#317 ‒ Reforming medicine: uncovering blind spots, challenging the norm, and embracing innovation | Marty Makary, M.D., M.P.H.

Hey everyone.

Welcome to the Drive Podcast. I'm your host Peter Attia. This podcast, my website and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness and we've established a great team of analysts to make this happen. It is extremely important important to me to provide all of this content without relying on paid ads to do this. Our work is made entirely possible by our members and in return we offer exclusive member only content and benefits above and beyond what is available for free. If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peterattiamd.com subscribe.

My guest this week is returning guest Dr. Marty Makary.

Marty is a surgeon and public policy.

Researcher at Johns Hopkins University, as well.

As a former colleague of mine during our residency. He's a member of the National Academy of Medicine and writes quite regularly for the Washington Post, the New York Times, and the Wall Street Journal. He is also the author of two New York Times bestselling books, Unaccountable and.

The Price We Pay.

His current book, Blind Spots When Medicine Gets It Wrong and what It Means for Our Health, is set to be released on September 17th. In this episode, we talk about many of the themes in his new book, including how a new generation of doctors are thinking differently to ask new questions about the way things have been practiced in medicine historically. We lay the foundation for the conversation by discussing cognitive dissonance and how this theory applies to the medical community today.

We discuss a few examples of the.

Blind spots from the book, such as the treatment for appendicitis, the peanut allergy epidemic, the misunderstanding of HRT as it relates to breast cancer, antibiotic use, how childbirth has evolved over the years, and more, all detailing the many scenarios in which a new medical approach may be possible if we're able to ask different questions. We also reflect on where medicine has done a good job over the last few decades and where Marty believes there is room to challenge historic practices and.

Pave a new way.

So without further delay, please enjoy my conversation with Marty Makary.

Hey Marty, thanks for coming in.

Good to be with you, Peter.

Great to see you again as always. So you've got a new book out, Blind Spots. This is a book I guess I certainly remember talking about with you as it was in the works. We've had many dinners together when some of these topics have come up. Can I take 5% credit for the inclusion of HRT in this book?

No, you get 99% credit for that. That was incredible.

That was a late addition, right to.

The book 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. So thanks for tipping me off there and helping me shape the book.

So the book is a great read and it goes through a number of situations that all kind of have this theme in common, which is an idea comes up, the idea is a bit shaky in terms of lack of evidence, 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 sort of goes wrong? Why is there a book about this instead of a bunch of case studies of how everything has gone really well?

So there's a science to group think 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 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 since passed away, but had written a tremendous amount of material on this idea of cognitive dissonance. He really carved this entire discipline out in 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. So if something comes along that challenges your deeply held views or just what you've happened to heard 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. So this happens in day to day life, it happens in human interactions and it happens in medicine too. We get 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 I know we'll 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 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? 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 that can help me answer questions. And yet if I was to challenge every idea out there that I held sacred, I'm not sure I'd get anything done. So what's the balance in your mind between your doctor tells you something kind of makes sense. It seems logical, at least plausible, but technically you haven't done the thinking on it. How do you not allow yourself to become a crazy conspiracy theorist who doesn't trust anything and throws out what's 80% good in the pursuit of throwing out the 20% that's trash. How does one navigate that?

There are extremes on both sides. You see the pendulum swing, like with childbirth. There's this over medicalization of ordinary life and then this swing back to avoid all doctors and hospitals and deliver it home with nobody. It'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 should be part of the process. And I think there are times when we are very slow as the medical community to implement scientific evidence and it's okay to educate the public on it. There's a non operative protocol for appendicitis.

It's one of the things I wanted to talk about with you.

Okay. You want me to mention real briefly now?

Sure, yeah. 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.

Yeah. So inflammation of the appendix, an infection sets in, the 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.

And to give 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 acute appendicitis?

It was over 60%. Walter Reed, a famous physician himself, died of appendicitis. The hospital in D.C. is named after him. So it was a common cause of death.

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

I thought it was 5, but yeah, probably in that range.

Think about that, right? There's a 1 in 18 to 1 in 20 chance you'd get an infection of your appendix and a 60% chance that if you got it, it would kill you.

It still is one of the most common operations performed in American hospitals. We have learned as a reflex, as surgeons. When you were at Johns Hopkins, you did this many times. We may have been in the operating room together.

We did many together, yes.

