Unaccountable

1. American Healthcare Suffers from a Profound Lack of Transparency.

Instead, our health care system leaves its customers walking in blind.

Patients lack information. The healthcare system operates with a significant lack of transparency, making it nearly impossible for patients to make informed decisions about where to seek care or which doctor to choose. Unlike other industries where performance metrics are public, hospitals and doctors often keep crucial data hidden. Patients are left to rely on unreliable factors like advertising, parking accessibility, or word-of-mouth from non-medical friends.

Marketing vs. reality. Hospitals spend millions on marketing campaigns that often make vague or misleading claims, such as calling a small department a "comprehensive center" without the necessary staff or equipment. This contrasts sharply with the reality known by those working inside the hospital walls. Patients are encouraged to believe the system is flawless, when insiders know it's often chaotic and inconsistent.

Hidden information. Key information that could guide patient choice, such as complication rates for specific procedures, readmission rates, or even how many times a doctor has performed a particular surgery, is generally not available to the public. This secrecy benefits poorly performing institutions and doctors by shielding them from market consequences, while patients unknowingly receive substandard care.

2. Accountability is Largely Missing for Hospitals and Doctors.

Hospitals have merged and transformed into giant corporations with little accountability—and they like it that way.

Corporations without checks. Hospitals have evolved into large, profit-driven corporations that are not held accountable for their performance in the same way other industries are. They can be aware of consistently high complication rates for certain services but have little incentive to improve, as the public remains unaware. This lack of external pressure allows dangerous practices to continue unchecked.

Weak policing. The traditional mechanisms for policing doctors and hospitals are ineffective. State medical boards are often underfunded, slow to act, and sometimes prioritize protecting doctors over public safety. They may fail to investigate complaints thoroughly or share disciplinary information across state lines, allowing dangerous doctors to simply move and continue practicing elsewhere.

Internal silence. Within hospitals, a code of silence often discourages staff from speaking up about incompetent colleagues or safety concerns. Doctors and nurses fear retaliation, jeopardizing their careers if they challenge the status quo or report substandard care. This internal lack of accountability perpetuates problems that frontline staff are well aware of.

3. Medical Errors Are Common, Devastating, and Often Preventable.

As many as 25 percent of all patients are harmed by medical mistakes.

Widespread problem. Medical mistakes are a significant and persistent issue in healthcare, harming a large percentage of hospitalized patients. These errors range from minor issues to severe complications, disfigurement, or even death, and error rates have not significantly decreased despite various safety initiatives over the past decade.

Avoidable tragedies. Many medical errors are preventable and stem from systemic failures rather than just individual incompetence. Examples include:

• Operating on the wrong side or wrong patient.
• Leaving surgical instruments or sponges inside patients.
• Medication errors due to sloppy handwriting or incorrect dosing.
• Preventable infections or falls within the hospital.

Culture of silence. The healthcare system's closed-door culture contributes to complacency about errors. Mistakes are often swept under the rug, and discussions about them are confined to private meetings or settlement agreements that include gag clauses, preventing patients or their families from speaking publicly about what happened. This lack of open discussion hinders learning and improvement.

4. Impaired and Incompetent Physicians Are a Known Secret Within Medicine.

Every doctor knows of a physician you work with who should not be practicing because he or she is dangerous.

Known dangers. A significant number of doctors are impaired by substance abuse, psychiatric issues, or declining physical/mental abilities, making them dangerous to patients. This is a widely known problem among healthcare professionals, yet few formal actions are taken to stop them from practicing.

Systemic failures. The systems in place to identify and address impaired physicians are inadequate.

• State medical boards often fail to monitor doctors effectively or act on known issues.
• Hospitals may tolerate impaired physicians, especially if they are high revenue generators.
• Doctors' associations have historically been passive in policing their members.

Patient risk. Patients have no way of knowing if their doctor is impaired or has a history of poor performance. They rely on trust and reputation, which can be misleading. This hidden problem puts millions of patients at risk each year, highlighting a critical failure of the system to protect the public.

5. Financial Incentives Drive Overtreatment and Questionable Practices.

By my estimate, financial incentives lure the average doctor two to ten times a day, temptations that are not always ignored—particularly when treating patients with borderline indications, who comprise a large part of the patient population.

"Eat what you kill". The prevalent "eat what you kill" compensation model, where doctors are paid based on the volume of procedures or treatments they provide, creates a powerful financial incentive for overtreatment. Doctors and hospitals profit more by doing more, even when less invasive or no treatment might be more appropriate for the patient.

Conflicts of interest. Financial conflicts of interest are rampant and often undisclosed to patients.

• Doctors may receive royalties or consulting fees from medical device companies whose products they use.
• Hospitals and doctors can make commissions on expensive drugs like chemotherapy.
• Practices may invest in equipment (like radiation machines) and then recommend treatments that utilize that equipment, regardless of necessity.

"Hammer, nail" problem. Doctors tend to recommend treatments based on their specialty and what they are trained to do. A surgeon may recommend surgery, a radiologist radiation, even when other options exist. This "when you're a hammer, everything's a nail" phenomenon, combined with financial incentives, leads to wide variations in care for the same condition and contributes to unnecessary procedures and rising costs.

