Transparency in Medicine
This is the full version of this page.
The abbreviated version is at this link.
For all of his good intentions, Dr. Marty Makary still believes in snake oil. He imagines health care professionals to be objective and selfless people whose perceptions are not skewed by self-interest to a degree that would require them to be saints. He is not alone in this. It is one of the tenets of medicine. If you want to end a discussion, or see people become livid, question it.
He does a valuable service by revealing some of what is wrong in medicine, for instance saying, "As doctors, we swear to do no harm. But on the job we soon absorb another unspoken rule: to overlook the mistakes of our colleagues."
On rounds on his very first day members of his resident team kept referring to "Dr. Hodad." He didn't know who they were talking about. It turned out to be the nickname of a prestigious surgeon. Finally a fellow student clued him in by whispering, "It stands for 'Hands of Death and Destruction'."
Soon he saw for himself.
Hodad's patients frequently suffered. Hodad should not have been allowed to touch patients, but he had a great bedside manner. He was charming. Celebrities requested him for operations. When caregivers cause patients to suffer, medicine is well-practiced at persuading them that they are lucky to have been in such competent hands or things could have been much worse. So they worshipped him.
In time Dr. Makary saw that many hospitals have at least one Dr. Hodad, sometimes more. It can ruin any caregiver's career to report another caregiver. So Dr. Makary did what the other trainees do and rationalized that patients needed him to become a surgeon and not let reporting a Hodad end his career track. A refrain that caregivers routinely repeat is that you cannot let one patient ruin your whole career. Another that they absorb but do not repeat is that you cannot let one caregiver do that either, no matter how many ones there are.
What is the difference between absorbing
and being indoctrinated?
In a Book TV interview he said that he was in an audience of physicians one time when they were asked how many of them knew of a physician who should not be practicing. Every hand in the room went up.
I'll bet that if that same audience were asked how many of them hold the well-being of the patient as their highest priority, every hand would have raised again - one of the disconnects in the thinking in medicine.
If only Hodads were all that they overlook.
Dr. Makary has his heart in the right place, but his perspective literally is shackled by precepts he himself doesn't recognize having absorbed from the world of medicine.
I don't want anyone to think that I am anything but grateful for the stand Dr. Makary is taking and the effort he is making to make patients safer. But that is what makes him the right subject for criticism of the thinking in medicine on this subject.
In addition to the unspoken rules that he recognizes, they absorb unrecognized ones that erect a barrier between safety for patients and the thinking of caregivers. It doesn't matter if your heart is in the right place if your perspective is not.
Where his heart is became apparent when he was a student at one of Harvard Medical School's prestigious affiliated teaching hospitals. He had been assigned a patient, a Mrs. Banks, who had cancer that had spread throughout her body. She didn't want treatment. When he reported that to his superiors they criticized him. They wanted to do something. To her they overstated the benefits of treatment, understated the risks and bullied her into submitting to treatment.
Such behavior Makary felt was the profession's having wandered from its original mission and heritage. You cannot fault him for not knowing what it's actual heritage is. No one else in medicine does either.
In fact, misleading and bullying patients is its heritage. Even Hodads are part of its heritage. We had Hodads before the revolutionary war. One signed the Declaration of Independence (see Benjamin Rush - a page on this site). You didn't learn this about that most prominent of Hodads in history class because all information about him was hidden for 200 years. Hiding the information that could keep patients safe is medicine's heritage (see Medical Reporting), as is exposing patients to treatments they would refuse if they could get accurate information.
That aside, to Makary's great credit, what he saw disturbed him so much that he quit medical school. Now that is putting the well-being of patients ahead of your own.
Instead of medicine he took up the study of public health where he could focus on quality. It was here that he got to meet people like Lucian Leape (links to a page on this site) and absorbed more of what is believed by Leape and others. However, eventually he must have returned to the study of medicine because Dr. Makary now is a surgeon at Johns Hopkins in Baltimore as well as a professor of health policy at Hopkins's Bloomberg School of Health.