So as a reflex, you learn to take out the appendix. You do it swiftly, you do it with laparoscope as of the last 30 years or so. And pre med students know this, 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. Diagnose, treat, diagnose, treat. Diagnosis used to be tricky because it can present a lot of ways. Now the CAT scan just points out the bullseye and you go to work, you, 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 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.

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. 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. Plus there's the cost associated with surgery. 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.

Yes, exactly. And of those who respond well to the antibiotics, it's something like high. 80% will respond 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 got that pain back. And then you go to surgery for them.

So the total cure though is about 2/3.

2/3. And you don't get behind the eight ball. It's not like we gave a short course of antibiotics, washed 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. And it's not just you made a good point about the cost and the other thing. But the patient doesn't have to 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.

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

Yeah, we've got a nursing staffing crisis. There's so many implications to appropriately implementing this research. So I was talking to one of my colleagues because I offered this to a kid who came in to see me. I was really in a dilemma because I had read the study, I was convinced of it, and I thought, this is at least something to offer patients. Nobody else was really offering it at the time. The study had been a couple months out. So I had this guy come in, about 19 years old, perfect candidate, no rupture, no fecalith, early appendicitis, young, healthy guy. They're already getting antibiotics when they come in and get diagnosed in the emergency department anyway. So usually it's just running it a little bit longer. And I offer him the surgery versus no surgery. He tells me he has a wedding the next morning in Boston, which he has to fly to of his sister. And I'm thinking, oh my God, what gets him to the wedding faster? Just taking him to the operating room right now, which case? He might get there in a wheelchair. I don't, you know, he should be able to leave the hospital in the morning, get a flight, he might limp around, he'll be in some Discomfort or do I do the antibiotic protocol? So I just offered him both. And I told him what I don't know, which is, I think the most important part of being a doctor is understanding the unknowns and dealing with uncertainty. And guess what he chose between surgery and no surgery?

I'm sure he chose the antibiotic.

Yeah, yeah, of course, yeah. Do you want to go under the knife or not? Doesn't matter. Of course he chooses no surgery. So he goes to the wedding the next day, dances up a storm. And I become so convinced that this may be revolutionary. And I tell one of my colleagues about it and he says, I don't buy it. I said, well, have you read that randomized control trial? It's published in our top journal. And he says, I need to see two randomized control trials. So I'm like, okay, they've been doing this in Europe a lot longer than we've heard about it in the us. So a second randomized control trial comes out like a year later. I show it to him and he says, I need to see three randomized controlled trials. Believe it or not, a third one came out. I think it was like six months later. Long term follow up. The initial study was repeated in children's. Other studies came out that were non randomized. And I showed it to him and he says, I just think you're better with it out. And I'm thinking it would be unethical to do any more research like this. Is the cognitive dissonance that Leon Festinger was describing. Leon Festinger embedded himself into a cult to prove his theory correct. A cult that met in Chicago believed that aliens were going to pick them up because there was going to 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 believe first and we're not open minded to be objective.

The thing he wants to test is when the aliens don't come to rescue the people that were the firm believers, how many will say, oh my God, how stupid was I to think this versus what will be the set of stories that get spun to explain why their belief was still right.

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

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

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, because the pickup was supposed to happen at noon and they had removed their belts and medals for the flight and everything. 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 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, just openly once, almost in a Freudian way, said, 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 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. It's a theory that's now well accepted as cognitive dissonance. And it's tied closely to effort, justification. That's the concept in psychology. And that is, hey, I'm vested. I've spent all this energy on it. It must be good or justified. And we do that with our surgical residency fraternity hazing. It fosters this cycle of abuse. And in the examples by, I think their name was Aaron and Mills were the two psychologists right after Festinger around that time. And they took college students and they said, hey, we're going to have you do this task. We're going to pay you for the task. You take little pegs and you put them in the most tedious, boring thing you can design. And they paid 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?

The group getting paid a dollar.

The group getting paid a dollar. Because they had to justify. They did another experiment where they said, hey, we're going to have a sex talk and you have to take an entrance exam. And there were three groups that took the entrance examination. One had an entrance exam that was incredibly difficult. They didn't give them the results. They just said, okay, 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 kind of like, what 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. Guess which group said they enjoyed it the most?

The one with the hardest test.

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. We've got these traditions and dogmas and medicine that can take on a life of their own.

