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UNACCOUNTABLE
What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care
By MARTY MAKARY
BLOOMSBURY PRESS
Copyright © 2012 Marty Makary, MD
All right reserved.
ISBN: 978-1-60819-836-8
Chapter One
Dr. Hodad and the Raptor
"That patient belongs to Hodad," the senior surgical resident told me with a smirk.
It was my first day. I was beaming with delight. I was at the greatest health care institution on earth—Harvard. I could hardly believe people walking by thought I was a real doctor! I just wished the packaging folds in my brand-new white coat weren't such a giveaway of my rookie status.
Giddy with enthusiasm yet self-conscious, I masked my emotions by adopting a serious, doctorly expression, keeping my eyebrows militantly raised, and by speaking in a deep monotone. I didn't want to seem defiant or breach any unwritten code. If I relaxed my face, I thought, even for a moment, my senior resident might chastise me, saying, "Do you NOT CARE?"
I had no idea what I was doing that first week. Figuring that out was harder than passing med-school exams. I'd trot after my senior resident like a puppy, wondering—every time he dashed off to check a lab on another floor or talk to a patient—if I was supposed to be doing that too. Sometimes I'd just stand around wondering, Did he forget about me? and When will he be back?
This happened fifty times a day. Finally I decided just to follow him everywhere—until I found myself tailing him into the bathroom. I then tried to train my resident to command me to "sit" by pointing a finger at my feet whenever he might be headed somewhere I shouldn't follow. When he did remember to let me know, I'd stay vigilantly in place, my serious face screwed on tight.
As I acclimated to life in the hospital, the name Hodad constantly cropped up in physician circles. One day, hearing yet another Hodad reference, I felt I had to ask about this Hodad, as he seemed to be the hospital's most famous surgeon.
"Hodad?" I asked. "I haven't met that surgeon yet."
"Dr. Westchester ... Dr. Westchester is Hodad. That's what the surgical residents call him." Another student, grinning, leaned over and whispered, "It stands for Hands of Death and Destruction—H-O-D-A-D."
I nodded sagely as if I knew what the heck she was talking about. Later, I asked another resident what it meant. He perked up, eager to relate his own personal story of how Dr. Westchester had come to be known as Hodad. A celebrity actor had once come to our hospital—"America's best!"—diagnosed with what looked like a hernia. He wanted an operation. Like many famous people who flew in from far away, he had specifically requested Dr. Westchester based on his outstanding public reputation.
The celebrity's condition was one of two possible diagnoses: a hernia that would require surgery, or a normal muscle bulge that requires no treatment. Hodad saw the patient but ignored the need to diagnose which he had. The famous celebrity walked into the hospital very much expecting an operation—so that was what Hodad intended to give him.
When Hodad opened the celebrity up in the operating room, sure enough, he had a muscle prominence called a diathesis—a normal finding that can mimic a hernia. Even as a med student, I knew a muscle diathesis didn't require surgery. But the patient got surgery anyway, as medically unjustified as injecting Botox into a furry dog.
A senior anesthesiologist had been called in to help with the VIP patient. The anesthesiologist hadn't assisted at this type of surgery in a long time. He accidentally made the anesthesia too light. Reacting to the pain, the patient suddenly began jerking around on the operating table before the operation was over. With one thrash of the upper body, the assistant heard a few dreaded popping sounds coming from inside the patient's belly. These were the sounds of the patient's internal stitches breaking, a scenario that surgeons refer to as a "hard landing." The celebrity patient was now at risk for more complications, from a surgery he never even needed in the first place.
Of course, like most of the patients I've seen thrashing in pain in the operating room, Mr. Celebrity wouldn't remember a thing thanks to the memory loss associated with the anesthetic—God's gift to protect doctors from lawyers.
His incision site soon became infected, but after a long recovery, he bounced back to normal life. And the result of all this bad judgment, bad surgical technique, and bad outcome? A massive outpouring of gratitude to Hodad and his staff , including a Rolex watch, flowers, offers of vacations, and plenty of hugs.
The resident who told me this story enjoyed telling it. It was as if it helped him cope with his stress as a battered surgical trainee. His pace accelerated as his tale unfolded. The nurses took pains not to ask Dr. Hodad any questions, he explained. Asking questions exposed them to the risk of engaging in some awkward exchanges with him. Instead, behind the scenes, they'd nicknamed his surgical-instrument tray "the wrecking balls."
The more I asked around, the more incredible the stories I heard about Hodad. It was shocking and amazing to me. How could such a person be allowed to freely roam the hospital? I wasn't sure whether I should laugh or cry.