That a person such as he still has his thinking shackeled by what he doesn't recognize he has absorbed from the mind-set of medicine makes him a good example for why patient safety efforts have not improved the rates of unnecessary death and disablement and bankruptcy.
Learning to fit in, acculturation, collectivist orientation and organisational commitment are all components of the "absorb" he talks about. He doesn't recognize fundamental falsehoods that he absorbed from what the medical community likes to believe about itself.
He says that to find out where the best is care ask an ER nurse. That is advice that will work if you work in medicine or are among their family or friends. It will not work for most patients for reasons that simply are not on the radar of the medical profession.
Can you find anyone in medicine who knows what happens to the patients who get injured and how it is that there is no record of most of the injuries incurred in medicine? (If you work in medicine, you don't have a clue and you don't know it.)
See the book at right for yet another example of how energetically everyone in medicine covers up for a colleague who is serial killer.
Without understanding that, it is not possible to have discussions about issues like transparency and increased reporting, or really about anything concerning patient safety that will change anything more than varnish will change rotten wood. (see the book at right about yet another case in which health care professionals covered up a serial killer time and again to protect their own well being at the expense of the lives of patients - links to Amazon).
Such discussions must start with a coherent answer to this question.
What is the least that a patient should be able to expect to be protected from in medicine?
I have never spoken to a caregiver who could give a coherent answer to that question. They rattle off phrases that are common in their profession, but that happen to illustrate how far removed their minds are from the reality of the world they create for patients.
UNDER CONSTRUCTION (I've got to edit and rewrite and get this to be a fraction as long, and, if possible, more repectful of Dr. Makary who is trying so hard.)
To illustrate how believing in things that are not true hamstrings thinking about things like the safety of patients, consider how such thinking hamstrung Albert Einstein and what it took for him to escape it.
When Einstein was thinking about physics, one of the sacrosanct dictums of his profession was Ether. Ether was thought to be the gas through which electromagnetic waves traveled. For years Einstein struggled trying to unify what was known until, after a decade of making no progress whatsoever, he became so frustrated that he quit. He told a friend that it was over. He never was going to think about physics again.
That night, at home, he began clearing out his desk and his mind. One of the things he threw out was the idea of the Ether. He vowed never to think about it again. And with that out of the way everything else fell into place. He wrote Relativity.
In medicine they believe in things just as unfounded and nonsensical as Ether and have no awareness that they do.
People in physics reviled Einstein for dispensing with Ether. They turned on him and injured his career. The same thing happens in medicine to anyone who unsubscribes from the myths that they cherish. But as long as they continue to hamstring their thinking with cherished nonsense, their thinking will not be relevant to the world in which patients get killed unnecessarily in such great numbers. They only will be able to make things appear to be a little better, but without rates of things like unnecessary deaths budging.
It is not difficult to find caregivers who will insist that they have seen things improve greatly in their own practices. But they are putting varnish on rotten wood. They do not see the wood.
"If we believe absurdities, we shall commit atrocities."
Try to find a caregiver who knows what happens to patients who get injured in medicine. If you tell them, they do not believe you. This is a culture-wide denial that prevents them even from knowing what the most basic problems are.
Consider what must happen in order for there to be no record of iatrogenic injuries 90% of the time. It is not just the original event of which no record can be made. There must be no one willing to diagnose the patient seeking treatment (which is normal). Most patients have so much faith in their caregivers that they never figure out why no one appears to be able to find or treat their injuries. The patients don't look at their own records and so don't discover that their caregivers did not record what the patients stated as being the source of their injuries. If they looked at their records they would discover fictional accounts of their visits written by caregivers protecting each other rather than protecting patients.
Patients believe it when caregivers tell the patients that their lives have been ruined not because of negligence or incompetence or worse, but only because medicine is an art and not a science and not everything can be healed.
The "or worse" is the most common one since it follows most other injuries as caregivers commit acts of volition to prevent any record from being made even when the patient seeks help afterwards. An entire community must behave in a way that is in the disinterest of the injured patient, and the patient community in general, in order to prevent any record from being made.
