317 ‒ Reforming medicine: uncovering blind spots, challenging the norm, and embracing innovation

1. 0:00 – 1:10

   Intro

   1. MMMarty Makary0:00

      The father of modern medicine, Dr. Claude Bernard, he had said, "In science more than in any other discipline, you have to recognize that we bring biases to any question, and you have to actively suspend those biases as you take in new information so you have impeccable objectivity." And it's a lesson for everyone today. Unfortunately, I think we're going the other direction in science right now. We've got policing of, you know, misinformation. We've got, uh, this sort of culture of obedience in medical school that goes right down to, you know, th- uh, right down to your first day of medical school. So I, you know, I'm optimistic on the future of healthcare because enough people now are sort of anti-central authority, anti-corporate, and they're questioning things they didn't before, but this culture of just get in line and do what you're told is still a powerful force.

   2. PAPeter Attia0:57

      [upbeat music] Hey, everyone. Welcome to The Drive podcast. I'm your host, Peter Attia. [upbeat music] Hey, Marty.

   3. MMMarty Makary1:08

      Hey.

   4. PAPeter Attia1:08

      Thanks for coming in.

   5. MMMarty Makary1:09

      Good to be

2. 1:10 – 6:30

   The issue of groupthink and cognitive dissonance in science and medicine

   1. MMMarty Makary1:10

      with you, Peter.

   2. PAPeter Attia1:10

      Great to see you again, as always.

   3. MMMarty Makary1:12

      [laughs]

   4. PAPeter Attia1:12

      Um, so you've got a new book out, Blind Spots, and, uh, this is a book, I guess, I certainly remember talking about with you as it was kind of in the works. We've had many dinners together when some of these topics have come up. Um, do I take, can I take, like, 5% credit for the inclusion of HRT in this book?

   5. MMMarty Makary1:32

      No, you get 99% credit for that. That was incredible, and I cite it in the book.

   6. PAPeter Attia1:36

      That was a late addition, right, to the book?

   7. MMMarty Makary1:38

      That was, that tipped me off to do my own sort of investigative journalism, so I tracked down the people that made that initial announcement saying it caused breast cancer. And I pinned them down, and I went over the stats with them hard and finally got them to confess that it did not.

   8. PAPeter Attia1:54

      Yeah.

   9. MMMarty Makary1:54

      Uh, so thanks for, uh, tipping me off there and helping me shape the book.

   10. PAPeter Attia1:58

       So, you know, look, the, the book, the book is a great read, and it goes through, you know, a number of situations that all kind of have this theme in common, right? Which is an idea comes up. The idea's a bit shaky in terms of lack of evidence, um, which in and of itself is not really a problem. That really is the way medicine and science have to work. They have to start with ideas that we may or may not have great evidence for. But what, what sort of goes wrong? What, why, why [laughs] is there a book about this instead of, you know, a, a bunch of, uh, case studies of how everything has gone really well?

   11. MMMarty Makary2:33

       So there's a science to groupthink, and that's really what's going on a lot of times. It's the bandwagon effect. It's not just in medicine, it's in business, it's in politics, it's in relationships. People are s- dead set on an idea, not because they're convinced of it, but because they simply heard it first. And there was a psychologist named Leon Festinger who, uh, since passed away, but had written a tremendous amount of, um, material on this idea of cognitive dissonance. He really carved this entire discipline out in psy- psychology. And the idea is that the brain doesn't like to be uncomfortable with conflicting ideas. It likes to settle and be lazy with one thought, and so it's often the first thing you hear. And, um, so if something comes along that challenges your deeply held views or just what you've happened to heard b- before, there's this internal conflict. So what the body does is it will reframe the new information to make it fit what you already believe, or it'll dismiss it completely, kind of the modern day cancel culture. And, uh, so this happens in day to day life, it happens in human interactions, and it happens in medicine too. We get the, this sort of herd mentality. But the important thing is, in science is that the purpose of science is to challenge deeply held assumptions. And so that's something that I follow as a thread in so many areas of modern day health recommendations in this book.

   12. PAPeter Attia4:02

       And I, and I will come back to this because I think one of the take homes from this is not just the stories, but what a person can do going forward. But I would also have to say that, and maybe this is, you know, frankly, just a hard thing to hear, both as the author of the book, but as a person listening, which is how does an individual, like a normal person, navigate this, right? Like, I'll use myself as an example, not because I think I'm normal. I think I have, at my disposal, access to more information. I have a research team [laughs] that can help me answer questions.

   13. MMMarty Makary4:35

       [laughs]

   14. PAPeter Attia4:35

       And yet, if I was to challenge every idea out there that I held sacred, I'm not sure I'd get anything done.

   15. MMMarty Makary4:44

       Yeah.

   16. PAPeter Attia4:44

       So, so what's the balance in your mind between, you know, your doctor tells you something, kinda makes sense, right? Like on first... You know, it sort of just, it seems logical, at least plausible. Um, but technically you haven't done the thinking on it. Um, how do you, how do you, how do you not allow yourself to become a crazy conspiri ther- conspiracy theorist-

   17. MMMarty Makary5:08

       Yeah

   18. PAPeter Attia5:08

       ... who doesn't trust anything-

   19. MMMarty Makary5:11

       Right

   20. PAPeter Attia5:11

       ... and throws out what's 80% good in the pursuit of throwing out the 20% that's trash? How do you, how does one navigate that?

   21. MMMarty Makary5:19

       Right. How do you sift through that? It lo- it's, there are extremes on both sides, and then you see the pendulum swing, like with childbirth. You know? There's this overmedicalization of ordinary life, and then this swing back to avoid all doctors and hospitals and deliver at home with nobody, and that is, uh, that's a dangerous proposition. And so you see that frequently in the history of modern medicine. And for the everyday consumer out there, I think the flag should go up when something is put out there as a health recommendation with such absolutism as science, evidence-based, when really there's nothing to point to. That should be a flag for everyday folks. We don't want to create hysteria. We need people to trust doctors. I need my patients to trust me a lot of times, but asking questions is, should be part of the process. And I think You know, there are times when we are very slow as the, as a medical community to implement scientific evidence, and it's okay to educate the public on it. You know, there's a non-operative protocol for appendicitis

   22. PAPeter Attia6:24

       Yeah, which I, well, it's one of the things I wanted to talk about with you.

   23. MMMarty Makary6:27

       Okay. You want me to-

   24. PAPeter Attia6:28

       Yeah

   25. MMMarty Makary6:28

       ... uh, mention real briefly now, so-

   26. PAPeter Attia6:29

       Sure,

3. 6:30 – 13:22

   How a non-operative treatment for appendicitis sheds light on cognitive dissonance

   1. PAPeter Attia6:30

      yeah

   2. MMMarty Makary6:30

      ... the, you can, um-

   3. PAPeter Attia6:31

      Let's talk about how you and I learned to treat appendicitis, and what is appendicitis, first of all? Maybe give folks a sense of this.

   4. MMMarty Makary6:36

      Yeah, so inflammation of the appendix. An infection sets in, the sort of tight junctions break down, and bacteria from the colon will creep in there and infect the appendix. It becomes inflamed, gets into the blood system in late stages.

   5. PAPeter Attia6:51

      And, and to be- give sense to people a sense of this, I mean, what's the lifetime prevalence of this? And prior to any treatment, so 200 years ago, what was the mortality from, uh, acute appendicitis?

   6. MMMarty Makary7:01

      It was over 60%. Uh, Walter Reed, a famous physician himself, died of appendicitis. The hospital in DC's named after him. Um, so it was a common cause of death. Uh-

   7. PAPeter Attia7:14

      And the lifetime prevalence was not that small. It was, like, 7% or something.

   8. MMMarty Makary7:17

      I thought it was five, but yeah-

   9. PAPeter Attia7:18

      Yeah

   10. MMMarty Makary7:18

       ... probably in that range. Um, and so-

   11. PAPeter Attia7:21

       Think, think about that, right? There's a one in 20, one in 18 to one in 20 chance you'd get an infection of your appendix, and a 60% chance that if you got it, it would kill you.

   12. MMMarty Makary7:29

       Yeah. [laughs] I mean, it was, it, it still is one of the most common operations performed in American hospitals, and we have learned as a reflex as surgeons, uh, when you were at Johns Hopkins, you did this many times. We, we may have been in the operating room together.

   13. PAPeter Attia7:45

       We did many together, yes.

   14. MMMarty Makary7:46

       [laughs] And, um, so as a reflex, you learn to take out the appendix. You do it swiftly. You do it with a laparoscope as of the last 30 years or so. And, um, heck, pre-med students are l- you know, know this. This is like we, we'll take the interns through the case. This is a reflex. We don't even think about it in the hospital. So it's been one of these easy things, like diagnose, treat, diagnose, treat. Diagnosis used to be tricky 'cause it can present a lot of ways. Now the CAT scan just points out the bullseye, and you go to work. You call the team, mobilize, high-five each other after the case, talk to the family. It's a quick, great case for a surgeon and a surgical trainee. Well, then a study came out showing that you don't need to operate, and a short course of antibiotics is 67% effective in patients that don't, that come in with appendicitis if the appendix is not ruptured or there's no little stone, what we call a fecalith in the appendix, which is the vast majority of people don't have rupture or a fecalith. So here's a discovery that really shook up the whole field of modern surgery.

   15. PAPeter Attia8:56

       So just to make sure folks are following us, the study said, look, if you're in the majority of cases of appendicitis, it's not yet ruptured, and it doesn't have an obvious mechanical cause, um, you can, instead of taking a person to the operating room, which is low risk, but not zero risk, you're still subjecting a person to general anesthesia.

   16. MMMarty Makary9:14

       That's right.

   17. PAPeter Attia9:14

       Plus, there's the cost associated with surgery.

   18. MMMarty Makary9:16

       Yep.

   19. PAPeter Attia9:17

       Um, you're saying that you can get 60 to 70% the same outcome if you give them an antibiotic, and if they don't respond to the antibiotic, then you'll take a third of those people otherwise back to surgery?

   20. MMMarty Makary9:28

       Yes, exactly.

   21. PAPeter Attia9:29

       Okay.

   22. MMMarty Makary9:29

       And of those that, um, uh, do not, um, the, o- of those who respond well to the antibiotics, it's something like high 80% will respond it to the initial course of antibiotics. A small fraction, maybe 12%, will come back with recurrent symptoms in the first month, and say, "Hey, I s- I got that pain back." And then you go to surgery for them.

   23. PAPeter Attia9:50

       Yeah. So the total cure, though, is about two-thirds-

   24. MMMarty Makary9:52

       Two-thirds

   25. PAPeter Attia9:53

       ... of cases.

   26. MMMarty Makary9:53

       And you don't get behind the eight ball. It's not like, oh, you know, well, we watched it with anti- we gave a short course of antibiotics, watched it, and now it's so far along we can't do anything, and the patient is far worse. They've done the long-term follow-up.

   27. PAPeter Attia10:06

       Yep.

   28. MMMarty Makary10:06

       So, and it's not just, you know, you made a good point about the cost and the other thing, but the patient, uh, doesn't have to go undergo an incision, anesthesia, risk of infection, risk of hernia, all the minor risk, but they're present. The carbon footprint of the hospital, the amount of waste produced, the nursing staffing resources. I mean, the wait list at a hospital every night in every hospital in America has cases that are waiting to go, and typically there's an appendix or two on that list.

   29. PAPeter Attia10:36

       And sometimes these are operations that are gonna be done in the middle of the night anyway.