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

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. There are many theories as to why that might have crept up from zero generations prior, but 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 0 through 3 to avoid all peanut products, including the little peanut butter moms would put into food in infancy. And pregnant mothers and Latin 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 allergy, where if someone used the same ice cream scooper in the pistachio, even though they had rinsed it, that kid could end up in the emergency room. When we saw emergency room visits skyrocket. So the medical establishment, the elites, I'll say, not the rank and file Doctors that think independently and a lot of 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 had known it as the dirt theory. Sometimes you're around kids, kids that play on dirt. Yeah, yeah.

Develop a robust immune system. They're healthier later in life. Bubble kids end up getting really, really sick later on.

There was a pediatrician named Gideon Lack, who's an allergist, who was one of these enlightened guys early on. And he said he noticed kids that had, I think it was like iron or metal in their teeth for dental work were less likely to get a reaction to ear piercing later in life. So he had done research in immune tolerance and knew this concept. If you're exposed to something, you're less likely. Well, a bunch of pediatricians detested this recommendation, tried to speak up. They were basically silenced or sideline. And this recommendation took on a life of its own. Parents were told for their kids, remember, 1, 2, 3. At age 1, you can introduce milk. At age 2, eggs. And age 3, finally you can introduce some peanut products. So it became known as the 1, 2, 3. 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 a little echoes here 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 1 in 18 kids has a peanut allergy. But the severe peanut allergies 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. Because now you have to think about the 1 in 18 kid with an allergy. So it became a self licking ice cream cone. It was like more abstinence, more abstinence. What are you doing? And the parents who were like, no, I'm going to introduce peanut butter, as my grandmother did. And for generations, when there were no peanut allergies, they were seen as anti Science. They were ridiculed. Schools would address these parents sometimes. I have two medical students, graduate students, doing research in my research center at Johns Hopkins from Africa. One's from Cameroon and one's from Zimbabwe. 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 they are announcing it on the plane to bwi. All these products are like, contains no tree nuts. And they're like, what? Never seen this before in my life. Some student invited one of them to dinner at his house because 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 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 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. And you realize this is a unique American epidemic that was created, but there.

Must have been some index cases that caused the hysteria.

Yeah. So that incidence from Mount Sinai suggested half 1%. It might have been microbiome related, we think, but the peanut abstinence threw lighter fluid into this fire, and it really resulted in where we are today.

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

So here's the thing. The study got done eventually. Fifteen years into the recommendation that Dr. Gideon Lack, I mentioned in London, published a study in the New England Journal of medicine with 640 kids doing a randomized control trial to early peanut butter exposure in infancy. Four, five, six months, not as their sole diet. He's still pro breastfeeding. Right. And whole peanuts have a choking risk. So, I mean, the smart way. And then 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. Fifteen years.

And sorry, what year was that study published?

2015.

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

Yeah. One of the biggest odds ratios you see in research. And then, of course, the bureaucrats at NIAID and NIH from the National Institute of Allergy and Infectious Disease. Two years later, they get around to putting a position paper and all this stuff. So 17 years.

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

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 at which you pointed out initially? Why not show some humility? 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.

To me on my soapbox, that's really the beef I have with the HRT stuff is the absolute, I mean, megaphone of 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. But again, not only is it too little, too late, you've got a generation of women, literally a generation of women, over 20 million women, who have been deprived of HRT. But even women that are 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, there's an enormous asymmetry in these information campaigns.

And one little piece. I know you've done a great job covering hrt, but one of the guys in that committee, 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, this is not how we do research. 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 hrd, 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 there were no increase in breast cancer deaths, maybe with a gun to his head when we were, you know, I was doing the interview with him.

Not a single increase in breast cancer deaths.

Unbelievable.

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 can't tell you, Marty, how many times I get asked this question. It is probably the single most prevalent topic of discussion I have in a public setting, like at a dinner or something like that. So it tells me how much incorrect information still exists out there.

It's amazing. There's probably no modern day medical intervention that has improved the health of a population as much as HRT for postmenopausal. 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 peanut allergies wrong for 17 years. Where's the apology? Where's the humility? That's why there's distrust right now.