This does not require communication between them. It requires only that they be on the same page. That they manage to do this without any awareness of having done it shows how deeply they believe that patients with grievances are cranks, that complaints are frivolous, and that the important thing is to protect the careers of their colleagues and themselves "for the good of the patient community." Anything can be rationalized in the belief that they have to be here for the next patient and that the patient community needs for them to survive to become surgeons, etc.
The care giving community might be open minded enough about this to see the Hodads, but Hodads only are the part of the iceberg that is above water. Medicine does not see the rest. It won't even allow discussion of the rest of it.
The Rest of the Berg
Any good person can have moments when he/she behaves like a sociopath - like when "failing" to make a record of what the patient says when describing how the iatrogenic injuries being presented for treatment were incurred. And when doing an exam designed to find no injuries. Both are common experiences for injured patients.
There are no large communities without sociopaths. There are almost no people who cannot cannot behave like sociopaths when it serves their interest.
What is the least that patients should be able to expect in medicine?
Unfriendly practice is believed not to be a problem. It is the last thing anyone in medicine will report, the first thing that will be covered up, and the most likely thing to be disbelieved by everyone else in medicine. If your safety mechanisms are not sufficient to cut through that to protect patients, you do not have either foot on the ground in this landscape.
What is the least a patient should be able to expect? Caregivers do not give coherent answers to that question and are not in tune with that fundamental issue so there is no mechanism in medicine to protect patients from the first thing from which they should be protected. There are no mechanisms to protect patients against caregivers who are not good people. Even the best people can find themselves tempted or provoked into doing something bad. Others live to do things that are bad. If you were an evil person who was smart, do you think you could find a safer place to indulge your passion or greed than in medicine?
Do they have a name for the caregivers who prey on patients? It appears that they have so thoroughly absorbed the perspective in medicine that "medicine is full of good people" that they do not recognize the opposite when it is right in front of them.
Until evil is named, it cannot be addressed
Discussions among and with caregivers only are about things like needing more transparency, a discussion that assumes that caregivers all are good people who are lucid, selfless and honest enough to recognize what needs to be made transparent. If The Psychology of Care giving were a prerequisite in medical school, work to improve the safety of patients might not be as stymied by assumptions that are as false and misleading as the Ether.
Dr. Makary said that he absorbed the rule to overlook the mistakes of his colleagues, and we are grateful for his having shared that. But what about the rules they absorb of which they themselves are not aware, like the rules that govern the way they interpret the evidence of their senses? I've yet to hear a caregiver demonstrate any awareness of the extent to which they are subjective products of a selfserving culture.
They believe in a world view that that is in denial of the fundamental problems for patient safety.
A patient's medical records are a doctor's autobiography. Autobiographies are novels in which authors portray themselves as heros. Even Al Capone thought he was a good person who merely was misunderstood. The worst people in medicine think they are good too.
If our caregivers were lucid enough to understand the extent to which they are not objective and are not selfless, they would stop imagining that there is some point in saying we need more transparency and move on to erecting the structures necessary for accountability in a system where caregivers never will provide honest information. Some caregivers are evil and most of the rest, always and forever, will fail to recognize what and who is evil. Even if they did, few would be selfless enough to risk reporting it, as history has shown. They will recognize some who are incompetent, and based on that assume that nothing is off screen, but they are seeing only some ice cubes and believing that's all there is in a sea of icebergs.
That will sound like an exaggeration to caregivers, but not to injured patients. Caregivers do not even know what happens to the patients they injure. Ask them to see for yourself.
Dr. Makary says that the discussion of patient safety should include some patients. If he were in tune with the fundamental problems, he would say it should include some patients who were injured and who were unable to get anyone to treat or even acknowledge the injuries. Those are the people who finally have had shattered their faith in the Ethe, a faith they got from believing what their caregivers tell them to believe.
