“Unaccountable”: An Important, Courageous, and Deeply Flawed Book

In his new book, Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, Johns Hopkins surgeon Marty Makary promises a “powerful, no-nonsense, nonpartisan prescription for reforming our broken health care system.” And he partly delivers, with an insider’s and relatively unvarnished view of many of the flaws in modern hospitals. Underlying these problems, he believes, is an utter lack of transparency, the sunshine that could disinfect the stink.

The thesis is important, the honesty is admirable, and the timing seems right. Yet I found the book disappointing, sometimes maddeningly so. My hopes were high, and my letdown was large. If your political leanings are like mine, think Obama and the first debate.

Makary hits the ground running, with the memorable tales of two surgeons he encountered during his training: the charming but utterly incompetent Dr. Westchester (known as HODAD, for “Hands of Death and Destruction”) and the misanthropic “Raptor,” a technical virtuoso who was a horse’s ass. Of course, all the clinicians at their hospital knew which of these doctors they would see if they needed surgery, but none of the patients did. (Of HODAD, Makary writes, “His patients absolutely worshipped him… 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.”)

This is compelling stuff, and through stories like these Makary introduces several themes that echo throughout the book:

1) There are lots of bad apples out there.

2) Patients have no way of knowing who these bad apples are.

3) Clinicians do know, but are too intimidated to speak up.

4) If patients simply had more data, particularly the results of patient safety culture surveys, things would get much better.

A bit simplistic, but there’s enough there to motivate an interested reader to soldier on. In subsequent chapters, Makary conducts a guided tour of a House of Horrors: widespread and unjustifiable variations in care; the medical bias favoring action over patience; patient safety hot spots like Walter Reed Army Medical Center; unnecessary procedures; impaired physicians; even (oddly) why you shouldn’t donate money to pediatric hospitals.

You can’t help but be impressed by the author’s candor. “Doctors swear to do no harm,” he writes. “But on the job they soon absorb another unspoken rule: to overlook malpractice in their colleagues.” He indicts his own institution, Johns Hopkins, and others he trained at, including Georgetown and Harvard. Although some of the names are changed, others are not. And his prescription – more transparency – is clearly part of the solution.

Yet with so much going for it, I simply can’t recommend Unaccountable to either lay or professional audiences. The book is simplistic when it should be nuanced, hyperbolic when it should be restrained, anecdotal when it should be evidence-based, and egotistical when the author should be getting out of the way of the story.

Here are a few examples:

Overly Simplistic: Makary reviews the data, some of which he contributed to, on the value of safety culture surveys, making the point that physicians and nurses can identify good and bad cultures, and that these survey results correlate reasonably well with safety outcomes. He advocates for making such surveys widely available to patients. (“It could spark a health care ‘spring,’” he writes, in what I assume is a breathless but inelegant reference to the Arab Spring.) But there is complexity here: if clinicians know that their responses on a survey could harm their organization, isn’t it plausible that this knowledge will influence their responses? Makary never even raises this possibility. Similarly, he endorses a punishment-over-rehabilitation approach to doctors with substance abuse problems, but here too he tiptoes past the substantial complexities surrounding this issue.

Hearsay Instead of Research: Too many of Makary’s stories begin with a version of “I heard from a guy…” I have no problem with this as a way of opening the door to a few pungent anecdotes. But in Unaccountable it seems more like the product of intellectual laziness, especially when there are hard data to bolster some of his points. For example:

“One pediatrician friend… told me that [his hospital’s] CEO had been making cutbacks while increasing his own annual salary to $2.1 million.”[Couldn’t he have found out what really happened and the CEO’s actual salary?]

[In describing a few hospitals he likes, including the Mayo Clinic] “I’d bet that if surveyed, 90 to 99 percent of these hospitals’ employees would want to receive their own care there.” [He could have found out those data as well]

“I ask my orthopedic surgeon friends and colleagues every time I run into them if it’s true that there’s too much back surgery going on. They insist it is true, and it’s driven by money.” [Really, every time? And why not cite one of the many studies on this point?]

“Conservative back surgeons maintain that degenerative disc disease does not require surgery and can be treated just as effectively with physical therapy and pain medication.” [How about citing a study instead of anecdote?]

The dearth of research extends to the chronic lack of citations of crucial work in the areas he is describing – work that would have substantially informed his analysis. He discusses disclosure and medical malpractice, but makes no mention of Rick Boothman’s pioneering efforts at the University of Michigan. In sections on overdiagnosis and inappropriate care, there is no indication that he’s heard of Gil Welch’s or Bob Brook’s work. The section on regional variations has a drive-by mention of Jack Wennberg and ignores Elliott Fisher. As a result, his discussions in these areas are cocktail-party superficial.

