What Modern Medicine Gets Wrong (with Marty Makary)

Marty Makary: Great to see you, Russ.

Marty Makary: Yeah, I left doing the research for this book very optimistic, but there’s a phenomenon that’s true in every discipline, and that is: People with good intentions can develop giant blind spots. There’s a groupthink and a psychology to the herd mentality, and it affects how people think about politics and business and relationships.

And medical science is no different. There’s a sort of way of thinking in medicine that has an allegiance to the–what the senior people, what we’ve been taught. And the psychology to it is that we tend to believe what we hear first, not what’s most logical.

And so, the way we take in new information is now been well-described by Leon Festinger and other experts to show us that we tend to resist new ideas.

And so I wrote the book really to be a guide to impeccable objectivity when we hear new information and give examples in medical science.

You know, in medicine, we have good people. I have never met a physician that doesn’t want to try to do good. But we have good people working in a bad system. We’ve got perverse incentives, burnout; we’re fragmented; there’s cracks in care.

And, this is not a system we designed. It’s a system we inherited. And it’s working for a lot of stakeholders. It’s producing a lot of money.

But it’s not working for the one stakeholder that has the smallest lobbying effort: and that is the American worker–who is funding this entire system on the backs of their paychecks.

It’s their healthcare deduction and their Medicare excise tax that’s funding this giant industry that is now the Number One business in America.

Marty Makary: There is an inspiring new generation of students and residents, young doctors, senior doctors who recognize the system is entirely broken–who want to deliver care differently. They don’t want to have anything to do with the hamster wheel of billing and coding and short visits and delivering care that is so sub-specialized and fragmented we lose sight of the entire person.

The fact that every cell is connected, every disease is interrelated to five basic principles of health that we don’t talk about that we need to talk about: General body inflammation, mitochondrial health, food as medicine, micronutrients, the role of the microbiome, and the hormone systems in the body.

And, so there’s no one specialty for the microbiome or food as medicine. We have these silos based on these old-fashioned NIH [National Institutes of Health] funding centers.

And so, a new generation of doctors now are saying: Maybe we need to treat more diabetes with cooking classes than just throwing insulin at people. Maybe we need to treat more high blood pressure by talking about the quality of one’s sleep and stress, not just throwing antihypertensives at people. Maybe we need to treat more childhood obesity by talking about school lunch programs, not just putting every kid on Ozempic. Food as medicine: the role of the microbiome. Maybe we need to study the environmental causes of cancer, not just the chemotherapy to treat it.

We have the most over-medicated generation in human history. And, the path that we’re on is not a good path. Pretty soon every teenager is going to be on multiple medications on the trajectory that we have now. Maybe we need to look at communities, addressing loneliness, frailty, and seniors.

So, there is a recognition now that we’ve got to do things differently, and actually a business model for people to develop point solutions and graft it into the current system. And we’re seeing that disruption slowly.

Marty Makary: Yeah. So: Thank you for saying that, Russ, because I couldn’t agree more. We don’t want people to become cynical about the medical field. It’s a wonderful profession. Physicians and everybody attracted to the field of medicine–from a nurse to even a hospital administrator–is united around a common feeling; and that is a sense of compassion. We’ve chosen the profession because we think it’s wonderful to be able to help people at a time of need. And so, there is an incredible calling to the field.

The purpose of the book is to tell people that in science we discover things by asking questions.

And when we have a central authority with central planning in science–as we’re seeing emerge in medicine–we don’t have a very good track record.

When we use good scientific evidence and basic scientific methodology, we shine as a profession in making recommendations to the public. But, when we wing it–when we use opinion in the absence of evidence and put out recommendations with such absolutism–we have a terrible track record.

We got peanut allergies wrong for 15 years. We got hormone replacement therapy wrong for 22 years. We got opioids are not addictive wrong for 30 years, igniting an opioid epidemic.

These are uniquely American problems. They don’t exist in other parts of the world.

We got the low-fat diet wrong for 60 years–the government-issued food pyramid.

So, when we use good scientific principles, that’s when we shine as a profession.

And the book is essentially a reminder that if we’re going to put out recommendations as a health profession, we’ve got to do it with humility and show the level of underlying scientific support, or else we’re going to lose trust. And right now, we have an epidemic of distrust.

Marty Makary: Yes, peanut allergies are real. And we have now a new type of allergy, which is you can go into anaphylactic crisis just by being near a peanut if you have one of these very severe allergies.