It was only later that I came to see that Hodad embodied a much larger problem in medicine, one the public knew little about. I was at that point just perplexed and vaguely intrigued. The patients whose numbers came up with Dr. Hodad were just the unlucky victims of a system lacking in standardization, oversight, or ways to mea sure quality. And yet patients left Hodad's care—and the care of thousands of doctors like him, every day—overjoyed and deeply grateful for their shoddy treatment.
I got online and started researching Dr. Hodad. HealthGrades, an in de pen dent ratings agency, confirmed he graduated from medical school, was board certified in surgery, and gave him five stars.
Preparing to meet Hodad in the hospital for the first time, I wondered what he must look like. I imagined a modern-day Dr. Jekyll—disheveled, arrogant, visibly hazardous. Waiting for the demonic Hodad to turn up for morning rounds, I noticed a distinguished, well-dressed man in his sixties in an impeccable white coat gliding toward our group of residents. He had a debonair appearance that inspired supreme confidence. Seeing that I was the new guy on the team, he approached me first, holding my gaze with his eyes. Confusion overwhelmed me as I realized that this inspiring figure was the infamous Hodad.
"Good morning. I'm Dr. Bob Westchester," he said, leaning into me with a sparkling smile as I stood there paralyzed.
"Hands of Death and Destruction, my name is Marty," I thought to introduce myself, but had to choke off an urge to blurt out this moniker.
The truth is, Hodad was terrifyingly normal.
As we visited several patients together, I observed his compassionate bedside manner and warm demeanor. His patients absolutely worshipped him, clearly grateful to have him as their doctor. In time, even I grew to like him. He sat closely next to patients to comfort them. It was model doctor behavior that I still emulate and teach to my students to this day.
The patients were not to be blamed for their adoration. Behind his charm and soothing bedside manner, Hodad's patients didn't really know what was going on. They had no way of connecting their extended hospitalizations, excessive surgery time, or preventable complications with the bungling, amateurish, borderline malpractice moves we on the staff all witnessed. His patients chalked up their misfortunes to random God-decreed chance. Some would thank Hodad for saving them from a worse fate. What his patients loved was his commanding authority, his fancy title, his Ivy League stripes, and his loving touch. His patients liked his care, despite its infernally low quality in the operating room.
When it comes to medical judgment and overall doctoring, good listening skills are both a powerful diagnostic tool and have the power to heal. But watching Hodad in action made me realize that patient satisfaction was only half the story. Patients couldn't know what we staff in the operating room could see: that the man was dangerous, had poor judgment, and practiced outdated medicine.
Hodad's popularity was no aberration. Americans are brought up to respect and defer to doctors—a trust I, too, enjoy many times when I recommend a complex treatment to my patients.
The public's disgust with our broken health care system as a whole, however, is akin to its disgust with Congress. Americans say they hate Congress, and consistently give it very low approval ratings. Yet most simultaneously like their own member of Congress, saying their own representative is a terrific man or woman. And apparently, Americans like their doctors even more. A 2009 New York Times–CBS poll says a whopping 77 percent of Americans are satisfied with the quality of their care.
Doctors work in a disjointed system with perverse incentives, little oversight, and a lot of haggling that goes on behind closed doors far from public view—kind of like Congress. Factors irrelevant to health care quality, such as parking, are the leading influence on patients in choice of health care. One day out of every two weeks, many of my colleagues and I travel to a suburb to see patients in a Johns Hopkins–satellite office park that has free and easy parking, addressing this paramount patient concern.
So how does a patient who hasn't been to medical school find the best care? The only real way to judge health care quality is to ask health care professionals who work closely with doctors daily.
Hodad's popularity with his patients was in stark contrast with the reputation of another surgeon on the staff . All the residents called him the Raptor. They feared him. Unlike Hodad, the Raptor fit the surgeon stereotype—six foot two, a relentless jock, able to lift a medium-sized resident off the ground with one hand effortlessly during his all-too-common fits of rage.
The Raptor terrorized patients and staff with his curt bedside manner and drill-sergeant humiliation of the residents. Hospital lore told of how he was approached by a would-be mugger one night while walking out of the hospital. The criminal, not knowing the Raptor, held him at knifepoint and demanded his wallet. The Raptor picked up the assailant by his hair, shook him down for everything he had, and threatened him in a deep voice before the criminal got ground traction and fled for his life.
I had the distinct misfortune of peering nervously into the Raptor's eyes several times during my rotation. It was terrifying. Crossing him in the hallway felt like a slow-motion Jurassic Park encounter between human and beast. My heart would beat loudly and my mind would scramble in preparation for what ever he might ask, whether it was the latest news on his patients or one of the many random inquiries he would come up with just to torture underlings like me.