And here’s one doozy of a non-reference: “So the door-to-balloon time metric sounded like an excellent way to measure quality of a hospital. At least that’s what I thought, until a bombshell article came out in the Journal of the American Medical Association showing that hospitals recording the best door-to-balloon times were performing angioplasties indiscriminately.” That would have been an interesting study, but a) Makary doesn’t cite the actual paper; b) I couldn’t find this “bombshell article” in 30 minutes of PubMed searching; and c) I asked one of the nation’s preeminent cardiology outcomes researchers whether he knew of the study and the findings and he had never heard of either of them. (The closest we got was a 2007 JAMA study showing that 10 percent of patients who received emergent caths for suspected ST-elevation MI proved to have clean coronaries, a far cry from the point Makary is trying to make.)

The Book is Poorly Written: There’s this: “To my students at Johns Hopkins, I teach that yelling at a nurse even once can intimidate them…” And this: “…these hospitals continue to conduct business as usual that is substandard.”

Even more irksome, Makary writes like he’s just read “Writing for Beginners” and got psyched about adding a thumbnail description of new characters as they are introduced. Many of these efforts are nauseatingly clumsy. Safety culture expert Bryan Sexton is “a warm, intelligent, fortysomething man and keen observer” and a “genuine and approachable researcher.” Joint Commission CEO Mark Chassin is a “well-spoken, clean-shaven physician whose speech toggles from Harvard brainiac to street talk in the same sentence.” I know Mark Chassin, Mark Chassin is a friend of mine, and Jay-Z he’s not.

Enter the Ego:  Finally, and perhaps most annoyingly, there is an egotistical cast to Makary’s writing that is distracting and, at times, strains credulity. He talks of the “multidisciplinary clinic I founded,” tells us that, “Among the nurses, I have a reputation for being soft spoken, kind, and unflappable,” and describes how a victim of a medical error “thanked me for working on preventing medical mistakes and man-hugged me as if we were brothers.”

He also tells us that, in his clinic practice, “I like to let patients talk for ten to fifteen minutes about everything [i.e., without interrupting them]… oftentimes I will uncover something medically relevant amid verbose descriptions of how a patient was watching TV with Grandma.” Really? Later, he describes the same clinic, in which he is often “seeing twenty to thirty patients in a single clinic day, I might be juggling dozens of cases at once….” I wasn’t a math major, but those two scenes simply don’t compute. It also feels awfully petty for a book about safety at Johns Hopkins to barely mention the seminal work of Peter Pronovost, the world’s top safety researcher and clearly someone who has opened doors for the author. Pronovost’s name is conspicuously not among the 30 or so people mentioned in the Acknowledgements.

In reading Unaccountable, I had the feeling that Dr. Makary was trying to establish himself as a “player” in the safety field. (I note from the book jacket, which misspells his “MPH” as “MPD”, that he is a commentator for CNN and Fox News.) That’s well within his rights, and the book is being discussed in safety circles. I admire Markary’s courage in writing it, I agree with its central message, and I suspect that it will help move the healthcare system in the right direction. I only wish it were a good book.

4 Responses to ““Unaccountable”: An Important, Courageous, and Deeply Flawed Book”

  1. Ryan E November 2, 2012 at 3:23 pm #

    I agree completely with your review. Also concentrated KCl is not widely available on “wards” as he says and it is colchicine not cholchicine as spelled in the book, but anybody with a medical background would know that.

  2. Nancy Foster November 3, 2012 at 1:57 pm #

    Bob – Your review is thoughtful, accurate and elegantly articulates — in ways I could not quite articulate myself — why this book was so incredibly frustrating.

    There are serious issues to be addressed regarding professionalism, the role of professionals in holding each other to performance standards, and how to establish and maintain organizational cultures that continuously promote safety and quality for patients. More work is obviously needed, but it must build off the progress and lessons we have learned in the past 15 years, and it will require the effective application of many different strategies to resolve.

  3. AD November 4, 2012 at 4:48 am #

    The flamboyance and self back slapping of Dr Makary distorted an otherwise very important message, physicians are human subject to the same foibles and temptations as other humans and we need to monitor ourselves…,,,,,,responsibly

  4. Menoalittle November 11, 2012 at 1:55 am #

    Bob,

    I am puzzled why this author got under your skin. He has gotten much mileage from the book, including well deserved coverage in the WSJ: http://online.wsj.com/article/SB10000872396390444620104578008263334441352.html

    You and he are similar, in many ways, which may explain your biting criticism.

    He goes deeper than you in critical issues, but not deep enough. I like the part about transparency, but it is more complicated than that. The administration of hospitals intimidate the truth, and they hand pick medical staff “leaders” who support the intimidation with sham peer review.

    But they give the illusion to the Joint that there is self governance. Are these multi-million dollar corner suite folks merely bow tied despots, ruling their hospitals not unlike the rule in Libya?

    You and Makary are also similar in your failure to hold HIT EMR and CPOE systems of care accountable by ignoring basic medical science requiring proof of safety and efficacy in randomized statistically valid comparative trials.

    Taking this a step further, for the doctors who realize the sham of HIT, that these so called marvels of modern medicine may do more harm than good, and report the truth of the deaths and why, they are blamed by the administration with vendor dogma, “user error”, and are “peer reviewed”. The truth: use error afflicting most of these systems, but no one wants to know how many patients are killed from this.

    Best regards,

    Menoalittle

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