Podcast Episode #317: Reforming Medicine with Dr. Marty Makary

The Peter Attia Drive, hosted by Dr. Peter Attia

Introduction

In Episode #317 of The Peter Attia Drive, Dr. Peter Attia welcomes Dr. Marty Makary, a renowned surgeon and public policy researcher at Johns Hopkins University. An esteemed member of the National Academy of Medicine and author of multiple New York Times bestselling books, including his latest, "Blind Spots When Medicine Gets It Wrong and What It Means for Our Health," Dr. Makary joins Peter to discuss critical issues in modern medicine, emphasizing the need to uncover blind spots, challenge established norms, and embrace innovative approaches.

Cognitive Dissonance and Groupthink in Medicine

Dr. Makary introduces the concept of cognitive dissonance, drawing from psychologist Leon Festinger's work. He explains how the medical community, like other sectors, often falls prey to groupthink—the tendency to conform to prevailing ideas without sufficient evidence. This can lead to resistance against new information that challenges entrenched beliefs.

"We get this sort of herd mentality. But the important thing is in science is that the purpose of science is to challenge deeply held assumptions." (04:07)

Key Points:

• Cognitive dissonance causes discomfort when new information conflicts with existing beliefs.
• This leads to reframing or dismissing new evidence, hindering medical progress.
• Science thrives on questioning and testing assumptions, which is often suppressed by groupthink.

Reforming Appendicitis Treatment

A significant discussion revolves around the treatment of appendicitis. Traditionally, appendicitis has been treated with immediate surgery to remove the inflamed appendix. However, recent studies suggest that a non-operative protocol using antibiotics is effective in approximately 67% of cases where the appendix is not ruptured and lacks a fecalith.

"Instead of taking a person to the operating room, you're still subjecting a person to general anesthesia... you can get 60 to 70% the same outcome if you give them an antibiotic." (09:31)

Insights:

• Antibiotic treatment can reduce surgical interventions, lowering risks related to anesthesia and surgery.
• Implementing antibiotic protocols can alleviate hospital resource strains, such as long waitlists and staffing crises.
• Dr. Makary shares a personal anecdote demonstrating patient preference for antibiotic treatment over surgery, validating its effectiveness.

The Peanut Allergy Epidemic

Dr. Makary delves into the rising rates of peanut allergies, attributing the surge to misguided medical recommendations. In 2000, the American Academy of Pediatrics advised complete avoidance of peanuts in children aged 0-3, aiming to prevent allergies. Contrary to intentions, peanut allergy rates increased dramatically post-recommendation.

"It became known as the 1, 2, 3. It took on a life of its own. ... the more they doubled down, the worse it got." (18:08)

Discussion Points:

• Early avoidance strategies inadvertently promoted immune sensitization rather than tolerance.
• Cultural and institutional rigidity prevented early correction of this flawed recommendation.
• Current estimates suggest that 1 in 18 children now suffer from peanut allergies, a stark increase from the initial 0.5% prevalence.

Hormone Replacement Therapy (HRT) and Breast Cancer

A critical examination of Hormone Replacement Therapy (HRT) reveals a significant medical misstep. Early claims that HRT increases breast cancer risk led to widespread fear and the denial of HRT benefits, despite later evidence disproving these claims.

"Where's the apology? Where's the humility?" (27:38)

Key Takeaways:

• Initial studies linking HRT to breast cancer were flawed yet were publicized with alarming certainty.
• The medical community failed to promptly acknowledge and correct these errors, fostering distrust.
• Millions of women were deprived of HRT benefits due to this misinformation, showcasing a lack of accountability within medical institutions.

Antibiotic Overuse and Resistance

The podcast addresses the overuse of antibiotics, both in outpatient and inpatient settings, highlighting its dire consequences on public health. Overprescription leads to increased antibiotic resistance and disrupts the gut microbiome, contributing to chronic diseases.

"About 60% of outpatient antibiotics are unnecessary, according to several studies." (34:30)

Important Points:

• Antibiotic resistance is accelerating, with bacteria developing resistance in as little as one year.
• Overuse in surgeries, such as administering antibiotics before every minor procedure, is common despite questionable efficacy.
• Studies have linked early antibiotic exposure in children to higher rates of obesity, asthma, and other chronic conditions.

Overuse of Cesarean Sections (C-Sections)

Dr. Makary critiques the increasing prevalence of C-sections—now exceeding 30% in the United States, with rates as high as 90% in some private hospitals abroad. This overuse stems from cultural consumerism and medical practices that favor convenience over necessity.