But, the peanut allergy story is fascinating, because peanut allergies don’t exist in Africa and many parts of the world. It is almost a uniquely American problem. And that is because the peanut allergy epidemic was ignited by an incorrect recommendation 24 years ago by the medical establishment telling mothers and young children to avoid peanuts, ages zero through three, in order to prevent developing a peanut allergy later in life. What they forgot about was the basic principle of immune tolerance.

A small group of people made this recommendation, got blasted in a classic groupthink, sort of herd mentality. No one really, except for a few smart people, said, ‘Wait a minute: you got it backwards. It’s not peanut avoidance that prevents peanut allergies. It’s early introduction of peanut butter, milk, eggs, cats, dogs, you name it.’ The old dirt theory: the concept of immune tolerance. When a child is young in infancy, when they’re exposed to allergens, they tolerate them. Later in life, they don’t see them as foreign.

So, back in the 1990s, there was an uptick in peanut allergies in the United States. I mean, still less than half of 1%. The vast majority were mild. It might’ve been related to the microbiome. And so, the American Academy of Pediatrics–and I interviewed the people who made this recommendation–I asked them, ‘Why did you recommend peanut avoidance as a way to prevent peanut allergies?’ Well, of course they now know they got it backwards. And they said, ‘Well, people were asking us what to do, and peanut allergies seemed to be a problem, so we had to tell them something.’

And, I said: No, you don’t. You don’t have to make something up if you don’t know. You can say ‘We don’t know how to prevent peanut allergies.’

So, when they said ‘Avoid peanuts to prevent peanut allergies,’ it became this beatdown, where people who were introducing peanut butter in infancy early on were seen as anti-science. Medical establishment, putting out the wrong recommendation, was watching the epidemic soar, and peanut allergy rates were going up like crazy years after this broad-sweeping recommendation for peanut avoidance.

And, what we saw was a new type of peanut allergy, which is the ultra-severe allergy–severe anaphylaxis just from a touch of peanut products. And so, we started, basically, peanut apartheid in food, in the food system, and everyone had to distinguish: this contains peanuts, this doesn’t. Announcements, waiters–and they had to do it because this was a real problem.

Marty Makary: It made the problem worse.

Marty Makary: And, Dr. Gideon Lack, a Jewish allergist in the United Kingdom, was back in Israel giving a lecture in the 2000s, and he asked the pediatricians there, ‘How many of you have a child with a peanut allergy?’ About 200 people were in the room and only a couple of people raised their hands. And he was blown away by this. Because, when he asked the same question back in London, every hand went up. He noticed that the Jewish kids living in London that he saw in his clinic had very high rates of peanut allergies, but Jewish kids back in Israel did not. So it clearly was not a genetic association.

He did a randomized control trial [RCT] with 640 kids and proved to the world, in a famous New England Journal paper that came out about eight years ago, that if you avoided peanuts in the first few years of life, your rate of peanut allergies went up almost ninefold later in childhood. He had identified the cause of the peanut allergy epidemic, and it was the bad guidance to avoid peanuts.

Why wasn’t the study done before the recommendation? This is not an expensive study. It was embarrassingly simple.

And this is a broader problem in medicine: issuing broad recommendations not just as an opinion but with absolutism when there’s a void of science.

Marty Makary: It’s okay to have an opinion as a medical professional, but to put it out there scientific-based when it’s not, that’s where the distrust starts.

You look at COVID–I don’t write about COVID in the book; it’s just too tribal and people are sick of it. But, many times during the pandemic, the right answer should have been, ‘We don’t know.’

Marty Makary: Most guidelines in medicine are vague. They’re written by a very old guard who may be out of touch with the latest therapies or against them because it’s not the way they practiced. They have a heavy hand of industry. Industry is funding many of these organizations, be it baby formula companies–still one of the major sponsors of the largest pediatrics association. The companies that are promoting mammograms in low-risk 40-year-old women are still sponsoring the radiology conferences.

I don’t believe in routine mammography and women in their 40s who are low-risk. That’s a new recommendation from last year. It was expanded from starting mammography at age 50. They lowered it by 10 years without any randomized control trial data.

So, the medical industrial complex can have a life of its own. I don’t want people to become cynical and jaded. But, there are things that people should know to ask about, and that’s why I wrote the book Blind Spots: I wanted to educate people on what we know on the latest scientific evidence on many of the big health recommendations of today.

