[ed. note: Michael Jorrin, who I call Doc Gumshoe, is a longtime medical writer (not a doctor) who writes for us about medicine and health a couple times a month. He has agreed to our trading and disclosure restrictions, but does not generally write directly about investments. His ideas, thoughts and words are his own, and you can see all his past pieces here.]
At the end of the previous Doc Gumshoe installment, I promised to reflect on what Marty Makary, MD, wrote about in his recent book, Unaccountable. The book is primarily about the lack of transparency that affects the entire medical field when it comes to the question of the individual performance of many of those practitioners into whose hands we entrust our lives. This is especially true of physicians who perform procedures that demand a high degree of skill. Makary himself is a surgeon, practicing at Johns Hopkins Hospital, and he recounts a great many specific examples of that lack of transparency and how it can result in significant harm to patients.
A great deal of what physicians learn might be classified as book learning enhanced by practical demonstrations and experience. They learn anatomy by the book, but they also study anatomy by dissecting cadavers, and they go on to relate what they have learned to actual experience with living patients. From the outside, they know how your organs and bones and muscles and nerves and blood vessels all fit together. But that doesn’t mean that they’re competent to pick up a scalpel and slice into your body and find your spleen and remove it (without spilling any potentially harmful fluids) and then put all your parts back together and send you home good as new, or nearly good as new.
It should be obvious that surgery and other interventions of that sort demand highly specific skills and dexterity, which cannot reliably be predicted by a physician’s academic training. And these skills are indeed highly specific; my excellent knee surgeon, for example, does not do coronary artery bypass grafts (CABG), nor does the cardiac surgeon do knees. Interventional cardiologists can place stents in coronary arteries, but actually opening up the chest cavity and replacing a section of a coronary artery may be beyond their skill level. Moreover, skill levels are not merely a matter of education and training. Underlying dexterity, as well as character and disposition, also has quite a lot to do with it.
A trivial example may cast some light on what I’m trying to say: I happen to be the best dicer of onions of anybody I know, and probably the best peeler of mangoes in the state (there may be better ones across the state line). But when it comes to tying neat little knots in tiny bits of string, or folding laundry, I am a clumsy oaf. I have one kind of manual dexterity, but not the other. Also, the end products matter to me differently – food outranks neatly folded laundry in my prioritized value system. But you cannot tell from my academic records or my résumé how good I am at dicing onions, nor yet how bad I am at folding laundry.
Returning to Dr Makary’s interesting (if disquieting) book, he cites a number of examples in which patients wound up in the hands of the wrong doctors for a wide variety of reasons. The circumstances that led to these wrong choices are such that any of us could find ourselves in similar positions, undergoing vitally important procedures under the wrong hands.
Most of these particular instances passed under the radar. Sometimes not even the patients themselves were aware that the poor outcomes they suffered from their procedures could have been easily avoided, had they been treated by a more skilled and experienced practitioner. But one example did receive a great deal of attention, including international attention at the highest levels, although the specific nature of the error was not widely publicized at the time. That was the surgery performed on the Shah of Iran, His Majesty Mohammed Reza Pahlavi, by the physician who at that time was probably the most eminent surgeon on the planet, Dr Michael DeBakey.
What was special about Dr Michael DeBakey?
To remind those of us whose recollection of DeBakey is a bit spotty, here are some excerpts from his obituary in the New York Times:
“ ‘Many consider Michael E. DeBakey to be the greatest surgeon ever,’ the Journal of the American Medical Association said in 2005. By the time Dr. DeBakey stopped a regular surgical schedule, when he was in his 80s, he had performed more than 60,000 operations. …
Dr. DeBakey’s surgical innovations have become common practice today and have saved tens of thousands of lives. An early invention, the roller pump, devised while he was in medical school in the 1930s, became the central component of the heart-lung machine, which takes over the functions of the heart and lungs during surgery by supplying oxygenated blood to the brain….
Yet he achieved his fame as much for what he did outside the operating room as what he did in it. His care of ailing world leaders, like President Boris N. Yeltsin of Russia, made headlines. …
In his public and professional lectures, Dr. DeBakey, an inveterate name-dropper, often showed photographs of his celebrated patients and spoke about their ailments. Among these notables were the deposed shah of Iran, Mohammed Reza Pahlavi; the duke of Windsor, the former King Edward VIII of England; Marlene Dietrich; Joe Louis; Leo Durocher, the baseball manager; and Jerry Lewis. …
Dr. DeBakey was a pioneer in performing coronary bypass operations. In one of his last lectures, at the New York Academy of Medicine in Manhattan in November 2005, Dr. DeBakey said that his team had performed the first successful coronary bypass operation, in 1964, but that it did not report it until 1974.… His team was the first to transplant four organs (a heart, two kidneys and a lung) from one donor to different recipients….