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

Marty Makary delves into the problem of entrenched dogma in the medical community, suggesting that deeply held beliefs can persist even in the face of new evidence, largely due to cognitive biases and groupthink.

Medical community often clings to deeply held beliefs and assumptions, even in the face of new evidence

Marty Makary highlights that the medical community can fall prey to cognitive biases that reinforce existing beliefs. He discusses how individuals, including doctors, might believe an idea more strongly because it was the first they heard and how they tend to dismiss new information that conflicts with their beliefs. This phenomenon can be explained by Leon Festinger’s theory of cognitive dissonance, which suggests that the brain prefers to avoid conflict by maintaining "lazy" thoughts.

Makary emphasizes how essential it is for science to question assumptions. However, he observes that it’s challenging for doctors to acknowledge even the slightest possibility—such as a 0.1% chance—that their long-held beliefs could be wrong. He criticizes the culture in academic medicine which sometimes values menial tasks over critical soft skills like self-awareness and empathy.

A teaching approach advocated by Makary and Cameron is to model humility to medical students and residents. They recommend experienced surgeons showing that they still collaborate and consult with their peers, which promotes a healthy respect for the uncertainty in medicine.

Examples of medical beliefs and practices that have been challenged and overturned

Marty Makary and his colleagues discuss various well-established medical beliefs and practices that have been upended by new evidence, showing the necessity of reevaluation in medical science.

The non-operative treatment of appendicitis

A profound shift Makary highlights is the reevaluation of appendicitis treatment. A study indicated that for most patients without a ruptured appendix or fecolith, a short course of antibiotics could be an effective treatment, with a success rate of 67%. This challenges the reflexive surgical approach, where the appendix is removed upon diagnosis. Surgery brings risks and costs, whereas non-surgical treatment may be safer and less resource-intensive. A 19-year-old patient opting for antibiotics over surgery and recovering quickly to attend a wedding the next day further confirmed the viability of this approach.

The recommendation to avoid peanut exposure in early childhood to prevent peanut allergies

Makary criticizes the American Academy of Pediatrics' 1999 advice to avoid peanuts, which had unclear scientific backing, for potentially causing increased rates of peanut allergies in the U.S. Doctors skeptical of the recommendation were supported by the principle ...

The medical community, like any other group, is susceptible to cognitive biases and the effects of conformity pressures that can hinder the adoption of new evidence and ideas. Marty Makary and Peter Attia shine light on how these influences can shape medical practice and education.

Doctors are susceptible to the "bandwagon effect" and the desire to maintain existing beliefs, even in the face of contradictory evidence

In conversations with peers, Makary notes the use of heuristics or standardized practices, such as recommending antibiotics at the time of incision for all operations. This is an example where simplicity and uniformity can overshadow individual patient needs. Attia echoes the challenge of staying open to new information while practicing medicine based on existing beliefs. The policing of modern medicine, at an all-time high, can create an environment where independent thinking is stifled and conformity is rewarded, essentially reinforcing herd mentality.

The "cognitive dissonance" theory, developed by psychologist Leon Festinger, explains this phenomenon

Makary references Leon Festinger's cognitive dissonance theory to explain why changes in medical practice lag behind new evidence. Festinger theorized that holding conflicting beliefs causes mental discomfort, leading people to resist changing their beliefs even when faced with compelling new evidence. For example, despite evidence to the contrary, pediatricians who questioned delaying peanut introduction in children were silenced, and when peanut allergy rates soared, the medical establishment blamed non-compliance rather than reassessing their advice.

The same resistance can be seen in relation to non-operative treatment of appendicitis. Despite evidence from randomized controlled trials, some physicians are still requesting more trials, exhibiting cognitive dissonance. Festinger's observation of cult members rationalizing their unmet prophecy to avoid admitting their belief was false parallels the difficulty some in the medical community have in accepting new evidence that questions long-standing practices.