   30. MMMarty Makary10:40

       Yeah. We've got a nursing staffing crisis.
4. 13:22 – 17:53

   How cognitive dissonance and effort justification shape beliefs and actions

   1. MMMarty Makary13:22

      embedded himself into a cult to prove his theory correct. A cult, uh, that met in Chicago believed that aliens were gonna pick them up 'cause there was gonna be a great flood on a certain day, a certain time, and he read about this in the paper that they were assembling to be picked up by this spaceship, and he realized, "This is the real world example of my theory of cognitive dissonance, why we cling to what we ho- believe first, and we're not open-minded to be objective."

   2. PAPeter Attia13:52

      So, so the, the thing he wants to test is when the aliens don't come-

   3. MMMarty Makary13:57

      Yes

   4. PAPeter Attia13:58

      ... to rescue of, of the people that were the firm believers, how many will say, "Oh my God, how stupid was I to think this?"

   5. MMMarty Makary14:06

      [laughs] Right, right.

   6. PAPeter Attia14:07

      Versus-

   7. MMMarty Makary14:08

      Right

   8. PAPeter Attia14:08

      ... what will be the set of stories that get spun to explain why their belief was still right?

   9. MMMarty Makary14:14

      Sounds like you, you somehow knew that the aliens did not come and pick them up. [laughs]

   10. PAPeter Attia14:18

       I was able to make the leap of faith that the aliens indeed did not come.

   11. MMMarty Makary14:23

       So they didn't come that night, and he was there in the room with all the cult members. And somebody says at 12:05, 'cause the pickup was supposed to happen at noon, and they had removed their belts and medals for the flight and everything, and [laughs] they, somebody says, "Oh, the other clock is wrong. It's really 11:55," and everyone gets excited. And there's this denial and denial through the night. And then in the morning, basically, it, you know, it, it was obvious it did not come true. And they did not abandon their views. They dug in deeper. Those who had a little belief, they thought, "This is nuts," and they just left. But there was a physician that Festinger spent time with, and he writes about it in his book called When Prophecy Fails, where the doctor said, uh, just openly once, almost in a, a Freudian way said, "You know, I just have so much vested in this now at this point. My job, my family, my friends, everybody knows I'm so into this. I, I have to hold on." And Festinger watched in plain view what we all experience in a subconscious way, and that is this resistance to new ideas, and you see it in politics and business and everything else, and it was really amazing. Um, it's a theory that's now well accepted as cognitive dissonance, and it's tied closely to effort reporting... uh, effort, um, justification. That's the concept in psychology. And that is, hey, I'm vested. I've s- spent all this energy on it. It must be good or justified or, or... And we do that with our surgical residency, fraternity hazing. It fosters this cycle of abuse. And, um, in the examples by, I think their name was, uh, Aronson and Mills were the two psychologists right after Festinger around that time, and they took college students and they said, "Hey, we're gonna have you do this task. We're gonna pay you for the task. You take little pegs and you put them in," the most tedious, boring thing you can design.

   12. PAPeter Attia16:27

       Mm-hmm.

   13. MMMarty Makary16:28

       Um, and, uh, they paid them so- half of them 20 bucks and the other half $1 to do it for an hour. Which group said they enjoyed doing the task more?

   14. PAPeter Attia16:40

       The group getting paid a dollar.

   15. MMMarty Makary16:42

       The group getting paid a dollar, because they had to justify.

   16. PAPeter Attia16:45

       To justify. Yep.

   17. MMMarty Makary16:47

       And, um, they did another experiment where they said, "Hey, we're gonna have a sex talk, and you have to take an entrance exam," and there were three groups that took the entrance exam. One, they, uh, had an entrance exam that was incredibly difficult. They didn't give them the results. They just said, "Okay," you know, "You passed." The other had a moderate exam, and the other one had no exam. Then they had the talk, and it was the most boring, disappointing letdown you could possibly... They basically said, "Yeah, bees get together and multiply." And they're just kinda like, "What?" You know, "This is what we tried hard to get in for this class?" And then they asked them, "Did you enjoy the class?" It was designed to drive you nuts bored, and the... Guess which group said they enjoyed it the most.

   18. PAPeter Attia17:32

       The one with the hardest test.

   19. MMMarty Makary17:33

       The one with the hardest test. And this plays out in our lives every day. Now that I've read these studies and have written about them, I think about this in our research meetings when new ideas get suggested, when people ask me if we should do it a certain way. You know, we've got these traditions and dogmas in medicine that can take on a life of their own.

5. 17:53 – 26:15

   How misguided peanut allergy recommendations created an epidemic

   1. PAPeter Attia17:53

      So let's talk a little bit about peanut allergies. Um, probably everybody listening, uh, is, is no stranger to a peanut allergy. In fact, there's, uh, I, I don't know what the prevalence is, perhaps you do, but, but it's quite prevalent. So there's, again, the probability that someone listening to this doesn't either have a peanut allergy or knows somebody with one is probably close to zero. Um, so let's talk a little bit about this. Has it always been this way? Um, and if not, when did this, um, when did this become an epidemic?

   2. MMMarty Makary18:22

      Well, it really is an epidemic, and it's tragic, and people can go into severe anaphylaxis just being near a peanut without even ingesting the peanut. In 1999, Mount Sinai did a study and estimated the prevalence to be about half of 1%, and the vast majority were very mild. And it's, there are many theories as to why that might have crept up from zero, uh, generations prior, but, um, the American Academy of Pediatrics decided to address this problem by issuing a recommendation. Now, they didn't know what to recommend. They honestly literally had no idea what to recommend. I went back and interviewed some of the individuals who made that recommendation. It was a strong recommendation. Even if it wasn't made with such absolutism, it was interpreted as the law of the land, and the recommendation was for all children zero through three to avoid all peanut products, including the little peanut butter moms would put into food in infancy. And, [lip smack] um, pregnant mothers and lactating mothers should also avoid 100% peanut abstinence. And what happened immediately after that recommendation in the year 2000 is peanut allergy rates in the United States began to soar, and we saw a new type of allergy, which is the severe anaphylactic reaction, the ultra, um, allergy where if someone used the same ice cream scooper as in the pistachio, even though they had rinsed it, that kid could end up in the emergency room. And we saw emergency room visits skyrocket. So the American... So the medical establishment, the elites, I'll say, not the rank and file doctors that think independently, and a lot of them, the rank and file doctors knew they just made this up, and some were, had immunology backgrounds and knew this doesn't fit with immunology. In immunology, you need to be exposed to things early in life to be immune tolerant, something called oral and immune tolerance. Parents have known it as the dirt theory sometimes, that you're around cats and dogs.

   3. PAPeter Attia20:26

      Kids that play in dirt, yeah.

   4. MMMarty Makary20:28

      Yeah.

   5. PAPeter Attia20:28

      Get, develop a robust immune system.

   6. MMMarty Makary20:30

      Yes.

   7. PAPeter Attia20:30

      They're healthier later in life. Bubble kids end up getting really, really sick later on.

   8. MMMarty Makary20:35

      There's a, um, pediatrician named Gideon Lack who's an allergist who was one of these enlightened guys early on, and he, he said he noticed kids that had, um, I think it was like iron or a metal in their teeth for dental work, were less likely to get a reaction to ear piercing later in life. And so he had done research in immune tolerance and knew this concept. If you're exposed to something, you're less li-... Well, a bunch of pediatricians detested this recommendation, tried to speak up. They were basically silenced or sidelined, and this rec- recommendation took on a life of its own. Parents were told for their kids, "Remember one, two, three. At age one you can introduce milk, at age two eggs, and age three, finally, you can introduce some peanut products." So it became known as the one, two, three. It took on a life of its own. It became dogma. As the peanut allergy rates soared, the medical establishment said, "What's going on here? We're telling people what to do. They're not listening. We need to double down. We need to get people to comply. We have non-compliant parents out there. If we can only get everyone to comply with this, we can defeat this epidemic." If you can hear little echoes here of, of modern-day correlations. So this doubling down took place, and the more they doubled down, the worse it got to the point where now there's an estimate that one eight- one in 18 kids has a peanut allergy. But the severe peanut allergy is the real issue now, where it's banned in a lot of schools. About 20% of schools in America have banned all peanut products altogether. And the more you ban, the less exposure, the more immune sensitization, 'cause now you have to think about the one in 18 kid with an allergy. So it became a self-licking ice cream cone. It was like, you know, more abstinence, more abstinence. What are you doing? And the parents who were like, "No, I'm gonna introduce peanut butter as my grandmother did, and for generations when there were, were no peanut allergies," they were seen as anti-science. They were ridiculed. Uh, schools would address these parents sometimes. I have two, uh, medical students, or well, graduate students doing research in my research center at Johns Hopkins from Africa. Um, one's from Cameroon and one's from Zimbabwe. And they came to fly over to the research meeting in their first days, and they were like, "What is it with the peanut allergies here?" Like, they're announcing it on the plane to BWI. There are these, all these products are like contains no tree nuts. And they're like, "What is... I've never seen this before in my life." [laughs] And like some student invited one of them to, uh, dinner at his house 'cause he was a new student from Africa, and he goes, "Oh, would you like to come over for dinner sometime?" And he goes, "Yeah, sure." "Do you have any peanut or other allergies?" And he's like, "Marty, what the hell [laughs] is it with this peanut obsession here? We have no peanut allergies in Africa." And I was like, "Wow, Faith, have you ever heard of a peanut..." These are public health graduate students. "No, we have no peanut allergies in Zimbabwe." Then I would call, uh, relatives that I have back in Egypt. Same thing. "I've never heard of a peanut allergy, except for there was an expat living here in Cairo, he had a peanut allergy." [laughs] And you realize this is a unique American epidemic that was created.

   9. PAPeter Attia23:58

      But there must have been some index cases that caused the hysteria.

   10. MMMarty Makary24:02

       Yeah, so that incidence from Mount Sinai suggests half of 1%. It might have been microbiome related-

   11. PAPeter Attia24:07

       Hm

   12. MMMarty Makary24:07

       ... we think. But, um, but the peanut abstinence just threw lighter fluid into this fire, and it really resulted in where we are today.

   13. PAPeter Attia24:17

       So where is the American Academy of Pediatrics today on their recommendations?

   14. MMMarty Makary24:21

       So here's the thing. The study got done eventually, 15 years into the recommendation, that Dr. Gideon Lack I mentioned in London published a study in the New England Journal of Medicine with a, with 640 kids doing a randomized control trial to early peanut butter exposure in infancy. Four, five, six months. Not, not as their sole diet.

   15. PAPeter Attia24:45

       [laughs]

   16. MMMarty Makary24:45

       He's still pro-bre- breastfeeding, right? And whole peanuts have a choking risk. So, I mean, the smart way.

   17. PAPeter Attia24:50

       Yeah.

   18. MMMarty Makary24:51

       And, [laughs] and then, um, the... Then so peanut abstinence and peanut introduction in infancy. Fast-forward a couple years, radically eightfold different rates in peanut allergies and severe allergies. Published in The New England Journal 15 years... Why didn't the American Academy-

   19. PAPeter Attia25:07

       And, and sorry, what year was that study published?

   20. MMMarty Makary25:09

       2015.

   21. PAPeter Attia25:10

       Okay.

   22. MMMarty Makary25:11

       And then of course-

   23. PAPeter Attia25:11

       Eightfold difference. So we're talking about, that's almost, like, as significant as smoking giving lung cancer versus not. Like, smoking versus not smoking and lung cancer was about a tenfold difference.

   24. MMMarty Makary25:22

       Yeah, one of the biggest odds ratios you see in research.

   25. PAPeter Attia25:24

       Yeah.

   26. MMMarty Makary25:25

       And then of course the, you know, the, the bureaucrats at NIAD and NIH from the National Institute of Allergy and Infectious Disease, they fi- two years later they get around to putting a position paper and all this stuff. So s- 17 years, and n-

   27. PAPeter Attia25:38

       But do we also understand how much, how much has that position paper reversed the behavior in, in parents? 'Cause when it comes to kids that are born today, do we know that the, the amount of peanut abstinence going on is virtually gone now?

