317 ‒ Reforming medicine: uncovering blind spots, challenging the norm, and embracing innovation

KEYPOINTS

• 01

  Groupthink in medicine runs on cognitive dissonance and effort justification

  Makary draws on Leon Festinger: the brain dislikes holding conflicting ideas, so it reshapes or dismisses new evidence to protect what it heard first. Festinger joined a Chicago cult awaiting an alien rescue before a flood. When the noon pickup failed, the committed members dug in deeper. One physician member admitted he had too much invested to let go. Aronson and Mills showed the same pull: people who passed the hardest entrance test rated a deliberately dull talk the most enjoyable.

• 02

  Most uncomplicated appendicitis can be treated without surgery

  Before treatment, appendicitis killed more than 60% of those who got it, and lifetime risk is roughly 5–7%. Randomized trials found that a short course of antibiotics cures about two-thirds of patients without a rupture or a fecalith (a small stone in the appendix). About 12% come back with symptoms within a month and then have surgery, with no worse outcome for waiting. It also avoids anesthesia and frees operating-room time.

• 03

  Peanut avoidance advice likely helped create a US allergy epidemic

  In 1999 a Mount Sinai study put peanut allergy at about 0.5%, and most cases were mild. Around 2000 the American Academy of Pediatrics told parents to keep all peanut products from children aged 0–3, and from pregnant and breastfeeding mothers. This became the '1-2-3' rule. Allergy rates and ER visits climbed, and severe anaphylactic cases appeared. Makary cites an estimate of about 1 in 18 children now, and about 20% of US schools ban peanuts.

• 04

  Reversals rarely get the same megaphone as the original warning

  Gideon Lack's 2015 NEJM trial of about 640 infants found that early peanut introduction (around 4–6 months, as a supplement to breastfeeding and not as whole nuts) gave about an eightfold difference in allergy rates. NIAID took about two more years to issue guidance, about 17 years after the original advice. Peter says the HRT breast-cancer scare is worse: more than 20 million women went without therapy, and the correction never got the same publicity.

• 05

  The HRT scare was announced before investigators could object

  Makary says the roughly 40 WHI investigators were told at a meeting to drop the agenda because the paper was already submitted. Investigator Bob Langer warned that the 'genie' could never be put back in the bottle. Makary says the lead investigator acknowledged to him that there was no increase in breast cancer deaths. He says that held at publication and at follow-ups about 9 and about 20 years later.

• 06

  Think in probabilities to avoid both blind faith and blanket rejection

  Peter worries about a bimodal public: some reject all of medicine, others trust it completely. His fix is to train doctors in statistics and probability theory and treat beliefs as probabilities that get updated. For COVID's origin, that might mean 90% wet market at first, then 80/20, then 50/50 as evidence came in. That makes it easier to change your mind.

• 07

  Antibiotic overuse drives resistance and may harm the gut microbiome

  Makary estimates about 100,000 US deaths a year from resistant bacteria. The time it takes bacteria to develop resistance has fallen from about 23 years to 14 years to about one year. About 60% of outpatient antibiotics are unnecessary. He no longer gives routine antibiotics before minor laparoscopic procedures. The evidence came from open abdominal surgery. University of Chicago work suggests some surgical infections start in the gut, not on the skin.

• 08

  Most 'ovarian' cancer appears to start in the fallopian tube

  Makary says the most common lethal type, high-grade serous carcinoma, starts in the fimbriated end of the fallopian tube and the cells move onto the ovary. A large UK screening study found that ultrasound and CT didn't improve outcomes. Lifetime risk is about 1 in 78, and fatality is over 50%. Johns Hopkins now removes the tubes instead of tying them. Germany and most of Canada offer tube removal, with the ovaries left in place, during other elective abdominal surgery for women who are done having children.

• 09

  Tube removal is offered only alongside another operation

  Peter asks about the risk of damaging the ovaries. Makary agrees this is the main unknown: if one surgeon in 20 had a 5% complication rate, a broad stand-alone recommendation could cancel out the public-health gain. So Hopkins offers it only during other procedures, mostly to women below the mid-60s (the average age at ovarian cancer diagnosis is about 67). Canadian data show lower long-term ovarian cancer rates.

• 10

  Medical education and funding reward memorization and narrow ideas

  A recent graduate estimated that about half of his medical training was rote memorization, including about 20% on enzyme names. Makary criticizes the AAMC's control over curricula and licensing exams, and the paid board-recertification requirements. NIH spends about $80 billion in siloed institutes, while trials no one profits from go unfunded. Peter's counterpoint: memorizing still matters, but students need to know why it matters.