by Marty Makary
Moreover, medical school barely touches on the business of medicine. Nowhere in my training was I taught about pricing failures, overtreatment, or middlemen. The problems are staring us right in the face and the solutions are begging to be implemented. But instead of discussing them, we focus students on memorization—just as we did 50 years ago, before the Internet brought information to our fingertips nearly instantly.
Patients are crying out about care being too fragmented, too rushed, and about billing practices that are ruining their lives. Doctors must lead the charge to restore medicine to its mission. The most logical solutions have been largely absent from curricula.
Perhaps the greatest omission of medical education today has to do with the fact that most of our problems in public health are self-inflicted. Despite best intentions, medicine’s limited view of healing has resulted in some of our greatest health care challenges, including the opioid crisis, antibiotic resistance, medical errors, and medicine’s trail of financial toxicity. It’s time to focus on what matters most to our patients.
Individualism
One entrenched problem in health care is that medical education has traditionally espoused individualism. Doctors are attracted to medicine by a deeply felt mission to help others, yet if a hospital has only two doctors in any one specialty, chances are they are at each other’s throats. Exceptions abound, but if a random U.S. hospital has, say, a couple of thoracic surgeons, the odds are high that one resents the other.
I’ve traveled to hundreds of U.S. hospitals and met with countless doctors. I’m always amazed by the maverick phenomenon, even within small groups of physicians. Let’s say there’s a group of three physicians. Often, one will criticize the others for not practicing up-to-date medicine; another will feel that she deserves to take fewer calls; and the third finds a creative way to hoard the good cases.
Don’t get me wrong, many doctors get along as swimmingly as my partners and I do in my surgical faculty group. We are personal friends, we don’t keep score, and we help with one another’s patients. But many groups wrestle with dynamics that can put internal politics above the needs of patients.
How is it that doctors can start off so altruistic and end up so cannibalistic? The answer lies in how we educate and shape young physicians. We credit individuals over teams and promote empire building. We teach technical skills, but not behavioral skills. I learned a lot in my 15 years of medical education. That’s four years of premed, five years of med school and public health graduate school, five years of surgical residency, and a one-year specialty fellowship—a typical length of training for a surgical specialist. About 10% of what I learned has since been disproved and 80% is as irrelevant to how I practice medicine as the use of Botox on a furry dog.
That leaves approximately 10% of what I learned in med school that’s relevant to my job. Of course, if I were a cancer research scientist, the biochemistry is something I might use every day, but that was never my path. I always knew I wanted to be a practicing surgeon, taking care of people.
I have no problem learning stuff I will never use simply for the sake of knowledge—though I prefer not to do any more Latin. Noticeably absent from that 15 years of study were the behavior skills that enable doctors to perform well. Yes, some people are naturally good at teamwork, communication, and humility. But most of us enter the profession fresh off a 20-to-30-year sprint of competing against one another academically—in a culture that promotes independence.
During my medical education, a dozen different times I had to memorize the Krebs cycle, a series of names of changing molecules inside a cell. I took a written exam almost every year to see if I could quickly recall the names of the intermediate molecules in the Krebs cycle. Of course, I could have used my brain space for things relevant to my patients, and if not, I can always look up the names of these molecules. The Krebs cycle has not come up once in my years of clinical medicine in any way, shape, or form. I would have been better off studying Latin. Necrosis.
There was a good reason medicine promoted memorization. Before Google and iPads, the doctor who could memorize the most differential diagnoses had a valued skill set. But now we can look things up. However, things haven’t changed much on campuses because medical education is controlled by an establishment guard of accrediting boards and institutionalists.
Medical education needs lipo. Instead of teaching every medical student how to refract people’s eyes to fit them for eyeglasses, how about teaching teamwork and communication skills? I learned the Krebs cycle, but not how to communicate effectively with nurses. I learned the microscopic stages of prostate cancer, but not how to deal with an underperforming person on my surgical team. I learned subatomic particles for the MCAT, but never learned how to explain diabetes at a sixth-grade reading level. To address the serious gaps in education, the traditional 15-year track to becoming a specialist doctor needs one giant enema.
Thankfully, we are getting started at Johns Hopkins. We have added teamwork and communication training to our medical curriculum and residency programs.
Humility
If you ask patients what makes a great doctor, they will tell you it’s a doctor’s judgment, skill, and humility. I tell my medical students that it’s vitally important that they know their limits—even more than knowing your Krebs cycle. More than knowing subatomic particles, we need to know when to summon another doctor for advice. We must recognize when a patient is not understanding us, or when something causes a patient to lose trust.
When getting medical care, patients ask: Do I need this prescription? Do I need this test? Do I need this operation? They are concerned about the appropriateness of medical care. They want to get the care they need. And the number one mark of a quality doctor is how well the doctor discerns when medical care is appropriate and when it is not.
