How Medical Groupthink Produces Disastrous Results: Dr. Marty Makary

We've got to recognize now that best practices are exactly opposite of what the medical establishment pounded into pediatricians for 15 years. Dr. Marty McCary is a surgeon, a professor at Johns Hopkins University, and author of Blind Spots, What Medicine Gets Wrong and What It Means for Our Health. But the medical establishment created a dogma in 1955 that fat was bad for your health. It was based on one guy, Dr. Ansel Keys. In this episode, we explore the culture of medical groupthink and cases where health recommendations have produced disastrous results. Why are there doctors practicing today with C-section rates of 70-80% in low-risk deliveries? The foundation of the medical profession is not to have a one-size-fits-all. It's always to consider nuance and to consider scientific detail. This is American Thought Leaders, and I'm Jan Jekielek. Dr. Marty McCary, such a pleasure to have you on American Thought Leaders. Good to be with you, Jan. Thank you. Blind Spot, you make the case that groupthink is actually one of the biggest health issues that we have. Groupthink is a huge problem. It creates bandwagon thinking, and in the field of science, it creates dogma that can take on a life of its own. It turns out that dogma can do far more damage than some of the good that's discovered in medical science. You come up with a huge number of examples, decades of bad policy developed out of initially an erroneous finding, but then develops the common denominator, is this groupthink or orthodoxy that develops afterwards. I'll just use one because this is I've known about for quite some time, but it still seems to be an issue. Peanuts. Well, you're so right. When we as a medical profession use good scientific evidence to make health recommendations, we shine and we help a lot of people. But when we rule by opinion and issue these edicts based on the opinion of a small group of oligarchs in medicine, we have a terrible track record with health recommendations. The peanut allergy epidemic today, by and large, was ignited by a bad recommendation about 24 years ago by the American Academy of Pediatrics. Creating an illusion of consensus, they put out a recommendation that all mothers and children zero through three years of age should avoid peanuts. All mothers who are lactating, all mothers who are pregnant, and children zero through three years of age should avoid peanuts altogether. Total peanut abstinence was their idea on how to prevent a peanut allergy from developing. Turns out they got it perfectly backwards. They forgot about a basic principle in science called immune tolerance. Mothers had known it as the dirt theory. When you're around something in infancy, your immune system learns not to see it as foreign and you don't become sensitized and allergic to it later on. Because of this catastrophic wrong recommendation by the American Academy of Pediatrics, putting out their gut feeling to avoid peanuts with no scientific evidence and put it out with such absolutism that everybody needs to do this, we saw peanut allergies skyrocket. And as this happened with the new recommendation, they thought, well, we just got to get more compliance. We got to double down. If we're going to beat this epidemic, we have to get more people to comply. Mothers that fed their infants a little bit of peanut butter to develop some immune tolerance to it were seen as anti-science and spreading misinformation and uneducated. Turns out they had a lot of wisdom. And a group of doctors who had disagreed with this big recommendation were basically sidelined. They were silenced. Ultimately, the science caught up with this bad recommendation into a very severe peanut allergy epidemic where we now saw a new type of allergy common, a severe anaphylactic reaction. That is a kid is just near a peanut. They don't even consume it. They're near it. They can go into a life-threatening anaphylaxis. And so finally, the study got done, a randomized controlled trial. They took 640 kids, randomized them to peanut abstinence in the first few years of life or early exposure to peanut butter in the first several months of life. And there was a markedly radical difference in peanut allergy development later in life. And the scientists believe it's the same for milk and eggs and many other things that should be introduced a little bit early in infancy. The study that was eventually published in the New England Journal was embarrassingly simple to do. They could have done it before they put out their recommendation with so much absolutism. And when you get it so perfectly wrong, where's the humility to then issue a correction with the same vigor by which the initial recommendation was put out, really spreading misinformation. And this dogma still lives to this day. We still suffer from a terrible peanut allergy epidemic. Schools have now banned peanuts. And it became a vicious cycle because the more you had to avoid it for those sensitive, the less immune exposure infants got for the next generation. And we created this crazy self-licking ice cream cone, which was perpetuate dogma and address it by more dogma. The science is now clear. The American public deserve an apology. And this is one little peek into a broader medical establishment that can put out things with such absolutism as if it's based on scientific evidence, when the reality is it was just an opinion. So I guess the solution right now is to expose kids in their infancy to peanuts. We still have to watch out for the older people, some of whom have these potential anaphylactic reactions. Kids have real peanut allergies, and they're often downplayed, but they are real. I mean, people should not mock them. They shouldn't ignore them. A kid can die from getting an ice cream serving from a scooper that was in a pistachio ice cream bin before they were served their non-nut-based ice cream. And so we've got to be sensitive, but we've got to recognize now the best practices are exactly opposite of what the medical establishment pounded into pediatricians for 15 years. The best practice is to introduce a little bit of peanut butter at four or five, six months of age when a child is an infant, and milk and eggs. And some pediatricians say it's good for them to be around dogs and cats in the first year or two of life. A basic concept of immune tolerance was known at the time, but it was ignored by the hubris of the medical establishment. And it's not just peanuts. Well, so this is what I was going to say. I mean, anything that's sort of prevalent in society, like any kind of item that you