Trusting that medical innovation, new ideas and practices are offered to the public through the support of concise and accurate study results, data, evidence and research should come naturally to us. We should be able to trust that the medical community are developing healthcare with a people-centred approach to save lives, heal and care for patients.
However, trust is earned and when we discover that a record 10,000 medical studies were retracted in 2023, that medical dogma has persisted with dangerous misconceptions about opioid use, peanut allergies, antibiotic use, the microbiome and more, how can we maintain that trust?
In the follow up to Dr Marty Makary’s bestseller The Price We Pay: what broke American healthcare and how to fix it published in 2021, his latest book, Blind Spots, pulls on the threads of some of the avoidable mistakes made in medicine, the “groupthink” attitude, and the medical dogma that has led to public harm without apology.
Blind Spots is validating for many in recognising that trust in medical establishments and medical personnel must be earned, but the medical elites have a history of eroding that trust with poor judgment and commentary, dangerous decisions and medical paternalism. Blind Spots is a frightening read in many ways and induces a lot of anger as Makary takes us through examples of some of the darkest moments in recent medical history.
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Throughout his commentary, Makary, a public health researcher and John Hopkins professor, delivers his understanding of these “blind spots” by dissecting the research, conversing with its authors, the teams involved, and discussing the impact of misinformation with colleagues across the spectrum of his career who similarly “noted the same patterns of medical elites ruling by edict and kneecapping the brave souls who challenged their dogma”.
To this day, the misconception and myths surrounding hormone replacement therapy continue and the benefits are largely ignored
There are harrowing accounts of what would now be deemed medical negligence, ineptitude and a violation of human rights such as the belief, as recently as the 1970s, that premature babies did not feel pain due to underdeveloped nerves. “Even major operations were done on preemies without anaesthesia,” Makary tells us before enlightening us to the fact that some were left in closets to die.
Furthermore, he shares that many premature babies “were given 100% oxygen, which was later found to cause blindness and even leukaemia,” while stating that many did not have any difficulty breathing and did not need such medical interference. And yet, this was the way things were done and, as such, remained standard protocol until challenged.
Some of the biggest recommendations in health have been reversed. Some we know about, such as the reversal of the consensus on peanuts, which once were believed to cause allergies in children after a loose interpretation of an American Academy of Pediatrics recommendation in 2000. There was also the belief that the surgical removal of the appendix was necessary to treat appendicitis. Today we know a short course of antibiotics, which goes against the decades of performing one of the most common operations in medicine, is a possible treatment option.
Makary goes into detail about the studies that changed opinion on the possibly unnecessary surgery but notes that despite the recommendations being reversed, medical dogma exists. As he says, for some, “it wasn’t a scientific view, it was a belief system”. Other necessary shifts in the medical field we are unlikely to ever be informed about until someone like Makary brings it to our attention. Medicine is political, and as with many controversies, politics can bury the evidence.
Challenging medical dogma, which Makary defines as “an idea or practice given incontrovertible authority because someone decreed it to be true based on a gut feeling”, does not come without its warnings for the medical profession. Medical careers have been destroyed, teams disbanded, funding pulled and research left on the hotplate to burn if challenged. Some of Makary’s colleagues no longer publish their research while the research of others gets “lost in a sort of Bermuda triangle”, going largely unnoticed.
While others who toe the line climb the ladder to enviable careers with the medical elite (many of whom, Makary notes, have fallen). Makary openly calls out associations and organisations that people turn to for knowledge, guidance and understanding. It is this little thing called trust again. If a doctor warns a pregnant mother to avoid peanuts for fear of a deadly allergy being passed to her newborn, and that advice is based on clinical research and apparent evidence pushed by a giant in the world of paediatrics, a parent will probably adhere to that guidance. And so, this was the case for 15 years after initial research was published and the American Academy of Pediatrics led a recommendation for children to avoid nuts altogether.
We now know the results were misconstrued and the lead author, Dr Jonathan Hourihane, a professor of paediatrics in Dublin, was not consulted on the guidance. So, how do we maintain a level of trust when mistakes are made but not rectified in a timely manner and no one is held accountable?
