Now it’s time to thump Dr. Makary.  If you are wondering why I’m picking on him and his book so hard, it is because this will be quoted by every one of the health care policy wonks as the gospel.  

Here’s another quote from his book.  ”Not all doctors fail to disclose all the options to patients, or don’t refer when they should.  In my hospital rotations, I met terrific doctors who were honest to the bone.  I saw pockets of strong collegial teamwork, doctors who would refer a patient without hesitation if it meant better care (or lower risks) for the patient.  Great teamwork like this comes about when doctors and nurses feel they are able to speak freely with one another and stay friends.  Everyone is happier that way.  It usually occurs at hospitals where doctors are salaried ( italics mine) and there are no giant bonuses for racking up more operations or treatments.”

Salaried by whom?  If not by the patient, who is the doctor working for?  Later in the book, “Hospitals explicitly pressure their doctors to do more procedures and see more patients in order to make more money.  One doctor I know received an e-mail from his department head that read:  As we approach the end of the fiscal year, try to do more operations.  Your productivity will be used to determine your bonus.”

Inconsistencies like this are incredibly damning to the book in particular and to his logical abilities in general.  We can’t have these “eat what you kill” doctors (that’s what he calls private practitioners) running things.  Only the altruistic, salaried doctors, those who are immune from the profit motive can be trusted to keep the patient’s interest at heart.  I’m reminded of Adam Smith’s famous line:  ”It is not from the benevolence of the butcher, the brewer or the baker that we expect our dinner, but from their regard to their own interest.”  The salaried doctor has his own interest at heart, it’s just that he must satisfy his employer rather than his patient to satisfy his self interest.  To think that their can be no conflict here is naive.  

Makary likes the Cleveland Clinic model, certainly not an “eat what you kill” setup.  ”They are all paid a flat salary to encourage appropriate medical care.”  I suppose Makary is unaware of the firing of Dr. Eric Topol, the famous cardiologist at the Cleveland Clinic, after he outed his boss for an inappropriate relationship with Merck pharmaceutical company.  Topol was the physician that alerted the medical community to the cardiovascular dangers of Vioxx.  Oops.  Turns out the Cleveland Clinic’s research faculty had “an arrangement” with Merck.  Topol’s academic position was abolished.  Doesn’t sound like a saintly altruistic setup to me.   

The doctor patient relationship, properly re-named the patient-doctor relationship by the Association of American Physicians and Surgeons has yet a new twist in Makary’s book, revealing I think what he thinks of this relationship.  He refers late in the book to “the doctor-to-patient relationship.”  I’ve never heard this one.  I think it means what you and I think it does.  I’m not finished with him by a long shot.

G. Keith Smith, M.D.