Dr. Makary says that to find good care ask an ER nurse. That is good advice for caregivers and for people who count among their family and friends. It is not good advice for most other people.
Sociopaths smart enough to have built careers in medicine are smart enough not to tip their hands to other members of their profession. They are smart enough not to victimize people who are in a position to respond. Just consider the case of Dr. James Burt (links to a page on this site). Twenty-two years of being the cash cow for his hospital without the nurses ever figuring him out. Later one nurse said that he dazzled them so they just didn't see.
How many physicians have arranged for a third party to monitor the long-term well-being of their patients? If the well-being of their patients really were their highest priority, they all would be doing that.
I'm not sure how you can believe anyone who says his/her highest priority is the well-being of patients when they have done nothing to get an independent evaluation of the net effect they are having on the patient community. Having colleagues evaluate it only is having others selling the same snake oil vouch for yours. Some things can be learned from them, but some things cannot.
When caregivers are the source of the information there is no transparency.
Of course caregivers report the things they don't mind having reported. Good things about their care they will put in press releases. But the things most important to know to make patients safe are the last things caregivers report.
One time a study of autopsies in a hospital found that 30% of the deceased patients had been misdiagnosed. If the hospital really were interested in the well-being of patients, would they not do autopsies routinely and work backwards from there to figure out who was in charge of misdiagnosed patients or of things like patients who died of hospital acquired infections? Is there a specific nurse who was present every time a patient contracted a fatal infection? Hospitals don't do autopsies that could uncover such things. They don't want to know And if you get them to start doing autopsies, they still are not a disinterested party. They want a certain kind of information to be found and that is what will tend to be found.
There are sugical groups hiring experts to examine the results of their surgeries. It is very encouraging to see that. But what more might be discovered by an independent organization looking at where those patients are five years later? And how many places in medicine is this actually occurring?
Currently most safety systems in medicine are set up on the assumption that no humans ever even are at fault, let alone bad. One of the mantras of patient safety initiatives is that no one goes to work to do a bad job. Must be nice to be working in a place populated with saints. The places the rest of us get health care are not.
People do go to work to do bad jobs. As long as that is not recognized any patient safety effort will be shallow and mostly ineffective. Caregivers will imagine that they have seen great changes, but the important numbers will not have improved.
Transparency assumes that humans are not self-servingly blind or stupid and are able to see the world through an objective lens. But whole teams of caregivers are wrong and stupid and dishonest (how else do you explain their not even reporting serial killers, see Examples). Sometimes they transfer dangerous people to other facilities and let them be dangerous there. We need mechanisms that protect patients in spite of such self-interested blindness.
Calling for more transparency is like calling for more good weather.
"More transparency" is a dream that caregivers have when they want to feel altruistic and well-meaning without having anything actually change. Change is not in their interest. It only is in the interest of the patients. Does anybody in medicine even consider how their conflict of interest governs what they are willing to think and see?
For many years we have been listening to caregivers surface from time to time to say, yet again, that we need the Root Cause Analysis of the airline industry (my comments on that here) or to create a culture rich in reporting (covered in several places on this site) or more transparency. It is difficult not to become shrill when hearing the same nonsense resurface again and again and then still yet again without anyone in medicine seriously wondering why the large numbers do not improve.
It is reasonable to conclude that if it is left up to caregivers they still will be discussing these same things a hundred years from now, but without a sense of how long they have been discussing it, and without any deeper understanding of why these things are problems in the first place. They have been trying to get caregivers to wash their hands more often for 160 years without 160 years of failure causing them to wonder if they are operating on false assumptions.
I have heard them ask, "What would we have to do to get them to wash their hands more?" When I offered suggestions that assumed that caregivers are not selfless enough to do it out of the goodness of their hearts, I was dismissed from the conversation. They care more about maintaining the myths that make them comfortable than about saving the lives of patients.
That is not a flippant statement off the top of my head. That is something that I doubt they ever will understand that about themselves. So patient safety initiatives, and honest information, must come from outside of the care giving community. Apparently, the goals of patient safety must be formed outside of it as well or we never will focus on root problems.