would expect someone to get regular exposure to, like milk, eggs, and so forth, would be something that you would want to give in small amounts early on to sort of get the child ready for the future. Yeah, it's best practices. It's good parenting. And if you look back a generation or two, this is what grandparents were teaching for a long time. In their wisdom, they had known it's good for a kid to be around some of these exposures safely. We don't want kids to consume whole peanuts. It's a choking risk. But do you know that they use peanuts in soups in Africa? And Africa has essentially no peanut allergies. The United States has the worst peanut allergy epidemic in the world. It is non-existent in Africa. I've got students from Africa who've described this to me when I did the research for the book. But they said the few people in Africa that have peanut allergies are American and UK expats who are living in Africa. They grew up with that incorrect dogma, the misinformation put out by the medical establishment, parroted by everyone. And as a result, the United States has the worst peanut allergy epidemic in the world. It's expensive, a lot of emergency room visits, lives lost, tragically young, healthy kids otherwise. And the expense of EpiPens in every school in America and these expensive treatments that are also very uncomfortable for kids. We just got a new drug approved for peanut allergies in the United States this year. So the story of the American peanut allergy epidemic is really a broader story of the arrogance of a medical establishment saying things with such absolutism when the truth is that the right answer when people wanted to know what causes peanut allergies was, we don't know. And you saw that during COVID and so many other different times in American modern history. The right answer from the medical establishment should have been, we don't know. That's just generally very hard for people to do as we've been discovering over how many years and not just in the medical field. If you're an expert, you're kind of expected to give an answer. Yeah, and I interviewed the people who made some of these recommendations for peanut avoidance. And I wanted to see if they had some humility, felt terrible about it and what their rationale was. And while some of them did feel bad, most of them were very arrogant about the recommendation and justified it. And one of them even basically told me the public was asking us what causes peanut allergies. And we felt like we had to tell them something about what to do. And my thought was, no, you don't. You can say we don't know. That's okay. The public is very forgiving if you're entirely honest. If you're making stuff up, then they're going to perceive that you're lying to them. And that's why we have this epidemic of distrust in the United States of the medical profession. Dr. McCary, we're going to take a quick break right now, and we'll be right back. And we're back with Dr. Marty McCary, professor at Johns Hopkins and author of Blind Spots. Let's talk about the psychology of this, because a central thread is the blind spot. And where does that come from? It's not just the peanut allergy dogma that we got wrong for 15 years in modern medicine. We got the low-fat diet wrong for 60 years. We got opioids or non-addictive wrong for 30 years, igniting the opioid epidemic. We got hormone replacement therapy wrong for, we're still getting it wrong for 22 years, incorrectly telling women that it causes breast cancer, resulting in needless suffering in the post-menopausal population. So again, when we use opinion and just make a recommendation based on a gut feeling, we don't have a good track record. We've got to get back to the scientific process. And in order to do that, you've got to have impeccable objectivity. It's not just in science, in business, in politics, in management, in relationships. You've got to be objective. You've got to have humility to recognize what you believe may be wrong. And no one studied this more than Dr. Leon Festinger in the 1960s. He created the term based on the idea that you were dissident or uncomfortable. Dissidence essentially means discomfort. You had this internal conflict if there were two ideas that were in your brain competing for truth. If you had believed something because you had heard it prior, that belief then occupied your brain. And it was very happy because it had no competition from other ideas. But when a new idea comes along, it then challenges the idea that's currently in your brain. And that conflict is very uncomfortable. People don't like it. Human beings resolve that conflict in a very passive subconscious way by ignoring the new information, even if it's logical, by reframing the new information to make it fit what you already believe, or reframing what you already believe to say, yeah, it's basically the same thing. For example, if we say that smoking can kill you and you're an avid smoker, you might say, well, that's in people who smoke their whole life. I just smoke one or two cigarettes a day, and I've only done it for 10 years. You try to reconcile two opposing ideas in your mind by reframing them. And we do this all the time in society. You see it in politics. In medicine, we tend to have these belief systems, and we get afraid to challenge them. But the purpose of science is to challenge deeply held assumptions in the field. And in the field of psychology, they've described this dissonance by doing some experiments. They took college kids, Dr. Festinger and his colleagues took college kids and had them do a very tedious task of putting pegs in a board. It was an hour-long task. It was designed to be boring and not fun, and a bit of a disappointment. And they paid people to do this. The students were paid either $20 or $1. And then they asked them, did you enjoy the task? And guess who enjoyed it more? The students who were paid $1. Because they had to justify that they did this incredibly boring task somehow. So the way to reframe this experience was to say, well, it must have been enjoyable, because it wasn't that lucrative. In order to justify what I did by saying I believe that I want to do this, you have to make it enjoyable in your brain. And another experiment by Aronson and Mills, they did this famous experiment where they said that there was a sex talk to attract students to come listen to. You had to take an entrance exam. And they were divided into three groups randomly. They didn't know what the other person had as a requirement. One group had a very hard exam. Another group had an easy exam. And the other group had no exam. Then they gave