How Transparency Can Empower Patients and Fix Health Care

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Who's watching the health care professionals? A Johns Hopkins surgeon calls for a major paradigm shift.

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As patients, we don't know nearly enough about the care that we are receiving in our hospitals, and the closed door culture of medicine prevents us from gaining the tools to make vitally important health decisions, argues Dr. Marty Makary, who attacks the corporatized hospital culture contributing to unreasonably high rates of medical errors in Unaccountable, released yesterday from Bloomsbury Press (you can watch the intriguing book trailer here).

A surgeon and professor of public health at John Hopkins University who has already made innovations in the improvement of patient care, Makary draws on his years of experience -- and leverages his influential position in medicine -- to step forward as a whistle-blower. He shares striking anecdotes from a system gone wrong, where 25 percent of all patients are harmed by medical mistakes and a focus on the bottom line leads to overtreatment at the expense of quality care.

"We all know the health care system is broken, burdening our families, businesses, and national debt. It needs common-sense reform," writes Makary, who argues that this reform will be driven not by political sound bites, but by the consumer. "Transparency can empower their consumers to make their hospitals accountable and make the practice of medicine more honest."

I spoke with Makary about his decision to speak out about these issues and his vision of a reformed, patient-driven health care system.

You argue that you're talking about problems that everyone in medicine knows about, but that there's a culture of silence surrounding it all. Why are you speaking out now, and what are the repercussions of you bringing these issues to light going to be? Do we need to worry about there being an AMA version of a fatwah issued against you?

We need to address the massive differences in the quality of health care among everyday hospitals.

Well the way I see it is that, increasingly over the last couple of years, we as doctors have been much more open in talking about our problems. I'm part of a generation that's willing to admit that we as a profession have made mistakes that have resulted, in part, in a loss of the public trust. There's been more discussion about medical errors, which are now recognized in top journals like the New England Journal of Medicine to be occurring in 1 in 4 hospitalized patients.

I see the issue of quality to be one of those issues that we need to be open and honest about, and that doctors are starting to be open and honest about. The fact that a hospital with a good reputation can have a complication rate that's five times higher than another good hospital in the area -- that's a subject that gets little air time, and even worse, that the public doesn't know much about, because the public has no information to make decisions about where to seek their care. So they are walking blind into a hospital where research now shows the differences in quality are massive.

So I think the bigger subject is, if we're going to get serious about health care costs in the United States, we need to address the massive differences in the quality of health care among everyday hospitals. We're not talking hospitals on the brink of closing, or hospitals that nobody goes to -- we're talking about mainstream hospitals. And we need to address the 20 to 30 percent of health care that's unnecessary. I think talking about health care, without addressing the 20 to 30 percent of health care expenditures that are unnecessary, is just talking about how to pay for a broken system differently, and not how to fix the broken system.

The impression I got is that this is really a critique of the system, rather than just you calling out bad doctors.

Yes, we've got good doctors working in a bad system. Hospitals are told they need to fill their empty beds, so they fill their empty beds. Doctors are told they need to see more patients, so they see more patients. Surgeons are told to do more operations, so they do more operations. So everybody's doing their job -- the problem is it's a bad system, and we need to redesign the jobs.

A big problem, from the patient's end, seems to be that we just have faith that our doctors know what's best for us, and maybe don't know the right questions to ask of them. What could the consequences of undermining this authority, and giving patients more power, be?

The smart patients already have the power to get the best care. It's just that smart patients tend to be patients that are themselves doctors or nurses and who know how to navigate and ask the right questions. Or, they're people that have good connections. The reality is that probably the best metric of a hospital's performance is asking someone who works there where they would go, or to whom they would go, for their own medical care. And we've done that research now, and it shows that over 40 percent of hospitals have the majority of their employees saying that they would not go there for their own care.

Over 40 percent of hospitals have the majority of their employees saying that they would not go there for their own care.

That's useful information now being collected on a national basis. There are graphs that demonstrate the wide variation in where people would go for their own care. But the hospitals are de-identified on the graphs, and the information is not available to the public.

I believe that the American public has the right to know about the quality of their hospitals. It's already being collected, so why can't the public have access to it? We consider utility as part of the public domain, we consider the way the FAA monitors aviation to be in the public interest in maintaining safety. Why don't we consider quality in U.S. hospitals to be in the public interest?

Many professional doctors' groups have already developed sounds ways of measuring health care quality that appropriately adjust for how complex the patients are, and differences in how risky the patients are in the hospitals. And these sound ways of measuring quality are being used, but the information is not available to the public.

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Lindsay Abrams is an assistant editor at Salon and a former writer and producer for The Atlantic's Health Channel.

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