Marty Makary: And I’m glad you mentioned Vinay Prasad–real quick, Russ–because we talked about the sort of centralized authority in medicine. It’s being disrupted. It’s one of the reasons I’m optimistic about medicine.

But we don’t want snake oil being sold, and people putting the same weight on that as in experts like Vinay Prasad. But, you have the free-market working. Now with podcasts–Vinay Prasad, Sensible Medicine; Peter Attia–these are doctors who are wholistic. They are also specialists. They do deep dives; and they challenge deeply-held assumptions in the field.

It’s just like the media. We used to have three networks and they would all say the same thing. And now people are learning, ‘Hey, I’m listening to this podcast and that podcast, and guess what? The government was lying to us about Afghanistan for 20 years.’ Or Iraq. And they realize, ‘Hey, there’s another point of view.’

And the same thing is happening in medicine.

We need civil discourse. And the oligarchs in the medical priesthood have basically said, ‘This is the way it’s going to be.’ Again, you saw it during COVID–the book is not about COVID–but you see the culture of medicine.

And, the truth is, now, with social media and other forms of communication, prominent doctors–who are smart, like Vinay Prasad–are able to challenge deeply-held assumptions and have tremendous influence in the medical profession. A hundred thousand physicians follow Peter Attia. Sensible Medicine, which Vinay Prasad and several doctors and I started a newsletter. Sixty thousand physicians are actively reading that.

That’s like–there’s only a million–1.1, 1.2 million–physicians in the United States. We are seeing a sort of decentralized, a sort of liberated civil discourse now occur. Among experts: We’re not talking about selling snake oil.

Marty Makary: That’s my favorite chapter in the book. So, the investigative journalism I did around hormone replacement therapy in postmenopausal women was just–it just blew me away. For decades–for nearly half a century–women had benefited from taking estrogen or estrogen-plus-progesterone when they hit menopause, and it replaced their body’s own estrogen level. Which science has clearly shown has many health benefits.

Women who took estrogen after menopause or started it within 10 years of menopause in general live three and a half years longer. They have half the rate of fatal heart attacks. They feel better. It alleviates the symptoms of menopause, which can last for five or 10 years sometimes. There was less cognitive decline–studies show women had 50% to 60% less cognitive decline–and a 35% reduced risk of Alzheimer’s if they started estrogen around the time of menopause.

If a woman fell or was in a car accident, they were half as likely to break a bone–which can lead to immobility later in life and eventually, a cascade of events and frail women that can result in demise.

The benefits are overwhelming. And they still are.

But, something tragic happened 22 years ago. A doctor at the NIH [National Institutes of Health] held a press conference saying that hormone replacement therapy causes breast cancer. He scared the crap out of millions–tens of millions–of women worldwide.

Immediately, they flushed their pills down the toilet. Doctors called their patients, told them to stop taking it. It was a media frenzy. Headlines were bannered around the world. The doctor from the NIH made the announcement was on the cover of Time Magazine. This was a big deal 22 years ago. Most women remember it if they were perimenopausal.

The tragedy was that doctor who made that announcement did–

Marty Makary: Jacques Rousseau. He’s now retired; but he never released his data at the time of the announcement.

And so, everyone believed him. Eventually, the study was published, and I took a deep look at it. Many people had said, ‘Hey, this is something you should really do a deep dive on.’ Deep in the article, when you look at the actual data, there was no statistically significant increase in breast cancer rates among women who were on hormone therapy compared to placebo.

And this was a giant study, actually the largest taxpayer-funded study in U.S. history, almost a billion dollars. This was the result of a massive study, and supposedly we were being told the truth. Turns out they had misrepresented their data.

Now there were doctors with all the credentials who were co-authors from Stanford and Harvard, famous doctors, and it just became dogma, medical dogma.

And so, fifty million women have been denied the benefits of hormone replacement therapy after menopause because of this dogma. There is probably no medical intervention in the history of medicine–with the exception of, arguably, antibiotics–that has helped the health outcomes of a population more or does more for a population’s health outcomes than hormone replacement therapy after menopause.

So, when I did this investigation, I thought, ‘Gosh, people need to know about this.’ That is one of the chapters of the book; and it’s just incredible. My mom was one of those women. She went through menopause around the time of the study: was told, ‘Don’t you dare start this.’ Many women asked their doctors, ‘Hey, I heard replacing your body’s estrogen level when it goes down at menopause has all these benefits.’ They were told, ‘Don’t you dare.’ An entire generation of women was denied.

