#317 ‒ Reforming medicine: uncovering blind spots, challenging the norm, and embracing innovation | Marty Makary, M.D., M.P.H.

Marty Makary, a Johns Hopkins surgeon and New York Times bestselling author, returns to The Drive to discuss his latest book, Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health. In this episode, Marty explores how a new generation of doctors is challenging long-held medical practices by asking critical new questions. He discusses the major problems of groupthink and cognitive dissonance in the medical community and delves into several of the “blind spots” raised in the book, including treatments for appendicitis, the peanut allergy epidemic, misunderstandings about HRT and breast cancer, antibiotic use, and the evolution of childbirth. He explains the urgent need for reform in medical education and the major barriers standing in the way of innovative medical research. Throughout the conversation, Marty offers insightful reflections on where medicine has succeeded and where there’s still room to challenge historic practices and embrace new approaches.

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We discuss:

• The issue of groupthink and cognitive dissonance in science and medicine [2:30];
• How a non-operative treatment for appendicitis sheds light on cognitive dissonance [7:00];
• How cognitive dissonance and effort justification shape beliefs and actions [13:15];
• How misguided peanut allergy recommendations created an epidemic [17:45];
• The enduring impact of misinformation and fear-based messaging around hormone replacement therapy allegedly causing breast cancer [25:15];
• The dangers of extreme skepticism and blind faith in science, and the importance of understanding uncertainty and probability [28:00];
• The overuse of antibiotics and the rise of antibiotic resistant infections and poor gut health [33:45];
• The potential correlations between early antibiotic use and chronic diseases [40:45];
• The historical and evolving trends in childbirth and C-section rates [50:15];
• Rethinking ovarian cancer: recent data challenging decades of medical practice and leading to new preventive measures [1:05:30];
• Navigating uncertainty as a physician [1:19:30];
• The urgent need for reform in medical education [1:21:45];
• The major barriers to innovative medical research [1:27:30];
• The dogmatic culture of academic medicine: why humility and challenging established norms is key for progress [1:38:15];
• The major successes and ongoing challenges of modern medicine [1:51:00]; and
• More.

The issue of groupthink and cognitive dissonance in science and medicine [2:30]

• Marty’s new book is out: Blind Spots
• Peter remembers talking with him as it was in the works and asks, “Can I take 5% credit for the inclusion of HRT in this book?”
  • [Discussed in-depth in episode #253 and a previous newsletter]
• Marty explains that Peter gets 99% credit for that; that was incredible 
• That tipped him off to do his own investigative journalism
• He tracked down the people that made that initial announcement saying HRT caused breast cancer and he pinned them down and went over the stats with them hard and finally got them to confess that it did not
• Peter thinks the book is a great read and it goes through a number of situations that all have this theme in common, “The idea is a bit shaky in terms of lack of evidence, which in and of itself is not really a problem. That really is the way medicine and science have to work. They have to start with ideas that we may or may not have great evidence for, but what goes wrong?”

Why is there a book about this instead of a bunch of case studies of how everything has gone really well? 

• There’s a science to groupthink, and that’s what’s really going on a lot of times
  • It’s the bandwagon effect
  • It’s not just in medicine, it’s in business, it’s in politics, it’s in relationships
  • People are dead set on an idea, not because they’re convinced of it, but because they simply heard it first
• There was a psychologist named Leon Festinger who since passed away, but had written a tremendous amount of material on this idea of cognitive dissonance
  • He really carved this entire discipline out in psychology
  • The idea is that the brain doesn’t like to be uncomfortable with conflicting ideas
  • It likes to settle and be lazy with one thought; it’s often the first thing you hear
  • If something comes along that challenges your deeply held views or just what you’ve happened to heard before, there’s this internal conflict
• What the body does is it will reframe the new information to make it fit what you already believe or it’ll dismiss it completely, kind of the modern day cancel culture
• This happens in day-to-day life
• It happens in human interactions and it happens in medicine too

“We get this herd mentality, but the important thing in science is that the purpose of science is to challenge deeply held assumptions. That’s something that I follow as a thread in so many areas of modern day health recommendations in this book.”‒ Marty Makary 

One of Peter’s takeaways from the book is what a person can do going forward 

How does a normal person navigate this? 

• Peter thinks this is a hard thing to hear both as the author of the book and as a person listening
• Using himself as an example, he has access to more information
  • He has a research team that can help him a answer questions
  • If he was to challenge every idea out there, he’s not sure he’d get anything done

What is the balance in your mind between when your doctor tells you something that makes sense (seems logical, plausible) but technically, you haven’t done the thinking on it? 

Peter asks, “How do you not allow yourself to become a crazy conspiracy theorist who doesn’t trust anything and throws out what’s 80% good in the pursuit of throwing out the 20% that’s trash? How does one navigate that?” 

• There are extremes on both sides
• You see the pendulum swing, like with childbirth 
  • There’s this over medicalization of ordinary life, and then this swing back to avoid all doctors and hospitals and deliver at home with nobody
• It’s a dangerous proposition
• You see that frequently in the history of modern medicine

For the everyday consumer out there, I think the flag should go up when something is put out there as a health recommendation with such absolutism as science evidence-based, when really there’s nothing to point to 

• We don’t want to create hysteria
• We need people to trust doctors
• Marty needs his patients to trust him a lot of times, but asking questions should be part of the process
• There are times when we are very slow as the medical community to implement scientific evidence and it’s okay to educate the public on it

How a non-operative treatment for appendicitis sheds light on cognitive dissonance [7:00]

What an appendicitis is 

• It’s inflammation of the appendix and infection sets in
  • The tight junctions [in the appendix] break down and bacteria from the colon will creep in there and infect the appendix
  • It becomes inflamed, and gets into the blood system in late stages

200 years ago, what was the mortality from acute appendicitis? 