   28. MMMarty Makary25:53

       I think it's unknown, but it's a great point you raise. Why not reverse the recommendation now that the science is clear, with the same vigor-

   29. PAPeter Attia26:00

       Right

   30. MMMarty Makary26:00

       ... at which you put it out initially? Why not show some humility? Why, what if the leaders got out there and called CBS Mornings and other morning shows and said, "Hey, we got something terribly wrong. We really need to correct the record on this." You didn't see that.

6. 26:15 – 29:13

   The enduring impact of misinformation and fear-based messaging around hormone replacement therapy allegedly causing breast cancer

   1. PAPeter Attia26:15

      Yeah. That, that's, to me, on my soapbox, that's really the beef I have with the HRT stuff, is the, the, the, the absolute, I mean, megaphone of, um, uh, y- you know, fear that was promulgated through estrogen hysteria in 2001. And even though, if you read the fine print today, many of those people have walked back those recommendations of estrogen avoidance. Um, but again, it's, not only is it too little too late, you've got a generation of women, uh, literally a generation of women, over 20 million women, who have been deprived of, of HRT. But even women that are available or el- eligible to take HRT today, they're still confused because the same megaphone that was used to say estrogen will give you breast cancer is not being used to correct course. So it's, there, there's an enormous asymmetry in these, in these information campaigns.

   2. MMMarty Makary27:11

      And one little piece. I know you've done a great job covering HRT, but one of the guys in that committee... So I, in the investigative journalism I did around the HRT dogma, before the announcement, there was a committee meeting where they were hoodwinked, and the 40 investigators were basically told, "Hey, throw out the agenda. We've got some breaking news on this study. Causes breast cancer. We already submitted the journal. It's coming out." And a bunch of guys there are like, "What the... This is not how we do research," right? One of them, Bob Langer, who I interviewed, had said in a shouting match with the lead investigator, he said, "Look, if you put something out there as sensitive as breast cancer is caused by HR, if you, you will never be able to put that genie back in the bottle." And that's exactly what happened. And sure enough, that guy had confessed to me that it did not cause... There were no increase in breast cancer deaths, you know, maybe with a gun to his head when we were inter- you know, I was doing the interview with him, but.

   3. PAPeter Attia28:07

      Yeah, not a single increase in breast cancer deaths.

   4. MMMarty Makary28:10

      Unbelievable.

   5. PAPeter Attia28:10

      And that was at the time of publication. That was again demonstrated nine years later, and again demonstrated 20 years later on the follow-up of the same cohort. I, I can't tell you, Marty, how many times I get asked this question. Uh, it is, it is probably the single most prevalent topic of discussion I have in a, in a public setting, like at a dinner or, you know, something like that. So, um-

   6. MMMarty Makary28:35

      It's amazing

   7. PAPeter Attia28:35

      ... it tells me how much incorrect information still exists out there.

   8. MMMarty Makary28:39

      It's amazing. There's probably no modern day medical intervention that has improved the health of a population as much as HRT for post-menopausal. But it's not just HRT. The medical establishment got opioids wrong for 35 years. They got heart stents wrong for 15 years. They got the low fat diet wrong for how many? 60 plus years. They got, uh, peanut allergies wrong for 17 years. Where's the apology? Where's the humility? Where's the, you know... Uh, that's why there's distrust right now.

7. 29:13 – 35:45

   The dangers of extreme skepticism and blind faith in science, and the importance of understanding uncertainty and probability

   1. PAPeter Attia29:13

      Yeah. And again, this is, this is where I really, really struggle. Because I have friends who are otherwise smart people who have such ridiculous views in terms of, like, where the pendulum has swung the other way. And, like, they're convinced, like, you shouldn't microwave your food because microwaves are harmful. And I, I don't say this to be, um, kind of arrogant, but, but there's also such a degree of scientific illiteracy, um, that even when I try to explain to one of these friends what a microwave is-

   2. MMMarty Makary29:51

      [laughs]

   3. PAPeter Attia29:52

      ... um, and why a microwave can't be harmful, like why it... You know, you have to understand what ionizing radiation is. You have to understand what a light... Like, if, if microwaves are harmful, then light is more harmful [laughs] based on the wavelength.

   4. MMMarty Makary30:05

      [laughs]

   5. PAPeter Attia30:05

      But that's a hard thing to explain to people who don't understand science. You can't see wavelengths, right? So it is, it's, it's, it's difficult. So, uh, I think that's what bothers me, is we've created kind of a bimodal distribution, right, of complete rejection of science, and everything that medicine says is wrong, and you should never go to a doctor, and anything your doctor says is wrong, to complete and utter blind faith. And again, it comes back to my question, which I don't have a great answer to, which is how do, how does a reasonable person maintain skepticism but, you know, not be paralyzed by it and, and not be pushed so far to either extreme? And I, I still, I, I still come away thinking I don't know the answer to this.

   6. MMMarty Makary30:49

      Yeah, I don't have a satisfying answer either, and I feel for the everyday person out there, a friend of mine who will come up to me and says, "Well, I asked about hormone therapy, but my doctor, whom I love, said no, it does this." You know, you don't want to create so much skepticism where people are denying a chest tube when they have [laughs] an, a suction pneumothorax.

   7. PAPeter Attia31:13

      [laughs]

   8. MMMarty Makary31:13

      Right? So it's like what is that bal- I don't have a, a satisfying answer, but it is exactly what Leon Festinger was describing. And the father of modern medicine, Dr. Claude Bernard, he had said, "In science more than in any other discipline, you have to recognize that we bring biases to any question, and you have to actively suspend those biases as you take in new information so you have impeccable objectivity." And it's a lesson for everyone today. Unfortunately, I think we're going the other direction in science right now. We've got policing of, you know, misinformation. We've got, uh, this sort of culture of obedience in medical school that goes right down to, you know, th- uh, right down to your first day of medical school. So I, you know, I'm optimistic on the future of healthcare because enough people now are sort of anti-central authority, anti-corporate, and they're questioning things they didn't before, but this culture of just get in line and do what you're told is still a powerful force.

   9. PAPeter Attia32:22

      Yeah. I mean, I'd love to spend some time when we get through a few more of these interesting examples talking about how to, how to at least change medical education. And to me, one of the most important changes I would make if I were medical education czar would be a very, um, dedicated track of, uh, statistics and probability theory.

   10. MMMarty Makary32:45

       Mm-hmm.

   11. PAPeter Attia32:46

       And I think this is important for all of science, right? I mean, you've ... I'm, I'm, I know you would agree with me I think, but, um, you know, there are no proofs in science. You know, I've said this many times before. So nothing is 100% certain. Uh, so, so science is not a thing, right? It's a process. And, um, what is highly probable today is, is probably a better way of describing something that we think is true. So, you know. And, and, and new information should always be updating probability. So if you, if you think about that framework, right, if, if people are trained in, in, in the mathematics of uncertainty, which is what statistics and probability theory are, um, and I feel very fortunate because I was a math major before I went to medicine, so that kind of came a little more naturally to me to think that way. Um, you could look at, you know, you could look at some index cases of peanut allergies in the '90s and you could say, "Well, my hypothesis is this is due to being exposed to peanuts as a child." Now, that turns out to be wrong, but that would be your hypothesis. But you wouldn't cling to that hypothesis with absolute certainty because you would understand that it's a probability distribution, and you might assign it a probability of 50%. And you would say, "Well, if this is true, how would I test it?" I would test it, and then based on information as it's coming in, I'm updating that probability. Is it now more than 50% or less than 50%? And I, I know that sounds very mechanical, but I can't really think of another way. I mean, and I, and I know we're gonna try not to talk about COVID today because-

   12. MMMarty Makary34:20

       [laughs]

   13. PAPeter Attia34:20

       ... the world's COVID fatigue is, is rampant, but, but COVID offered so many lessons in this, right?

   14. MMMarty Makary34:26

       Yes.

   15. PAPeter Attia34:27

       Which is, "Hey, did this, did this virus come from a lab or did it come from a wet market?" I don't know. I'd say 90% it came from a wet market because we have a precedent of viruses coming out of wet markets. Okay. Well, say it's, it's three months later. We have some more information. We found out about this research being done there. Should we update the probability? Okay, maybe it's 80/20 now. Great. That's an update in probability. Six months later, "Hey, we still haven't found the vector." [laughs]

   16. MMMarty Makary34:56

       [laughs]

   17. PAPeter Attia34:56

       Okay, maybe it's 50/50 now. But if we thought about it that way, I think it's easier to change your position-

   18. MMMarty Makary35:02

       Yes

   19. PAPeter Attia35:02

       ... because you're not wed to a binary outcome, yes or no. You're, you're thinking about it as a probability distribution function-

   20. MMMarty Makary35:10

       That's right

   21. PAPeter Attia35:10

       ... which is constantly getting upgraded and updated and improved, and it's theoretically converging on what is true as we go. And that's true of everything, right? I mean, like, I've lost track of all the other things. Fortunately, I've purged most of them from my brain. But like ivermectin, you know, hydrocor- you know, w- all of these things. I mean, all of these are reasonable things to have assumed, but what became unreasonable was to not go through this process. Both sides.

   22. MMMarty Makary35:37

       Yeah.

   23. PAPeter Attia35:37

       The sides that clung to them and the sides that morally oppose them. Um-

   24. MMMarty Makary35:41

       Yeah. Yeah

   25. PAPeter Attia35:41

       ... so anyway, we, we should, we should probably revisit that. Um-

   26. MMMarty Makary35:44

       [laughs]

   27. PAPeter Attia35:44

       Let's,

8. 35:45 – 43:09

   The overuse of antibiotics and the rise of antibiotic resistant infections and poor gut health

   1. PAPeter Attia35:45

      let's shift gears a little bit and talk about, um, antibiotic use.

   2. MMMarty Makary35:49

      Mm.

   3. PAPeter Attia35:49

      So this is something that probably doesn't get that much attention. I, I know, Marty, when I was in the hospital, we did talk a lot about this. In particular, we talked a lot about it in the ICU, which was the idea of, um, antibiotic resistance being a real problem. But as a person who lives outside a hospital now, I don't hear much about it, so that makes me think one of a couple scenarios. Scenario one is it was greatly exaggerated in the early 2000s when I was a resident because it hasn't materialized.

   4. MMMarty Makary36:20

      Resistance you're talking about.

   5. PAPeter Attia36:20

      Resistance, yeah.

   6. MMMarty Makary36:21

      Okay.

   7. PAPeter Attia36:22

      Um, it was real, and it's still real, but more and more drugs are being developed to keep the bacteria at bay. Uh, so, so, so you know, you, I could walk through of several other machinations, but, but give us a sense of what this means, what the implications are, and, and what can be done about it.

   8. MMMarty Makary36:40

      So about 100,000 people in the US die a year, uh, roughly from resistant bacteria that are resistant to the antibiotics we've had. The time period it took for bacteria to develop resistance through their natural evolution Was about 23 years when antibiotics were first mass-produced in the 1950s and '60s. Then it shrunk down to 14 years, and now it's about one year. Within a year, and a bacteria will mutate around an antibiotic and it'll be a blank, say, methicillin-resistant Staphylococcus. We're now seeing, um, C. diff, one of those common bacteria, take the life of somebody, um, you know, every other month or so in the hospital, in most hospitals. It's-- You tend to pick it up in the hospital. Sadly, you look back and you say, "Oh yeah, they took Ancef for this tiny little thing they didn't need to take the Ancef antibiotic for." The-- About 60% of outpatient antibiotics are unnecessary according to several studies. And inpatient antibiotics, I'm not sure it's much better. I personally have given thousands of unnecessary antibiotics because I've been forced to. When I say I give them, I-- it's the operations that I do, there's this protocol that you give every single operative patient antibiotic before the incision.

