At the Cosmos Club, Washington, DC
January 20, 2017
President Larry Millstein called the 2372nd meeting of the Society to order at 8:06 p.m. He announced the order of business and welcomed new members. President Millstein presented a summary of the 34th meeting of the Society, held in 1872. The minutes of the previous meeting were read and approved. President Millstein then introduced the speaker for the evening, Martin A. Makary, the Surgical Director of the Multidisciplinary Pancreatitis Center at the Johns Hopkins Hospital, and a Professor of Health Policy and Management at the Center for Global Health at the Johns Hopkins University. His lecture was titled “Eliminating the Third Largest Cause of Death”.
Dr. Makary began by suggesting that the major theme of the last five years of medicine has been rolling back recommendations made over the last several decades. Recommendations such as daily aspirin for everyone and mammograms starting at age 40 were found to cause more harm than good in most people. Appendicitis may be treatable using antibiotics alone in many cases, which could avoid what is currently one of most common causes of surgery in the United States.
Dr. Makary related the story of the assassination of President James Garfield in 1881, in which one Dr. Bliss—against the advice of other attending physicians with Civil War experience—performed seven operations on the president to remove the bullet. The president ultimately died of sepsis resulting from the surgeries, more than a decade after Dr. Joseph Lister had introduce the techniques of antiseptic surgery.
Dr. Makary explained that President Garfield, along with many other patients, died of “unwarranted medical variation”, meaning the practice of medicine that did not conform to the theories or techniques broadly accepted in the field.
Dr. Makary identified medical errors as the third largest cause of death in the United States. One major source of such errors is unnecessary medical care, including over-prescribing and unnecessary procedures and tests. Dr. Makary related that some doctors estimate that 15-30% of medical care is not necessary, and brings with it real financial and health costs.
Dr. Makary turned to explaining what can be done about it. One approach has been to attempt to reduce the incidence of unwarranted medical variation by identifying objective metrics for comparing physicians’ practice and feeding that information back to them. For instance, Mohs surgeries for the treatment of skin cancer involve repeatedly removing thin layers of tissue from around a cancer site until only cancer-free tissue remains. By analyzing the number of cuts, researchers identified the doctors that were cutting substantially wider or narrower than their colleagues. Dr. Makary noted that characterizing performance as “below average” triggers defensiveness and justifications. In contrast, telling people that they are an outlier creates very strong social pressure. By providing objective feedback, outliers can be encouraged to move toward the consensus position.
In this same vein, Dr. Makary explained that the simple intervention of the checklist has substantially reduced medical complications by helping ensure that scientific advances and best practices make the transition to everyday practice.
Another avenue toward improvement has been harnessing the cost incentive. Dr. Makary explained that one effect of the high cost of deductibles has been to drive patients to inquire more closely about the financial and health costs of tests and procedures. Dr. Makary noted that the system of networks and discounts has the effect of obfuscating the true cost of healthcare to the extent that even doctors do not know the cost to the patient of most procedures. Dr. Makary described the goal as a “competent marketplace” in which transparent financial and health costs are available to patients so they can make informed decisions, and market pressures can act to bring prices down.
Dr. Makary concluded by explaining that health care is a complicated, political, and polarizing topic, but improving medical care through reducing errors is uncontroversial and has wide benefits. After the conclusion of the talk, President Millstein invited questions from the audience.
One questioner asked about the extent to which defensive medicine drives unnecessary medical care. Dr. Makary confirmed that fear of malpractice was a primary driving factor of unnecessary care, but that overall it was only one of many factors contributing to the high cost of health care.
Another questioner asked what changes in the medical school curriculum might help new doctors better consider these issues. Dr. Makary observed that current medical students already show less tolerance for dogma, and theorized that the increasing diversity of the field may be driving productive inquiries into the validity of longstanding conventional wisdom as well as promoting transparency with patients.
Another questioner asked the “reference ranges” for blood tests. Dr. Makary agreed that individuals or groups commonly have results outside the reference range that are nonetheless normal and healthy for them. He reiterated the advice to treat the patient, not the test.
After the question and answer period, President Millstein thanked the speaker, made the usual housekeeping announcements, and invited guests to join the Society. At 9:45 p.m., President Millstein adjourned the 2372nd meeting of the Society to the social hour.
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