Dr. Makary repeatedly says that medicine is full of good people. That is Ether when working to protect patients. What is the least that a patient should be able to expect in medicine? When I ask caregivers that, routinely that repeat that a patient should be able to expect a competent caregiver who puts the well-being of the patient ahead of his/her own, etc.
That is the most any patient could expect.
What is the least? If we are trying to protect them we have to start there.
Consider what the darkest moment in medicine is. When I ask that of caregivers, they tend to say it is when a patient dies. Even when answering this question belief in the Ether shapes their thoughts. The answer is something innocent. An error.
Please. Let's get down to brass tacks. Are not unfriendly practices the darkest moment for medicine? It is when a patient is murdered. Not euthanasia, but murder.
Nearly all caregivers will behave like sociopaths in the moment when something that has happened could damage their careers. Any adverse event could be perceived as potentially damaging to careers. So 90% of the time adverse events do not get in the record because all of those good people in medicine have moments when they behave like sociopaths.
Where is transparency going to come from in a world of people who behave like criminals covering their tracks at the exact moments that are the most important ones to report if the goal is to keep patients safe?
If you were trying to bring transparency to the financial sector and said that we just need for bank robbers and embezzlers and such people to start creating honest records of what they do, you would be making as much sense as you are making when you ask the care giving community to be more transparent.
The fundamental problem for patient safety must be viewed as crimes committed against patients. The mechanisms necessary to address that are the fundamental ones necessary to address all of the rest of it. In that moment when something has gone wrong and the loyal teams of good people in medicine view the world through their self-serving lens, they believe they are doing the best thing for the patient community when they behave like criminals covering their tracks.
Until mechanisms are erected to address crime in medicine, there will be no mechanisms that can make more than a superficial difference to safety in general.
What is the least a patient should be protected from in medicine? Isn't it crime? If we are not protecting them from that, what does that say about all of our thinking about the problem?
There are no mechanisms in medicine to address crime committed by caregivers against patients. The average caregiver's response to that is "call the police," which shows how out of touch they are with the world they create for patients. What are the police to do when faced with a community of caregivers who have created records that say no crime was committed and who themselves will not testify to the truth?
Ask a few patients who have been victims, and read other pages on this site (there are more than a few), if you don't understand that there are no mechanisms in medicine to protect patients from crime.
If anyone in medicine really were concerned more about making patients safe than about making nice with the rest of the care giving community, the first people they would want to have be part of any patient safety discussion are patients who have been victimized by crimes committed by caregivers. But good luck finding them. There are almost no records of them. I can lead you to a few, with and without records. But whenever I bring up the subject of crime in a patient safety discussion, caregivers uniformly say that that is another subject entirely and dismiss me from the conversation.
We need to recognize that care givers always will be an elite that does not share the interests of patients. They say that when they get sick they are patients too so they understand, but what doctor or nurse is going to rape another doctor or nurse? It's not going to happen to them so they do not share the same interests of patients in such matters. They will be inclined to protect the rapist (try saying that in a group of caregivers to witness the scoffing).
Dr. Robert J. Weil, a neurosurgeon at the Cleveland Clinic, said that although it might seem a good idea to inform patients of differences in outcomes among hospitals, there would be “a variety of hurdles.” And David I. Shalowitz, a bioethicist, said that expecting surgeons and hospitals to disclose information about other doctors and medical centers would create an untenable conflict of interest for them and should be avoided.
Care givers are the wrong people to expect to make the problems in medicine transparent to patients.
Information from Dr. Marty Makary was in his article, " How to Stop Hospitals From Killing Us" in the Wall Street Journal, September 21, 2012 and in an interview with him on BookTV on PBS.
I hope to read his book "Unaccountable," but I do this work for free and must give up lucrative work to have time for it, so I haven't had time and also haven't been inclined to pay so much for the book yet. I'm sure there are good things in it and I will buy it when its price comes down, as I have with other books cited on this site.