   9. PAPeter Attia38:04

      Yep. Marty, I, I don't think I ever cut a person's skin in my life without an antibiotic being on board, except for a certain trauma case where you're literally putting a knife on them the second they walk in the door because they're gonna die. But yes, we would-- I don't know, we used to give Ancef. I don't know if that's still the case, right?

   10. MMMarty Makary38:21

       Yes. That's common.

   11. PAPeter Attia38:21

       Yeah.

   12. MMMarty Makary38:21

       That's common, Marty.

   13. PAPeter Attia38:22

       Okay. So and the, and again, the reason was, um, there are bacteria on the skin, and even though we scrub the skin, you can't get every bacteria out, so we're gonna give you an antibiotic that has to be in your system. It's gonna be given to you intravenously, the-- and usually the anesthesiologist still does it in pre-op or before you cut skin, so that by the time that incision goes through, whatever bacteria are on the edge of that skin aren't going to potentially get in. So again, makes a lot of sense. Um, I never questioned it. Um, w-were there-- And there must have been studies that demonstrated lower incidents of wound infections, right? I can't imagine something that prevalent was, was implemented without an RCT, was it?

   14. MMMarty Makary39:01

       There were studies and there were RCTs in major abdominal operations that were done open.

   15. PAPeter Attia39:06

       Yep.

   16. MMMarty Makary39:06

       Well, most surgery is done minimally invasive now, and people have inappropriately extrapolated those findings to minimally invasive surgery. I mean, have you ever heard of an infection after a laparoscopic inguinal hernia? Maybe like a case report. I've never seen it in my life.

   17. PAPeter Attia39:21

       But, but you, but isn't that because we're giving them antibiotics potentially?

   18. MMMarty Makary39:25

       I, I don't think so, but, um, if the-- because you would see at least some. I don't think it would be 100% effective. You don't see that with abdominal surgery. I mean, it reduces the incidents of infections a little bit. I just don't think there's any mechanism in some of these procedures. I don't think it works. I don't think it gets this... Well, for whatever reason, with no data, the f- the, the research from open abdominal GI cases got extrapolated broadly. And I remember asking, uh, I was actually in practice a little bit before the broad recommendation. I remember asking, uh, this guy Patch Dellinger, who was involved in these recommendations. It's called like the Antibiotic Society of America. You know, one of these [chuckles] there's all these niche meetings. You know, we have the Pancreas Club, you know. It's like all these meetings. It's more fun than the Spleen Society, by the way. They're, they're boring.

   19. PAPeter Attia40:17

       [chuckles]

   20. MMMarty Makary40:18

       And so I remember asking him, "Why is it the antibiotic recommendation at the time of incision for every operation? I've never seen or heard of an infection for these minor procedures." And he said, "Well, you know, we thought a lot about that on our committee, and we decided making it easy to remember to do it for every operation would ensure that the big operations get it." And I thought, "Well, we may have a blind spot in American medicine." Now it's very obvious to me, based on some research I've been seeing out there, that not only could we be breeding resistance, but what is-- what are these antibiotics doing to the gut microbiome? And it turns out that a new theory, which has emerged out of the University of Chicago, is suggesting that surgical infections don't come from the skin bacteria crawling in. It comes from the gut, some sort of weakness in the gut, and there may be a, uh, transposition of some bacteria. And they've actually done studies now in mice where they, they alter their gut microbiome prior to surgery, and they have found that there's some reduction in infection. So there may be sort of probiotics preoperatively that may reduce the risk. This is a big area of ongoing research. There's nothing definitive. We've learned that people should chug a Gatorade three to four hours before surgery. It's mostly for the glucose. But what's it doing to the gut? Or is the patient coming in in a starvation state, and is that doing something to the microbiome? We've had all this dogma in the operating room. You gotta wear your hats, like here. You gotta cover your shoes. Some places don't cover your shoes. And then you go overseas, as you may have as well. You go to Africa, and you realize they're not wearing anything. They're not even wearing masks when they're doing surgery, and their infection rate is no different.

   21. PAPeter Attia42:07

       Huh, really?

   22. MMMarty Makary42:08

       Yeah. Yeah, and this, I've, it seems-

   23. PAPeter Attia42:09

       That's surprising to me.

   24. MMMarty Makary42:11

       Yeah. And you think, "Well, what is the mask doing? Is it preventing sweat from dripping in? Is it preventing the airborne particles?" 'Cause the airborne particles are just coming out of the side of your mask, right? So there's still... So there, there's this University of Chicago research is challenging a lot of deeply held assumptions in operating room protocol. But one of the things I feel bad about, and I don't do it anymore now, is going in for a minor laparoscopic procedure, anesthesiologist says, "You want me to give Ancef?" And I say, "No, you can hold off." The average 10-year-old in America has taken 11 courses of antibiotics, and the average three-year-old has taken two and a half courses of antibiotics. We think that zero to three age group is the most, the microbiome is the most sensitive to antibiotics. But antibiotics are like carpet bombing your microbiome, you know, these millions of bacteria that live in a, in harmony.

9. 43:09 – 53:29

   The potential correlations between early antibiotic use and chronic diseases

   1. MMMarty Makary43:09

      And this study, I don't know if it's, um, if I can mention this, but this Mayo Clinic study This is what I was telling you before. I was dying to tell you about this study. Incredible study out of the Mayo Clinic that came out. I think maybe the most significant study of the modern era in that it's shattering our deeply held assumptions about chronic diseases. And the Mayo Clinic researchers took the 14,000 children that live in Olmsted County in the area of, uh, Rochester, Minnesota, and they looked at kids who took an antibiotic course in the first two years of life and tracked whether or not they developed asthma, learning disabilities, overweight, obesity, uh, later in childhood. And what they found were these incredible correlations. There were about 10,000 kids who had taken an antibiotic course and 4,000 who had not, and they matched them to the best of their ability statistically. A 20% increase in obesity among kids who had taken an antibiotic in the first two years of life, 21% increase in learning disabilities. These were all statistically significant findings. 32% increase in attention deficit disorder, a 90% increase in asthma, and a 289% increase in celiac. Other studies have shown a correlation between antibiotics early in childhood and ulcerative colitis and Crohn's disease. Makes sense. We're changing the microbiome. We may be carpet bombing the microbiome with the dogma that there are no downsides to antibiotics. You got some sniffles, it probably won't help you, but it won't hurt you. Not true.

   2. PAPeter Attia44:45

      Now how do we know in this study, Marty, that the 4,000 kids who were in the control arm that didn't get antibiotics weren't healthier kids-

   3. MMMarty Makary44:54

      Yes, yes

   4. PAPeter Attia44:54

      ... which is why they never needed the antibiotic, and that it wasn't some other factor about the 10,000 who did get the antibiotics, either they were just naturally less healthy kids, there was something about them that was less robust, there were other factors that couldn't be corrected for that actually explains those differences?

   5. MMMarty Makary45:14

      I love it. That's how a scientific mind should think, because there could be confounding variables. For example, maybe it's the infection that they were treating that is the cause-

   6. PAPeter Attia45:24

      That led to. That's right

   7. MMMarty Makary45:25

      ... that led to.

   8. PAPeter Attia45:25

      Yep.

   9. MMMarty Makary45:26

      Right? So those are all good questions. Now, the, my-- First of all, we cannot make conclusions from this study, but this study is an incredible signal that I think we should pay attention to for two reasons. Number one, it's been repeated in a Danish study of about a million children. Number two, there was a dose dependent relationship.

   10. PAPeter Attia45:46

       Hm.

   11. MMMarty Makary45:46

       The more courses of antibiotics a child took, the-

   12. PAPeter Attia45:48

       The more significant the delta

   13. MMMarty Makary45:50

       ... the more signi- the higher the odds ratio.

   14. PAPeter Attia45:52

       So again, worth maybe pausing and explaining to folks how you can increase the probability of a finding being real in an epidemiologic study. So again, it always comes back to this, what's the probability what you just said is causal? Causality is the single most important force in science.

   15. MMMarty Makary46:10

       Yes.

   16. PAPeter Attia46:11

       I'm, I'm convinced of that. If you don't have causality, you have nothing. Um, it's what makes the universe what it is, in my view. So you stated a correlation. It's only interesting to us if there's causality, and now the question is, how probable is the causality? And various factors defined by a, a, a statistician named Austin Bradford Hill speak to the strength of the association and the, the, the probability or likelihood that that association is causal. And you've outlined a couple, right? So one of them is what's the strength of the association, period. So if, if I knew nothing else, the, um... Was the asthma the 289%?

   17. MMMarty Makary46:52

       Celiac.

   18. PAPeter Attia46:53

       Celiac. So the fact that that had such a strong hazard ratio, that's a hazard ratio of 2.9 versus the others that are like 1.2-

   19. MMMarty Makary47:01

       Right

   20. PAPeter Attia47:01

       ... you would say, well, just on the basis of strength of association, that one's more likely to be causal. You then stated another factor, which was reproducibility. There's another study that's done the same analysis and it's coming up with the same answers, so that makes it a little more likely to be causal. And then you talked about the dose effect. Even within the association, like for example, all of this was sort of figured out during the kind of smoking cholera e- epidemics when people were trying to understand causality, and then you'd say, "Well, if smoking is causally related to lung cancer, then theoretically my correlations should get stronger and stronger the more cigarettes you smoked." If that's not the case, it becomes very hard to make the case that smoking is causing lung cancer. So you're saying that there was a dose effect. The more antibiotics you took, the more strongly you were having these associations.

   21. MMMarty Makary47:51

       Yeah, and this is the f- uh, first formal study I've seen like this on an epidemiologic basis that, that fits a hypothesis that, to me, makes sense. Cef- the cephalosporins had a higher correlation. They're generally considered to be a little more damaging to the microbiome than the ancefs and penicillins.

   22. PAPeter Attia48:11

       Is that because they target gram-negatives more or anaerobics more or what's the... I'm so far out of my-

   23. MMMarty Makary48:17

       Yeah

   24. PAPeter Attia48:17

       ... my life on antibiotics. [laughs]

   25. MMMarty Makary48:19

       [laughs]

   26. PAPeter Attia48:19

       I don't, I don't even remember why that would be the case.

   27. MMMarty Makary48:21

       I don't know, but this is, these are s- there are other observational data. For example, farmers have used antibiotics to fatten animals for food production for decades, and the world expert on the microbiome, Marty Blaser, who was the chief of medicine at NYU, his daughter developed chronic abdominal diseases and obesity. They feel terrible because they gave her a bunch of antibiotics in childhood, and they thought there was an association. He started-- He's a laboratory scientist. He started doing all these mice experiments. If antibiotics are making animals more obese, what are they doing to humans?

   28. PAPeter Attia49:00

       That, by the way, is another one of the Bradford Hill criteria. Do you have experimental evidence that also supports this? Which of course, in the case of human epidemiology, you would, you would look at, at, at animals. Um, so of course, someone listening to this might say, "Well, okay, Marty, but There's got to be some bad luck involved here. I mean, you had... Let's go back to the Rochester, Minnesota study. You got 4,000 kids who never took an antibiotic, 10,000 kids who did at least a course or two. Well, I mean, those 10,000 kids weren't just given antibiotics for no reason. They must have had ear infections.

   29. MMMarty Makary49:35

       Yeah.

   30. PAPeter Attia49:35

       They must have had tonsillitis.
10. 53:29 – 1:09:57

    The historical and evolving trends in childbirth and C-section rates

    1. MMMarty Makary53:29

       but you know, we held babies in the hospital for 10 days routinely, normal, healthy babies. Immediately s-

    2. PAPeter Attia53:36

       I, I was in the, uh, I was in the hospital for 14 days when I was born.

