Lambert here: Weirdly, I see no mention of Covid. However, the author of the book reviewed, Marty Makary, has a track record. So worth a read.
By Lola Butcher, a health care business and policy writer based in Portugal. Originally published at Undark.
Like many surgeons, Marty Makary used to routinely treat appendicitis by removing the patient’s appendix, a procedure performed nearly 300,000 times a year in the U.S. That changed about a decade ago after he read a research study that found antibiotics may be an effective alternative.
Despite subsequent research confirming that appendectomies can often be avoided, Makary estimates only about half of surgeons have accepted the idea. “That means whether or not you go under the knife for appendicitis today in America depends on who’s on call when you walk into the emergency department,” he writes in “Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health.”
In detailed behind-the-scenes case studies, Makary, a surgeon and public health researcher at Johns Hopkins University, reveals how and why physicians often salute bad science and baseless opinions at the peril of their patients.
Among other things, Makary claims, the medical establishment created the opioid epidemic and the peanut allergy epidemic. Tens of thousands of women have died prematurely because of misinterpreted data about the danger of hormone replacement therapy. The U.S. government banned silicone breast implants for 14 years without evidence they caused harm. Physicians’ overuse of antibiotics is likely causing untold suffering. Doctors still tell overweight people to eat low-fat foods, even though low-fat diets are associated with obesity and diabetes.
“Much of what the public is told about health is medical dogma — an idea or practice given incontrovertible authority because someone decreed it to be true based on a gut feeling,” Makary writes.
Makary’s assertions are supported by hundreds of footnotes as he builds each indictment, but that doesn’t mean all physicians and researchers are nodding in agreement. One example: When a research team analyzed 13 studies comparing antibiotics to appendectomy, it found almost a third of the patients initially treated with antibiotics had an appendectomy within the year. Although the other two-thirds did not, the researchers called the evidence that antibiotics are better “very uncertain.” So surgeons who choose to operate immediately are not necessarily doing something wrong.
Makary, one of medicine’s most prolific iconoclasts, has been poking at America’s health care system since at least 1998 when, as a medical student, his article calling on hospitals, medical schools, and health insurance companies to divest their tobacco stocks was published in the prestigious Journal of the American Medical Association.
A few years later, ignoring criticism from his colleagues, Makary created a checklist to improve surgery safety; after proving that safe surgery checklists reduced surgical errors and deaths, they are now used in most operating rooms around the world. His 2012 book, “Unaccountable,” demanded that hospitals reveal their infection rates and medical errors. A few years later, Medicare began requiring public reporting of those and other indicators of health care quality. His 2019 book, “The Price We Pay,” documented hospitals’ price-gouging practices and called for all hospitals to post cash prices for certain services — which is now required by law.
In each case, Makary cannot claim to be solely responsible for influencing these big changes, but he did have one of the biggest megaphones. Both of those books — and “Blind Spots” as well — became New York Times bestsellers.
The thread running through Makary’s harangues is that America’s health care system is getting a lot of things wrong. “Blind Spots” focuses on the failures of the “medical establishment” — a term Makary does not explicitly define but refers to more than 40 times, almost always in a derogatory context.
He excoriates medical journals, government agencies, and professional medical societies for actions that, in his view, harm the people who trust them. He does not call the medical establishment nefarious; rather, he accuses it of frequently embracing a narrative — that stress causes ulcers, for instance — without evidence, ignoring scientific findings that do not support the idea, and blackballing those who question their position.
Medical journals, for example, are a primary way in which doctors learn about new scientific knowledge that informs the medical care they provide. Most journals use a peer-review process, meaning that an article is only accepted for publication if a panel of experts deems it to be accurate and of high quality.
Makary has written more than 250 peer-reviewed articles in medical journals, but he is no fan of the genre. In his view, editorial boards, the gatekeepers of peer-reviewed publishing “tend to be composed of like-minded friends.”
“I have been shocked to see studies so flawed that the results are rendered invalid, yet they were published in prestigious medical journals and upheld as scientific proof when instead they just support a groupthink narrative,” he writes.
Invalid results? Inconsistent and fraudulent data published in medical journals is commonplace, with more than 10,000 articles retracted in 2023 alone. Earlier this year, the Dana-Farber Cancer Institute retracted seven published articles — and corrected 31 others — because of errors or allegations of manipulated images.
The National Institutes of Health, the world’s largest public funder of biomedical research, also loses some of its luster under Makary’s gaze. Among other things, he lambasts the institution for its 2002 decision to stop a clinical trial about the long-term effects of hormone replacement therapy, citing an increased risk of breast cancer that was based on bad science. Presenting a vigorous defense of the therapy’s many benefits, Makary quotes an estimate that around 140,000 women died prematurely over two decades because they did not use hormone replacement therapy. “The message that HRT causes breast cancer stuck,” he writes. “And that message is still believed by most doctors to this day.”
Medical societies, which provide guidance for physicians and the public, also draw Makary’s critique. The American Heart Association, for example, promoted a low-fat diet for six decades, despite a lack of evidence that fat causes heart disease. The American Academy of Pediatrics’ baseless recommendation that children under 3 avoid peanuts fueled America’s peanut-allergy epidemic; introducing peanuts early in life actually reduces the risk of an allergy. The American Medical Association supports what Makary considers to be government censorship of health information.
