Eliminating the Third Largest Cause of Death
How Transparency Can Disrupt the Medical Care Industry and Change it for the Better
Martin A. Makary
Surgical Director, Multidisciplinary Pancreatitis Ctr.
Johns Hopkins Hospital, and Professor of Health Policy and Management
Center for Global Health, Johns Hopkins University
About the Lecture
To patients, the healthcare system is a black box. Doctors and hospitals are unaccountable. The lack of transparency leaves both bad doctors and systemic flaws unchecked, producing a medical culture that does little to eliminate costly preventable errors: routinely leaving surgical sponges inside patients, amputating the wrong limbs, and administering medications incorrectly because of sloppy handwriting, to name a few. Consequently, error rates and the costs of medical care continue to go up despite rapid scientific progress and others efforts to curb expenses. Patients need to know more of what healthcare workers know, so they can make informed choices. Accountability in healthcare would expose dangerous doctors, reward good performance, and force positive change through the power of the free market. This lecture will use art and presidential history to describe America’s heritage of transparency. It will explore how transparency has become an American value and how transparency has positively disrupted, and re-defined entire industries for the better. The modern transparency revolution in medicine, from compassionate bedside care to big data , and its potential to solve improve outcomes, eliminate mistakes and reduce the costs of medical care will be discussed. The lecture also will discuss what medical practice will look like in the coming years in America, in terms of technological innovation and consumer choices.
About the Speaker
Marty Makary is Professor of Health Policy & Management at the Johns Hopkins University Bloomberg School of Public Health and, concurrently, Surgeon and Chief of Islet Transplantation Surgery at the Johns Hopkins Hospital, where he previously held the Mark Ravitch Chair of Gastrointestinal Surgery. Marty created The Surgery Checklist, popularized in Atul Gawande’s book, “The Checklist Manifesto”. He is the lead author on the original publications introducing it’s use and measuring its impact on patient safety. He served on WHO’s Safe Surgery Saves Lives Initiative which developed the WHO Safe Surgery Checklist, and he chaired WHO’s technical workgroup on measuring surgical quality worldwide. His current research and advocacy work focuses on physician led efforts to reduce waste in the healthcare system. Marty is an author on more than two hundred medical and technical publications. He is the author of “Unaccountable”, a New York Times bestseller about the health care system. His articles have appeared in wide variety of general readership publications, including the Wall Street Journal, Time and Newsweek, and he is a frequent commentator on health issues on broadcast media, especially on programs on CNN and FOX News. Among other honors, Marty was named one of America’s 40 Smartest People in Healthcare” by Becker’s Review. Marty holds an MD and MPH. He attended Bucknell University, Thomas Jefferson University and Harvard University, earning his undergraduate, MD and MPH degrees and did a surgical residency at Georgetown University.
President Larry Millstein called the 2372nd meeting of the Society to order at 8:06 p.m. He announced the order of business and welcomed new members. President Millstein presented a summary of the 34th meeting of the Society, held in 1872. The minutes of the previous meeting were read and approved. President Millstein then introduced the speaker for the evening, Martin A. Makary, the Surgical Director of the Multidisciplinary Pancreatitis Center at the Johns Hopkins Hospital, and a Professor of Health Policy and Management at the Center for Global Health at the Johns Hopkins University. His lecture was titled “Eliminating the Third Largest Cause of Death”.
Dr. Makary began by suggesting that the major theme of the last five years of medicine has been rolling back recommendations made over the last several decades. Recommendations such as daily aspirin for everyone and mammograms starting at age 40 were found to cause more harm than good in most people. Appendicitis may be treatable using antibiotics alone in many cases, which could avoid what is currently one of most common causes of surgery in the United States.
Dr. Makary related the story of the assassination of President James Garfield in 1881, in which one Dr. Bliss—against the advice of other attending physicians with Civil War experience—performed seven operations on the president to remove the bullet. The president ultimately died of sepsis resulting from the surgeries, more than a decade after Dr. Joseph Lister had introduce the techniques of antiseptic surgery.
Dr. Makary explained that President Garfield, along with many other patients, died of “unwarranted medical variation”, meaning the practice of medicine that did not conform to the theories or techniques broadly accepted in the field.
Dr. Makary identified medical errors as the third largest cause of death in the United States. One major source of such errors is unnecessary medical care, including over-prescribing and unnecessary procedures and tests. Dr. Makary related that some doctors estimate that 15-30% of medical care is not necessary, and brings with it real financial and health costs.
Dr. Makary turned to explaining what can be done about it. One approach has been to attempt to reduce the incidence of unwarranted medical variation by identifying objective metrics for comparing physicians’ practice and feeding that information back to them. For instance, Mohs surgeries for the treatment of skin cancer involve repeatedly removing thin layers of tissue from around a cancer site until only cancer-free tissue remains. By analyzing the number of cuts, researchers identified the doctors that were cutting substantially wider or narrower than their colleagues. Dr. Makary noted that characterizing performance as “below average” triggers defensiveness and justifications. In contrast, telling people that they are an outlier creates very strong social pressure. By providing objective feedback, outliers can be encouraged to move toward the consensus position.
In this same vein, Dr. Makary explained that the simple intervention of the checklist has substantially reduced medical complications by helping ensure that scientific advances and best practices make the transition to everyday practice.
Another avenue toward improvement has been harnessing the cost incentive. Dr. Makary explained that one effect of the high cost of deductibles has been to drive patients to inquire more closely about the financial and health costs of tests and procedures. Dr. Makary noted that the system of networks and discounts has the effect of obfuscating the true cost of healthcare to the extent that even doctors do not know the cost to the patient of most procedures. Dr. Makary described the goal as a “competent marketplace” in which transparent financial and health costs are available to patients so they can make informed decisions, and market pressures can act to bring prices down.
Dr. Makary concluded by explaining that health care is a complicated, political, and polarizing topic, but improving medical care through reducing errors is uncontroversial and has wide benefits. After the conclusion of the talk, President Millstein invited questions from the audience.
One questioner asked about the extent to which defensive medicine drives unnecessary medical care. Dr. Makary confirmed that fear of malpractice was a primary driving factor of unnecessary care, but that overall it was only one of many factors contributing to the high cost of health care.
Another questioner asked what changes in the medical school curriculum might help new doctors better consider these issues. Dr. Makary observed that current medical students already show less tolerance for dogma, and theorized that the increasing diversity of the field may be driving productive inquiries into the validity of longstanding conventional wisdom as well as promoting transparency with patients.
Another questioner asked the “reference ranges” for blood tests. Dr. Makary agreed that individuals or groups commonly have results outside the reference range that are nonetheless normal and healthy for them. He reiterated the advice to treat the patient, not the test.
After the question and answer period, President Millstein thanked the speaker, made the usual housekeeping announcements, and invited guests to join the Society. At 9:45 p.m., President Millstein adjourned the 2372nd meeting of the Society to the social hour.
The weather: Foggy
The temperature: 8°C
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