Book Review: Why the Medical Establishment Often Gets It Wrong

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Like many surgeons, Marty Makary used to routinely treat appendicitis by removing the patient’s appendix, a procedure performed nearly 300,000 times a year in the U.S. That changed about a decade ago after he read a research study that found antibiotics may be an effective alternative.

Despite subsequent research confirming that appendectomies can often be avoided, Makary estimates only about half of surgeons have accepted the idea. “That means whether or not you go under the knife for appendicitis today in America depends on who’s on call when you walk into the emergency department,” he writes in “Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health.”

BOOK REVIEW — ” “Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health” by Marty Makary (Bloomsbury Publishing, 288 pages).

In detailed behind-the-scenes case studies, Makary, a surgeon and public health researcher at Johns Hopkins University, reveals how and why physicians often salute bad science and baseless opinions at the peril of their patients.

Among other things, Makary claims, the medical establishment created the opioid epidemic and the peanut allergy epidemic. Tens of thousands of women have died prematurely because of misinterpreted data about the danger of hormone replacement therapy. The U.S. government banned silicone breast implants for 14 years without evidence they caused harm. Physicians’ overuse of antibiotics is likely causing untold suffering. Doctors still tell overweight people to eat low-fat foods, even though low-fat diets are associated with obesity and diabetes.

“Much of what the public is told about health is medical dogma — an idea or practice given incontrovertible authority because someone decreed it to be true based on a gut feeling,” Makary writes.

Makary’s assertions are supported by hundreds of footnotes as he builds each indictment, but that doesn’t mean all physicians and researchers are nodding in agreement. One example: When a research team analyzed 13 studies comparing antibiotics to appendectomy, it found almost a third of the patients initially treated with antibiotics had an appendectomy within the year. Although the other two-thirds did not, the researchers called the evidence that antibiotics are better “very uncertain.” So surgeons who choose to operate immediately are not necessarily doing something wrong.

“Much of what the public is told about health is medical dogma.”

Makary, one of medicine’s most prolific iconoclasts, has been poking at America’s health care system since at least 1998 when, as a medical student, his article calling on hospitals, medical schools, and health insurance companies to divest their tobacco stocks was published in the prestigious Journal of the American Medical Association.

A few years later, ignoring criticism from his colleagues, Makary created a checklist to improve surgery safety; after proving that safe surgery checklists reduced surgical errors and deaths, they are now used in most operating rooms around the world. His 2012 book, “Unaccountable,” demanded that hospitals reveal their infection rates and medical errors. A few years later, Medicare began requiring public reporting of those and other indicators of health care quality. His 2019 book, “The Price We Pay,” documented hospitals’ price-gouging practices and called for all hospitals to post cash prices for certain services — which is now required by law.

In each case, Makary cannot claim to be solely responsible for influencing these big changes, but he did have one of the biggest megaphones. Both of those books — and “Blind Spots” as well — became New York Times bestsellers.

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The thread running through Makary’s harangues is that America’s health care system is getting a lot of things wrong. “Blind Spots” focuses on the failures of the “medical establishment” — a term Makary does not explicitly define but refers to more than 40 times, almost always in a derogatory context.

He excoriates medical journals, government agencies, and professional medical societies for actions that, in his view, harm the people who trust them. He does not call the medical establishment nefarious; rather, he accuses it of frequently embracing a narrative — that stress causes ulcers, for instance — without evidence, ignoring scientific findings that do not support the idea, and blackballing those who question their position.

Medical journals, for example, are a primary way in which doctors learn about new scientific knowledge that informs the medical care they provide. Most journals use a peer-review process, meaning that an article is only accepted for publication if a panel of experts deems it to be accurate and of high quality.

Makary has written more than 250 peer-reviewed articles in medical journals, but he is no fan of the genre. In his view, editorial boards, the gatekeepers of peer-reviewed publishing “tend to be composed of like-minded friends.”

Makary excoriates medical journals, government agencies, and professional medical societies for actions that, in his view, harm the people who trust them.

“I have been shocked to see studies so flawed that the results are rendered invalid, yet they were published in prestigious medical journals and upheld as scientific proof when instead they just support a groupthink narrative,” he writes.

Invalid results? Inconsistent and fraudulent data published in medical journals is commonplace, with more than 10,000 articles retracted in 2023 alone. Earlier this year, the Dana-Farber Cancer Institute retracted seven published articles — and corrected 31 others — because of errors or allegations of manipulated images.

The National Institutes of Health, the world’s largest public funder of biomedical research, also loses some of its luster under Makary’s gaze. Among other things, he lambasts the institution for its 2002 decision to stop a clinical trial about the long-term effects of hormone replacement therapy, citing an increased risk of breast cancer that was based on bad science. Presenting a vigorous defense of the therapy’s many benefits, Makary quotes an estimate that around 140,000 women died prematurely over two decades because they did not use hormone replacement therapy. “The message that HRT causes breast cancer stuck,” he writes. “And that message is still believed by most doctors to this day.”

Medical societies, which provide guidance for physicians and the public, also draw Makary’s critique. The American Heart Association, for example, promoted a low-fat diet for six decades, despite a lack of evidence that fat causes heart disease. The American Academy of Pediatrics’ baseless recommendation that children under 3 avoid peanuts fueled America’s peanut-allergy epidemic; introducing peanuts early in life actually reduces the risk of an allergy. The American Medical Association supports what Makary considers to be government censorship of health information.

Makary’s critique of the medical establishment at large brings to mind oncologist Vinay Prasad’s critique of cancer care in “Malignant: How Bad Policy and Bad Evidence Harm People with Cancer,” published in 2020. The similarity in the authors’ in-your-face approach is no coincidence; in his acknowledgments, Makary refers to Prasad as “the great sensei.”

Makary’s writing style makes it easy for general readers to follow along as he identifies a “blind spot,” flies around the country to gather information about its history, and digs into research studies to collect data points. His many tangents and asides — readers get a long and gory description of a seaman’s scurvy symptoms, discover that President John Adams defended British soldiers in court, and learn that VIP patients can be a pain in the butt — can be jarring at first. But his enthusiasm for his material — the book is peppered with “amazed” and “amazing” — is contagious.

Makary quotes an estimate that around 140,000 women died prematurely over two decades because they did not use hormone replacement therapy.

That said, physicians, specifically those he considers to be part of the medical establishment, seem to be his primary audience because he includes so many calls for action. Among other things, he wants apologies from government agencies and medical societies that give bad advice. He wants to see funding for repeat studies that confirm research results. He wants America’s medical education system to stop propagating “outdated groupthink.”

His most frequent call is for civil discourse, in which medical consensus can be questioned without the questioners being dismissed or disparaged. Makary’s strident opinions and broad-brush derision of the medical establishment may turn off those he seeks to influence, but his track record for fomenting change cannot be ignored.

So perhaps readers can hope that his vision will come to be: “Open debate and a discussion of the merits of data over dogma make for a stronger society, more civility, and a faster rate of medical discovery.”