Sensible Medicine is a new newsfeed created by Makary with the aim of combating flawed articles and the bandwagon effect in medical literature. It’s an acknowledgment of susceptibility to groupthink even among peers in prestigious journals.

Medical education and training can reinforce dogmatic thinking and resistance to new ideas

Makary criticizes the heavy emphasis on rote memorization within medical education, suggesting that it doesn't adequately teach critical appraisal of research, understanding ...

Research is increasingly focusing on how early-life exposures such as antibiotics and birth methods can affect the microbiome and influence health outcomes later in life.

Emerging research suggests that early-life exposures, including antibiotics and mode of birth, can have significant long-term impacts on the microbiome and health outcomes

Makary discusses research from the University of Chicago that suggests surgical infections may stem from a weakness in the gut microbiome rather than skin bacteria. In context, the conversation acknowledges that a baby's gut, which is sterile in utero, is initially colonized by bacteria from the vaginal canal during vaginal delivery, a process that is expanded upon with bacteria from colostrum, breast milk, and skin contact. In comparison, babies born by C-section may acquire a different microbiome from hospital bacteria. This difference in microbiome seeding is significant due to emerging data associations, such as a JAMA Surgery published study revealing higher rates of colon cancer before age 50 in children born by C-section.

Studies show associations between early antibiotic use and increased rates of obesity, learning disabilities, and chronic diseases later in life

The conversation further identifies a Mayo Clinic study with 14,000 children that found correlations between taking antibiotics in the first two years and developing asthma, learning disabilities, obesity, attention deficit disorder, and celiac disease later. The risk increased with more courses of antibiotics taken. Additionally, cephalosporins were specified as having a stronger link to health issues than other antibiotics like penicillins.

The medical community has been slow to adopt new practices that could protect the microbiome, such as delayed cord clamping and less aggressive use of antibiotics

Despite the knowledge of the microbiome's importance and the impact of early-life exposures on long-term health, practices that affect the microbiome, such as the overuse of C-sections and antibiotics, remain common ...

The conversation with Marty Makary from Johns Hopkins discusses significant issues in the healthcare industry, touching upon the pervasive problem of medical overtreatment and the re-evaluation of established medical practices.

Many common medical practices, such as routine appendectomies and hysterectomies, are being re-evaluated as potentially unnecessary or even harmful

There’s a growing trend in the medical community to reconsider whether some historical practices are necessary. Evidence is now suggesting that, for instance, appendicitis may not always require the routine appendectomies that have been the standard treatment. In the context of rethinking medical practices, there’s also concern that the medical community sometimes resists change, which can delay the adoption of new insights.

Ovarian cancer may primarily originate in the fallopian tubes, not the ovaries, challenging the rationale for routine ovary removal

Marty Makary discusses breakthrough research at Johns Hopkins, where studies indicate that the primary origin of what has been termed 'ovarian cancer' may actually be the fallopian tubes. This revelation challenges the established practice of routinely removing ovaries to prevent ovarian cancer and suggests that focusing on the fallopian tubes instead could be a more effective preventative measure. The conversation notes that in some countries, standard care now offers the removal of the fallopian tubes instead of the ovaries during elective abdominal surgeries for women who have finished having children.

Economic and cultural factors, rather than just medical evidence, can drive the overuse of certain procedures and treatments

Peter Attia and Marty Makary highlight that the frequency of procedures like C-sections can vary greatly among doctors, with rates ranging from 12% to 100%. They suggest that cultural beliefs, convenience, personal preference, liability concerns, and financial incentives can contribute to the high rates of such procedures.

In Brazil, for example, private hospitals have a C-section rate of about 90%, influenced by cultural beliefs that vaginal delivery affects sexual pleasure. They discuss how consumerist culture can impact medical decisions, with patients potentially coaxed into scheduling C-sections on a first prenatal visit without informed consent, due to doctors' preferences or desires for convenience.

Makary points out that OB doctors he trusts have C-section rates of 12 to 15 percent and implies that this is the necessary range, suggesting that current rates often exceed what is medically required. The con ...