This is where I really, really struggle because I have friends who are otherwise smart people who have such ridiculous views in terms of where the pendulum has swung the other way and they're convinced you shouldn't microwave your food because microwaves are harmful. And I don't say this to be arrogant, but there's also such a degree of scientific illiteracy that even when I try to explain to one of these friends what a microwave is and why a microwave can't be harmful, you have to understand what ionizing radiation is. You have to understand what a light. If microwaves are harmful, then light is more harmful based on the wavelength. But, but that's a hard thing to explain to people who don't understand science. You can't see wavelengths. It's difficult. So I think that's what bothers me is we've created kind of a bimodal distribution 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 an utter blind faith. And again, it comes back to my question, which I don't have a great answer to, which is how does a reasonable person maintain skepticism but not be paralyzed by it and not be pushed so far to either extreme? I still come away thinking I don't know the answer to this.

Yeah, I don't have a satisfying answer either. And I feel for the everyday person out there. 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 don't want to create so much skepticism where People are denying a chest tube when they have a suction pneumothorax. So it's like, what is that balance? I don't have 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 misinformation, we've got this culture of obedience in medical school that goes right down to your first day of medical school. So 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.

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 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 dedicated track of statistics and probability theory. And I think this is important for all of science. I know you would agree with me, I think, but there are no proofs in science. I've said this many times before. So nothing is 100% certain. So science is not a thing, it's a process. And what is highly probable today is probably a better way of describing something that we think is true. So new information should always be obtaining probability. So if you think about that framework, if people are trained in the mathematics of uncertainty, which is what statistics and probability theory are, and I feel very fortunate because I was a math major before I went to medicine, so that came a little more naturally to me to think that way. 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 know that sounds very mechanical, but I can't really think of another way. And I know we're going to try not to talk about COVID today because the world's Covid fatigue is rampant. But Covid offered so many lessons in this, which is, hey, 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, 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. Okay, maybe it's 50, 50 now, but if we thought about it that way, I think it's easier to change your position because you're not wed to a binary outcome. Yes or no? You're thinking about it as a probability distribution function.

That's right.

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. I've lost track of all the other things. Fortunately, I've purged most of them from my brain. But like Ivermectin, all of these things, I mean, all of these are reasonable things. To have assumed that what became unreasonable was to not go through this process. Both sides, the sides that clung to them and the sides that morally opposed them. We should probably revisit that. Let's shift gears a little bit and talk about antibiotic use. So this is something that probably doesn't get that much attention. 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 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.

Resistance.

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

So about a hundred thousand people in the US Die a year 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, bacteria will mutate around an antibiotic and it'll be a blank. Say, methicillin resistant staphylococcus. We're now seeing C. Diff, one of those common bacteria. Take the life of somebody every other month or so in the hospital. In most hospitals, 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. 4. 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 the operations that I do. There's this protocol that you give every single operative patient antibiotic before the incision.

Yeah, Marty, 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 used to give Ancef. I don't know if that's still the case. Right?

That's a common one.

Yeah.

Okay. And again, the reason was 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. 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. I never questioned it. There must have been studies that demonstrated lower incidence of wound infections. I can't imagine something that prevalent was implemented without an RCT. Was it?

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

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

I don't think so, 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 incidence 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 to this. Well, for whatever reason, with no data, the research from open abdominal GI cases got extrapolated broadly. And I remember asking. I was actually in practice a little bit before the broad recommendation. I remember asking this guy, Patch Dellinger, who was involved in these recommendations. It's called the Antibiotic Society of America. You know, one of these. There's all these niche meetings. We have the Pancreas Club. It's like all these meetings, it's more fun than the Spleen Society, by the way. They're boring. And so I remember asking them, 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 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 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 is mostly for the glucose. But what's it doing to the gut? 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, not even wearing masks when they're doing surgery and their infection rate is no different.

Really?

Yeah.

That's surprising to me.

Yeah. And you think, well, what is the mask doing? Is it preventing sweat from dripping in? Is it preventing the airborne particles? Because the airborne particles are just coming out of the side of your mask. 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, the microbiome is the most sensitive to antibiotics, but antibiotics are like carpet bombing your microbiome, these millions of bacteria that live in harmony. And this study, I don't know 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, the area of 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 later in childhood. And what they found were these incredible Correlations 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 the 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.

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, 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.

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 right.

Yep.

Right. So those are all good questions. Now, 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. The more courses of antibiotics a child.

Took, the more significant the delta, the.

Higher the odds ratio.

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. I'm convinced of that. If you don't have causality, you have nothing. 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 statistician named Austin Bradford Hill speak to the strength of the association and the probability or likelihood that that association is causal. And you've outlined a couple. So one of them is what's the strength of the association, period. So if I knew nothing else was the asthma, the 289% celiac. 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, 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. For example, all of this was figured out during the kind of smoking cholera epidemics, when people were trying to understand causality. And then you would 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?