    3. MMMarty Makary53:41

       Normal, he-

    4. PAPeter Attia53:42

       Yeah

    5. MMMarty Makary53:42

       ... at term?

    6. PAPeter Attia53:43

       Yeah.

    7. MMMarty Makary53:43

       [laughs] That's like... I mean-

    8. PAPeter Attia53:45

       14 days.

    9. MMMarty Makary53:46

       It's crazy. I remember my s-

    10. PAPeter Attia53:49

        You could, you could be out of the hospital with an aortic root replacement in half that time.

    11. MMMarty Makary53:52

        [laughs] I, um, I remember my, my little sister was born around 1980s, and mom came home from the hospital after delivering her. You know, my brother and I are like, "Hey, we have a sister." And we, every day we'd ask, "Dad, when is my, our little sister coming home from the hospital?" "Well, the doctors haven't released her yet." She's totally normal, right? She's sitting in there for days and days. You go in there, there's some big glass window, you know, and they'd be like, "There she is, third row from the back, six one over." You know, [laughs] you see this little head of hair wrapped in some... And you're like, you're looking back on it, this is the medical paternalism. This is that white coat era. This never happened before in history. People would stay in the hospital for two weeks after a cataract. They'd measure their toe diameter. They'd, you know-

    12. PAPeter Attia54:43

        [laughs]

    13. MMMarty Makary54:44

        ... probe and poke and put babies in the NICU and feed them formula and, and, you know, the mother would be like, "Can I see, hold the baby?" "No, we have to take the baby-" Even when I was in, in, as a student, you know, I was in the OB rotations, my first rotation. I'm nervous. I'm even almost shaking thinking about it. They give me the scissors, you know, like, "Oh, room six." You know, you hear some moaning. You go in there, and all sorts of cha- chaos going. "Okay, as soon as you see the umbilical cord, you cut it." [laughs] And I'm holding the scissors. I want to learn about the process of childbirth, but I've blocked out everything I've, because I have one job, right? And I'm holding these scissors, and then there's chaos, and then all of a sudden this baby, and I can barely see this slippery cord, and they're putting clamps on. "Cut it You know, and I'm like swooping in to cut it, and then they s- take the baby off to the back table. "What are we doing?" "Oh, we have to rewarm the baby." "Okay." So they put the baby under this table with the French fry light.

    14. PAPeter Attia55:49

        [laughs]

    15. MMMarty Makary55:49

        And I'm thinking, "The baby-" [laughs]

    16. PAPeter Attia55:51

        The French fry light. [laughs]

    17. MMMarty Makary55:54

        The ba- [laughs] The baby, the irony, the baby was getting a warm blood transfusion from the mother with a pulsating umbilical cord, which was actively pulsating when you clamped it and told me to cut it. But I, I don't say anything. You know, I wanna be an, I wanna get, I wanna get a good grade. And I'm like, "Okay, well, um, you know, the mom wants to hold the baby. Wouldn't that be warm enough, you know?" "No, we have to warm the baby." Turns out the data now on skin-to-skin time, hours of skin-to-skin co- that's the best incubator. There's all kinds of incredible data now on how the baby has more normal blood pressure and heart rate, and more normal glucose levels when the baby is held by the mother. And the heart rate and blood pressures, I thought I heard that in the studies, and I was like, "That makes sense," but I don't get the glucose. Why would the glucose... Their stress hormones-

    18. PAPeter Attia56:46

        Cortisol, yeah

    19. MMMarty Makary56:46

        ... are not surprised. Cortisol, yeah. You figured it out quicker than I did. And, um, I'm kind of like, "What are we doing?" You know, they're sticking a metal temperature probe in the baby's rectum, and I'm like, "What? This just can't... Is this a nice way to welcome a, a human into the world?" You know, like, "What are we doing?" Like, the baby's temperature is what the mom's temperature was 'cause the baby just came from the mom two seconds ago. Like, what are we doing? And, um, they were just like, "Oh, we have to put it on the sheet," and all this probing and poking. And, um, then they have to wa- they wash the baby. It's like you don't... Now they know they, not to wash a baby for the first 24 hours 'cause there's kind of a proteines- proteaceous coat. And again, C-sections are, they've saved lives, but C-sections, like antibiotics, are also massively overused. And it turns out, as the head of the microbiome unit at the NIH explained to me when I did the research for this book, she said in a vaginal delivery, the baby's gut in utero is sterile, and so it's seeded, the microbiome is seeded from the bacteria in the vaginal canal and then augmented by bacteria from the colostrum, the early breast milk-

    20. PAPeter Attia57:59

        Yeah

    21. MMMarty Makary57:59

        ... and the skin and the kisses of grandparents. But when you're born by a C-section, the baby is extracted from a sterile operative field, and what may, what may seed the baby's microbiome are the bacteria that normally live in the hospital. And when she explained it to me that way, I thought, "My God, you know, it makes sense."

    22. PAPeter Attia58:17

        So what is the, uh, prevalence of C-section today, and, and how close are we to peak C-section versus what was it 50 years ago?

    23. MMMarty Makary58:26

        So we're at a, we're about 30% in the United States. Private hospitals in Brazil are at 90%. Um, overseas, it's sometimes even worse. Um, the individual doctor C-section rate ranges from 12% to we've seen 100%. So we have a big project at Johns Hopkins, uh, and through our consortium on the appropriateness of care, where we look at practice patterns of physicians, and we c- basically can profile a physician on their pattern of doing something where there's, uh, there's known to be a lot of inappropriate overuse.

    24. PAPeter Attia59:01

        But, but again, just help me anchor this to some context. Um, f- 50 years ago, presumably they were not doing elective C-sections. A C-section was done because it was medically necessary. Is that a safe assumption?

    25. MMMarty Makary59:14

        Yeah, there's definitely more unnecessary C-sections.

    26. PAPeter Attia59:16

        Right. So what was the prevalence of C-sections, pick your favorite decade when elective C-section was not done? Was it, is it like a five per- Should it be 5%? Should it be 10% if we're only doing it for medically necessary C-sections?

    27. MMMarty Makary59:30

        The OBs that I've grown to really respect, really trust ethically on s- They talk passionately about the overuse of C-sections, and they have impeccable judgment. They have C-section rates in the 12% to 15% range.

    28. PAPeter Attia59:45

        Okay. So we think that that probably is at least in the zip code of what is necessary. And by the way, that-- Let's go back to what we were talking about. In the world of Medicine 1.0, when we lived to, you know, we barely got to our 40th birthdays and infant and, um, maternal mortality were sky high, every one of those kids that would be getting a necessary C-section, they'd be dying, and probably the moms are dying. So this is a huge advance, the fact that we could do this operation. And, um, a- again, I know that you're not s- I, I don't, I d- I, I know you don't think this way, but I just wanna make sure people listening to us don't take away from this C-sections are bad.

    29. MMMarty Makary1:00:26

        C-sections save lives.

    30. PAPeter Attia1:00:27

        Yeah, C... It, it, I mean, like, I would argue C-sections, antibiotics-
11. 1:09:57 – 1:26:10

    Rethinking ovarian cancer: recent data challenging decades of medical practice and leading to new preventive measures

    1. PAPeter Attia1:09:57

       So basically-

    2. MMMarty Makary1:09:58

       [laughs]

    3. PAPeter Attia1:09:58

       ... if you want to get a tissue repair of an inguinal hernia, you gotta go to the Shouldice Clinic. Um, but you're saying maybe mesh is getting so much less intrusive now that it's, there's min- there's less downside to doing mesh than there used to be?

    4. MMMarty Makary1:10:12

       Yeah, when we used to operate together, they'd put in these big thick polypropylene meshes [laughs] in there, that I don't understand how you wouldn't feel it, right? It would f- and the idea was to promote scar tissue 'cause it's actually the scarring that-

    5. PAPeter Attia1:10:24

       Yep

    6. MMMarty Makary1:10:24

       ... is the he- but now they're lightweight, thin, like a fishnet almost.

    7. PAPeter Attia1:10:28

       Let's talk a little bit about ovarian cancer.

    8. MMMarty Makary1:10:30

       Ah, yeah.

    9. PAPeter Attia1:10:31

       So, um, maybe just give folks a little bit of a anatomy of the female reproductive system so that, what's an ovary? What are the, what are the little tubes that connect it to the uterus? You know, give f- give folks a sense of what that anatomy is.

    10. MMMarty Makary1:10:48

        Uh, yeah, so this is an incredible, um, area where we're doing some work. You know, our research team at Johns Hopkins is dedicated to studying the big issues in healthcare that we are not talking about, that we should be talking about, where research is taking off, new science is pointing to things that like, "Hey, pay attention," and there's not a lot of attention or NIH dollars. And one of those areas is the true origin of ovarian cancer. The ovary, uh, sits draped under the fallopian tube, and the end of the fallopian tube has, uh, finger-like projections called the fimbriae. So we're talking like a millimeter. I mean, they're almost really in contact. And so, um, you want me to explain how this works?

    11. PAPeter Attia1:11:32

        Yeah, yeah, yeah.

    12. MMMarty Makary1:11:32

        So it turns out we-

    13. PAPeter Attia1:11:33

        What is an ovary, first of all? Like, what does it make? Why do women have them? You know, where do the eggs go? All that kind of stuff.

    14. MMMarty Makary1:11:39

        So it used to be thought that the only purpose of the ovary is to produce sex hormones, but it's not true. It produces, um, uh, you know, e- as we, you've talked about with estrogens involved in heart health and so many things. Um, but it produces the eggs that then f- um, are, go down a little circulation through the fallopian tube into the uterus. And, um, doctors have really struggled with ovarian cancer. Really no major progress in modern medicine. You get, most of the cases are lethal or present in late stages. There's almost nothing you can do. Very little surgical intervention. There are some cases where it's early enough, but overall the fatality rate is over 50%.

    15. PAPeter Attia1:12:25

        And there's a strong association between certain types of breast cancer and ovarian cancer.

    16. MMMarty Makary1:12:30

        Yeah, there is, um, with the pr- uh, hereditary predisposition. So some people get tested, but a big study was just done in the UK looking at screening tests for ovarian cancer. Should we have mass population screening like we do for-

    17. PAPeter Attia1:12:45

        Using what? Ultrasound?

    18. MMMarty Makary1:12:46

        Using ultrasound, and they've done CAT scans, and none were show- shown to improve the outcomes in people, uh, f- and detecting ovarian cancer. None. Total failure. They abandoned the entire idea of ovarian cancer screening based on this big UK study. So here we are with a cancer with almost no advances, a ton of money, it's not for lack of funding at the NCI, and what is going wrong here? Well, I love this sort of blind spot of medicine because it shows how when you're certain of something in medicine, you can still benefit from challenging deeply held assumptions. It turns out that there was a recent discovery that ovarian cancer does not come from the ovary. The most common and lethal type comes from the fallopian tube, and the cells float onto the ovary. It, so we have taken out millions of healthy ovaries To prevent ovarian cancer, you know, during abdominal surgery, during a hysterectomy, the ovaries will be removed to so-called prevent ovarian cancer. Turns out we were targeting the wrong organ. And so w- with this new discovery that biologically, based on the genetics, based on, um, a lot of good research that's emerged from Penn, Dr. Drapkin, uh, a guy at Johns Hopkins, one of my colleagues, there's a gynecologic oncologist now, this is her entire career focus, is that we have to increase public awareness that this is really not ovarian cancer the vast majority of time, it's fallopian tube cancer. And we can prevent it because the fallopian tube serves no function after w- a woman's childbearing years. It's not like-

    19. PAPeter Attia1:14:27

        Right

    20. MMMarty Makary1:14:28

        ... even after menopause, there's very low levels of estrogen that can trickle out of the ovary for a while. But after a woman's done having kids, if they come in and say, "I want my tubes tied," the new answer at Johns Hopkins is?

