Blind Spots Reflection

In the past few years, I’ve observed a growing rift in medicine between the medical establishment and what I will call the “contrarians.” Of course, there have always been medical contrarians, but the COVID pandemic brought this divide to the forefront of our public discourse. The medical establishment is represented by the medical associations (AMA, AHA), government health agencies (FDA, CDC, NIH), medical journals (JAMA, NEJM), and most health systems - so basically the majority. Meanwhile, there are a small group of contrarians who are gaining social (and now political) influence by calling out where this establishment is leading the public astray. Some of them have strong academic and medical backgrounds, while others have none at all. Sometimes they get things right, and other times they spread mistruths and sow distrust in modern medicine altogether.

One such contrarian is Dr. Marty Makary, a surgeon-researcher at Johns Hopkins University. His 2020 book, The Price We Pay, had a major influence on me personally, motivating me to study how the misaligned incentives of our healthcare system lead to such high costs. So I was excited to listen to his new book, Blind Spots, which tells the stories of many cases where the medical establishment made egregious policy errors, resisted change, and failed to apologize.

The first and perhaps most clear-cut case is that of peanut allergies. In 2000, the American Academy of Pediatrics (AAP) responded to concerns about peanut allergies in children by recommending any child considered at high risk of allergies avoid peanuts for the first three years of life. While this recommendation may sound reasonable, it was in fact based on no rigorous evidence and indeed completely wrongheaded. Following this recommendation, peanut allergies skyrocketed in the US. This is because exposing children to peanuts and other potential allergens at a young age helps them develop a tolerance for such substances. 

Some researchers eventually conducted robust studies showing this phenomenon, but the AAP and the medical establishment resisted updating their guidelines fully until 2017. Makary points out that the original recommendation was made by a board of pediatricians, with no consultation from immunologists. He criticizes the way medical specialties are often siloed, as if the human body were split into isolated compartments.

Makary continues with cases ranging from hormone replacement therapy (HRT) to HIV in the blood supply to silicone breast implants. In the case of HRT, a handful of physicians used a non-statistically significant association to convince the medical establishment that HRT caused breast cancer. This resulted in a generation of women losing access to the many well-established benefits of this treatment during menopause, with no realized reduction in breast cancers. Despite the harm caused by their actions, the lead authors of this research went on to have very successful careers, faced no consequences, and never formally apologized for what they did. 

The tone of the book is annoyed verging on contempt. After quoting the questionable reasons people gave for promoting harmful polices, the author would often react sarcastically with, “Amazing.” Makary is clearly frustrated with the state of medicine in the US and wants the individuals and entities involved in these cases to be held responsible. Multiple times throughout the book he calls for them to own up to their mistakes and formally apologize to the public. He is convinced that this is an essential step for the medical establishment to regain public trust. 

Makary attributes blame for these cases to a few underlying factors. Namely, he cites psychological biases as critical ingredients protecting the status quo. For example, cognitive dissonance prevents physicians from accepting new information that challenges their long held medical beliefs and practices. Groupthink is another common issue preventing open-minded consideration of new ideas in the medical establishment. The perverse incentives and power dynamics among the medical establishment also help to explain these failures of medicine.

Just after finishing the book, I got a unique opportunity to see Dr. Makary and other medical contrarians make their arguments in a pandemic policy conference hosted by my own department, Stanford Health Policy. The program was marred with controversy from the start, as certain invited speakers declined to attend when they saw which medical contrarians were participating on the panels. The conference was organized by Dr. Jay Bhattacharya, the Stanford health economist who became one of the most (in)famous medical contrarians during COVID when he co-authored the Great Barrington Declaration, calling for focused protection of those most at risk from the virus, rather than blanket lockdowns. While I can’t defend every claim Dr. Bhattacharya made regarding COVID, in my view he was treated quite unfairly by the medical establishment, and over time more people seem to be coming to the view that lockdowns, particularly in the form of school closures, were not a great idea.

In the first panel of the event (which you can watch here), the topic was evidence-based decision making. Dr. Makary was sat center stage among seven panelists, including some of my professors. Each had a chance to share some thoughts before taking questions from the audience. I was pleasantly surprised to see that first question asked was the one I submitted - what was a policy you believed was best at some point during the pandemic, but later came to change your mind on? To my even greater surprise, Dr. Makary’s response to this question was “I can’t think of anything.” Amazing. For the record, in February 2021, Makary predicted in a Wall Street Journal article that COVID would be “mostly gone” by April 2021. Needless to say, that did not happen.

Let this be a reminder that our psychological biases run very, very deep. Daniel Kahneman, the renowned psychologist and Nobel laureate who discovered many of these biases was once asked if his familiarity with these innate tendencies helped him to overcome them - to which he simply replied, “No.” This is why it is so essential to have medical institutions that are committed to scientific principles rather than the opinions of a select few. No individual can be perfectly objective. We need systems that can course correct and reliably lead us to the truth.

Ultimately, I agree with many of the points Makary makes in this book. The medical establishment should apologize when they get things wrong. Perhaps more importantly, the medical associations and agencies should admit when they don’t know things and avoid making sweeping policy recommendations based on weak evidence. Medical journals should not politicize themselves by endorsing candidates, and they should publish research based on the merits of its methods, not its conclusions. 

I’ll conclude with two key takeaways I have from this book. First, some of the most important discoveries in medicine were made by people who were once considered contrarian, so we should never write off an idea just because it doesn’t fit into mainstream thinking. Second, if it is the case that we are currently getting something very wrong in medicine, be it fluoride in the drinking water or the long-term side effects of certain vaccines, our current system is not well-suited to uncover these truths. This is something that should concern us all. Marty Makary has recently been nominated to become the next FDA commissioner, while Jay Bhattacharya is set to run the NIH. If they are confirmed, I hope they take these lessons to heart and steer us in the right direction.