• The mortality was over 60%
• Walter Reed, a famous physician died of appendicitis
• It was a common cause of death
• The lifetime prevalence was not that small, 5-7%
  • There’s a 1 in 18-20 chance you’d get an infection of your appendix and a 60% chance that if you got it, it would kill you
• It’s still one of the most common operations performed in American hospitals
• As surgeons, we have learned it as a reflex
• When Peter was at Johns Hopkins, he and Marty did many together
• You do it swiftly
• You do it with a laparoscope as of the last 30 year
• This is a reflex; we don’t even think about it in the hospital
• It’s been one of these easy things: diagnose, treat, diagnose, treat
• Diagnosis used to be tricky, because it can present a lot of ways
• Now, the CAT scan just points out the bullseye, and you go to work
• It’s a quick great case for a surgeon and a surgical trainee

Then a study came out showing that you don’t need to operate, and a short course of antibiotics is 67% effective in patients that come in with appendicitis 

• If the appendix is not ruptured or there’s no little stone (what we call a fecalith in the appendix), which is the vast majority of people 
• Here’s a discovery that really shook up the whole field of modern surgery

Peter’s recap: If you’re in the majority of cases of appendicitis, it’s not yet ruptured, and it doesn’t have an obvious mechanical cause, you can get the same outcome as surgery by using antibiotics in 60-70% of the cases

• If they don’t respond to an antibiotic, then you take them back to surgery (approximately a third of those people
• Marty explains that something like high 80% will respond to the initial course of antibiotics and only a small fraction (maybe 12%) will come back with recurrent symptoms in the first month
  • Then you go to surgery for them

The total cure is 2/3’’s 

By avoiding surgery 

• The cost is reduced
• The patient doesn’t have to undergo an incision, anesthesia, risk of infection, risk of hernia
  • All of which are minor risks, but they’re present
• Other savings: the carbon footprint of the hospital, the amount of waste produced, the nursing staffing resources, the wait list at a hospital every night
  • Every hospital in America has cases that are waiting to go, and typically, there’s an appendix or two on that list
• Marty explains, “We’ve got a nursing staffing crisis. There’s so many implications to appropriately implementing this research.”

Marty offered this to a kid who came to see him 

• The study had been out for a couple of months
  • He read it and was convinced
• Nobody else was really offering it at the time
• A 19-year-old, perfect candidate, no rupture, no fecalith, healthy guy with an early appendicitis came in
• They’re already getting antibiotics when they get diagnosed in the emergency department 
  • Usually you just need to run it a little bit longer
• Marty offers him surgery versus no surgery
• He tells Marty that he has to fly out the next morning to Boston for his sister’s wedding 
  • Marty thinks, “Oh, my God. What gets him to the wedding faster?”
    • If he gets in the operating room right now, he might get there in a wheelchair
• He offered him both and told him what he didn’t know

“I told him what I don’t know, which is I think the most important part of being a doctor is understanding the unknowns and dealing with uncertainty.”‒ Marty Makary

• He chose the antibiotic; he chose no surgery
• He goes to the wedding the next day, dances up a storm

Marty becomes so convinced that this may be revolutionary; then he talks to one of his colleagues 

• He tells one of his colleagues about it and gets the reply, “I don’t buy it.”
• Marty pointed him to the randomized control trial, published in a top journal
• He says, “I need to see two randomized control trials.” 
• They’ve been doing this in Europe a lot longer than we’ve heard about it in the U.S. 
• A second randomized controlled trial comes out a year later, and Marty shows it to him 
• He says, “I need to see three randomized controlled trials.” 
• Believe it or not, a third one came out maybe 6 months later 
  • Long term follow-up
  • The initial study was repeated in children
• Other studies came out that were non-randomized
• Marty showed it to him and he said, “I just think you’re better with it out.” 
• Marty thought it would be unethical to do any more research [the case for it had been made]

{end of show notes preview}

Marty Makary, M.D., M.P.H.

Martin (Marty) Makary is a graduate of Bucknell, he earned a medical degree from Sidney Kimmel Medical College of Thomas Jefferson University and a Master’s in Public Health from Harvard Universities. He completed his surgical residency at Georgetown University and his specialty training at Johns Hopkins Hospital. 

Dr. Makary is Professor of Surgery, Chief of Islet Transplant Surgery, and a public policy researcher at Johns Hopkins School of Medicine. He writes for The Washington Post and The Wall Street Journal. He is also author of two New York Times bestselling books, Unaccountable and The Price We Pay. Dr. Makary served in leadership at the World Health Organization Patient Safety Program and has been elected to the National Academy of Medicine. He has published over 250 peer-reviewed scientific articles. His current research focuses on the underlying causes of disease, public policy, health care costs, and relationship-based medicine. [Johns Hopkins Medicine]

Website: Marty Makary MD

X: @MartyMakary