Makary’s critique of the medical establishment at large brings to mind oncologist Vinay Prasad’s critique of cancer care in “Malignant: How Bad Policy and Bad Evidence Harm People with Cancer,” published in 2020. The similarity in the authors’ in-your-face approach is no coincidence; in his acknowledgments, Makary refers to Prasad as “the great sensei.”
Makary’s writing style makes it easy for general readers to follow along as he identifies a “blind spot,” flies around the country to gather information about its history, and digs into research studies to collect data points. His many tangents and asides — readers get a long and gory description of a seaman’s scurvy symptoms, discover that President John Adams defended British soldiers in court, and learn that VIP patients can be a pain in the butt — can be jarring at first. But his enthusiasm for his material — the book is peppered with “amazed” and “amazing” — is contagious.
That said, physicians, specifically those he considers to be part of the medical establishment, seem to be his primary audience because he includes so many calls for action. Among other things, he wants apologies from government agencies and medical societies that give bad advice. He wants to see funding for repeat studies that confirm research results. He wants America’s medical education system to stop propagating “outdated groupthink.”
His most frequent call is for civil discourse, in which medical consensus can be questioned without the questioners being dismissed or disparaged. Makary’s strident opinions and broad-brush derision of the medical establishment may turn off those he seeks to influence, but his track record for fomenting change cannot be ignored.
So perhaps readers can hope that his vision will come to be: “Open debate and a discussion of the merits of data over dogma make for a stronger society, more civility, and a faster rate of medical discovery.”
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In U.K. a trainee doctor once wrote a screenplay and entered it in a competition. The BBC produced „Cardiac Arrest“ and non-medics hated what it revealed about the real medical experience
Later using his pen-name Jed Mercurio he wrote a series called „Bodies“ about maternity services in NHS hoping for reforms to reduce infant mortality – yet nothing happened in 20 years as the Lucy Letby hospital situation reveals
It is hard to penetrate the inertia in the system when the public is so ignorant and complacent – and dissident doctors sink beneath the waves of angry tides
Maybe it’s a power thing since power and dogma go hand in hand. Having a job where you constantly make life or death decisions may not promote humility. One doesn’t have to get into the cliche of the “God complex” to suspect there is a psychological dimension here.
Also there’s the routine defense here in the US that physicians are in constant danger of being sued making conformity a defense and originality a risk. And ultimately money considerations of all kinds likely explain much of the above.
we all make out own choices. by supporting the status quo we get more of it.
One needs to remember the travails of the good Hungarian doctor in 1800s trying to convince his colleagues to wash well their hands when going from autopsying a cadaver to a maternity ward to assist for birth, for instance…
Doctors are people too, and the succesfull ones will not accept to be told…
“Doctors still tell overweight people to eat low-fat foods, even though low-fat diets are associated with obesity and diabetes…The American Heart Association, for example, promoted a low-fat diet for six decades, despite a lack of evidence that fat causes heart disease.”
This leaves out the corollary that low-fat diets are by default high-carbohydrate diets. And that these high-carbohydrate diets are filled with ultra-processed “fuud.” Several years ago I spent about six months preparing a Grand Rounds presentation for our Department of Internal Medicine about the Diet-Heart Hypothesis (“Eat fat, get fat” in four words). Going into the lions’ den, so to speak, I wanted to be sure of the what the research really meant, without the dogma attached. The push back I expected did not come. Instead, the response was very favorable. But on the way out an internist with long experience said to me (paraphrase): “Very convincing, but we will still send our heart patients home from the hospital with a mandatory prescription for a statin and advise them to eat a low-fat diet (full of carbohydrates). And to exercise more.”
>>>>The American Heart Association, for example, promoted a low-fat diet for six decades, despite a lack of evidence that fat causes heart disease.
It wasn’t just “lack of evidence” is was manipulation of data by the original paper, see Robert Lustig’s book/speeches about sugar and heart disease, belatedly acknowledged by the NYT…
PS, the media is just as complicit too, not challenging the “star power” of the medical establishment
https://archive.nytimes.com/well.blogs.nytimes.com/2016/04/13/a-decades-old-study-rediscovered-challenges-advice-on-saturated-fat/
Thanks for this post.
“His most frequent call is for civil discourse…” [– from the tail of this post]
I think the lack of civil discourse so broadly displayed in the current political processes of the u.s. is a disease afflicting u.s. Society. Simple disagreement, correction, criticism … too often meets with rabid vituperation.
In June 1969 I was so weak I went to a hospital and their “doctor” said I had influenza of the muscles and would recover within a week.
One week later I was even weaker and the same hospital doctor shrugged his shoulders as to what to do. I told a friend who then referred me to his GP who asked me if I drank tap room beer. I affirmed I did, and his diagnosis was I had lead poisoning. By this time I was so weak I couldn’t even turn on the truck’s ignition with two hands, so I took an unpaid 30 day leave of absence from my truck driving job.
My mother’s GP’s diagnosis was I had a heart attack and would never be able to participate in sports again.
