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Saturday, December 14, 2013

Review: Unaccountable

Unaccountable is Dr. Marty Makary's book about the lack of transparency in medicine. For me, it's an eye opener about how to approach healthcare, surgeon selection, hospital selection, and potential surgery. Here are a few (by no means exhaustive) interesting titbits from the book:

  • The best hospitals don't pay doctors based on the number of procedures they do, but rather a salary. The incentive based/market based approach breaks down for healthcare because insurance companies pay per procedure, rather than on the basis of patient outcome. As a result of the "Eat What You Kill" model of compensation, many patients get unnecessary and potentially life-threatening procedures rather than minimally invasive surgery.
  • If you're told you need major surgery by an older doctor, get a second opinion from a younger one. The younger surgeon might know about newly invented minimally invasive surgery techniques that the older one does not.
  • If you're told you need surgery on a major body part for a disease, get second opinions from both experts on the disease as well as experts on the body part. For instance, if you have cancer of the liver, you want an expert on the liver, as well as an expert on cancer of the liver. For instance, many transplant experts would recommend a transplant, while a cancer surgeon would suggest eliminating the tumor through surgery.
  • The easiest measure of safety culture is simple. Collect answers from the nurses and doctors of a hospital to the question: "Would you want to be treated at this hospital." This data is actually collected, but isn't published by the government or hospital. Similarly, readmit rates are collected but are not published. This means that it's nearly impossible for a patient to select hospitals on the basis of competency, which is why hospitals compete on the basis of parking lots and advertising.
  • Ask for a video of your procedure if possible. Merely knowing that someone else will watch the video improves quality and increases time spent on the procedure.
  • Children's hospitals frequently have a more people in fundraising than doctors. That's because fundraising for children's hospitals is so effective that it's a better revenue model than actually treating patients.
Fundamentally, there's a culture of secrecy in healthcare today where transparency is not the norm. Nearly everyone at a given hospital, for instance, knows which doctors routinely screws up on his patients or has a higher complication rate. But the culture is such that you'll have a hard time getting anyone to tell you this. For instance, a story told in this book was that a patient asked an intern if his surgeon was good. Since his surgeon was terrible, the intern replied, "He's one of the top 4 surgeons in this specialty at this hospital." (There were only 4 surgeons in that department)

What strikes me over and over again is the importance of culture at hospitals. Makary refers to many prestigious hospitals that nevertheless have poor safety culture (and therefore poor patient outcomes). In keeping with the culture of secrecy in medicine, however, he's not allowed to name them. If you read between the lines, however, you get a good idea of which hospitals he's not recommending. Furthermore, he explains why certain hospitals such as the Mayo clinic are so highly regarded and how they come about having a great safety culture.

At $3.99 at the Kindle store, buy this book and read it. It has the potential to save you and your loved ones a lot of pain. Highly recommended.

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