I was operating with one of our best surgeons-in-training one day when I saw him get extremely discouraged after placing a stitch a bit too far from the last one he placed. As soon as he placed the needle in the tissue, he recognized the mistake and backed it out, then placed it perfectly. “That’s terrible! I should know better,” he said, beating himself up. I had to stop him to remind him he was a great surgeon technically and that placing one stitch a hair off was not a problem because he immediately recognized and corrected it.
Disrupting Medical Education
Unfortunately, most medical schools still haze students by making them commit to memory thousands of details that do not need to be rapidly recalled in the real world of doctoring. Some medical schools blame the accrediting boards for requiring all the memorization. Well, here’s an open invitation to the old guard of medical school accreditation: come spend a day with me in the hospital. Medical students don’t need to learn facts only to forget them weeks after an exam. No patient ever died because their doctor couldn’t rapidly recall the Krebs cycle. Swap out the Krebs cycle with a patient testimonial about routine medical care gone awry. Or replace the Krebs cycle with a teenager’s testimonial about going to one MRI center that overcharged her so much she lost her college savings.
Medical schools should take a lesson from the innovators in medical education today, like Dr. Stephen Klasko, CEO of Thomas Jefferson University and Jefferson Health. Dr. Klasko is restructuring medical education to teach humility and compassion. His curriculum educates future physicians in effective communication and empathy and includes a strong set of courses by Dr. David Nash about the money games of medicine. Klasko believes in making medical education highly relevant to the medical, social, and financial needs of patients—the whole person.
I reached out to Klasko to find out how his school is disrupting medical education. We talked about the culture of training doctors. He shared with me the results of a simple series of interviews his team conducted with past graduates who have been in practice for years. They asked how well their medical education prepared them to practice medicine. Graduates consistently felt that their education did not prep
are them well at all. When they got into practice, they didn’t have the basic skills they needed, like effective communication skills, how to run a meeting, or how to recognize burnout.
Klasko based his new curriculum in part on a $1.5 million grant he received to study what makes doctors different from everybody else. He learned that the way we select and educate physicians is akin to joining a cult. He identified four fundamental traits that get ingrained early: a competitive bias, an autonomy bias, a hierarchy bias, and a noncreativity bias. He learned that the profession attracts highly creative team players but that we ingrain in them the qualities of focus, discipline, and rigidity. Other professions generally promote those who are the most creative, but medicine often rewards people who are the most focused. “We select people based on GPA, MCAT score, and organic chemistry and somehow we’re amazed they’re not more empathetic,” said Klasko. He decided to rethink how the medical school selects students. “We decided to choose students based on self-awareness and empathy.”
Klasko partnered with two nonmedical companies to learn how to select better. The medical school partnered with Southwest Airlines to see how they chose pilots to deal with crisis. They also partnered with Telios, a company that does the interviewing for Google. Once a candidate meets a certain academic standard, the criteria for certain behavioral traits that are set by the companies come into play. The difference between a great pilot and a good pilot is not scoring 99% versus 96% on their exams. It’s teamwork and communication skills. Similarly, Google is far more interested in creative talent than in test scores.
Under Klasko’s leadership, Jefferson selects students based on their emotional intelligence and trains them to be highly effective communicators with sound clinical judgment. Boston University is also now using a holistic admission process, and other schools are beginning to see the benefits as well.
People like Klasko are changing the culture of medicine for the better by putting the focus back on the patient.
Speaking the Right Language
My Latin didn’t prepare me for medical school. My medical school didn’t prepare me for doctoring. In a similar way, our approach toward fixing what’s wrong with our medical system has skipped over key points.
One of our biggest problems is vocabulary. We use code words for the problems we see around us instead of calling things what they are. We should be using patient-centered terms. Instead, health care has adopted business-centered terms.
In his book Catastrophic Care: How Healthcare Killed My Father, David Goldhill has written eloquently how health care’s vocabulary fosters a false reality. He cites the difference in impact between experts saying “Petroleum costs are increasing” and a consumer saying “Gas prices are going up.” The first term creates distance between you and the problem; the latter hits home.
The official medical dictionary is full of terms that depersonalize problems by being technical when they should be visceral. We’ve seen this before. The banking industry told us that markets were so complex that we should leave it to the experts. They supported this notion with a lexicon that was so technical that people outside Wall Street were left out of the dialogue. But the complex terms got decoded after the financial collapse of 2008. What the experts called a “credit default swap” was really borrowed money that bypassed insurance requirements. What experts called a “collateralized debt obligation” was just a group of bad loans. In health care, we do something similar all the time. We need to start fixing health care by switching to a more honest lexicon.
Health care experts use the term “costs.” We should talk about “prices.”
Health care experts use the term “preventable adverse event” when we should call it “medical care gone wrong,” or an “error” when appropriate. “Preventable adverse event” is a term that washes everyone clean of responsibility, while the plainer terms express the truth a patient experiences.