And the tragedy is another generation right now are being denied because 80% to 90% of physicians still believe this dogma. And it’s not because they’re bad people. One primary care doctor told me when I interviewed him for book, ‘It was pounded into us like crazy in our training that it causes the breast cancer.’ Sure enough, it’s still everywhere today in the medical culture: ‘It causes breast cancer.’

Marty Makary: It appeared they had already made up their mind before the data were in, Russ, because–

Marty Makary: I found the lead researcher had written in a journal long before the study results were clear. He said, ‘We have to stop the hormone replacement bandwagon.’ And so, he was on a mission.

Before he made the press conference, he organized the 40 different researchers that were part of this giant national study in a hotel room–in a meeting room–in Chicago at the Sofitel Hotel. He basically said, ‘Hey, we’re about to make this announcement; and we got the results and it looks like it causes breast cancer. And here’s the paper. We already submitted it for publication. Your names are on it.’

And these researchers say, ‘What the hell is going on here? First of all, you can’t submit a research study with our names on it when we haven’t reviewed it. And second of all, it does not have a statistically higher rate of breast cancer.’

And so, there’s this shouting match erupts in the Chicago hotel room, in the year 2002. And, one of them tells the lead investigator, screaming, he says, ‘You cannot say that this causes breast cancer because if you put something out there without any data to support it with an issue as sensitive as breast cancer to women, you will never be able to put that genie back in the bottle. It’ll create mass fear and you will do damage for a long time and may never be able to reverse that.’

And in fact, that was very prophetic. He was correct.

So, we need transparency. We need open discourse, and we need an honest evaluation of data. You didn’t see it with that announcement. And, that is–to this day, we’re still fighting the battle of letting people know the truth. And you’re right, some people don’t–they can’t tolerate hormone replacement therapy. It could increase vaginal bleeding if they have endometriosis. There’s a couple different contra-indications.

But the vast majority of women–99% of peri-menopausal women–need to start it within 10 years of menopause in order to get the long-term benefits. If you start it after that, there is that higher rate of cardiac events–which is what people cite, frequently. But that is if you start it too late. Because estrogen oxidizes and increases your nitric oxide level. Nitric oxide in blood vessels keeps the blood vessels dilated and soft. And so, if you are not on estrogen for years after menopause, those blood vessels will narrow and harden and increase your risk of cardiac events. You can’t start it after the hardening and the narrowing has set in for more than 10 years. That’s why it’s important to start it within 10 years of menopause. And most doctors who are advocate for it do not recommend starting it more than 10 years after the onset of menopause.

Marty Makary: Yeah. Claude Bernard, the father of modern medicine, said ‘We all have our biases in a scientific question or extrapolate to life a management decision, a political favor. We all bring biases to every decision.’

And, he didn’t say that there’s nothing you can do about it. He said, ‘You have to actively recognize those biases and temporarily suspend them in your mind as you intake new information so you can be as objective as possible.’ But, he said, ‘If you don’t think you need to do it actively’–if you think you naturally do it passively–he said, ‘That’s the fallacy.’

And think about it. We’ve got a doctor at the hospital who is very affable. You like these people who are impeccably objective. They don’t rush to judgments. They hear new information, even if it’s–they don’t like it or they find it offensive. And they listen to it. We’re attracted to those people. They make good leaders. They’re affable. And so, that is a challenge that we all have, and that is part of civil discourse. Imagine if we all heard new information, public policy with that sort of spirit.

Marty Makary: There was a member of the Baltimore Ravens football team who had an allegation against him. And we were talking at work about this player, and people were trash-talking him. Somebody said something that sort of silenced the conversation. He said ‘We don’t have all the information. We’ll have to see.’ The reality is every person who is–

Marty Makary: Everybody–and I recognize this in myself, just like you had mentioned. I mean, my own research meetings, people are throwing research ideas and sometimes I’ll very quickly dismiss them. That is the same natural tendency that Claude Bernard was talking about.

Every closed-minded person perceives that they are impeccably open-minded. And so, we have to recognize this is a part of the human condition. We’re not bad people. It is part of the human condition. This is what Leon Festinger, in describing cognitive dissonance, dedicated his life to: showing that the human brain does not like holding two conflicting ideas at the same time. It struggles–passively, subconsciously–to reframe new information, to make it fit and consistent with what you already believe. Because the brain wants peace. It doesn’t want conflict or dissonance. And that’s what the idea of cognitive dissonance is.