Women’s health is a strong conversation throughout Blind Spots, with observations on HRT, ovarian cancer, pregnancy and birth and more
Makary cites several studies including the Women’s Health Initiative debacle that led to a generation of menopausal women not availing of hormone replacement therapy (HRT) due to a misinterpretation of research leading to the conclusion that HRT causes breast cancer. The study, with a cohort of 16,608 women, was completed with Harvard and Stanford researchers and resulted in the shock announcement creating fear and unease among women and the medical profession.
To this day, the misconception and myths surrounding HRT continue and the benefits are largely ignored – not only does it alleviate the symptoms of menopause but HRT also reduces cognitive decline, lowers the risk of bone fractures, prevents heart attacks and delays the onset of Type 2 diabetes. “HRT saves lives,” says Makary and yet he explores the 20-odd years it took to challenge the medical hierarchy and advocate for women’s health that was consumed in deafening silence.
When researchers make breakthroughs in medical care, the expectation is that the data has uncovered some level of new thought that will lend itself to positively affect health outcomes. But Makary builds the story of how medicine gets it wrong and how that affects our health. He goes further into understanding the weaknesses of the peer-review process, the suppression of scientific debate and the silencing of legitimate advocacy concerns when the “medical elites” shout louder.
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He delves into the groupthink mentality of medicine, with one of his “greatest concerns” being the inability of today’s public health and medical experts to “think critically”. Groupthink, as defined by the author, is the “human tendency to follow a crowd and not think independently”, which “often creates an illusion of consensus”. Everyone believes it so it must be true.
Makary is simultaneously aghast at the misinformation perpetuated by those we trust and enchanted by the individuals who challenge not only the misinformation but the organisations protecting medical doubt. He encourages the reader to be as enthusiastic as he is about medical discovery while also questioning it. He notes his own innovations, including the co-development of the surgical checklist that is now used in operating theatres worldwide. Imagine if these standard checklists were not used. We’d certainly be apprehensive sitting in an aeroplane seat knowing the standard preflight checklist had not been completed.
A surgical checklist, while innovative, also seems like a common-sense prerequisite. And yet, we need innovators such as the author to put forward these ideas, to put patient care and advocacy first and not only search for the underlying evidence but scrutinise it to within an inch of its life before supporting a health recommendation – to fear getting it wrong or to simply say we don’t have an answer yet.
As Makary delves into the medical misconceptions and myths it is difficult not to see a pattern. Women’s health is a strong conversation throughout Blind Spots, with observations on HRT, ovarian cancer, pregnancy and birth and more. He goes so far as to highlight how there was a time when the medical profession was opposed to women doing their own pregnancy testing. A clear illustration of medical paternalism – when a doctor interferes with a patient’s understanding and ability to make decisions about their care. Lobbying for access to full medical records and test results, having the ability to conduct safe and reliable at-home tests, being offered healthcare options and patient informed care are all ways Makary challenges us to think, recognise blind spots in medical care and to choose good doctors.
Makary seeks to restore objectivity. He suggests that the public are hungry for civil discourse and says, “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”. He believes it is a case of “good people working in a bad system” and so encourages the reader to challenge the deeply-held assumptions of the medical hierarchy, to ask questions, look at the data, have open discussions about best practice, and consider the potential for bias in research. In short, be open-minded.
Further Reading
Random Acts of Medicine: the hidden forces that sway doctors, impact patients, and shape our health by Anupam Jena and Christopher Worsham (Vintage, 2024) A thought-provoking read on the use of natural experiments (random events leading to experimentation) to improve medicine and save lives highlighting the differences in how doctors diagnose and treat patients with similar conditions. In different environments and with specific data doctors will probably make individual judgments related to care.
Unwell Women: a journey through medicine and myth in a man-made world by Elinor Cleghorn (W & N, 2022) Elinor Cleghorn highlights the disturbing and misaligned medical treatment of women in this social commentary that evokes anger in response to the myths and misconceptions of women’s health. An important read for a generation of women who have battled the scientific, cultural and social history of medicine.
Viral BS: medical myths and why we fall for them by Seema Yasmin (Johns Hopkins University Press, 2021) Filtering the myth out of medicine becomes a little easier when guided by Pulitzer Prize finalist Seema Yasmin who draws out medical misinformation from the Viral BS. Yasmin entertains and gets practical when asked why bad science is believable and contagious.