"What was Ms. Smith's white-blood-cell count today?" he'd bark.
"Nine-point-five, SIR!" I would reply, praying for no follow-up questions. If I didn't get the information out quickly enough, I would brace for the Raptor's claws.
We were constantly adding new and more unbelievable chapters of how the Raptor off ended patients. Our consolation prize for being collectively victimized by him was to swap stories in our moments of downtime. One intern was shaken to hear the Raptor, through a door, bellowing at a patient, "You are not listening!" and "You could die!" Once, the Raptor stuck a nurse with a needle—on purpose. He told her, You stick me, I stick you. Hospital legend held that he once broke the news to a family that their child did not survive by walking into the waiting room and blurting, "Guess who just died?"
The Raptor may have looked like a jock, but he was an odd character, no doubt about it. I heard he once ate food directly out of a patient's tray without asking, like a scavenging bigfoot, the patient staring on. At a medical conference in a nice hotel, the Raptor was reportedly seen looting an unattended maid's cart for home supplies. Rumor had it that on a short airplane trip he sat on the toilet for the entire flight, just to enjoy the extra legroom.
Attending surgeons often punished residents by ordering us to stay late after work or walk their patients individually—a tedious and dreaded task. When the Raptor was a resident, he once fulfilled this assignment by gathering his ailing patients to be walked for a group walk. In classic, efficient Raptor style, he asked each patient to report behind a starting line demarcated by tape on the floor. One frail ninety-two-year-old Korean dignitary left the starting area with a few short, distinguished steps before all the other patients had gathered. The Raptor lassoed him back, yelling, "Get back! Behind the tape line until everyone is here!" The man stood there with his IV pole and ridiculous hospital gown in silence and humiliation. He later explained to the patient-relations representative, "The way that doctor walked me. I ... felt ... like ... DOG!"
Not surprisingly, complaints at the patient-relations department abounded.
Patients simply hated the Raptor. His abrasive communication style off ended about half of those in his care, and many would request another surgeon. They would sometimes ask to be switched to Hodad. This was especially ironic because, despite his awful behavior, the Raptor's surgical precision and insistence on perfection earned him a reputation within hospital walls as the best surgeon on the staff .
Known by all the other surgeons and staff for his superhuman surgical knowledge and gifted hands, the Raptor was one of our era's greatest master technicians in the operating room. His clinical judgment and surgical skill were impeccable, even though his beside manner was toxic.
To this day, the Raptor routinely performs some of the greatest technical operations in the country. He also continues to off end and emotionally injure patients each week. In fact, a few of the patients he has jarred have ended up in my office seeking a second opinion. I always ask what brought them to me, and the response is always about the same: "He seemed incompetent" or "He doesn't seem to know what he's doing." Of course, if only they asked the nurses, doctors, and technicians who work with him, they'd know that the high quality of the Raptor's operations is the envy of the worldwide surgical community.
I wondered how different life would be if Hodad understood his limits and the Raptor helped him out. They'd be a dream team. But it was rare for docs to work together when getting paid individually. Moreover, the hospital's culture didn't seem to encourage it. At most of the "reputable" hospitals at which I trained, quality was highly variable and teamwork notoriously lousy.
As an exercise, I routinely began asking patients why they decided to come to the hospital where I worked (Georgetown, Hopkins, D.C. General Hospital, Harvard, and others). Here's a sampling of patient responses:
• "Because you're close to home."
• "You guys treated my dad when he died X years ago."
• "I figured it must be good because you treated [famous person] here."
• "I figured it must be good because you have a helicopter here."
• "I figured it must be good because you do robotic surgery here."
Parking accessibility and parking complaints came up a lot. Other reasons included the friendliness of the reception desk (often composed of rotating volunteers), hospital advertising, and "I was born here"—hardly strong metrics of safe, quality medical care. In health care, unlike other ser vice industries, satisfaction is only part of the story.
In my experience as a medical student, it became clear to me that patient satisfaction tells you something, but where health care workers go for their own care tells you everything. The only people really able to rate the safety and quality of other doctors are those who work with them. No one else really knows. During my Harvard rotations as a medical student, I asked the staff who they'd go to if they were dying and wanted comfort measures. They all specified Hodad, qualified with something like "as long as he doesn't operate on me." When I asked who they would go to for an operation, the answer was unanimously "the Raptor"—usually qualified with something like "even though he's a jerk."
(Continues...)
Excerpted from UNACCOUNTABLE by MARTY MAKARY Copyright © 2012 by Marty Makary, MD. Excerpted by permission of BLOOMSBURY PRESS. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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