Marty Makary: Well, that’s right. The old-school thought was that the overprescribing of antibiotics is bad for the community because it creates superbugs: bacteria that learn to be resistant to antibiotics. So we need to reduce the overall community use of antibiotics.

And that’s still very true, and that is very much a problem that is creating the next pandemic of superbugs–which by the way kill a hundred thousand people a year. And it’s increasing every year, and we’re not keeping up with new antibiotics.

But, we’re also learning about the downsides to individual health from taking an antibiotic. You know the dogma, ‘Hey, it probably won’t help you, but it won’t hurt you, can’t hurt you.’ No, no, no. Actually, not only can it hurt you with adverse side-effects; but also, we’re learning now that antibiotics essentially are carpet-bombing the microbiome. The microbiome are the millions of different bacteria that live in harmony in the gut, and it’s a garden with a balance. And when you kill certain bacteria, other bacteria overgrow. And we’re learning that that imbalance affects health.

These bacteria in the gut are involved in digestion. They’re involved in allergies. They produce GLP-1 [Glucagon-like Peptide-1] in low levels. They regulate estrogen. They train the immune system. They produce serotonin which is involved in mood and mental health.

So, just taking an antibiotic, thinking it’s not doing anything–it is actually massively altering the microbiome, especially in the first couple of years of life when it’s being formed.

Now, a study came out of the Mayo Clinic that was incredible. It’s very recent. When I talked to the authors for the book, they looked at kids who took an antibiotic in the first couple years of life versus kids who did not, and they followed them. Now, these kids were matched roughly so they were similar kids otherwise, and they looked at 14,000 kids in one county in Minnesota.

Kids who took an antibiotic had a 20%-higher rate of obesity, a 21%-higher rate of learning disabilities–some things, a diagnosis that’s been on the rise with no explanation–a 32%-higher rate of Attention Deficit Disorder [ADD]; a 90%-higher rate of asthma, and nearly a 300%-higher rate of celiac disease.

Now, you can’t conclude that it’s definitely cause-and-effect from the antibiotics. There’s other variables.

However, there was a dose-dependent relationship. The more courses of antibiotics a child took early in life, the greater the risk of each of those chronic conditions. Certain antibiotics increase it even further, like the cephalosporin class.

And, it fits with a model of health that’s been out there. Farmers have been noticing for decades that when you give animals antibiotics, they’re fatter, and you can get more produce out of it. You can get more productivity or more mass out of the animals.

This researcher, who is the world expert in the microbiome, I interviewed for the book basically had this ‘Aha’ moment where he thought: ‘Hey, wait a minute. If antibiotics are making the animals fatter, what are they doing to humans? Does it also drive obesity?’

And, the obesity hypothesis is not fully explained by calories-in/calories-out. How do you account for the fact that newborns are larger–they’re heavier–than in a prior generation? There’s a condition now of newborn obesity. It is not explained for by the calories-in/calories-out. But it would make sense if we recognize the role of the microbiome because you pass on your microbiome to your offspring.

And, the rise of C-sections [Caesarian sections] may be a massive contributing factor. Ultra-processed foods, high refined carbohydrates–what we call a high glycemic load in medicine–that maybe that’s feeding certain bacteria. Fluoride in drinking water is there because it kills bacteria in the mouth and reduces cavities. But what is it doing to the microbiome bacteria? No one has thoughtabout this.

C-sections–if you just look at C-sections on the rise–and by the way, antibiotics save lives, and if you need one, it can be life-saving. C-sections save lives. If you need one, you should have one. But, both are massively overused in the modern era.

And, when you’re born by a C-section, you don’t get the normal seeding of the microbiome because a baby in utero has a sterile gut; and the microbiome is formed initially with the seeding of bacteria when the baby passes through the birth canal and then is augmented by bacteria from the colostrum–the initial breast milk–that the baby will take in. And then kisses from grandparents, and holding, and skin contact. That forms the microbiome–the garden of millions of bacteria that live in equilibrium. And it takes a couple years, maybe longer, for that really to take a foundation.

But, when you’re born by C-section, the baby’s gut is not seeded with the bacteria from the birth canal. It may be seeded by the bacteria that normally live in the hospital. A sterile baby is extracted from a sterile operative field, and what may seed its microbiome are the bacteria that may live in the hospital. So we’re altering the microbiome in ways we’ve never appreciated.