    21. PAPeter Attia1:14:41

        Take them out.

    22. MMMarty Makary1:14:42

        We don't do that anymore. We remove the fallopian tubes to massively reduce your 1 in 78 chance of developing ovarian cancer in the future.

    23. PAPeter Attia1:14:50

        It's that high?

    24. MMMarty Makary1:14:50

        Yeah, it's that high.

    25. PAPeter Attia1:14:52

        1 in 78?

    26. MMMarty Makary1:14:53

        Yeah, I love it that you have that reaction, 'cause I had the same reaction. I realized we don't think like that in clinical medicine. Like at the pancreas cancer conference once, I asked, "What i-" This patient was asking what is her lifetime chance of developing pancreatic cancer. And I said, "Well, you have no risk factors." And she goes, "Well, what is it?" And I'm like, "You mean just for an everyday person?" And I asked the experts. No one knew. I looked it up. It's 1 in 67.

    27. PAPeter Attia1:15:21

        See, I would've guessed one in, I was gonna guess 1 in 20, actually, but maybe it's less than that. That's, that's for all pancreatic cancers. You mean pancreatic adeno lethal cancer?

    28. MMMarty Makary1:15:30

        Yes. 1 in 67 is what we found.

    29. PAPeter Attia1:15:32

        Oh, it's that? Okay. I would've guessed even more frequent, truthfully. Okay. Interesting.

    30. MMMarty Makary1:15:36

        Yeah, I think the fourth most common lethal GI cancer or something like.
12. 1:26:10 – 1:28:40

    Navigating uncertainty as a physician

    1. PAPeter Attia1:26:10

       any situation, and it all makes sense. But now you want to think about how difficult this is to put into practice. You're, you're a doctor, and this is what you do. You have 99% certainty, which means you're a good doctor because you don't have 100% certainty on anything.

    2. MMMarty Makary1:26:26

       Yes.

    3. PAPeter Attia1:26:26

       You have 99.9% certainty that this cancer is coming from these ovaries, and you're-- everything that you do in your practice is predicated around that. But now you have to somehow work with a 0.1% probability that everything you believe about this is wrong. Now, again, that's a really low number. That's, that's a one in a thousand dil- delta. How do you not squash that and allow that to remain open and flexible while you continue to do your best work here and periodically come back to revisit this, assuming you're not even the one who's doing the primary work, but you're just trying to keep update on your practice and, and your practices and say, "Well, maybe that's now a 1% chance. Maybe that-- At, at some point, you know, if that's a 10% chance, I really need to pay attention. If, if there's a 10% chance I'm wrong, I really need to pay attention to this. I need to pause." Um, we're not trained to do that.

    4. MMMarty Makary1:27:27

       [chuckles]

    5. PAPeter Attia1:27:27

       So how, h- how do we go about thinking about this, right? If you were-- You know, I already said what I would do if I were czar of medical education. Um, I don't know enough about medical education today. It's been twenty-five years for me, but you're closer to it because you're still part of a university system. Um, is medical education significantly different today when it comes to this? Like, what-- how does a medical education today at Hopkins differ from, you know, what it was twenty-five years ago?

    6. MMMarty Makary1:27:58

       Well, one of the most important qualities of a physician is humility, knowing your limits, and having the awareness, the self-awareness that you could be wrong, as you said. And when you are wrong, when it's clear you might be wrong, feeling bad about it, and offering the patients, "Hey, you know, we got this wrong. I thought this is the best way to approach it." One thing I love about Rebecca Stone and so many of the doctors I work with at Hopkins is they don't say you need to have your fallopian tubes out. They say, "We have some data that is suggesting that if we take the fallopian tube out, we can reduce your risk of ovarian cancer significantly." And I think the, the danger in medicine,

13. 1:28:40 – 1:34:55

    The urgent need for reform in medical education

    1. MMMarty Makary1:28:40

       one of the poisons today, is the absolutism that's out there. And when we go through medical school, it's a-- you're just memorizing and regurgitating, and it's this terrible, robotic, dogmatic training.

    2. PAPeter Attia1:28:52

       Is it still that way?

    3. MMMarty Makary1:28:53

       It's still that way. You might even think it, say it's worse. I was talking this morning to Dr. Will Bruhn, who just graduated. You met him, um, buddy of mine I'm working with on the appropriateness work. And he just graduated from Oklahoma University School of Medicine. We were talking about all the useless, dumb me- rote memorization stuff. He said it was like 50% of his medical education. This bacteria is catalase positive, catalase negative. This is a branch chain bacteria. This is a straight chain. It just, it's mind-numbing. Memorizing the names of enzymes, he says, was like 20% [chuckles] of his medical education. What are we doing to these kids? They come to us in medical school bright, creative, altruistic. They want to do good. Social justice is a generational value. And we beat them with the rote memorization of these enzymes and stuff you can look up. We have phones nowadays. You don't have to know the Krebs cycle on demand in the trauma bay.

    4. PAPeter Attia1:29:58

       [chuckles]

    5. MMMarty Makary1:29:58

       [chuckles] And we do this to this incredible generation. You s-- They s-- We spit them out seven, eight years later. They're different people. They're robotic. They're sometimes emotionally disconnected. They've learned to reflex as a survival mechanism in order to do what we tell them to do, which is get through the exams. And the thing that kills me, and a lot of students, they see the tension, they feel it, they hate it, they're fighting it. And we do have incredible students that are able to stay normal through the process. But it's a struggle because the culture of medicine says obey. And it's one private company that controls the medical education in every medical school in America, the AAMC. A small group of people get to decide what every doctor learns in their medical education. And these people are dinosaurs. They're forcing these kids to memorize the names of all these-

    6. PAPeter Attia1:30:55

       And what's the relationship between the AAMC and the company that administers, um, the USMLE and the accreditation? Are they, are they linked in some way? Presumably-

    7. MMMarty Makary1:31:06

       Yes.

    8. PAPeter Attia1:31:06

       Yep.

    9. MMMarty Makary1:31:07

       Yeah.

    10. PAPeter Attia1:31:08

        S-

    11. MMMarty Makary1:31:08

        That is the private organization, AAMC. Small group of people.

    12. PAPeter Attia1:31:11

        Is the entity that also regulates the USMLE-

    13. MMMarty Makary1:31:14

        Yeah

    14. PAPeter Attia1:31:14

        ... the licensing exams?

    15. MMMarty Makary1:31:15

        Yes.

    16. PAPeter Attia1:31:15

        Got it.

    17. MMMarty Makary1:31:16

        They collect a lot of money from these students. It's a private organization, and they are dec-- So I know, um, I was talking to a, you know, one of the cool things that we get to do is talk to a lot of people out there in America and get a b- a bit of a bird's eye view on things, and I was talking to a conference of medical school deans. And later on, I had met the dean of a medical school in San Antonio, University of the Incarnate Word, UIW, it's called. Great medical school, San Antonio. And she's like, "Gosh, Marty, you're so right. Why do we have to teach all this rote memorization and just beat them to regurgitate?" "I would love," she's told me, "to teach self-awareness and understanding uncertainty and focus on applied statistics and the critical appraisal of research, and the fact that there are nerves that extend to every aspect of the hand without having to name 50 nerves in the hand, you know, and regurgitate it on the exam. I would love to have a modern-day education, but I can't because the AAMC dictates what we teach, and we have to teach to a test and our test score pass rates." So it's this terrible system, and it's connected to the American Board of Medical Specialties, which issues board certification. And recently they've basically said, "In order to keep your board certification, you gotta pay us two to three hundred dollars every two years or so and take a quiz that we give you." And, um, they're out there, like, making a ton of money off this new thing. Now they're require-- they're telling hospitals, "You have to require current board certification, and unless they've paid us, we're a private company, they're not currently board certified." Imagine your college, UCSF or, no, Berkeley. Where'd you go to college again?

    18. PAPeter Attia1:33:10

        I went to college in Canada.

    19. MMMarty Makary1:33:11

        Okay. Imagine your college called you and said, "Hey, your degree, you don't have it anymore. You gotta pay us every year to keep your degree." That's exactly what the American Board of Medical Specialties is doing. They're a private organization. It's a monopoly. My buddy Will was telling me at Oklahoma University School of Medicine, I probably shouldn't say this, but what the heck, eight hours on transgender sensitivity training, two hours on nutrition. The two hours on nutrition, he said, "Were so pathetic, it might have been better to have zero hours." You know, HDL is good. You know? It's like the most basic... And I see this awareness among a generation of doctors and students that they know something is missing. This isn't right to just be memorizing. They're smart people. And that's why you've got a huge number of people, doctors who are learning from you as you learn. Talking about evolving your position. You're out there learning, reading, talking to people. People are learning with you, and they're hungry for this kind of honesty with where medicine's going. Maybe we should be talking about more, uh, chronic diseases differently. Maybe we should be talking more about treating diabetes with cooking classes than just throwing insulin at people. Maybe we should talk about school lunch programs, not just putting kids on Ozempic. Maybe we should talk about sleep medicine when we treat high blood pressure, not just throwing antihypertensives at people, first line, second line, third line. Maybe we should talk about ice and physical therapy instead of just surgery and opioids when somebody comes in with pain. Food is medicine. The microbiome, general body inflammation, these are the topics that a generation of doctors are starving to talk about. We

14. 1:34:55 – 1:46:45

    The major barriers to innovative medical research

    1. MMMarty Makary1:34:55

       need more research in them. They wanna think differently.

    2. PAPeter Attia1:34:58

       But who would fund this research, Marty? I mean, I think w- when I, when I talk about the pillars of, of medicine, right, we have nutrition and exercise and sleep and emotional health, and then molecules. So that's roughly five things. Then you could really add a sixth pillar, which it would be like a, a sort of a, a waste bucket, uh, you know, of everything else that may or may not have benefit, like sauna, cold plunge-

    3. MMMarty Makary1:35:21

       Mm-hmm

    4. PAPeter Attia1:35:21

       ... you know, red light therapy-

    5. MMMarty Makary1:35:23

       Mm-hmm

    6. PAPeter Attia1:35:23

       ... all that kind of stuff. Okay. Now, one of those buckets is really taught well in medical school. We really do learn, and by medical school, I mean medical school and re- re- residency, right? So you learn about procedures and medications very well. That's, that's what we, we learn, and I think we do learn that quite well. Um, but to your point, we learn nothing about exercise, sleep, nutrition, and emotional health and well-being. Um, but part of that, if you're not trying to be-- If you're trying to be as uncynical as possible, is at least when it comes to molecules and procedures, the way to study it is straightforward. The interventions are easy. You take this pill or you don't take... You take this pill or you take the placebo. Um, and then on top of that, there's a financial engine that supports the use of that which justifies the cost of the studies. But when it comes to doing research on many of these other things, you know, outside of philanthropic and government causes, um, such as the NIH, it's very difficult to get any of that research funded. So how, how would we create a new medicine around something for which it would be so difficult to, to really gather the right evidence? Or would you argue, look, we already know enough today that we could teach off the current practice?

