#317 ‒ Reforming medicine: uncovering blind spots, challenging the norm, and embracing innovation | Marty Makary, M.D., M.P.H.
Dr. Marty Makary, a Johns Hopkins surgeon and NYT bestselling author, discusses "Blind Spots: When Medicine Gets It Wrong." He explores medical groupthink, cognitive dissonance, and challenges historical practices in areas like appendicitis treatment, peanut allergies, HRT, and antibiotic use, advocating for reform in medical education.
Deep Dive Analysis
14 Topic Outline
Introduction to 'Blind Spots' and Cognitive Dissonance
Cognitive Dissonance and Effort Justification in Psychology
Non-Operative Treatment for Appendicitis
The Peanut Allergy Epidemic and Misguided Recommendations
The Enduring Impact of HRT Misinformation
Navigating Medical Skepticism and Scientific Uncertainty
Overuse of Antibiotics and Rise of Resistance
Early Childhood Antibiotic Use and Chronic Disease Risk
Historical and Evolving Trends in Childbirth and C-Section Rates
Challenging Dogma: The True Origin of Ovarian Cancer
The Urgent Need for Reform in Medical Education
Major Barriers to Innovative Medical Research Funding
The Dogmatic Culture of Academic Medicine
Successes and Ongoing Challenges in Modern Medicine
6 Key Concepts
Cognitive Dissonance
The brain's inherent discomfort with holding conflicting ideas, often leading it to reframe new information to fit existing beliefs or dismiss it entirely, as described by psychologist Leon Festinger. This psychological phenomenon explains resistance to new scientific evidence.
Effort Justification
A psychological concept closely tied to cognitive dissonance, where individuals become more invested in an idea or task if they have expended significant energy or effort on it, even if the objective value is low. This explains why people cling to beliefs they've 'worked hard' for.
Oral and Immune Tolerance
An immunological principle stating that early exposure to certain substances in life can lead to the development of immune tolerance, making an individual less likely to develop allergic reactions later on. This concept was ignored in early peanut allergy recommendations.
Probability Distribution Function in Science
A framework for understanding scientific truths not as binary (true/false) but as probabilities that are continuously updated with new information. This approach encourages flexibility and open-mindedness in scientific inquiry, rather than clinging to absolute certainty.
Bradford Hill Criteria
A set of nine principles used in epidemiology to assess the likelihood of a causal relationship between an observed association and an outcome. These criteria help evaluate if a correlation is likely to be causal, considering factors like strength of association, consistency, and dose-response.
Fallopian Tube Cancer
A recent discovery challenging decades of medical practice, indicating that the most common and lethal type of cancer previously identified as 'ovarian cancer' actually originates in the fallopian tubes, with cells then migrating to the ovary. This redefines the target for prevention.
11 Questions Answered
Groupthink, driven by cognitive dissonance, causes the medical community to cling to initial ideas, even if evidence is shaky, and resist new information that challenges deeply held views, hindering scientific progress.
For the majority of appendicitis cases without rupture or a fecolith, a short course of antibiotics can be 67% effective, avoiding surgery and its associated risks.
In 2000, the American Academy of Pediatrics recommended that children aged 0-3 avoid all peanut products, which inadvertently led to a soaring rate of severe peanut allergies by preventing early immune tolerance.
Misinformation from a 2001 study, which falsely linked HRT to increased breast cancer deaths, led to a generation of women being deprived of HRT, despite later evidence showing no such increase in deaths.
Individuals should be wary of health recommendations presented with absolutism, ask questions, and understand that science involves probabilities and constant updates, rather than binary certainties.
The overuse of antibiotics, with about 60% of outpatient prescriptions being unnecessary, contributes to the rapid development of antibiotic-resistant bacteria, leading to approximately 100,000 deaths annually in the U.S.
A Mayo Clinic study found significant correlations between antibiotic use in the first two years of life and increased risks of obesity (20%), learning disabilities (21%), ADHD (32%), asthma (90%), and celiac disease (289%) later in childhood.
While C-sections save lives, their rates have risen to about 30% in the U.S. (and up to 90% in some private Brazilian hospitals), often due to non-medical factors, leading to potential negative impacts on the baby's microbiome and other long-term health outcomes.
Recent discoveries indicate that the most common and lethal form of "ovarian cancer" actually originates in the fallopian tubes, with cells then migrating to the ovary, challenging previous understanding and opening new avenues for prevention.
Medical education needs to shift from rote memorization of facts to fostering humility, critical appraisal of research, understanding uncertainty, and focusing on applied statistics, while also emphasizing broader health pillars like nutrition, sleep, and emotional well-being.
The NIH funding system is broken, with siloed centers that prioritize narrow, incremental research favored by established professors, hindering funding for big, interdisciplinary ideas and crucial clinical studies on practices lacking scientific evidence.
21 Actionable Insights
1. Early Peanut Exposure for Infants
Introduce peanut products to infants between four to six months of age (not as a sole diet and avoiding choking risks with whole peanuts) to significantly reduce the risk of developing peanut allergies, based on research showing an eight-fold difference.
2. Minimize Unnecessary Antibiotics
Be judicious about antibiotic use, especially in early childhood, as studies suggest 60% of outpatient antibiotics are unnecessary and overuse is linked to increased risks of obesity, learning disabilities, ADD, asthma, and celiac disease.