All this to say: There’s new research out. People should know about it. And the dogma that has been out there for 50 years, ‘Hey, the antibiotics won’t hurt you,’ is not true. The dogma that there’s no difference between a vaginal delivery and a C-section is not true.

Again, antibiotics and C-sections save lives, but we’ve been missing this organ system called the microbiome that interacts with every aspect of health. I mean all those diseases in the Mayo Clinic study that are increased with kids who took antibiotics early in life, they’re all on the increase in the modern society.

And so, what do you do when you see these massive epidemiologic correlations? I’m not saying we have to conclude a cause and effect, but there’s enough of a signal in the data there to say: The old silos of the National Institutes of Health–the NIH–may be outdated: these silos of kidney disease, cancer, heart disease. Maybe we need to look at these common threads of health, inflammation, food as medicine, the microbiome, micronutrients, mitochondrial health.

And so, that’s an exciting area of medicine right now where there’s a lot of research that’s starting to take off.

Marty Makary: Well, it is 100% true, that story in the book; it seems to be one of the most popular stories.

There is a protocol to treat appendicitis without surgery. We call it the non-operative protocol. And it really involves a short course of antibiotics. If ever there were a good reason to give antibiotics it’s to avoid surgery with a short course. And, people get the antibiotics anyway even when they have surgery: When they’re sitting waiting for surgery, they’re being infused with an antibiotic.

But, European researchers had noticed that when they couldn’t get people into the operating room–let’s say you’re at the NHS [National Health Service (Europe)] or something, and the schedule was full and people were waiting a long time–they got better. They were cured from just the short course of antibiotics.

And so, they developed a protocol that said if you don’t have a ruptured appendix–if it’s the first time you’ve had appendicitis, and there’s no little stone–what we call a faecolith in the appendix–then they’re going to make that the first line treatment: Give them a short course of antibiotics and see if they get better.

And what they found is that a small number of people come back with similar symptoms in the first few months. But, two-thirds of people never needed surgery.

And then they did long-term studies. Well, American doctors had downplayed this: ‘That’s European data. You can’t trust it.’ Just like the hand-washing data that first came out of the United Kingdom by Joseph Lister. ‘Ah, you can’t trust it. It’s European data,’ showing it lowered infection rates.

Well, a randomized control trial was done, with elegant trial clearly showing the benefits of this non-operative therapy. It works. I showed it to a colleague at the hospital.

Of course, it was very hard for me to accept this. Right? I had this bias. It had been pounded into me my entire life that this is a reflex we do in American healthcare. Somebody has appendicitis, boom, right to the operating room. We take out the appendix. It’s a beautiful case. You get good at it. You can do it almost blindfolded. It’s just a reflex. And we help people; and we feel good about ourselves.

This study challenged that assumption. It suggested that two-thirds of people don’t need the surgery.

So, I offered it to a patient once; and I did it with some trepidation. I said ‘I’ve never done this before, but this study just came out. Here’s a copy of the study. If you want to try this, I’m happy to treat you with antibiotics and we can try to see if we can avoid surgery.’

Marty Makary: He had his sister’s wedding–

Marty Makary: That’s right. The fact that his sister was getting married the next day in New England just sort of made me realize, like, ‘Do we take him to the operating room right now and maybe he can get there in a wheelchair or something, or do we do the non-operative protocol, which means he could be better by the morning?’

And so, I didn’t know. I was torn. And I gave him the option. By the way, you’re right, people are busy. They don’t want to just hang out in the hospital and eat our Jell-O. So, I offer him–do you like Jell-O or something?

Marty Makary: We’re keeping the Jell-O company in business.

So, I offered it to him, and guess what he chose? ‘Hey, do you want to have surgery or not have surgery?’ Of course, he’s, like, ‘Yeah, how about we hold off on surgery?’ He got better, went to the wedding, danced up a storm, and followed up with me. I was nervous the whole time. Like: ‘Is he going to pass out from a recurrent appendicitis?’

Marty Makary: How old was I at the time?

Marty Makary: Forty-two-ish.

So, he has this great outcome; and I share it with my colleagues. And one colleague in particular tells me, ‘You know, Marty, I need to see two randomized control trials before I believe something like that. It just seems ridiculous.’

