The Arrogant Doctor

At the risk of sounding arrogant, most physicians are arrogant. Some are so downright arrogant that they make Obama look humble.

The Wall Street Journal recently had a two-page article from a Dr. Marty Makary (“How to Stop Hospitals from Killing us.”) This self-righteous yellow journalism article went on to regurgitate the Institute of Medicine’s 20 year old review paper claiming that there were 98,000 deaths a year from medical errors. Before I respond to Dr Makary, I need to repeat what I wrote here on PJ and elsewhere a short time ago:

We hear much about the number of deaths from “medical errors.” This narrative began when an Institute of Medicine article stated that medical errors cause up to 98,000 deaths a year in U.S. hospitals. This received huge play in the mainstream media. While any medical error is bad — and sometimes tragic — they do not occur to the extent reported. The original report relied on a study from 1991. Only a small subset (27%) referred to negligent or substandard care. That still leaves the number of medical error deaths at a staggering 27,000, but the remainder of these adverse events were normal complications of medical and surgical care, such as infection and post-surgical bleeding. There we go again with “complications” equaling malpractice.

The other neglected point: how many “complications” were due to care in a teaching institution or training program? This study also failed to consider the quality of outpatient facilities or private medicine.

The problem with yellow journalism is that it is based on a little truth, and then it runs wild with speculation. Dr Makary does just that.

First, he makes the assumption that no other doctor but himself was capable of improving health care outcomes. Thank you Dr Makary. The Institute of Medicine paper is more than 20 years old. He assumes that we physicians have stood still for 20 years. There have been incredible advances in the treatments of cancers, spinal cord injuries and more. Umbilical cord blood stem cell therapies are about to revolutionize medical therapies.There has also been tremendous strides to improve and limit any complications from surgeries, re-admissions and the like. While any complication is a horrible occurrence, it does not happen anywhere near the rate that Dr Makary claims. He should know better than that. He is using 20 year old data — and faulty data at that.

Second, Dr Makary works for a major teaching institution. In other words, a teaching hospital. Using his arguments, we should ban all teaching facilities. Teaching hospital allow residents (physicians who are being trained) and nursing students to actually treat patients. These residents actually operate on patients. It does not matter how much supervision he or she may have. Using a scalpel or cutting near the aorta has risks. By Dr Makary’s argument, this should not be allowed. Let me go further. Teaching institutions will have complications, I can guarantee that almost any surgery will be safer in the hands of a board certified surgeon than a 1st year resident. If we follow Dr Makary, there will never be any well trained surgeon. Ever hear the old adage, never go to a teaching hospital in July. That’s because all the new interns start July 1st!

OK, lets go a little deeper. Most hospitals now have extensive precautions to minimize any of those horrible complications he sites. St. John’s Health Center and Cedars Sinai here in Los Angeles, and all other good hospitals, institute double and triple check systems before any surgery. We have what we call time outs, where everyone in the operating room must stop what they are doing and either the surgeon or the nurse will do a sort of pre-flight check. ALL must be in order.

The first paragraph of the WSJ article claims that American medicine is more deadly than the airline industry. I love a smart guy who can mix and match whatever he likes. Reminds me of the silly joke that went around when I was a kid, but makes sense now: “Do you walk to school, or carry a lunch?” One has nothing to do with the other. Except if you believe in yellow journalism.

His solutions are interesting and I’m not opposed to them in principle, but I reject his claim that this will remove all medical errors. He is trying to quantify what he considers being a good doctor. Dr Makary, that can not be done. That’s like trying to quantify and qualify what makes a good person. It’s a bell shaped curve.We can give general guidelines, but that’s about it. Government intervention can not make a good doctor, nor can it prevent a bad one. Just like voting for a President doesn’t make him a good one, no matter how much hope is promised.

His first solutions:

Online Dashboards are completely misleading. Again, in principle this may make sense, but posting infection rates, re-admission rates will force hospitals and doctors to refuse care of the very ill. It will happen, mark my word. He mentions online sourcing to check out physician and hospital. These are as scientific as… the internet. Statistics alone are misleading, just like the Institute of Medicine article. Dashboards are the equivalent of psychobabble — makes you feel good about yourself. If we use dashboards, we will then treat for the end result… better dashboards, and not take the time to give individualized care at least and refuse care of the very ill at worst.

His second solution: Safety culture scores are already being done, but he can take credit for it, sort of like Al Gore and the internet.

Third solution: cameras: Makes for an interesting privacy argument, but I actually have no problem recording every second of my encounter with all of my patients. We can’t just pick and choose when to record. If he wants to go that route, then lets go whole hog. I’ll let him deal with lawyers and privacy issues. This will be a trial lawyer’s wet dream!

His fourth solution, Open Notes: Every patient has a right to get a copy of his or her notes. It seems that Dr Makary has a lot of time on his hands. That’s the benefit of working for a teaching institution.

Finally, No more gagging. Dr Makary argues for more transparency. I totally agree, but we come at it from polar opposites. His solution: “… the government must play a role in making fair and accurate reports available to the public.”

The government is not the solution as he argues.What he does not say, but is inherent in his argument, is that he is arguing for a government-controlled healthcare platform. He does not argue for the curtailment of the medical legal system which prevents so much of what he wants to accomplish. We as physicians are severely limited as to what we can do to discipline poor physician performances. I have been on many a committee where we tried to do just that. Lawyers have prevented our every move. His solutions are not solutions, just a shifting of care to a more centralized distribution of health care.

While I reject his claim that somehow the medical profession, save for him and a few brave others, are wantonly killing patients from pure neglect and ineptness. I do agree and have always felt we need to be a little more humble and honest in what we can do and what we can not. His implication that only government health care (Obamacare) can solve these problems is the arrogance of which I spoke of in the beginning.

I , and most of my colleagues who still practice clinical medicine, are in awe of our patients. They are putting their lives and the lives of their loved ones in our hands every day. We learn from them everyday, and we have devoted ourselves to doing the best we can. I am not in awe of the physician who thinks he or she has the solutions for everything that ails all of us. That’s where errors happen… the arrogant doctor who knows it all.