Overcoming Blind Spots in Modern Medicine w/ Dr. Marty Makary

Blind spots in our thinking and decision-making are an inevitable part of the human experience.

But what does this mean in the context of medicine?

In this episode of CareTalk, David E. Williams and John Driscoll explore these challenges with guest Dr. Marty Makary, author of Blind Spots, delving into our natural resistance to new ideas, the impact of these tendencies on healthcare, and strategies for addressing blind spots in modern medicine.

This episode is brought to you by BetterHelp. Give online therapy a try at https://betterhelp.com/caretalk and get on your way to being your best self.

As a BetterHelp affiliate, we may receive compensation from BetterHelp if you purchase products or services through the links provided.

TOPICS
(0:25) Sponsorship
(2:01) What got Dr. Makary into Medical Blind Spots?
(3:40) The Biggest Blind Spots in Medicine
(5:26) Looking Into the Questionable Data Around HRT and Cancer
(7:48) Where did Peanut Allergies Come From?
(10:08) Do Eggs Cause Heart Attacks?
(12:32) Understanding Dietary Cholesterol
(13:47) How to Reestablish Trust Between Patients and the Medical Community
(16:19) Exploring Historical Blind Spots
(18:19) How Human Nature Affects Medical Progress
(22:49) What Blind Spots will There be in the Future?
(25:00) How Should Patients Approach Blind Spots in Medicine?

🎙️⚕️ABOUT CARETALK
CareTalk is a weekly podcast that provides an incisive, no B.S. view of the US healthcare industry. Join co-hosts John Driscoll (President U.S. Healthcare and EVP, Walgreens Boots Alliance) and David Williams (President, Health Business Group) as they debate the latest in US healthcare news, business and policy.

🎙️⚕️ ABOUT DR. MARTY MAKARY
Dr. Marty Makary, a bestselling author and healthcare expert at Johns Hopkins University, is renowned for his work in improving healthcare systems and transparency. His latest book, The Price We Pay, earned him the 2020 Business Book of the Year Award and has been hailed by Steve Forbes as essential reading. As a leader in public health research, Dr. Makary focuses on redesigning healthcare to enhance reliability and coordination, especially for vulnerable populations. He is also the chief of Islet Transplant Surgery at Johns Hopkins, has received the Nobility in Science Award, and is a member of the National Academy of Medicine. With over 250 peer-reviewed articles and extensive teaching experience, Dr. Makary's academic background includes degrees from Bucknell, Thomas Jefferson, and Harvard, along with surgical residency at Georgetown and specialty training at Johns Hopkins.

