I heard Marty Makary, MD, speak at the annual meeting of the American College of Mohs Surgery (ACMS) a few months ago, and got to meet with him there. He is the author of the book “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” published in 2013, and is a potent advocate for physicians, patients, and effective, safe, and efficient medical care.
His personal epiphany centered around the stubborn, continued use of open colonic resection of polyps by one of his professors, despite the availability of much safer and less expensive endoscopic removal. He is a powerful advocate for abandoning obsolete treatment techniques for safer and more effective ones. He insists on transparency in selecting the best treatments for patients.
Dr. Makary , professor of surgery at Johns Hopkins University, Baltimore, is collaborating with the ACMS to define the correct range of layers it should take a Mohs surgeon to treat skin cancers. These data, which were presented at the meeting, will be published soon.
In his writings, Dr. Makary points out that when looking for areas to improve, it is most productive to focus on treatments that have wide variations in treatment settings and modalities. Sometimes, this is due to a lack of data to support a consensus, a lack of information about a superior treatment modality – or more disturbing, stubbornness and ingrained patterns of behavior. This is the familiar, “This is the way we have always done it” syndrome that was behind his personal epiphany.
This is exactly the situation we face in the United States with the continued treatment of skin cancer in the hospital operating room. At least 40% of all skin cancers are excised in the hospital setting, in the face of overwhelming evidence that excision or destruction in the office setting is safer, yields higher cure rates, and is much less expensive.
It is time to speak up, and admit that 99% of all skin cancers should be treated in the office setting, under local anesthesia. Currently, this is most commonly done by a dermatologist, or a primary care physician, who is not operating room dependent. Those specialists who have been trained exclusively in hospital operating rooms need to become more knowledgeable about local anesthesia, and how to operate in their offices. This should be fertile ground for the government, insurers, patient advocates, and accountable care organizations looking to cut costs and improve quality of care. Moreover, the percentage of these conditions being treated in the office setting by a provider should be a quality indicator.
Maybe it is time for Dr. Makary, a surgical oncologist, to issue a shout out to physicians to stop treating thin melanomas (80% of those diagnosed), nonmelanoma skin cancer, and “lumps and bumps” in the operating room.
We need to publicly expound on the benefits of office-based surgery, and take this message to national patient advocacy groups and the public. New “bedless” hospitals are being built to perform outpatient surgery, and avoid the serious infections (think methicillin-resistant Staphylococcus aureus and Clostridium difficile) that are prevalent in hospitals. It is time to realize a properly equipped physician’s office is as good as a bedless hospital operating room for the treatment of skin cancer, with additional benefits of already being built and staffed.
Dr. Makary, this is a great opportunity to improve the health care of the United States, and at reduced cost.
Dr. Coldiron is past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.
