“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 inUnaccountable 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.

Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is chair-elect of the American Board of Internal Medicine. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

16 replies »

  1. Excellent book that should be read by state and federal legislators. Sadly I’ve experienced what Dr Makary wrote about at every hospital I’ve worked. It is our American healthcare which IHI was been trying to improve for 25+ years. There is too much misguided financial incentives in our system.

  2. It refreshing to have a doctor come out in support of those of us whose lives have been destroyed by a “bad apple”. Not all doctors are infallible despite what the medical community would have use believe. I appreciate what Dr Wachter has tried to do here and I would expect him to take a lot of heat from the dyed-in-the-wool, “we are perfect, we are doctors” crowd.

  3. It needs to be said. Over and over and over. By an insider. Solutions? Why does Makary have to give us solutions right now? It is a big thing, this medical mess, and simple exposure, anecdotal or otherwise, goes a long way to a) give a sense of validation to those outsiders (patients) who experience things the medical establishment wants to deny or call them crazy for seeing and b) keeps the thought that maybe all is not what it seems in the public eye, and c) informs people who haven’t heard the concept before. For now, that is enough.

  4. I am in the hospital on the 5 week anniversary of my wife’s botched hysterectomy. The surgeon unknowlingly perforated her small intestine and after a week of suffering and several CT scans it was finally discovered that she had sepsis, went into septic shock, and spent about 10 days in the ICU on life support. Today she is having her 12th follow-up surgery. I had complained to various doctors that somethig was amiss and asked for a GI doctor and ID doctor to see her. At my request she was put on strong antibiotics and then the next day after another CT she had emergency surgery to cleanse her bowel and resection it. So I’ve experienced one pretty inept doctor and a few life savers. But had I not been there to advocate every day for my wife I’m not sure where she would be? So in spite of Dr. Wachter’s review I’m anxious to read this book. Things like this should not happen.

  5. Unaccountable should also be the correct name for the Affordable Care Act, which was built in almost entirely non-transparent manner by a President who based much of his campaign on ‘Transparency” and openness. The sad and perhaps damning thing is that few Congressmen really read it nor understood the nuts and bolts of it. Otherwise it might have been squarely defeated with some Democratic votes changed. Now many Democrats will deserve their defeat in the next election. This is not a GOP fight alone. I also did enjoy the reviews. It’s hard to extract personal ego’s from writings at times. It’s the best of both worlds and the worst as well. Like life

  6. I read “Unaccountable” after my leg was amputated (above knee) three years after I (pedestrian) was hit by an SUV. The amputation was necessary due to a string of missteps made by medical professionals, one of whom is world renowned.

    As I was reading Robert Wachter’s review of this book, I thought he somehow had read my mind. My enjoyment of the book was short-lived because Dr. Makary’s primary purpose for writing it seemed to be to let all his readers know what a regular (yet phenomenal) guy he is–which was NOT why I bought the book.

  7. I am the public you doctors are talking about. I do feel this information was desperately needed.We don’t get to ask too many questions of you doctors as you are all too busy.We don’t see reports from the hospitals as they usually are not published. How can we make good decisions about the hospital and doctors if we are shut out of the kind of information that Dr. Makary is talking about.
    I live in the Sunshine state. We have Sunshine laws. Letting the light shine in an infected system is a good way to cure the infection. Even you doctors tell us to take the “bandages off” sometimes! Well Dr. M is doing just that! Sunlight and air brings about disinfection and A CURE!
    With information Dr. M is absolutely right! We the public can finally choose better hospitals and doctors now that we understand that the system is flawed and that we should be asking these questions!! By being able to make better choices,we, the public, will bring about change! We will choose to go to the better hospitals. WE WILL ask more questions about our doctors . Hooray for Dr. Makary! Who cares how simplistic the book was to you doctors. He didn’t write the book for you all doctors.You know about all this stuff already. Its no revelation to you! … He wrote it for “we the people”! I thank him for exposing to the public the mess this system is in! We patients have been in danger too long. There has been no one(overtly) to champion our cause! You all didn’t tell us about this mess and warn us! Finally we have someone who cares!