them the sex talk and made it as much of a disappointment as you could possibly design. They basically said, bees get together and multiply. And then they asked the students, did you enjoy the talk? And guess which students enjoyed it the most? The one who had the hardest entrance exam. Because they had to justify that effort, what psychologists call effort justification, having done that difficult exam. And that's why they claimed that the exact same experience their colleagues had was more enjoyable to them because they had taken the exam. And then this theory of cognitive dissonance, or sometimes what's known as the founder's effect, you believe what you hear first, not what's most logical. It was very sort of accepted in a theoretical realm, but it had no real world data. So Festinger was sitting home one day and read in the newspaper that a cult was organizing to meet because they believe that they were going to be picked up by aliens in a spaceship on a particular day and time and location. And so he went and traveled into this Illinois-based cult and embedded himself in the cult. And if his theory of cognitive dissonance and the founder's effect were true, when the spaceship did not come, they wouldn't abandon their views. They would dig in even deeper because they had to stick with their belief system and new information had to be reframed or ignored or somehow changed. And sure enough, that's exactly what happened. Somebody claimed that the clocks were wrong and maybe the aliens were still going to come and everyone got excited. They would sort of justify why the aliens were late and that prophecy was still true throughout the entire evening. And by the morning they had claimed that they got a revelation that because there was a lot of light shining from the cult, the aliens had changed their mind. You would think that this would result in people abandoning their belief system, but they didn't. They became more evangelical and more deeply rooted. And one member of the cult who was a doctor said in very plain English I can't abandon this belief system. I have everything in it. My life, my family, my job, my career, everything is invested in this belief system. I can't possibly give up on it now. We have a human tendency to want to cling to our belief system, not because it's more logical or correct, but because we held that view first. I see it almost every day now that I'm aware of it from doing this research for the book. And what I noticed is that on my research team at Johns Hopkins, people will suggest research ideas and I'll tend to dismiss it a little more readily than I should. And I realized this is the founder's effect and I've got to be aware of it. Now, the father of modern medicine, Claude Bernard, said, we have to recognize that we all have biases. It's part of the human condition, but you have to be aware of your bias. And when you receive new information, as in the scientific process, you have to actively and temporarily suspend your biases, being aware that they're there, and try to objectively assess new information as an active process. And there's probably no other more prophetic words from the modern era of hyperpolarization and deeply entrenched views than the words of Claude Bernard, and even specifically to the medical science community itself. Absolutely fascinating. You're reminding me, I remember being told of the person who originated the ice pick lobotomy, which turned out to be a very bad procedure, wasn't really helping people. But from what I understand, this person traveled later to try to look at some of his patients and the level of this cognitive dissonance was so strong that he couldn't see the damage that had been done. He recorded his experiences with them and he believed that they had been helped. You're familiar with this story? Yes. A lot of damage was done. It was, again, medical dogma and people hold on to it. And it's not that doctors are bad people or diabolical. Every doctor I know is trying to do the right thing or always tries to. But we have good people working in a bad system. And this groupthink mentality creates a herd thinking where people are not encouraged to think independently. There's a culture of obedience to get in line. Well, every major scientific discovery has come from somebody challenging a deeply held assumption, challenging a dogma of the day. But you see this cognitive dissonance play out. I had a colleague who, when a study came out showing that you don't need to treat appendicitis with surgery 100% of the time, two-thirds of the time, you can manage the person without surgery. You follow them closely, give them a short course of antibiotics, and you don't need to do surgery. It's an amazing discovery. And there was a great study done that shows not only are you avoiding the pain and suffering and the complications, but the cost. We have a nursing staffing crisis in the United States. That helps. It decongests our operating rooms. It enables us to focus on other sick patients. It's an incredible research study. And when it came out, I remember asking a colleague, and he said, well, I don't buy it. I need to see two randomized controlled trials. Then a second randomized controlled trial came out. And he said, well, I need to see three randomized controlled trials. And a third one came out. This is incredible data, long-term follow-up, top medical journals. And then I went back and showed him the third trial, and he said, well, you know, I just still think it's just better to take them all out. You see this cognitive dissonance playing out right in front of my eyes. There is a group of us that are interested in the redesign of medicine. We don't know what to call it. Is it functional medicine? It includes that. Is it holistic medicine? Not officially, but it is holistic. Is it alternative? Not really, but it includes alternative ideas. And so this group of doctors now are emerging in direct primary care. That way the employer is paying the bill and anyone can access it. Concierge medicine. We're seeing new clinics emerge for Medicare beneficiaries that are at no cost to the beneficiary. And I've a lot about these clinics in the book, The Price We Pay. But there is this opportunity now to connect with this new generation of doctors who are thinking about the redesign of medicine instead of just being on the hamster wheel, which nobody's enjoying at this point. Well, Dr. Marty Makary, such a pleasure to have had you on. Thanks so much, Jan. Great to be with you. Thank you all for joining Dr. Marty Makary and me on this episode of American Thought Leaders. I'm your host, Jan Jekielek.