In Search of a Second Opinion

When patients turn to professional societies like the AMA or the American College of Physicians or the American Association of Pediatrics for vital health information, one might expect that the information is based on publications in prestigious medical journals of carefully designed and meticulously interpreted studies. Dr. Marty Makary, in his book Blind Spots, shows how wrong these assumptions can be.

Makary is a frequent commentator on health-related topics. He is a surgeon and surgical oncologist at Johns Hopkins Hospital. Blind Spots consists of several examples where the medical establishment has perpetuated a myth often based on a single academic’s opinion that became ingrained in the culture as "truth" despite the flimsiest of evidence. Using examples like avoiding exposure to peanuts in infants, producing an epidemic of peanut allergy, or denying the benefits of hormone replacement therapy in perimenopausal women, resulting in premature deaths and suboptimal health outcomes, Makary proves his case against groupthink in medicine. He goes on to rail against the overuse of antibiotics because of their potential for altering the microbial composition in the GI tract. Recent research shows that this effect of antibiotics may contribute to serious complications, including risks for cancer and cardiovascular disease.

Another section recounts the saga of the treatment of ulcers of the upper GI tract. Ulcer disease was treated as a neuropsychiatric disorder that required behavioral modification and buffering stomach acid to prevent recurrences. The evidence that a particular bacterium caused stomach ulcers was known for several years, but the medical establishment resisted this insight simply because it flew against conventional wisdom. Eventually, Dr. Barry Marshall won the Nobel Prize in medicine for the discovery. He had to induce his own ulcer disease by ingesting the bacteria that he identified to finally convince the skeptics.

Makary also visits the controversy about so-called gender-affirming care for children. This treatment involves drugs that prevent children with confusion about their sexuality from experiencing a normal puberty, administers sex characteristic-altering hormones, and even life-altering surgical procedures like mastectomies. He quotes some of the most thoughtful critics of these procedures, such as Lisa Littman, who first identified the phenomenon of the rapid onset of gender dysphoria when teenage girls first encounter the earliest phases of puberty. Despite overwhelming evidence that she was correct in her idea that these children had a temporary form of juvenile angst, she was effectively "canceled" because the concept undermined the theory of an underlying biological basis for the psychological disorder.

Gender-affirming care is yet another idea that falls into the category of dangerous treatments accepted by the medical establishment despite ongoing proof that it harms many children. Sadly, almost every major American medical society supports gender-affirming care for these troubled children, while several European nations have examined their own experience with this therapy and the published medical evidence with an open mind and now severely restrict its implementation.

Readers will find this book interesting if they have not had much of a background in biomedical science. It is clear, concise, and well-documented. They may ask a few more questions at their yearly checkup, and that is a good thing.

Why do these wrongheaded approaches to medical care exist, and what can be done to prevent their perpetuation? Makary describes the phenomenon of maintaining a closed mind in the face of contravening data but never quite gets to the originating cause of this attitude in the medical establishment. He does make a strong case for the benefit of classical liberal principles, such as freedom of speech and willingness to confront hierarchies as antidotes. But at a time when conformity and groupthink seem to have taken hold of the most recent generations of physicians, Makary nonetheless praises the current young generation as including vigorous disruptors who will challenge the medical status quo. But has he watched the cult-like recitations of new medical students at their white coat ceremonies about land acknowledgments to indigenous people and obeisance to the oppressor/oppressed paradigm of "systemic racism"? They don’t seem likely to challenge anything.

The unwillingness to have an open mind when examining controversial topics or confronting new information suggests a deeper problem. The problem is, in large part, the culture of medical education. More and more, physicians are taught and regurgitate the "facts." Medicine has increasingly focused on doing rather than knowing. The monetary rewards are skewed toward performing procedures and tests. Understanding basic disease mechanisms or evaluating the quality of medical studies are less valued. This is not a new problem, and Makary cites examples of physicians ignoring best practices or new knowledge in favor of traditional approaches going back centuries. It is easy to understand how this attitude predominated in the era when medical science was primitive, and all that existed was opinion. But modern medical science allows physicians to approach clinical problems with a deep understanding of the mechanisms of disease and underlying biomedical science. Despite this, the failure to improve the closed-mindedness is ongoing. The problem has become more acute given the recent trend in training medical students to be social justice warriors rather than rigorous clinical scientists.

Medical students now learn almost exclusively through taking practice exams and studying the answers to the multiple-choice questions that make up the exams. It is virtually unheard of for students to be assigned textbooks or even specific articles in the medical literature and then asked to interpret the information. They chafe when presented with basic science information if its clinical relevance is not immediately obvious. Yet such knowledge is crucial to good medicine.

To develop independent thinking among physicians, the medical curriculum should develop critical thinking skills about biomedical topics, and students recruited to become physicians should be those who embrace such an approach. Instead, students are increasingly chosen based on their agreement with theories of "systemic racism" and "social determinants of health" rather than their potential to become clinical scientists.

Makary believes that among the current crop of trainees are those who will disrupt the modes of thinking that produce the wrongheaded outcomes he describes. I fear he is wrong in his prescription. I think a more active intervention is needed. Undergraduate and graduate medical education need a reform agenda. Deep learning on experimental design, data interpretation, critical reading of the medical literature, and understanding the philosophy of science should replace the many hours currently spent trying to turn young physicians into social workers.

Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health
by Marty Makary
Bloomsbury Publishing, 288 pp., $28.99

Stanley Goldfarb is an emeritus professor of medicine at the University of Pennsylvania and father of Washington Free Beacon chairman Michael Goldfarb.

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