Nine years later my wife’s GP said my weakness was caused by mononucleosis. Ten years after that, I was diagnosed the Epstein Barr Virus (EBV) caused my disability.
Corporate interests have established near total control of the medical field, both through pharmacology and through their impact on medical education:
https://hannenabintuherland.com/usa/john-rockefeller-how-he-took-control-over-modern-medicine/
Whenever I see “disease”, “disorder” or “syndrome” tagged onto the end of a medical descriptive, the medical arts folks are admitting to those who pay attention, they don’t know what they are dealing with. One example of this is bi-polar disorder which at one time was called manic depression.
The bible of most shrinks is the DSM:
https://www.cchr.org/documentaries/diagnostic-and-statistical-manual/
“Isn’t it a bit unnerving that doctors call what they do ‘practice’?”
— George Carlin
The Viennese doctors who criticized Semmelweis‘s suggestion that “doctors should wash their hands before diagnosing patients” probably knew he was right, but they would have had to admit that they had killed their patients through ignorance if they had accepted his idea. For doctors who considered themselves omnipotent, that was intolerable.
And then there was and still remains Illich and “the social determinants of health”.
https://www.thecollector.com/ivan-illich-medical-nemesis-modern-medicine/
See also, “O’Mahony cites Illich and argues that many of his warnings of the medicalisation of life and death; runaway costs; ever declining value; patients reduced to consumers; growing empires of doctors, other health workers, and researchers; and the industrialisation of healthcare have come true.”
https://blogs.bmj.com/bmj/2019/02/13/richard-smith-most-devastating-critique-medicine-since-medical-nemesis-ivan-illich/
As for appendectomy…seems to me avoiding even 2/3 of them is arguably a very good thing….
Watching Youtube censor 2 doctors discussing a peer reviewed paper (IVM of course) was eye opening for me.
I no longer trust much of anything from industrial medicine. And as Chris Martensen notes “Now when I read a journal paper, I start with the conflicts of interest. And often go no farther….”
We’d heard about SARS CoV2 as Sikh coworkers isolated, returning from China. We’d researched astute Chinese, Asian, Italian then NYC HCW (on Twitter) & by the time of our 1st infection, had a list from Dr Weill’s folks @ UA & a French Canadian & African team, testing the regimen they’d used on SARS & Ebola. Here’s NIH, after five years of denial:
https://ods.od.nih.gov/factsheets/COVID19-HealthProfessional/
https://healthsciences.arizona.edu/connect/stories/integrative-medicine-doctors-offer-approaches-combat-covid-19
My Opinion.
“Nobody ever got fired for buying IBM.”
Or its corrollary “Nobody ever got fired for promoting the Iraq war.”
When you are dealing with a doctor, you are dealing with someone who had to spend over a decade to earn there qualifications, (and probably alot of debt). Further if the professional bodies above them decide, that MD can become useless. Why risk your life, dieing on a hill which you might be wrong on anyway.
100%. don’t hate the player, hate the game.
Yes, thanks for this interesting review! Then, there was Dr. Bernie Fisher, who showed that crippling radical mastectomies were not necessary. He should be a hero to all women, yet I never heard him mentioned and only found out about him from a book. Predictably, getting doctors to accept the new procedure was not easy.
I’m currently reading an excellent book by the scientist who discovered the PSA test, who reveals the vast money making machine in the USA for testing for and treating (and mistreating) prostate cancer patients.
Not only does he reveal that contrary to popular belief, the PSA test does NOT detect prostate cancer, and that it is also highly unreliable, but that the medical profession allows men to be frightened into getting unnecessary biopsies and prostatectomies (prostate removal) that do not have any supporting evidence to show they extend their lives or reduce mortality.
In the decades since the PSA testing began, the data just doesn’t show any benefit. But the mostly unnecessary prostatectomies cause immense suffering to the hundreds of thousands of men (and their partners) that have the operation, in terms of permanent incontinence and loss of sexual function! A secondary, highly lucrative industry exists to provide mostly ineffective treatments for these side effects.
The USA’s FDA continues to turn a blind eye to the abuse of the system, that makes millions for so many pharmaceutical companies and practitioners.
This is yet another case of commercial interests overriding health interests.
Blame the game and those who write the rules (and make the big profits). The doctors on the ground are just playing the game, doing what they need to do to remain insurable and licenced after spending 10-years and $200k to get a ticket to play. Yet another broken system operating to line the pockets of a select few.
Peer review is not just by like minded friends. It’s well known that any negative evidence of a treatment that makes money for the doctor (or their sponsor/employer) is given a LOT more investigation than anything fueling their confirmation bias, and it’s rare any paper has no flaws at all. Peer review also doesn’t tend to look at the raw evidence and way it was gathered, so a well analyzed and written paper of garbage data can still get published. So yes, the system is set up to not criticize money makers.
Mad in America, the book by Robert Whitaker covers the same group think and corporate influence in psychiatry. Whitaker has a blog with the same name. One issue he covers is anti-psychotic medications. We should also add the Sacklers and other corporate drug dealers to the list of bad medicine. And dental implants. My God, the world is not a safe place.