"C sections save lives. That has doubled human lifespan." (56:38)

Insights:

• While C-sections have significantly reduced mortality rates, their overuse poses unnecessary surgical risks and impacts infant microbiomes.
• Community-based efforts at Johns Hopkins aim to monitor and reduce inappropriate C-section rates through data-driven profiling of physicians' practices.
• Awareness and education about the risks of overuse are essential in stabilizing and reducing C-section rates.

Revising the Origin of Ovarian Cancer

A groundbreaking revelation discussed is the reclassification of ovarian cancer's origin. It is now understood that many cases previously identified as ovarian cancer actually originate from the fallopian tubes, leading to more accurate preventive measures.

"The most common and lethal type comes from the fallopian tube and the cells float onto the ovary." (67:10)

Key Points:

• This shift in understanding has prompted practices like removing fallopian tubes during abdominal surgeries to significantly reduce ovarian cancer risk.
• Such proactive measures are standard in countries like Germany and Canada but have yet to be widely adopted in the U.S. due to lingering medical dogma.
• The misclassification delayed effective screening and prevention strategies, underscoring the need to challenge established norms.

Challenges in Medical Education and Groupthink

The dialogue extends to the rigidity of medical education, which emphasizes rote memorization over critical thinking and adaptability. Dr. Makary argues that this approach stifles innovation and independent thought essential for medical advancement.

"The culture of medicine says obey." (82:00)

Discussion Points:

• Current curricula focus heavily on memorizing biochemical pathways and enzyme names without contextual understanding.
• There is a lack of emphasis on statistics, probability theory, and critical appraisal of research, hindering physicians' ability to adapt to new information.
• Dr. Makary advocates for integrating these subjects into medical education to foster a more evidence-based and flexible medical practice.

Rebuilding Trust and Fostering Innovation

Rebuilding public trust in medicine requires humility and transparency from medical professionals and institutions. Acknowledging past mistakes and being open to revising practices based on new evidence are crucial steps toward regaining patient trust.

"We need people to trust doctors. But asking questions should be part of the process." (06:15)

Key Takeaways:

• Apologizing for and correcting past medical errors can restore confidence in the healthcare system.
• Encouraging a culture of continuous questioning and evidence-based practice is essential for innovation.
• Medical institutions must prioritize patient-centric approaches over rigid adherence to outdated protocols.

Accomplishments in Acute Care

Despite the critiques, Dr. Makary acknowledges significant advancements in acute medical care, such as improvements in cardiac surgery, reduced hospital-acquired infections, and enhanced obstetrical practices. These achievements demonstrate the medical profession's capacity for excellence when adhering to rigorous scientific standards.

"The acute care has been mastered." (111:23)

Highlights:

• Innovations in laparoscopic surgery and pancreas transplants have significantly improved patient outcomes.
• Adoption of best practices in obstetrical care, like delayed cord clamping and promoting breastfeeding, have positively impacted infant health.
• Continued success in acute settings underscores the importance of maintaining scientific rigor and adaptability.

Conclusion

The episode underscores the necessity for the medical community to continuously challenge established norms, embrace innovative practices, and foster a culture of humility and evidence-based decision-making. Dr. Makary emphasizes that while acute care has seen remarkable advancements, the true potential for improving public health lies in addressing chronic diseases and preventive measures through critical thinking and scientific inquiry.

Final Thought:

"We need to focus on impact. Everything we do now in our research group focuses on impact." (105:20)

Dr. Makary remains optimistic, believing that a new generation of healthcare professionals is eager to drive meaningful change and rectify the blind spots within modern medicine.

Notable Quotes:

• Dr. Marty Makary at 05:07: "We get this sort of herd mentality. But the important thing is in science is that the purpose of science is to challenge deeply held assumptions."

• Dr. Marty Makary at 09:31: "Instead of taking a person to the operating room, you're still subjecting a person to general anesthesia... you can get 60 to 70% the same outcome if you give them an antibiotic."

• Dr. Marty Makary at 27:38: "Where's the apology? Where's the humility?"

• Dr. Marty Makary at 56:38: "C sections save lives. That has doubled human lifespan."

• Dr. Marty Makary at 67:10: "The most common and lethal type comes from the fallopian tube and the cells float onto the ovary."

• Dr. Marty Makary at 82:00: "The culture of medicine says obey."

• Dr. Marty Makary at 111:23: "The acute care has been mastered."

This episode of The Peter Attia Drive serves as a critical examination of systemic issues in modern medicine, advocating for a shift towards evidence-based practices, continuous questioning, and the removal of entrenched biases to enhance patient care and public health outcomes.