"That's how I like to do it." This is a phrase Marty Makary, MD, cannot forget.
Dr. Makary, associate professor of surgery at Johns Hopkins School of Medicine in Baltimore and author of the book "Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care," delivered a keynote address at the National Center for Healthcare Leadership's 2013 Human Capital Investment Conference in Chicago Tuesday.
Back when he was a resident, Dr. Makary saw two physicians perform separate colonoscopies, in which they discovered polyps in their respective patients. Each, however, went about removing the polyp in a different way — one via endoscopic surgery, another through open surgery. Despite having the resources and expertise to perform the procedure endoscopically, the physician who decided on surgery said his reason was a simple one: "That's how I like to do it."
The surgical method obviously involves more pain and scarring for patients, along with a higher rate of infection. The likely reason patients agree to undergo surgery when they could have a polyp removed endoscopically is they simply do not know better. "It's [about] 'how I like to do it.' It's a problem where we desperately need some transparency and accountability," said Dr. Makary.
Dr. Makary believes variation, or two ways of treating the same clinical presentation, is what plagues healthcare. "It turns out medical mistakes are so common they're endemic in medicine, and variations in quality have almost come to define the entire profession in the eyes of some patients," he said. It can be difficult to have a sense of the 210,000 to 440,000 hospital patients who die each year from preventable errors, according to a study published in the Journal of Patient Safety. So Dr. Makary put these numbers in context.
Dr. Makary said heart disease, the number one cause of death in the United States, kills 597,689 people each year, according to the Centers for Disease Control and Prevention. Second to that is cancer, which causes 574,743 deaths. The third-leading cause of death, taking 138,080 lives annually, is chronic lower respiratory diseases.
When you look at it that way, medical errors actually make up the third-leading cause of death in the United States, said Dr. Makary. Yet rarely is this problem brought front and center. "A lot of clinicians have said discussions about healthcare are important," he said. "But most discussions frustrate clinicians in some degree because [people] talk about different ways of financing a broken system, not how to fix a broken system."
Healthcare variation isn't a new problem. It's what ultimately led to the death of President James Garfield in 1881, after all. After he was shot, the bullet rested in his back but caused no damage to his organs. Two groups of physicians cared for the president — one that wanted to remove the bullet and another that wanted to keep the bullet intact based on their experiences with Civil War soldiers.
Ultimately, the former group prevailed. These physicians were dubious about infection control at that time, so eight of them inserted their unsterilized hands in President Garfield's wound to remove the bullet. They missed the bullet's pathway and ultimately caused the president to contract septicemia, which killed him.
Education or even competition doesn't always leave people doing their best. Instead, Dr. Makary pointed to several modern-day mechanisms of accountability that have changed human behavior, such as TripAdvisor, speed cameras at intersections and even the Uber app for taxi cabs.
Although there need to be more of them, Dr. Makary has also seen some successful accountability mechanisms in the operating room. He mentioned a study led by Douglas Rex, MD, a gastroenterologist with IU Health in Indianapolis. Dr. Rex watched physicians perform colonoscopies via video camera.
At the time of the study, the amount of time physicians spent looking for polyps was "all over the place," said Dr. Makary, from two minutes to seven minutes and anywhere in between. When Dr. Rex told physicians he would be watching them conduct colonoscopies, the time they spent looking for polyps settled neatly at six minutes. The variation was largely eliminated as physicians knew they were being held accountable.
Dr. Makary recommended hospital leaders further transparency about variation in their organizations and use the local wisdom of their physicians, nurses, techs and other staff to improve outcomes. "Ask any hospital executive, 'What's your number one priority? and they'll say patient safety or quality," he said. And with an answer like that, hospitals simply can't be the third-leading cause of death in America.
More Articles on Hospitals, Quality and Transparency:
235,000 Preventable Deaths, 158,000 Preventable Complications: Healthgrades 2014 Quality Report
5 Recommendations to Reduce Preventable Patient Deaths
The High Cost of Inaction: Retained Surgical Sponges are Draining Hospital Finances and Harming Reputations