6. Hospital Culture is a Critical Driver of Quality and Patient Safety.

Much of the wide variation in the quality of your medical care can be explained by culture—an institution’s level of teamwork and its local sense of common mission.

Culture matters. The internal culture of a hospital significantly impacts the quality and safety of patient care. Hospitals with strong cultures of teamwork, open communication, and a focus on patient well-being tend to have better outcomes and fewer errors. Conversely, cultures of intimidation, poor communication, and prioritizing profit over patients lead to dangerous environments.

Insider knowledge. Hospital employees, from nurses to janitors, often have the best insight into the true quality and safety of care provided. They know which doctors are skilled, which units are dangerous, and whether management is responsive to safety concerns. This "word on the ground" is a powerful indicator of culture and quality.

Listening to staff. Hospitals that actively solicit and act on feedback from frontline staff, like the Mayo Clinic or Geisinger, demonstrate a strong safety culture. Empowering employees to speak up about concerns and fostering teamwork directly translates into safer patient care and better efficiency, contrasting with institutions where staff feel ignored or punished for raising issues.

7. Patient Outcomes and Doctor Experience Data Should Be Public.

New York’s transparency program changed the way heart hospitals compete.

Transparency works. Making hospital performance data public can dramatically improve the quality of care by forcing institutions to address their shortcomings. The New York State experiment with publishing heart surgery mortality rates led to a significant statewide decrease in deaths as hospitals scrambled to improve and compete on outcomes rather than just marketing.

Valuable metrics exist. Reliable methods for measuring patient outcomes and doctor experience exist but are largely kept secret.

• National registries collect detailed, risk-adjusted complication rates for various procedures (e.g., surgical outcomes).
• Data on the volume of specific procedures performed by hospitals and doctors is often tracked internally.
• Employee safety culture surveys can predict error rates and overall quality.

Empowering choice. Public access to this data would empower patients to choose providers based on objective measures of quality and experience. It would create a functional free market in healthcare, rewarding high-performing hospitals and pressuring low performers to improve or cease offering dangerous services.

8. New Medical Technology Adoption Often Lacks Evidence of Patient Benefit.

The surgical robot perfectly symbolizes how our widespread adoption of new, high-tech solutions without proper evaluation of their benefits is breaking the bank.

Technology craze. The healthcare system has a tendency to rapidly adopt expensive new technologies, often driven by marketing and the perception of being "state-of-the-art," even when there is limited evidence of clear patient benefit over existing methods. This adds significant cost without necessarily improving outcomes.

Unproven benefits. The widespread adoption of surgical robots is a prime example. Despite costing millions and adding thousands per procedure, studies often fail to show a significant clinical advantage over standard minimally invasive surgery, except in specific niche applications. Marketing claims often outpace scientific evidence.

Cost driver. The rush to acquire and use new technology, regardless of proven value, is a major driver of rising healthcare costs. Hospitals compete by showcasing expensive gadgets, and doctors may be incentivized to use them. Patients, influenced by marketing and the allure of technology, may even demand procedures done with these devices, believing it's superior care.

9. Patients Must Become Empowered and Informed Consumers of Healthcare.

If you want to know what doctor is good, ask hospital employees.

Take control. Given the lack of transparency and accountability in the system, patients must take an active role in advocating for themselves and seeking out reliable information. Relying solely on doctor recommendations or hospital marketing is insufficient.

Seek insider knowledge. The most reliable source of information about a doctor's skill and judgment is often the healthcare professionals who work with them daily. Asking nurses, technicians, or other staff (informally or through public surveys) can provide invaluable insight.

Ask critical questions. Patients should not hesitate to ask doctors direct questions about their experience, procedure volume, complication rates, and alternative treatment options.

• How many times have you done this specific procedure?
• What are the complication rates for this procedure in your practice vs. national averages?
• What are all the treatment options, including less invasive ones or no treatment?
• Can I get a second opinion?

Utilize transparency tools. Patients should push for and utilize emerging transparency tools like:

• Accessing their own medical notes ("open notes") to review and correct information.
• Requesting videos of their procedures if available.
• Engaging in shared decision-making discussions with their doctors, reviewing evidence-based materials together.

10. A New Generation of Doctors Demands Honesty and Systemic Reform.

I am convinced that the new generation of doctors is poised to usher in a revolution of transparency, open-mindedness, and honesty.

Changing values. A new generation of doctors and medical professionals is entering the field with different values than their predecessors. They are often more diverse, have prior career experience, and are less tolerant of the traditional hierarchy, secrecy, and unethical behaviors they witness.

Pushing for transparency. This new generation is more willing to question authority, speak up about safety concerns, and be transparent with patients. They are advocating for:

• Open communication and teamwork in the workplace.
• Honest disclosure of mistakes and complications.
• Transparency about financial incentives and treatment options.
• Addressing impaired physicians and disruptive behavior.

Seeking systemic change. Many younger doctors are interested in public health and healthcare policy, seeking to understand and fix the systemic issues that contribute to poor quality and high costs. They are driving initiatives for better measurement, accountability, and patient-centered care, offering hope for transforming the culture of medicine from within.

Last updated: May 12, 2025