    7. MMMarty Makary1:36:44

       The NIH could not be more broken. They've got these siloed funding centers, as you suggested. And on, you know, unless your research falls under kidney, you know, cardiovascular disease, and it's what the old belt, belts and suspenders professors there want to fund. It's a legacy system where if the senior guys who've done the research and made a name for themselves on an idea like it, they throw money your way. I think the disruption is happening right now. Private industry. You're seeing private in- industry fund research on different probiotics and bacteria you can introduce. We're seeing private industry fund research. They funded our research on price gouging and predatory billing, another big blind spot in medicine. I do think, you know, a lot of our work is not funded by the NIH, and people come up and say, "My gosh, it makes sense what you're saying. Why don't we have a big study on natural immunity?" And we could draw the blood of these people. I mean, how many studies have you put out there where you've said, "This study needs to be done. It's not what falls in line with the NIH silos, but it needs to be done"? A classic example, a practice right now that is surging in the United States is taking a newborn and cutting the frenulum under their tongue, either routinely-

    8. PAPeter Attia1:38:00

       Hmm

    9. MMMarty Makary1:38:01

       ... or if, if it's a foreshortened tongue. Some people believe in routine, and other people believe in only in foreshortened, and other people believe never should be done. I don't know what the truth is. I have good ENT friends

    10. PAPeter Attia1:38:13

        What is the rationale for doing this?

    11. MMMarty Makary1:38:16

        The rationale, the claim, is that it'll improve breastfeeding and lactation rates, that it may help, there's claims out there that it may help with sleep apnea, with speech impediments. Um, I think they're outrageous claims when it goes that far. These are people who are also cutting the frenulum under the upper inside lip.

    12. PAPeter Attia1:38:37

        Mm-hmm.

    13. MMMarty Makary1:38:38

        And sometimes the side of the tongue, and the frenulum under the tongue as all... Yeah, so there's been babies that don't breastfeed because they're in pain from this. And this practice is taking off like crazy. It's driven a lot in dentistry. It's in that l- lactation world of lactation consultants could refer you to somebody. And it's this dogma that has never had any scientific evidence to support the claim. Now, I'm not saying it's bad or-

    14. PAPeter Attia1:39:06

        Is it being tested?

    15. MMMarty Makary1:39:07

        No. I'm not saying it's bad or wrong, but I'm saying this desperately needs a randomized control trial. Desperately. Just like the peanut allergy study, just like the antibiotic study. Do it in a cohort of a couple hundred, randomization, follow them, take a look five years or whatever the study design is needed. Who's gonna fund that study? Big Pharma? [chuckles] No, fat chance. Um, the NIH? Not one of their clinical centers. Um, the American Academy of Pediatrics with their, you know, $1,000 a year membership of all these $130 million in revenue they take in a year? No, no, they haven't. Possib- No, they, no interest. This is the Bermuda Triangle of healthcare in the United States and worldwide. We desperately need to fund things where there are d- ideas, people are doing things, and they're doing them in a black hole with no scientific evidence. We need to do the appropriate study. We could answer the controversy in less than a year. You s- I hate to mention COVID. We saw this during COVID. All of those COVID controversies could've been answered in three weeks or a month or two. They could've done the clinical study immediately, done the randomization, answered the question. Instead they, everyone went on, on TV and opined about it. It's easier. The NIH controls $80 billion. What are they funding? They were funding [laughs] this cruel dog experiment at the University of Iowa, trapping these dogs and con- having these sandflies bite their heads in these cages, and concluding in the, in the article that is published, uh, leishmaniasis can spread through, you know, from dog to dog via sandfly bites. Who gives a shit? Okay, who g- It's, it... Th- this is where our tax dollars are going, and then we're not funding basic clinical research out there?

    16. PAPeter Attia1:41:10

        Why do you think that is?

    17. MMMarty Makary1:41:11

        I think it's just, I don't think it's diabolical. I think people, um, get set in their ways. I think it's Leon Festinger's cognitive dissonance. I think people think, "Oh, this would be interesting. Find out whether or not, you know, what's the average diameter of stones on Thames Street? That would be interesting." No, it's not interesting. I'm seeing it a l- a lot now with health equity. I think describing disparities in health equity, in my personal opinion, is not interesting at all. We know there are massive disparities in health equity. Saying, "Oh, well, there's also a health disparity in, you know, chronic myelogenous leukemia according to h- health," that's not interesting. What's, we've, that's known. What's interesting is what you're doing to reduce disparities in health equity. And yet half of the papers now, when I go to these conferences, are on, you know, differences in so and so by, you know, race and socioeconomic sta- Yeah, it's been known since the beginning of time, the number one driver of health status overall in a population is the socioeconomic status of that community. So I, I think it's just, I don't know, intellectual laziness, the old guard. There are fresh ideas in medicine, but when you show up in medicine, and you've done this, you show up in the academic world as a resident or you get a peek of it as a student, you have big ideas. "Hey, this thing about the microbiome and the rates of this, and it all fits, and maybe chronic diseases have gone up with antibiotics," whatever the big idea is. You're told, "No, no, you need to pick one narrow area and work on an incremental little scientific paper that'll go to the abstract of the Southern Surgical Society," or whatever it is. And that's how the NIH funds their research, little small ideas. We need big ideas. They don't fund that. We need new ideas on cancer. What's the ROI on our cancer funding? Paper at ASCO showed that Avastin increased, uh, glioblastoma s- survival rates by, um, two months. Well, patients wanna know what's the cure. Did you cure anyone else that you haven't cured before? If that's the top paper at ASCO, our investment on research has a terrible ROI, and I think it's 'cause we're not funding big ideas. We need Ben Franklin thinkers. Ben Franklin, intellectually curious, starts thinking about ophthalmology, invents bifocals, is interested in electricity, invents the lightning rod, invents a stove called the Pennsylvania stove, which is an amazing invention. I mean, he's a sci- He's a true scientist. We don't have Ben Franklin thinkers today in medicine. I think Vinay Prasad is one. I think you're one.

    18. PAPeter Attia1:43:58

        You think we don't have them, or you think we don't have a, a, a vehicle to fund them?

    19. MMMarty Makary1:44:02

        We don't have a vehicle to encourage them. I think, and I'm just saying this because I've said this to other people, you're one of those Ben Franklin type thinkers. You think broadly about healthcare. That's what we do on our research team, is you're told in med school, day one Hey, here's the Netter textbook of anatomy. Pick an organ. You're gonna have to f- focus on just one. Which one do you like? Do you like kidney? Do you like brain, heart? Just, you have to pick one. You're like, "Well, what if I'm interested in the whole body, or the system, or the way we deliver care, or the way we fund research or approve drugs? Or what if I'm interested in all of it? What if I'm interested in gun control and violence prevention, and I'm interested in trauma and all, everything?" You're basically told, "No, no, stop thinking like that. You gotta pick an organ." I mean, I went to the gym as a medical student, and there were some docs there who also used the gym, and they would ask me every day, "What are you going into again?" And I wanna be like, "I'm a second-year medical student. I don't know. Is that okay? I don't know." And I think you can get a s- a specialization, and then come around and get off the hamster wheel. There's a lot of these docs now saying, "I don't care about my RVU bonus. I wanna do something more meaningful." And they're starting businesses. 50% of our medical students at Johns Hopkins are getting a second degree with their medical degree. They, they don't wanna live the life that they see.

    20. PAPeter Attia1:45:34

        Hmm.

    21. MMMarty Makary1:45:34

        You know, these guys who are like, "I got four NIH grants and presented, you know, I got 60 papers." I mean, I hit that point where I was like, "Okay, I've published 300 scientific peer review articles. Nobody's reading them. I don't think I've made, beyond maybe a couple, meaningful contributions. Like, what are we doing? We've gotta focus on impact." So everything we do now in our research group focuses on impact, and that's how we got into the science of medical errors, frailty as a condition, predatory billing, and price gouging in medicine. You know, 62% of Americans say in a Harvard survey they don't trust the medical profession to bill them fairly, and they avoid care or delay it for fear of the bill. So you can now have the cure for pancreas cancer, but that cure is only, instead of being 100% effective, it's only 38% effective because you've lost, you've lost that connection, right? So, um, rebuilding trust is the hottest topic right now in medical journals, essays.

    22. PAPeter Attia1:46:43

        So, so speaking of that,

15. 1:46:45 – 2:01:30

    The dogmatic culture of academic medicine: why humility and challenging established norms are key for progress

    1. PAPeter Attia1:46:45

       um, in 2020, the New England Journal of Medicine broke with a 208-year tradition, and, um, it, it, it endorsed one of the candidates for presidency. Um, which again, this is a, this is the most esteemed journal in, in, in all of medicine that for 208 years was decidedly apolitical, um, and it chose to, it chose to break that. Now, regardless of a person's political stripes, why do you think that's a bad idea?

    2. MMMarty Makary1:47:15

       I think there is a political narrative, and in politics, everyone sticks to the same s- talking points. But in science, science is based on a civil discourse of different ideas among experts, and so they're directly in conflict. So, you know, we, the journal decided to endorse a presidential candidate for the first time. Okay. Other journals have said, "Here are some issues. We're not gonna be both sides-ing." Like, okay, what, what if you said that about peanut allergies back in the days? What if you said that about people who are suggesting opioids are very addictive? They've seen it. Uh, the New England Journal is the one, is the place that published that study that out of, I don't know, 30,000 cases of people taking narcotics, there was only one patient who developed dependence, and that became the dogma. And dogma takes on a life of their own, a life of its own. I think the journals are in a bubble. I think just like we need term limits for politicians, just like presidents should turn over after eight years, journal editors should not serve terms like monarchs in Europe or African presidents. They're there for life, and it's, they're loading these journal editorial boards with their buddies. It's cronyism. Everyone in the field knows it. It's hard to criticize 'cause we all need the journals to publish our research. The New England Journal of Medicine, just a couple years ago, out of 51 editors, had one African American. Now, you can only find one African American to serve in the editor... What's going on is it's their buddies from the Brigham and Women's Hospital and, you know, Beth Israel Deaconess, and Mass General. It's my buddy from... I m- remember meeting the editor of the New England Journal when he came to visit Hopkins. Um, Jerry Casera, I think was his name. I don't know why I'm mentioning these names. These guys will probably all send me some hate mail, but what the heck? And I said, "Oh, I got a chance to meet your predecessor at a conference. We actually had a nice time together talking about issues." He goes, "Oh, yeah, he was my roommate when we were cardiac fellows together." And so you have all these internal medicine doctors who look alike, think alike, they're buddies from one institution and from one part of the country deciding the, what should go through the gates for the rest of the doctors of the world to see. It's changing. Vinay Prasad and, uh, John Mandrola, and Adam Cifu, and, and I, and some others started a new newsfeed called Sensible Medicine, where we're publishing our thoughts in me- in real time when we see articles that look, uh, flawed, when there's a bandwagon effect, when we c- call things out. Yeah, like 100,000 subscribers to this thing now. Uh, we're starting a new journal now, which is designed to be objective, and it's called The Journal of the Academy of Public Health. Um, Jay Bhattacharya and Martin Kulldorff and I and s- a bunch of others. So there is this effort now, and with social media

    3. PAPeter Attia1:50:25

       But how do you know you won't fall into the same trap of the New England Journal of Medicine, Science, Nature? A- again, I, I wanna-

    4. MMMarty Makary1:50:34

       Yeah

    5. PAPeter Attia1:50:34

       ... bring it back to this thing, which is the biggest journals in the world became political in 2020. They made a very concerted, conscious decision to weigh in on politics, to endorse presidential candidates. And again, I don't think it matters who they're endorsing. I don't think it matters what party you're in. I'm amazed more people don't look at that and say, "Oh, no. That is awful. That is awful."

    6. MMMarty Makary1:51:04

       Yeah.

    7. PAPeter Attia1:51:04

       We cannot have science and policy, uh, politics, I should say, we, we can't have those things commingle. Again, it doesn't matter if they're endorsing your party, you should be just as concerned-

    8. MMMarty Makary1:51:17

       That's right

    9. PAPeter Attia1:51:18

       ... as if they're endorsing the other party.

    10. MMMarty Makary1:51:19

        That's right.