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Transcript

0:00

Even intelligent, well -meaning people often have huge blind spots in their thinking. In medicine, that's led to severe problems, like the opioid crisis, overuse of antibiotics, and rejection of hormone replacement therapy. Where did these blind spots come from, and how can we erase them? As kids, we're always learning and growing, but as adults, we can sometimes lose that sense of curiosity that makes life exciting. It's easy to fall into a routine. Therapy can help you break out of it. If you've been considering starting therapy, now is the perfect time to give it a try. BetterHelp offers entirely online therapy that's designed to be convenient, flexible, and tailored to fit your schedule. Whether you're dealing with stress, anxiety, or seeking personal growth, BetterHelp connects you with licensed therapists who can support you on your journey to rediscovering your curiosity and becoming your best self. Don't miss out on therapy. Visit betterhelp .com slash care talk to get 10 % off your first month and take the first step toward enhancing your mental wellbeing. That's betterhelp, H -E -L -P dot com slash care talk. Welcome to care talk, America's home for incisive debate about healthcare business and policy. I'm David Williams, president of Health Business Group. And I'm John Driscoll, senior advisor at Walgreens. Well, today's guest is Dr. Marty McCary. He's author of Blind Spots, a deep dive into the human tendency to resist new ideas and a guide to improving objectivity. Join the vibrant Care Talk community on LinkedIn, where you can dig deep into healthcare business and policy topics, access Care Talk content, and interact with the host and our guests. And please be sure to leave us a rating on Apple or Spotify. while you're at it. Dr. McCary, welcome to Care Talk. Great to be with you, David and John. So Dr. McCary, if I could call you Marty, at least for the length of this podcast. Please. What got you interested in this super important topic of blind spots and how do you define it? Well, it's amazing the power of group think and medical dogma that we see in every specialty in medicine can take on a life of its own. And the purpose of science is really to challenge deeply held assumptions in the field. So what inspired me to write the book, Blind Spots, is the young generation of doctors right now that are coming up and think differently. They want to change the way we deliver healthcare. They don't want to accept, well, this is the way it is. You gotta see patients in quick 10 minute visits and bill in code and burn out yourself. they want to redesign the entire healthcare system. They wanna talk about treating diabetes with cooking classes instead of just throwing insulin at people. They wanna talk about school lunch programs, not just ozempic for children. They wanna talk about food as medicine and body inflammation and microbiome health. So these are all topics where there's incredible emerging research, but it's not quite prime time. It's just not accepted within the field in part. because we have an old guard oligarchy in Madison that controls the gates of what goes in the journals, what gets funded at the NIH. But this area of research is exciting and I thought the public deserves to know about it. If you look back, you mentioned in the book, you go into a number of blind spots. Can you mention some of those that are maybe the most interesting have had the biggest impact? Well, I think the one that blew me away the most, the one where I did some original investigative journalism. was looking into the dogma that hormone replacement therapy for women after menopause causes breast cancer. It's not true. And it overshadowed the incredible benefits of hormone replacement therapy. That is estrogen plus or minus progesterone for women. When a woman starts hormone replacement therapy within 10 years of menopause, the data are overwhelming. And we never hear about this because of the, improper dogma that was put out that it causes breast cancer. Turns out the benefits include cutting the risk of heart attacks in half, reducing cognitive decline by up to 60%, reducing the risk of Alzheimer's by 35%, reducing the risk of bone fractures if a woman falls in half. The benefits are... overwhelming. Women live three and half years longer on average and feel better, not just alleviating the symptoms of menopause. And so there's probably nothing that has improved the health of a population more in terms of population level outcomes than estrogen for women. And yet 90 % of women to this day are still not offered estrogen. because of the dogma that it causes breast cancer. So I did a deep dive on it. Yeah, Marty, I actually think it's worse than that. I think because breast cancer is so common among women and because of just the fear of the big C, there are still a lot of oncologists, PAs, techs, people working in oncologist offices who are inappropriate or inappropriately basing their recommendations of sort of against HRT in a way that kind of terrifies women who are suffering from this disease, is breast cancer, which touches so many women. think it's an incredibly important call out. I think in your book, you actually suggest that HRT may actually be somewhat preventative. mean, actually it's not choosing one set of benefits against another. It's really you sort of unpack how weak the data is. that this is in some ways promotes breast cancer. That's right. About 1 % of postmenopausal women cannot take hormone replacement therapy for a number of reasons. But overwhelmingly, this has tremendous benefits to a population. And I'm glad you said what you said, because fear is what drove so many people away. And it's amazing when they had the initial deliberation within the study committee. I interviewed one guy at that meeting who said something, there was a shouting match before they released the results because many felt it was misleading. Turns out there was never any statistical significance that it increases breast cancer. And women who took estrogen alone had lower rates of breast cancer, ironically. That's wild. But one guy said, look, if you