A second randomized control trial came out a year later–massive trial, long-term outcomes, elegantly done, published in the top medical journal. And I show it to him, because this has become a running conversation of him and I. He’s a nice guy, good friend of mine; I think he cares deeply about his patients.

And he looks at the study and he just looks at the title and he says, ‘Marty, I need to see three randomized control trials.’

Well, a third randomized control trial came out; and I showed it to him again; and he said, ‘You know, I just think you’re better with your appendix out.’ And it’s like all the research in the world wouldn’t matter. This was a deeply-held dogma. This is groupthink.

To this day, only maybe half of general surgeons are using this protocol–this is like 10 years later–for non-operative management. It is Dr. Leon Festinger’s theory of cognitive dissonance right in front of my eyes. It’s Claude Bernard imploring us as doctors to suspend our biases and consider new information objectively. It’s being violated right in front of my eyes. And this guy is a good friend. I mean, he’ll take call for me any night. He’s a great guy.

And you realize that it’s part of the human condition; and we have to actively manage these biases.

But, it is also a statement of American healthcare.

Marty Makary: Imagine–sorry, Russ.

Marty Makary: Imagine: We have a nursing staffing crisis in the United States, okay? It is–the number one reason why hospitals are posting losses is their nursing staffing costs after COVID. Imagine if we took one of the most common operations in the United States and managed it without surgery, what does that do to our nursing staffing crisis? Nursing teams coming in, in the middle of the night, congested operating room waitlist is at every hospital in America? What does it do to our carbon footprint? What does it do to healthcare costs?

And so, there is scientific truth that can rescue American healthcare in many areas. And so we’ve got to usher in great data and recognize that these biases that we have to hold on to the old way of doing things can be actually preventing us from moving to the next level of health–healthcare 3.0.

Marty Makary: We took out millions of healthy ovaries–there’s nothing wrong with them–with the argument that we were preventing ovarian cancer. It turns out ovarian cancer from the latest research–in part from my institution Johns Hopkins, from Penn, from Dana-Farber [Dana-Farber Cancer Institute] at Harvard–ovarian cancer comes from the fallopian tube.

The most common and the most lethal type of ovarian cancer does not come from the ovary. It comes from fallopian tube. And then, those cells fall onto the ovary where they grow. And, it looks like it’s ovarian cancer, but it should be really called fallopian tube cancer.

Now, there is a sub-type–a subset of ovarian cancers that do come from the ovaries. They generally tend to be benign or favorable. It’s a fraction of ovarian cancer.

But the most common lethal form of ovarian cancer–remember, this is, like, the most common cause of GYN [gynecological] cancer death is ovarian cancer in the United States. There’s no screening for it, whatsoever. There’s a big trial in the United Kingdom that looked at ultrasound and screening with imaging–totally failed. There’s no screening tests for ovarian cancer. The chemotherapy doesn’t work well. Usually, it’s late-stage when it’s discovered. That may be because it’s floating from the fallopian tube to the ovary. It’s got a space. It may be spreading into the [?] cavity, the abdominal cavity, and maybe that’s why it’s spreading early.

So, we have not made progress with ovarian cancer–not made hardly any progress.

And, here’s a discovery that has pretty strong support, where it’s the data telling us, ‘Hey, if you want to prevent ovarian cancer,’ which affects 1 in 78 women in their lifetime, ‘take out the fallopian tube after they’re done having children.’ Not the ovary. You can leave the ovary in place. In fact, the ovary–leaving the ovary in place–is good. Produces hormones like estrogen; and there are other benefits.

So, when a woman comes in now to Johns Hopkins and says, ‘I would like my tubes tied,’ we’re now telling that person: ‘We don’t do that anymore. We remove the fallopian tubes, leaving the ovary in place, to massively reduce your 1-in-78 chance of developing ovarian cancer.’

And, in Canada and Germany, now, this has become kind of standard of care. The Obstetrics and Gynecology Association in the United States just put it into one of their official statements, recommending that when doctors are in the abdomen–in a woman who is finished having children–that offering removal of the fallopian tube is a way to reduce the risk of ovarian cancer.

So, all the stuff we’ve been doing–chemotherapy, everything–to try to hit ovarian cancer and reduce deaths from ovarian cancer, not been very successful. Here may be an opportunity to do something.

And in the past, in centralized medicine and the culture of medicine, we would have, sort of, central planning, right? We would make the decision and just tell people: ‘This is what we now tell you to do.’ It’s changing. Now people are getting the information and making their own decisions.