    11. PAPeter Attia1:51:20

        There's, there's, there's a, there's an objectivity that can't be commingled there, and I, I think, um, a- as much as I respect Martin and Jay and you, I, I just-

    12. MMMarty Makary1:51:33

        Mm-hmm

    13. PAPeter Attia1:51:33

        ... I don't think I have a sense of, like, what the answer is here and why just coming up with the new rogue journal is the answer, um, because I still don't understand systemically what's going on. And, and, and, you know-

    14. MMMarty Makary1:51:47

        Yeah

    15. PAPeter Attia1:51:47

        ... anyway, so-

    16. MMMarty Makary1:51:47

        Yeah. No, you're right

    17. PAPeter Attia1:51:47

        ... so I don't mean to sound, I don't mean to sound pessimistic.

    18. MMMarty Makary1:51:50

        We're-

    19. PAPeter Attia1:51:50

        But, but I'm, but, but, but I, I, I worry that the, uh... I, I just, I don't... You know, all the terms for, for kind of the, the non-conventional thinking world, um, is the goal of that to be a little bit more provocative in the other direction, even if it's deliberately provocative? But, but I, I just wanna be careful that we don't-

    20. MMMarty Makary1:52:12

        Yeah

    21. PAPeter Attia1:52:12

        ... you know, we don't, we don't, we don't create disagreement for the sake of disagreement.

    22. MMMarty Makary1:52:17

        That's right. We are prone to the same bandwagon groupthink as the JAMA New England Journal editors that are a bunch of like-minded friends. We are at risk of that, and we have to be constantly aware of it, and we've invited people who disagree. Um, in Sensible Medicine, we love publishing pro/con articles on the same issue, uh, same topic, a- and you'll see that. You know, Vinay Prasad is wrong, Adam Cifu is wrong on this topic, and, and they're f- they're sparring in the spirit that we should have in academics. Remember when Obama first ran for president, he was asked, "What is your favorite book?" He said, "Team of Rivals," how Lincoln brought together all these different opinions. "No, don't go to war. Do the..." And he wanted them on his cabinet. He wanted to moderate a civil discourse.

    23. PAPeter Attia1:53:06

        Well, I think, I think it, it wasn't just different opinions. Lincoln's cabinet was composed of the people who had attacked him and run against him during the election.

    24. MMMarty Makary1:53:15

        Yes.

    25. PAPeter Attia1:53:15

        It was, "These are the people who have just spent the past six months telling the American public why Lincoln is an idiot and should never be president," and that's the-

    26. MMMarty Makary1:53:26

        Yes

    27. PAPeter Attia1:53:27

        ... that's the team that he assembled his cabinet from.

    28. MMMarty Makary1:53:29

        We, um, need to stay humble, avoid celebrity worship in medicine. We do that a lot. It's the culture, um, of how we create these... The greatest, highest attainable achievement you can have as a physician is to be the chief of a department. And the way you do that is-

    29. PAPeter Attia1:53:50

        Is that really true, though, Marty? Like, I-

    30. MMMarty Makary1:53:52

        In-
16. 2:01:30 – 2:11:30

    The major successes and ongoing challenges of modern medicine

    1. PAPeter Attia2:01:30

       let's just keep it simple. What do you, what do you think medicine has done the best job of in the last decade?

    2. MMMarty Makary2:01:37

       Well, I think you look at cardiac surgical care. I think you look at, um-

    3. PAPeter Attia2:01:42

       Line infections in hospitals. I mean, there have been some really big wins here that don't get maybe as much attention as they deserve. What el- what else? Where else are we hitting it out of the park?

    4. MMMarty Makary2:01:52

       Obstetrical care. I think we've, not only now have, is the infant mortality rate as good as modern medicine can deliver it, but we've now accepted these, these new best practices of skin-to-skin time, delayed cord clamping, encouraging breastfeeding early on, reducing C-sections when not necessary. These are, those are in the last 10 years, those best practices. But, um, we're at a pretty good point where the system is humming on a lot of ac- acute care. And there's a video I saw on social media the other day where a guy said, "If I get shot, I want to go to a US hospital. We have the best care in the world. If I break a bone-" That's where I'm, I'm gonna go straight to a doctor. But when it comes to telling me, you know, what I should be eating or how to live my life, I don't think I trust modern medicine. If you come in with chronic abdominal pain, sometimes our sophisticated system doesn't know what to do, right?

    5. PAPeter Attia2:02:48

       Hmm.

    6. MMMarty Makary2:02:48

       So I think the acute care has been mastered, and I think, you know, I think about the operations I was a part of, these laparoscopic Whipple's, and it's a tour de force of science and technology and, uh, advancements, and we do something called a tran- pancreas transplant, uh, f- with islet cells now for people with chronic pain. So I think good stuff is happening. We have good people. People go into medicine, nursing, every aspect of healthcare, united by one common thing, and that is everybody wants to help other people who are in need. And that's an incredible bond that we have. It's a profession we should all be proud of. It's a heritage, you know, I'm, um, proud of, that my dad, uh, was a part of, and I get to do the things he encouraged me to do, little tips, ways to connect with patients. I still think of the time he said, "Don't ask somebody, are you taking your medication?" Instead, say, "You know, some people find it hard to take their medications as prescribed. How are you doing with it?" It's far less, you know, head-to-head. And so it's an incredible profession, and teaching these little pearls and gems, citing research, uh, calling out the importance of good scientific methodology, it's still, I think, the best job in the world. And medical centers are still some of the most respected institutions in America, which is wh- [laughs] which is why we've called on them to have ethical billing and, and pricing practices. But, uh, we can correct course, and I think all in all, it's an incredible privilege to be a part of the medical profession. I encourage anyone to, to, to get into it.

    7. PAPeter Attia2:04:42

       You would still encourage someone who's sitting here listening to us who's in college, who's on the fence about going into tech, going into business, going into law, going into medicine, you'd, you'd still give them the nudge to do medicine if it's, if it's something they're partially considering?

    8. MMMarty Makary2:04:59

       Yes. Where else can you put a knife to someone's skin within seconds of meeting them just because you're the doctor? People will tell you secrets they've never told their spouse within minutes of meeting you because you're the doctor. And so there's an incredible heritage in the profession, and, and so I think it's the best job in the world. Now, you gotta be okay with memorizing enzyme names over and over again. I mean, hundreds of names of useless molecules that you could look up on Google. That's just part of the old system, and people-

    9. PAPeter Attia2:05:33

       But, you know, I, I, I think the bigger issue isn't so much that you have to memorize those names. It's that you're, you're sort of lacking the context and why. I mean, Marty, I still memorize names of complex enzymes and pathways. Um, but the difference is I'm doing it because it's feeding my interest.

    10. MMMarty Makary2:05:49

        Yes.

    11. PAPeter Attia2:05:50

        Right? It's like I'm reading papers and I'm learning new things, and I have to draw diagrams to help my... So I mean, I'm doing the same thing I was doing 25 years ago. Um, so I don't... And I, I also don't wanna s- let people suggest that it's not important to have knowledge. Like it is important that I know these things, even if they seem a little bit esoteric. But it's just easier to know it when you understand why, when you have a scaffolding around why. Um, I, while I can't tell you every step of the Krebs cycle, I still remember in great detail how metabolism works, because it really matters to what I do. So I, I think if anything, I just hope that medical education can major in the major and minor in the minor, because while I, I think it matters that you understand these things, I, I think it-- And again, maybe this is already the case 'cause I'm so far from it, but, but if you understand why the Krebs cycle matters and why when the Krebs cycle isn't working, every disease in the body gets worse. Like why is it that a person with cardiovascular disease, type 2 diabetes, Alzheimer's disease, why do they have defective Krebs cycle? That's what I want medical students to be understanding and learning.

    12. MMMarty Makary2:07:03

        Yes.

    13. PAPeter Attia2:07:03

        So anyway.

    14. MMMarty Makary2:07:04

        Yes.

    15. PAPeter Attia2:07:05

        Um, I don't know where I stand on it truthfully. If I-- I do get asked from time to time by young people, "Hey, you know, would you do it all over again?" And of course, for me, the answer is undoubtedly yes, but, but I also realize there are a lot of other exciting fields in the world today that, that maybe weren't available to me, and I don't know.

    16. MMMarty Makary2:07:25

        How about surgical residency? [laughs] Would you do that part again?

    17. PAPeter Attia2:07:29

        You know, uh, uh, yeah, it's interesting. Knowing what I know today and knowing where I ended up today, would I have been better off doing a, you know, an internal medicine residency? You know, the answer is probably yes. I think it, it would be more logical. But look, I wouldn't know you. I wouldn't know Ted Schafer. I wouldn't know a lot of the amazing people that I've gotten to know through my surgical training. Um, and I, I think in many ways, surgical training, um, especially the way we did it so long ago, you know, when you didn't have regulations on work hours and stuff, it was so hard that it, um, it really gave me an appreciation for how much easier my life is today, um, and how, how lucky I have it to, you know, not be woken up every [laughs] 14 minutes when I sleep and, you know, things like that. So, so, so I don't know. I, I don't know.

    18. MMMarty Makary2:08:22

        Yeah.

    19. PAPeter Attia2:08:22

        I'd, I'd probably be reluctant to change anything. I think it all worked out okay, uh, and I'm really grateful for the folks I met along the way. Um, and, um And I, and I do hope that, that someone listening to this who's, who's contemplating medical school, as you said, I, I, I agree with you completely. Anybody who chooses to be anywhere within the vicinity of this field, you w- you want to be a nurse, you want to be a radiology tech, you want to be a phlebotomist, you want to be a doctor, the one thing that unites all of those people is, um, they're, they're doing it for the right reasons.

    20. MMMarty Makary2:08:55

        You know, the sort of kid in high school when asked, "What do you want to go into?" And they say, "I don't know, I'm thinking about being a nurse." They're different from their peers. It's a, it's a calling really-

    21. PAPeter Attia2:09:07

        Mm-hmm

    22. MMMarty Makary2:09:07

        ... to be in medicine. And so we attract these great folks. I think our challenge in the academic towers is how can we keep the focus both on the test-- technically sophisticated pieces of metabolism so they understand it, but at the same time not lose sight of the overall person.

    23. PAPeter Attia2:09:26

        Yeah, I agree. Yeah.

    24. MMMarty Makary2:09:27

        The-

    25. PAPeter Attia2:09:27

        It's the... You pr- you have to preserve the humanity of the field, uh, while harnessing kind of critical thought, um, and, and, and doing it around, as I said, kind of this scaffolding of purpose.

    26. MMMarty Makary2:09:41

        One quick thing. I, I discovered, classic example of this, the Pima Indians in New Mexico along the Gila River, they had been cut off with their water supply, farmers and ranchers and settlers. And so this nation of Indians all of a sudden wasn't-- they weren't able to grow crops and the healthy foods they had been eating for centuries. So the US government, recognizing how they were being depleted of food and the starvation that was happening, they started shipping food. But of course it wasn't, this wasn't whole food stuff. This was [laughs] spam and potato chips or whatever else. And they started developing massively high rates of obesity. Diabetes quickly ensued. And so you had this population that was massively obese and diabe- and with diabetes. And the NIH decides to swoop in and address this problem by looking for a predisposing gene for d- d- obesity and diabetes. And they tested the blood of all these poor Indians, and it's like we can't see the forest from the trees sometimes.

    27. PAPeter Attia2:10:46

        Yeah.

    28. MMMarty Makary2:10:46

        Right? They're... We've been feeding them shit for decades. [laughs] That is what's been driving the obesity and diabetes.

    29. PAPeter Attia2:10:54

        Yeah.

    30. MMMarty Makary2:10:54

        It's not that they have a gene.

Episode duration: 2:11:30