September 16, 2024 • 2hr 3min
#317 ‒ Reforming medicine: uncovering blind spots, challenging the norm, and embracing innovation | Marty Makary, M.D., M.P.H.
The Peter Attia Drive
Key Takeaways
- Cognitive dissonance and groupthink are major problems in the medical community that can lead to resistance to new ideas and evidence
- Several "blind spots" in medicine are discussed, including:
- Non-operative treatment for appendicitis being effective in many cases
- Peanut allergy epidemic caused by misguided recommendations
- Misunderstandings about HRT and breast cancer risk
- Overuse of antibiotics leading to resistance and microbiome disruption
- High C-section rates not always medically necessary
- Ovarian cancer actually originating in fallopian tubes in many cases
- There is an urgent need for reform in medical education to focus less on rote memorization and more on critical thinking, statistics, and challenging assumptions
- Major barriers exist to innovative medical research, including NIH funding structures and resistance from established researchers
- The culture of academic medicine needs to change to be more open to new ideas and challenging established practices
- While medicine has made great strides in acute care, there are still many opportunities to improve chronic disease management and prevention
Introduction
In this episode of The Drive, Peter Attia interviews Dr. Marty Makary, a surgeon and public policy researcher at Johns Hopkins University. They discuss Makary's new book "Blind Spots: When Medicine Gets It Wrong and What It Means for Our Health", which explores how a new generation of doctors is challenging long-held medical practices by asking critical new questions.
The conversation covers several examples of "blind spots" in medicine where established practices are being questioned based on new evidence. Makary argues that cognitive dissonance and groupthink in the medical community often lead to resistance to new ideas, even when evidence supports changing practices. The discussion highlights the need for more critical thinking and willingness to challenge assumptions in medicine.
Topics Discussed
Cognitive Dissonance and Groupthink in Medicine (2:31)
Makary introduces the concept of cognitive dissonance, based on the work of psychologist Leon Festinger. He explains that the brain doesn't like to be uncomfortable with conflicting ideas, so it often dismisses or reframes new information to fit existing beliefs.
In medicine, this can lead to groupthink and resistance to new ideas that challenge established practices. Makary argues that the purpose of science should be to challenge deeply held assumptions, but this often doesn't happen in medicine due to cognitive biases.
- Cognitive dissonance leads people to cling to initial beliefs even when presented with conflicting evidence
- The medical community is prone to groupthink and resistance to ideas that challenge established practices
- There's a need for more critical thinking and challenging of assumptions in medicine
Non-Operative Treatment for Appendicitis (7:00)
Makary discusses how appendicitis treatment is an example of resistance to new evidence. Traditionally, appendicitis was always treated surgically. However, recent studies have shown that many cases can be effectively treated with antibiotics alone.
"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."
- Surgical removal was the standard treatment for decades
- New evidence shows antibiotics alone can be effective for many cases
- Many surgeons are resistant to changing practice despite multiple studies supporting non-operative treatment
Peanut Allergy Epidemic (17:45)
Makary explains how misguided recommendations likely contributed to the peanut allergy epidemic in the U.S. In 2000, the American Academy of Pediatrics recommended avoiding all peanut products for children 0-3 years old and for pregnant/lactating mothers.
"What happened immediately after that recommendation in the year 2000 is peanut allergy rates in the United States began to soar, and we saw a new type of allergy, which is the severe anaphylactic reaction."
- Peanut allergy rates increased dramatically after the 2000 recommendation
- New research shows early exposure reduces allergy risk
- Took 15 years to reverse recommendations despite mounting evidence
Hormone Replacement Therapy and Breast Cancer Risk (25:15)
The discussion touches on how misinformation about hormone replacement therapy (HRT) causing breast cancer has had lasting impacts, despite evidence to the contrary.
- Initial studies claiming HRT increased breast cancer risk were flawed
- Follow-up studies showed no increase in breast cancer deaths with HRT
- Misinformation has led many women to avoid beneficial HRT
Overuse of Antibiotics (33:45)
Makary discusses the problem of antibiotic overuse and resistance. He cites a Mayo Clinic study showing correlations between early antibiotic use and later health issues in children.
- About 60% of outpatient antibiotic prescriptions may be unnecessary
- Early antibiotic use correlated with higher rates of asthma, obesity, learning disabilities in children
- Antibiotic resistance is a growing threat due to overuse
C-Section Rates and Natural Childbirth (50:15)
The conversation covers the high C-section rates in the U.S. and a return to more natural childbirth practices.
- U.S. C-section rate is about 30%, much higher than medically necessary
- Many C-sections are done for convenience or due to hospital practices
- There's a trend toward more natural childbirth practices like delayed cord clamping and immediate skin-to-skin contact
Ovarian Cancer Origins (1:05:30)
Makary discusses new research showing that many "ovarian" cancers actually originate in the fallopian tubes.
- Most common type of ovarian cancer likely starts in fallopian tubes
- This insight could lead to new preventive measures like removing fallopian tubes after childbearing years
- Demonstrates how challenging assumptions can lead to breakthroughs
Need for Reform in Medical Education (1:21:45)
The discussion turns to problems with current medical education and the need for reform.
- Too much focus on rote memorization of facts that can be easily looked up
- Not enough emphasis on critical thinking, statistics, research interpretation
- Need to teach more about nutrition, lifestyle factors, chronic disease prevention
- Current system discourages creative thinking and challenging assumptions
Barriers to Innovative Medical Research (1:27:30)
Makary outlines some of the major barriers to innovative medical research.
- NIH funding structure favors incremental research over big new ideas
- Academic culture discourages challenging established researchers/ideas
- Lack of funding for studying non-drug, non-device interventions
- Need for more "Ben Franklin thinkers" who look at medicine holistically
Culture of Academic Medicine (1:38:15)
The conversation covers problems with the current culture of academic medicine.
- Too much emphasis on publishing papers vs. making real impact
- Journal editors serve long terms and favor established researchers
- Need for more diversity of thought and willingness to challenge norms
- Importance of teaching humility and openness to new ideas
Successes and Ongoing Challenges in Medicine (1:51:00)
Makary reflects on areas where medicine has made great strides and ongoing challenges.
- Major improvements in acute care, surgical techniques, obstetrics
- Still struggling with chronic disease management and prevention
- Need to focus more on lifestyle factors, nutrition, sleep, stress
- Opportunity to leverage technology and big data to improve care
Conclusion
The conversation between Peter Attia and Marty Makary highlights many areas where established medical practices are being challenged by new evidence and thinking. They emphasize the need for more critical thinking, willingness to question assumptions, and openness to new ideas in medicine.
While acknowledging the tremendous advances medicine has made, especially in acute care, they argue that there are still many opportunities to improve chronic disease management and prevention. Reforming medical education, changing the culture of academic medicine, and removing barriers to innovative research could help drive further progress.
Ultimately, both Attia and Makary remain optimistic about the future of medicine, praising the dedication of those who enter healthcare professions. They encourage aspiring doctors to maintain their creativity and willingness to challenge norms as they progress through their training and careers.