Heath care experts talk about variation in a hospital’s “charge-to-cost ratio.” That’s what you and I might call a “markup.” I’m not judging the principle of charging more for a medical service at Hospital A versus Hospital B. The service might be better at one place than the other. But call it what it is: a markup.
Health care experts use the term “financial aid” to describe the meager discount they might offer on marked-up charges if they agree to pay in installments. They should be calling it “predatory lending.” If a bill is 1,000% higher than what Medicare would pay for the same service, a 10% discount is still taking advantage of the patient. Allowing a patient to pay that bill in monthly installments over a lifetime is manipulation.
In that same spirit, “charity care” should refer only to medical care that is entirely free. It’s not the difference between what a hospital charges and what they get after shaking down the patient.
Health care experts say “employers” pay for health care for most Americans. But it’s actually employees who are paying, since the money used to pay for health care comes from an allocation of funds set aside for employee compensation and benefits. We are told that payers, like insurance companies, foot the bill for medical care, but that money comes from beneficiaries like you who pay monthly premiums.
Similarly, we are often told that Medicare paid for a medical procedure, but actually U.S. taxpayers paid for it. Check your paystub and you will most likely see that you are paying a Medicare “excise” tax with every paycheck, in addition to your health care contribution. That contribution is in addition to what our employer is paying for your health care—money that could otherwise be paid to you in wages.
Using the more accurate terminology in plain English would help change the conversation about health care. People could better understand what’s really happening. It can also more effectively engage people with these important issues.
My research colleagues and I are trying to change the terms we use in our public conversations. It’s not easy. Several times, medical journal editors slap my wrist and insist that I use the wonky term instead of the plain English term. But to change health care, we need to alter the words we use to talk about it.
When people ask what they can do to get involved, I encourage them to discuss these topics with their local hospital board members, governors, and state and national legislative representatives. As someone who serves on a hospital board myself, I know board members are people from the community and highly accessible. Talk to them about these issues. Ask them how their hospital addresses charity care, and if the hospital sues patients.
Employers should take a hard look at their health insurance and PBM contracts and consider self-insurance or self-insurance pools. They should include pricing and quality tools to guide employees to high-value medical care. Employers are leading the redesign of health benefits in ways that are poised to disrupt the entire medical establishment, such as General Motors engaging in a direct contract with Henry Ford Health System, bypassing layers of costly middlemen.
In another example, the H-E-B grocery chain, the largest private company in Texas and an entirely self-insured business of 105,000-plus employees, is redesigning health care with new clinics, called Magenta Clinics. These clinics create a path to disrupting the medical marketplace by how they choose doctors for patient referrals; that is, how they pick specialists for the patients. Value is defined by quality and price. Using new metrics of quality and appropriateness and information on price, a large business like H-E-B could reward high-value physicians by sending them patients. At scale, this could have a powerful impact in reshaping competition for high-quality, fair-priced specialty care. Currently, we have competition in health care, but that competition has been at the wrong level. Medical centers have been competing on parking, billboards, and appointment scheduling ease. Medical centers should be competing on value (quality and price), not just on conveniences. Large businesses like H-E-B are the bright spot in health care, poised to change the way health care does its business.
The next time some
one says that your insurance company, your employer, or Medicare is paying for something, you might want to remind that person that it’s really all of us who are paying.
CHAPTER 18
What We Can Do
You wouldn’t believe the things people tell me.
When you’re a doctor, people tell you a lot about their physical problems—and not just when they’re sitting in your office. It could be a social gathering, dinner party, school event, kids’ soccer game, country music concert—pretty much anywhere. When some people discover I’m a doctor, it’s as though we’re suddenly transported into my examination room. The next thing I know they’re sharing their medical and dental history: telling me about a sports injury they got in high school, whether they have vaccinations, showing me a curious rash, perhaps soliciting my opinion about an intimate health issue experienced by a family member. As a result, I have thousands of loosely bound mental medical charts floating around in my brain from cocktail reception consults. It is a little embarrassing when I later remember someone because of their spleen issue. Every now and then I’ll see a guy at a social event and think, I know that person. Oh, yes, he’s the diarrhea guy.
One evening, I was attending a Washington, D.C., cancer fundraising event, and someone at our table mentioned I was a surgeon. With those magic words, the woman sitting next to me at the table perked up. “Oh, you’re a doctor?” Karen asked eagerly. “I wanted to be a doctor when I was in school.” She proceeded to list all the doctors she knew in town. Then the waiter came to pour wine in her glass.
“Oh, no, thank you,” she told him.
Karen turned to me and leaned in close, as though she were going to tell me a secret. Her voice dropped an octave as she explained she couldn’t drink because she was taking antibiotics for a chronic sinus problem. Next, she complained about how much her medications cost and everything she’d tried to treat her chronic sinusitis. I’ll admit that as Karen droned on about herself, a few times I zoned out. But then she said something that made me snap to attention: “I had the balloon done and everything.”