put this out there when it's not true, when there's no statistically significant increase in breast cancer. that you will never be able to put the genie back in the bottle with an issue as sensitive as breast cancer. And to this day, there's never been a study showing that it increases the death rate of breast cancer. But 90 % of doctors still do not prescribe it because that announcement made by an NIH researcher and researchers from Harvard and all the top regalia, it was so loud that people had... can't undo it in their mind and it's lived on as medical dogma. So here's another one. How about peanuts for kids? yeah, the modern day peanut allergy epidemic does not exist in many countries. There's no peanut allergies in Africa, according to the doctors there and people who live there. And so what happened was there was a slight increase in peanut allergies in the 1970s. The pediatrician community didn't know what to do, the American Academy of Pediatrics. So they decided they're going to issue a recommendation for all mothers and young children to avoid peanuts 100 % until age three to prevent peanut allergies from developing in those kids. Turns out they got it backwards. Peanut avoidance causes peanut allergies. They forgot about basic immune tolerance or what's been known as the Dirt Theory. So by and large, this Well, at that time when the recommendation went out in the year 2000, the peanut allergy rate in the United States soared. I mean, a massive surge. And we had a new type of peanut allergy, which is this severe allergy. can't even, a kid can't even be near peanuts. Just being close to a peanut without even ingesting it can put them into this severe anaphylactic reaction. And we saw ER visits go way up. I mean, this is a horrible epidemic. It's still dominating in the United States, but other countries don't have it because they didn't put out medical dogma that was wrong. Now, it came out, New England Journal papers is one as recent as a few months ago, proved this peanut avoidance idea wrong, that that's how you prevent peanut allergies. They pointed out that early exposure of little bit of peanut butter when a kid's four or five months of age and in infancy. prevents painted allergies. But you didn't hear an apology. And I think right now we have a big trust problem in medicine. People deserve an apology when we get things wrong, when the oligarchs get things wrong. I'm not talking about rank and file docs. I'm talking about when the medical elites put out something with such absolutism. And the reality is they don't know. And look, I don't talk about COVID in the book, but there's a connection there. Many times during COVID, the right answer was we don't know. We don't know. Marty, think my 90 -year -old mother would most like to hear your insight on do eggs create heart attacks? Because she always serves everybody in the family eggs. obviously, there's been a demonization of eggs over time. Can you talk a little bit about what you found in terms of eggs and cholesterol? I love this topic. every family, there's some pro -egg member of the family, typically from a prior generation. And then there was this medical dogma that inserted itself starting about 50 years ago, that fat causes saturated fat, natural fats in food causes heart disease. It was dogma. It was based on a flawed study. I go through all the stuff in the book, Blindspots. Turns out they got it backwards. It's not the natural fats. It's the refined carbohydrates and other drivers of inflammation, ultra processed foods. And so it turns out that eggs are a great source of protein. which most Americans are deficient in protein. As long as you're not overeating with massive portions, which is a separate issue, it's a great source of food. And we don't talk about food as medicine enough, but it turns out that there's no evidence. They tried three different times in massive studies to prove that natural fat causes heart disease. All three giant studies did not prove it to be true. And yet, Again, humility. You did not see that lack, that humility to say, got this terribly wrong. mean, this is the number one health recommendation we as doctors put in front of patients, maybe second to smoking, not smoking, for the last 60 years. We got it wrong for about 60 years. And this is just to be clear, you're not just going after Paul Dudley White and Eisenhower and all that stuff. This is the recommendation that cholesterol, the dietary cholesterol. is kind of driving cardiac risk. And I think you point out that we don't absorb enough. There's a whole series of other things that create heart risk. It's just another endorsement of, I think you sort of underestimate, Marty, the insight that you're bringing to these really everyday health care issues. I mean, dietary cholesterol. is not even absorbed by the body. It's esterified, so it's too bulky to be absorbed. a very small proportion, 99 % of your cholesterol is made by your body, produced by your, not from dietary sources. So I still see low cholesterol foods out there. You still see low fat cookbooks put out by the American. massive industry. It's so big. And the medical establishment created this massive industry. And we created this low fat, high carbohydrate move over the last 60 years. So we have to do an honest reckoning, apologize and tell the public, we got this wrong. Opioids being non -addictive, we got it wrong. Penid avoidance, we got it wrong. Hormone replacement therapy causing breast cancer. I think on the opioids, you may have something to do with the Sacklers may have had something to do with. kind of creating, I don't think the opioids, think are pretty, that may have been shared a little bit by the research that was purloined by the folks who've been convicted on the issue who were pushing it. But maybe you could, so beyond apologies, Marty, what's the right way to start establishing, reestablishing trust? Because I do think, again, you don't go into COVID, that's obviously an open wound. But I think there's no question. We've had Dr. Peter Hotez on the show. trust is a big issue because it both is the foundation of how patients engage with the system. And without that, I worry that