So, that’s–I had enough of my colleagues and friends say, ‘Hey, this ovarian cancer discovery that it comes from the fallopian tube not the ovaries. We don’t need to be taking out all these normal ovaries in low-risk women. You should write about it. You should use your platform to write about it.’

So, I thought, ‘Well, I’m writing a book about medical dogma,’ and I made that one of the chapters.

Amazing discovery. I interviewed the researchers who discovered its origin. And it has very real implications for women–and cancer.

Marty Makary: That’s right.

Marty Makary: Well, 60% of medical care administered by health professionals is discretionary. There’s no evidence to tell us we should be doing one thing or another. So there’s an important role for clinical wisdom. But, it needs to be presented with humility. In other words, we need to recognize that when we’ve been doing things just because that’s the way our ancestors in medicine have been doing them, that it’s healthy to ask questions.

And when we put them in front of patients, we need to let them know: ‘There’s no good studies on this, but I believe this is what’s in your best interest.’ People trust that level of honesty. People are hungry for that level of honesty. When recommendations are put without evidence in front of patients as ‘You have to do this,’ with an absolutism, that’s when we get into trouble.

I find that–well, let me just tell you. I had a patient once where I made a mistake. I assume I made the mistake. They got a CAT scan [Computed Axial Tomography scan] they didn’t need. I think it got done on the wrong person. And, I realized it; and I went immediately over to the patient’s room and I said, ‘I’m sorry. You just got back from a CAT scan. I actually I did not order that CAT scan. I ordered it for someone else. It may be it was done on you by mistake. I take responsibility. I’m happy to go get those results. I haven’t seen it yet, but I’ll go share it with you if you want.’

That patient–who was already a little frustrated with their care–never got angry at me. He looked at me and he said, ‘Thank you, Doctor, for coming up here and telling me that as soon as you found out. I really appreciate you.’ And he gave me this big smile.

People are hungry for honesty. I find the public can be very forgiving if we show humility: if we explain what’s based on wisdom and what’s supported with good science.

Within our own shop of medicine, we need better scientific studies. But, when we practice medicine, I find that the level of humility to be able to say, ‘I don’t know’ when we don’t know wins the confidence and respect of the public. And it has for centuries, before the modern era of more centralized planning and a small group of people at the top making all the decisions.

People can also do their own research on important health topics. I learn from my patients. And that’s okay. That’s good. They come in and say, ‘Hey, Doc, have you seen this study?’ They may present an idea that sounds crazy. ‘Hey, I heard eating ice cream can cause cancer.’ ‘Well, let’s take a look at where you heard that from. I’m happy to take a look at that.’ Not dismissing them as crazy. We need to be open-minded and show civil discourse.

But we can fix healthcare in ways that make us feel good: giving everybody gold-plated insurance, fixing the finance of medicine, fixing employer-sponsored healthcare, cutting the waste in the system. But, if we are still putting out the wrong information as a profession and doing it with such absolutism and not showing humility, then we’re going to continue to struggle.

Right now, somewhere between 40% and 60% of the public doesn’t trust us. Study just came out in one of the big medical journals, put the level of distrust at around 42% in the American population. And a prior study from Harvard that I had written about in the prior book talked about how 60% of the public avoids medical care or delays care for fear of the bill–because we have all these money games, and predatory billing, and price gouging.

So, if you have a cure for pancreas cancer that someone invents, but half the public does not trust us to come in and take it, that cure is now 50% effective, not a 100% effective.

And so, we’ve got to focus on clinical excellence: on great bedside care, on humility, on civil discourse, on representing studies fairly, and showing people where we have clinical wisdom where evidence is absent.

And I think that is our path to rebuilding public trust. Because American hospitals have always been, historically, a safe haven–the most respected institution in American communities. We would take care of anyone regardless of their race or what they believe or their ability to pay. That is our great medical heritage.

Pennsylvania Hospital–first hospital in the United States–had this incredible Charter. It didn’t matter who you were–didn’t matter if you were a slave, or a slave owner; if you fought in the North or the South in the Civil War; if you had money or you were on the Board of the hospital or you had no money. It didn’t matter. Everybody was treated equally. And that is the great heritage in the medical profession that I think we need to restore. And, a lot of times reminding ourselves of that heritage is how we rebuild that trust.

Marty Makary: Great to be with you, Russ. Thanks.