3. Re-evaluate HRT for Menopause
Postmenopausal women should re-evaluate the benefits of Hormone Replacement Therapy (HRT) with their doctors, as it has been shown to significantly improve health and the initial fears of increased breast cancer deaths were unfounded.
4. Consider Fallopian Tube Removal
If you are a woman who has completed childbearing and are undergoing elective abdominal surgery, discuss with your surgeon the option of removing your fallopian tubes (salpingectomy) to massively reduce your risk of developing what is commonly called ovarian cancer.
5. Prioritize Newborn Skin-to-Skin
Advocate for immediate and prolonged skin-to-skin contact for newborns, as it acts as the best incubator, promoting more normal blood pressure, heart rate, and glucose levels for the baby.
6. Delay Umbilical Cord Clamping
Advocate for delayed umbilical cord clamping until it stops pulsating (potentially up to two minutes) to allow the baby to receive additional blood and stem cells, based on studies showing clinical benefits.
7. Explore Antibiotics for Appendicitis
If diagnosed with appendicitis without rupture or a fecolith, discuss with your doctor the option of a short course of antibiotics, which is 67% effective and avoids surgery risks.
8. Question Absolute Health Claims
Raise a ‘flag’ when health recommendations are presented with absolutism, especially if they lack clear scientific evidence, to avoid blindly trusting unproven advice.
9. Suspend Personal Biases
When evaluating new information, particularly in science, actively suspend your personal biases to maintain impeccable objectivity and avoid premature conclusions.
10. Think in Probabilities, Not Binaries
Approach scientific findings and hypotheses by thinking in terms of probability distributions rather than binary (yes/no) outcomes, allowing for continuous updating of beliefs with new information.
11. Prioritize Diet for Metabolic Health
Understand that diet and food quality are primary drivers of obesity and diabetes, rather than solely genetic predispositions, which should inform personal health choices.
12. Challenge Deeply Held Assumptions
Embrace the purpose of science by actively challenging deeply held assumptions, rather than settling for the first idea heard, to foster objective understanding.
13. Ask Your Doctor Questions
Make asking questions a routine part of your medical consultations to better understand health recommendations and engage in your care.
14. Embrace Medical Uncertainty
Recognize that understanding unknowns and dealing with uncertainty is a crucial part of medical decision-making, both for doctors and patients.
15. Delay Newborn’s First Bath
Request to delay washing a newborn for the first 24 hours after birth, preserving the natural proteinaceous coat that provides benefits.
16. Understand Birth’s Microbiome Impact
Recognize that vaginal delivery seeds a newborn’s sterile gut microbiome with beneficial bacteria from the vaginal canal, colostrum, and skin, whereas C-section babies may be seeded with hospital bacteria, influencing birth plan discussions.
17. Choose OBs with Lower C-Section Rates
When choosing an obstetrician, consider seeking out those with C-section rates in the 12% to 15% range for low-risk deliveries, as this may indicate a more appropriate approach to childbirth.
18. Question Pre-Op Antibiotics for Minor Surgery
Discuss with your surgeon whether prophylactic antibiotics are truly necessary for minor laparoscopic procedures, as their routine use may be an outdated extrapolation from open abdominal surgeries and contribute to resistance and microbiome disruption.
19. Empathetic Medication Discussion
When discussing medication adherence, use empathetic phrasing like ‘Some people find it hard to take their medications as prescribed. How are you doing with it?’ to foster open communication rather than a confrontational tone.
20. Focus on Health Equity Solutions
Instead of merely describing health disparities, prioritize and engage in actions and research aimed at actively reducing them, as the existence of disparities is already well-known.
21. Consider a Medical Career
If you are considering a career in medicine, you are encouraged to pursue it due to the unique privilege of connecting deeply with people and helping those in need.
7 Key Quotes
The purpose of science is to challenge deeply held assumptions.
Marty Makary
If you put something out there as sensitive as breast cancer is caused by HRT, you will never be able to put that genie back in the bottle.
Bob Langer (quoted by Marty Makary)
Science is not a thing, it's a process.
Peter Attia
Antibiotics save lives, but they are also massively abused and overused, at least 60% in all the studies.
Marty Makary
When everyone's laughing at an idea, in science, that's a signal you should look into it. Your curiosity should kick in.
Chris (mentor of Ronnie Drapekin and Chris at Brigham and Women's Hospital, quoted by Marty Makary)
One of the most important qualities of a physician is humility, knowing your limits and having the awareness, the self-awareness that you could be wrong.
Marty Makary
We can't have science and politics. We can't have those things commingle.
Peter Attia
2 Protocols
Non-Operative Appendicitis Treatment Protocol
Marty Makary- Diagnose appendicitis in patients without rupture or a fecolith.
- Administer a short course of antibiotics.
- Monitor the patient for response; if symptoms recur (approximately 12% of initial responders), proceed to surgical removal of the appendix.
Fallopian Tube Removal for Cancer Prevention
Marty Makary- For women who have finished childbearing and are generally under their mid-60s, offer to remove the fallopian tubes during any elective abdominal surgery (e.g., laparoscopic cholecystectomy).
- Ensure the ovaries are spared to preserve hormone function.