the important clinical impact of doctors is sort of lost. How do we rebuild that? Well, civil discourse. And I'm glad you had Dr. Hotez on. People should hear from multiple different medical points of view, but in the medical establishment right now, that is seen as, no, no, we cannot share multiple medical opinions with the public. They're too stupid to handle it. It could result in them following the wrong thing. Well, we don't know what the right thing is sometimes. Now, Peter Hotez and I have a different opinion. recently said that he thinks the Department of Homeland Security needs to get involved in fighting misinformation. I tend to think you fight bad ideas with more ideas, with good ideas. And if we're going to rebuild trust, I think it is inviting dissenting ideas to a civil discourse, just like you do on your podcast. It's avoiding intimidation, creating a culture where people feel comfortable speaking up. That's what I do as a surgeon in my operating room. I want every medical student and nurse tech to speak up if they see something that doesn't look right. And if I mock them or intimidate them after they say something, then I'm not creating a culture of a civil discourse. We need to recognize our biases. The father of modern medicine, Claude Bernard, said we all have our biases. We need to recognize them. It's an active process. And then temporarily suspend them. as we hear new ideas to try to be impeccably objective. If you remember, Obama said when he first ran for president, when asked, what's your favorite book? He said, Team of Rivals, because he believes in a group, a sort of robust discussion of different ideas that would spar. And that is the essence of science. We've lost it. We've sort of developed this cancel culture in medicine like the rest of society. I wonder if looking back at some of these historical blind spots, if some of it has to do with the fact that a negative, something that's scary will overwhelm positive ones. So if there's one study that says something is bad or scary, does that overwhelm, do you need some ratio three or four to one to cancel that out? Or is it just, hear one thing that's big and loud enough and bad enough that it actually just keeps you away from it in the first place? Well, I'm glad you raised that, David, because we live in a scary time, and that is if a study supports a foregone conclusion that somebody wants to believe, it's held up as the great scientific evidence. And if they don't like the results, they ignore it or downplay it or find some way to nitpick, which you can do with any study. And so we've lost this ability to critically appraise research based very objectively on the research methodology. So I'm concerned about that. Now, that's a skill set that we don't actively promote. But people need to understand when there's a study that shows that a multivitamin helps you live longer. Was it just an observational study where healthier people tended to take a multivitamin? That is the critical appraisal of research. That is what we're missing. Most of my frustration with COVID was that Almost all these controversies during COVID could have been resolved with randomized control trials that were run expeditiously on everything from how it spreads from surfaces to airborne. You know, there was a recommendation for teachers to wear goggles and gloves during COVID in the middle of the summer in July of 2020. Now, why did it take six months for us to realize, no, it's spread airborne? Those are studies that could have been done rapidly. And we've sort of lost this allegiance to the scientific process itself. Well, and I think one of the important points, Dr. Michael, is you're not suggesting that an idea is a bad idea. You're saying that all ideas need to run through a rapid fire, real clinical trial. And if the idea is wrong, you change it. But I am reminded of a wise man once told me that science tended to advance one funeral at a time, that arrogance in in fields is not uncommon. And I think in your book, you talk about Dr. Semmelweis, who's really revolutionary recommendation that just washing your hands when delivering babies would deliver more healthy babies. I believe the medical establishment so rejected that his recommendations that he ended up being mentally ill. mean, This has been a problem for hundreds of years. And I just welcome the fact that you're reminding science of how science can move forward through classic randomized control, the trial where you actually test every idea. think what embedded in your recommendations is that we have to do this a lot faster in order to be a lot smarter. Have you seen any examples where that's happened? It happens well. with pharmaceutical related products. So when there's a question, does a cancer drug help? We see the pharma industry rush to run their tests and they do it with all the might of modern day sophistication and financing. But when it comes to assessing whether or not cutting the frenulum under the tongue of babies actually helps or hurts a child. Now, this is a rampant practice that's taking off like crazy. I write about it in the book, Blindspots. It is a classic thing where no one knows the real answer. Now, many of us have a hypothesis that it has a net harm to children. But taking kids routinely, cutting the frenulum under their tongue with the argument that, it's going to help them with their sleep and latching and breastfeeding and maybe with their speech in the future and maybe prevent sleep apnea. It's dogma, we don't know. It needs a randomized controlled trial. Who's gonna fund that study? Pharma? No, no way. The American Academy of Pediatrics? I don't think so. NIH? Not in one of their siloed organ system centers. And so this is the Bermuda Triangle of research. Practices take off like wildfire that desperately need scientific study. They desperately need a randomized trial and we don't have the infrastructure to do that. That's why we have to look at where our tax dollars are going. The NIH is sort of latched onto these old guard ideas and they're ignoring the microbiome. Now they actually have a tiny microbiome center. The microbiome is the lining of the gut with millions of