physician + E -genic). Of course this ancient term refers to inadvertently induced harm. What the Makary book talks about obviously goes beyond that.

    2. There is an important blog, http://hcrenewal.blogspot.com, that focuses on ethics problems in the medical care industry. The lead author is Roy Poses, MD who has been actively talking about it for a long time without getting much traction either within his profession or in main stream media. He refers to this as the “anechoic” effect. The blog describes its mission as “Addressing threats to health care’s core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.”

    3. @ Steve G. The medical malpractice system is more than weak. It is part of the problem because of the way “malpractice” is defined and determined by our court systems. This system helped open the door to what is generally referred to as “defensive” medicine based on “protocols” for testing and treatment concocted by the medical care system and (as it turned out) designed mostly to protect physicians against malpractice claims. As long as the physician follows the applicable “protocol,” legal claims are nearly impossible to pursue effectively. This is something that needs to be addressed by policy makers (e.g. legislators) rather than doctors or lawyers. The reason is that there are way too many conflicts of interest among the regular players in the existing medical system. And I agree with you that it is a greater problem than most of us realize — much greater.

  4. LemmusLemmus Says:

    This somewhat related post may be of interest:

    http://economiclogic.blogspot.de/2012/10/disclosing-hospital-quality-works.html

    (I have not read the paper it refers to.)

  5. JPB Says:

    Having lost several family members and friends to doctors pushing for surgery, etc., I have lost faith with the medical profession, despite coming from a family with 5 doctors, 7 nurses, and more. When is the medical “profession” going to come to it’s senses? How many more people will have to die before doctors start questioning the protocols?

  6. Alex Chernavsky Says:

    Unfortunately, you as a patient have to keep your wits about you and do your own homework. By remaining vigilant and skeptical in the face of “expert” medical opinions, I’ve saved myself a lot of grief on several occasions. God help you if you are, by nature, a trusting soul, or ignorant, or both.

  7. anand srivastava Says:

    There is a concept called Super Organism. I read it first time on FOFOA’s blog.

    Its not that only ants create superorganism (SO). Every organism will build one. And humans are no exceptions. The Medical establishment is also an SO. It has its own set of incentives, that define the SO.

    It is not that individual members of the SO are inherently evil, its just that they have to behave that way for the betterment of the SO. So the people who don’t work for the SO’s health are thrown out and the people who work in accordance are nurtured.

    Yes the only way to fix the problem would be to change the incentives. And yes criminal penalties for mistakes would make it better, as it will change some incentives.

  8. dearieme Says:

    “you as a patient have to keep your wits about you and do your own homework”: not always easy if you’re feeling ill.

  9. Nancy Lebovitz Says:

    You guys have been focusing on inappropriate care that given, and there’s certainly plenty of that, but the other side is appropriate care that isn’t given.

    Fat people (possibly especially fat women) are apt to have their actual symptoms ignored and just get told to lose weight. This can mean years of unaddressed illnesses, whether because the patient has to go through a number of doctors or gives up on trying to get help.

    I’ve only heard a little about it, but apparently unusually thin people are at risk of being told to just gain weight.

    What’s more, if you’ve got a disease that’s considered uncharacteristic of your weight (like type 2 diabetes in a person who isn’t fat), it can take a long time to get a diagnosis.

    Pain medication is frequently withheld, partly because doctors have a rational fear of being accused of giving pain meds to addicts or resellers, and partly because of a less rational tendency to not take pain seriously.

    More generally, only getting paid enough for very short appointments means that doctors have much less time for diagnosis, and are less likely to hear all the relevant symptoms or have time to think about them.

  10. WB Says:

    @ Nancy: You make valid points. But along a different line of thinking (such as becoming more aware of the things that we all could do to avoid many, all-to-common maladies in the first instance), there is the thing that is often never discussed by doctors: nutritional changes.

    Most physicians have no in-depth knowledge of this and, if they ever do advise life-style changes, it is usually along the lines of “eat less, exercise more” which is utterly useless advice. ( Our grandmothers can do better than that!) Beyond this, in the case of doctors, it’s usually a matter of pulling out the Rx pad or administering tests. But this is not working for most of us, and it will only get worse unless and until we take charge of our own health and well being. We all need to acquire more self knowledge of what works and what doesn’t, and it’s mostly free.

    What does (and can) work is some degree of individual effort to set aside certain assumptions (such as, e.g., the “balanced diet” is best) to find out what kind of nutritional changes can actually help many of us eliminate (reverse) many common “diseases” and then implement those changes. Seth has talked about some of these on this blog. There is a lot of great information out there on the world wide Web, and even in “old fashioned” books. One just has to open the mind a little bit and start digging. It’s not necessarily easy in the beginning, but is well worth it.

    In my view, that’s a lot better approach (and cheaper to boot) than expecting doctors to be able to show us the way to health. There may be a few, but you won’t find them in the main stream. Conventional “medicine” is fine for things such as repairing injuries and helping us overcome some infectious diseases. But if we’re seeking long term, every-day health, medicine is a wrong-way street.

  11. Nancy Lebovitz Says:

    WB, I’m in substantial agreement. Adjusting diets for individuals can make huge improvements.

    One of my friends has found that his digestive tract shuts down if he doesn’t eat a good bit of wheat fairly often, and it’s the same for a couple of his relatives. I wonder whether there are people with intractable ailments who just need to add the right food to their diets.

    Something else that was simple, cheap, safe, and effective– I cleared up a case of acid reflux by sleeping on my left side for a couple of nights. The suggestion was in wikipedia.