  8. Bob, I respect your ‘review’ on this book. However I don’t think his target audience was health professionals, rather a lay audience. I also don’t think it was written as a peer reviewed article for a journal (peer reviewed) Most of your criticism revolves around references, rules of grammar and perhaps the lack of a ‘Harvard’ or Chicago manual of style….meant for academic articles. Even as a physician who has been on an academic faculty I think your criticisms were a bit “elitist”. I do a considerable amount of translational writing, ie, dumbing down the professional or scientific literature so that the average person (6-8th grade reading level) can understand it and take it home. I also know we need to monitor ‘junk literature’, and I am sure you would agree that this was not ‘junk’.

  9. I am not sure that the central thesis of the book (summarized as: “If patients simply had more data, particularly the results of patient safety culture surveys, things would get much better.”) makes sense. Wouldn’t one logical thought be to call for the exisiting institutions – which receive large resources to guarantee quality in HC (by that I mean state medical boards, JCAHO, specialty boards) – to do better work?

    And of course, if there is too much back- and neck surgery (and yes, there is, even at quality institutions), just pay less for it and things will even out. In other words: adjust the medicare fee schedule.

  10. I have to agree that Michael Millenson’s book set the bar on this topic and that sadly, after all these years very little has changed with respect to the fundamental output of our health care “system”…

  11. This is a bit of irony. Having made the points: 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.
    Dr. Watcher is not intimidated to point out bad apple that the average reader may not have identified.

    I do agree with these three points, but am not sure what the remedy is. The problem is that without clear evidence, identification of bad-apples boils down to finger-pointing and opinion. Again, the irony is pretty thick.

  12. RS,

    I don’t think Bob was being overly harsh. When reading a book on a professional topic – and especially something as important and under-appreciated as safety – it”s reasonable to expect both lucid insights and rigor from the author.

    I don’t disagree that many health care authors are short or elegance. But a lack of rigor, even in an author with the best intentions (as Dr. Makary undoubtedly has) requires leaps of faith. translates to straightforward bloviation, and doesn’t help us move forward the discussion or, more importantly, change.

    My impression is that Bob was applying the same standards in this review that he’d apply to his own writings and efforts. To my mind, this is why he – and others – e.g., Michael Millenson, Patricia Salber, Matthew Holt, Jane Sarasohn-Kahn, Bob Laszewski, Merrill Goozner, Jaan Sidorov, Paul Levy and Kenny Lin – has become one of health policy’s best, most consistently honest, rigorous and trustworthy commentators.

  13. Bob, I appreciate your review. Like some of the other commenters, I’ve been a little surprised by the good reviews for material that seems to have already been well covered. But, I would like to add this….isn’t much of your criticism also applicable to other authors (including perhaps at times, dare I say, yourself)?

    True, that other books may be less anecdotal. But often times, these quality and safety books feel like death by statistics. I have often wondered if things are as bad as the numbers make them sound. Anecdotes shouldn’t usurp statistics, but they certainly do help to color the story.

    Poorly written – maybe it’s just me, but I find most books in the healthcare arena to be trying too hard to be great pieces of literary genius. And the corollary – when we find someone who can write, we feel a need to exalt their every thought even when not merited (enter the Cheesecake Factory).

    Overly simplistic – who, of this entire genre of writing, isn’t a little reductive, and trying to push their new politically popular viewpoint? It is exhausting to listen to the EMR vendor crowd talking about how their new ridiculous technology product will expose the evils of the hospital system, or any of the authors or public policy experts in this field who go on about transparency and saving healthcare with data. Not at all sure how this book is any different than the others. While I appreciate the merits of your work, there are many physicians I have heard complaining about how hospitalists are are overpaid shift workers who have significantly disrupted the communication flow and care given in hospitals in very reductive ways.

    Ego – really? And didn’t each of the authors in this field try to make a name for themselves, to help become ‘a leading figure in the patient safety and quality movements’??

    I think your points are fair ones, but perhaps a little harsher than needed, especially as the comments can be applied to much of the work and many of the authors in this area.

  14. I was a bit surprised when Health Affairs printed a (quite good) blog article from him all about CEO salaries referencing the book….as though it was all new

    Ground all well tilled — going back to THCB regular Michael Millenson’s (well written and well researched) Demanding Medical Excellence” that’s now 15 years old

    it is sad that a new book on the topic is necessary, let alone that (at least in Bob’s highly trustworthy opinion) it’s not much good