different bacteria that's involved in digestion and the immune system and mental health. some of the bacteria produce serotonin. What we're learning about antibiotics and the microbiome is revolutionizing medicine. We may even have some clues as to what's causing cancer. If you've seen cancers increasing in young people, colon cancer in particular, there are incredible new studies that are telling us, hey, alert, here's a signal in the data. Look at this. This is unbelievable. We've had no progress in addressing learning disabilities and Celiac disease. And we may have an underlying unifying theory here with the microbiome, but there's no department of the microbiome. There's no microbiome center at the NIH. There's no journal. What specialty is the microbiome? Infectious diseases, GI, primary care? It doesn't have a specialty. And this is the broader story in healthcare. We've got to pursue what matters to patients, not what matters to our NIH funding centers. So Marty, maybe one of the advantages of the calling for the grand unifying theory on the microbiome is gut. So maybe that'll be some of the branding for that. When you look ahead at some of the blind spots, it's interesting to look back and see where the blind spots have been and what have we learned from them. I would argue that some of these are maybe slowly being changed now, being addressed, the peanut allergies, the HRT, silicone implants you mentioned in the book as well, fats and cholesterol. Looking ahead, some of the ones you cite have some of the same characteristics, but also maybe relate to social movements or political side. And I'm thinking about in particular, cannabis and gender affirming care for children, are a couple that you talk about. I wonder what your perspective is. Are they just new blind spots that are very similar to what we had in the past? Is there something different? And what does that mean in terms of what you do about it? So the modern day application of all of these lessons of modern medicine where I go through the blind spots of the last 20 years or so of medical recommendations from the establishment, including many that are still out there today that are wrong. And I write about them so people can know the truth. It does beg the question, if we got all of these things wrong in the last 20 years, what are we doing right now that may not be correct or in the best interest of patients? And I get concerned when I see a community and medical community, a specialist community, an activist community in the general population speak about a scientific question with such absolutism when the reality is it's never been properly studied. So if we are truly objective and if we're true scientists, are we open to what a future study might tell us about marijuana, for example? The marijuana of today is not the marijuana of hippies 50 years ago. It's 10 to 20 times more potent. And it appears to have a different effect on an adolescent developing mind than it does on an older adult. So are we open to these nuances? Are we open to results that may show our deeply held assumptions were wrong? Or are we absolutely certain marijuana is totally safe and we're closed to the scientific process? Marty, maybe we could tie it back to how does a patient approach medicine? You identified the blind spots. We've talked a little bit about what the NIH should do. OK, you're a patient, and you've got some members of your family that are healthy and those that are chronically ill. How should a patient start to think about navigating health care? without sort of a specialist's view. What is your recommendation to your neighbors and your friends? Well, I find that people who love their doctors often love their doctors because their doctors are reasonable. They show humility. They know their limits. When I see a surgical trainee come through our residency at Johns Hopkins and get so frustrated by how they are placing a stitch and it's not the perfect way they want to place it, I tell them, look. What's gonna define you as a great doctor is learning from your own actions, listening to the patients and knowing your limits, knowing when to call for help. It's not, you know, I put in 76 stitches, I could have done it with 75. It is understanding your limits and the humility of being honest with patients. People are very forgiving with the medical establishment and their doctors. If they're being... talk to in an honest way. So I don't want people to be cynical about physicians. Most rank -and -file physicians are thinking independently. But we're living in a new era now where organized medicine with a small oligarchy at the top are making centralized decisions. And they're out of touch sometimes with everyday folks and docs. And so I encourage people to Look for doctors that they connect with, the doctors that listen to them and demonstrate humility, who will say, don't know, and they don't know, who will have conversations, who will spend time with them. This is what the new generation of medical students and residents want to do. They want to spend time with people. They don't want to be billing and coding on some hamster wheel their whole lives. so that's what I encourage. And then there are certain truths from the scientific literature people should know. Antibiotics are not totally safe, the dogma that, you might as well just take an antibiotic. probably won't help, but it won't hurt. Well, let me show you some incredible data. Now, antibiotics and C -sections save lives. Absolutely. But they're massively overused. And sometimes you got to take an issue straight to the public and say, here's some health information that's good for everyone to know. Well, that's it for yet another episode of Care Talk. We've been speaking today with Dr. Marty McCurry. He's author of Blind Spots, which is a deep dive into the human tendency to resist new ideas and a guide to improving objectivity. I'm David Williams, president of Health Business Group. And I'm John Driscoll, senior advisor at Walgreens. If you like what you heard or you didn't, we'd love it if you'd subscribe on your favorite service. And thank you so much, Marty. Great to be with you guys. Enjoyed it. Thanks.