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

Is that because they target gram negatives more or anaerobics more? I'm so far out of my life on antibiotics, I don't even remember why that would be the case.

I don't know. But 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's a laboratory scientist. He started doing all these mice experiments. If antibiotics are making animals more obese, what are they doing to humans?

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 look at animals. So of course, someone listening to this might say, well, okay, Marty, but there's gotta be some bad luck involved here. I mean, 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, those 10,000 kids weren't just given antibiotics for no reason. They must have had ear infections, they must have had tonsillitis, they must have had appendicitis. They must have had something. What were we supposed to do? How do we draw the line between what was medically necessary? Because as unfortunate as those consequences are, they pale in comparison to A life threatening infection that could have killed a kid. So how do we decide what the minimum effective dose is, what's absolutely medically necessary versus what is superfluous and potentially just exposing a kid to these complications later in life.

Antibiotics save lives. You've seen it and I've seen it right in front of our eyes. They're amazing medications. They ushered in the white coat error.

As I wrote in my book, Marty, it's what took us from medicine 1.0 to medicine 2.0. Yes, we died like dogs for 250,000 years of human existence. We died like dogs. You got an infection, life expectancy was 38. It's not the only thing that made the difference, but it was arguably the single most important difference with sanitation and antimicrobial therapy in the Transition from medicine 1.0. 2.0.

That's right.

So we don't want to throw the baby out with the bathwater.

This is the nuance which if people want just sort of a simple dumb message and all or nothing, which is where our echo chambers of media and politics take us in life and social media. Right? You want this all or nothing. Absolutism. Antibiotics save lives, but they are also massively abused and overused. At least 60% in all the studies.

40% of antibiotic use is justified.

Yeah, And I even question that number because they would say that I should be giving antibiotics before my minor procedures. But there's also epidemiologic data over time that, look at all these chronic diseases. Now, I know they're multifactorial, especially obesity, but look at all the increases we've seen in these exact diseases that they've seen increase in the antibiotic group after the broad administration of antibiotics in the 1940s and 50s. In the 60s, it just went up even further. The discoverer of antibiotics, Alexander Fleming, in 1922, he had warned after he got the Nobel Prize about the massive overuse of antibiotics. He had written in his diary that I found in my research that these mass factories producing penicillin, it blew them away. This was a mold that blew into his lab when he left the window open. We don't know if it's him or his lab tech, it's unknown, but somebody left the window open in his lab where he was growing staff in an auger gel. And some of that mold landed and formed a circle around the mold where all the bacteria were killed. And he had discovered what's considered to be the greatest discovery in modern medicine. And so you're right, it took Us from being surgeon barbers, where we had a lancet and a axe to do amputations and maybe digoxin, which didn't help. And that was it. And doctors weren't disrespected, but they were respected, like a priest or a barber. And then with the mass production of antibiotics, now we had the power and controlled a substance where only we could give you a magic pill. Doctors began to wear white coats. They had an unquestioned authority. We kept people in the hospital.

I'm a little disappointed you're not wearing a white coat today, Marty.

I'm not a white coat kind of guy. We held babies in the hospital for 10 days, routinely normal, healthy babies.

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

Normal at term.

Yeah, 14 days.

It's crazy.

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

I remember my little sister was born around 1980s. Mom came home from the hospital. After delivering her, my brother and I are like, hey, we have a sister. Every day we'd ask dad, when is 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 with some big glass window, they'd be like, there she is. Third row from the back. Six, one over. You see this little head of hair, you looking back on it? This is the medical paternalism. This is that white coat era. This never happened before in history. People stayed in the hospital for two weeks after a cataract. They'd measure their toe diameter. They'd, you know, probe and poke and put babies in the NICU and feed them formula. And mother would be like, can I still hold the baby? No. As a student, 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. Go, room six. You know, you're some moaning. You go in there and all sorts of chaos, okay? As soon as you see the umbilical cord, you cut it. And I'm holding the scissors. I want to learn about the process of childbirth, but I've blocked out everything because I have one job, 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 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. And I'm thinking, baby, French fry light. 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 don't say anything. I want to get a good grade. And I'm like, the mom wants to hold the baby. Wouldn't that be warm enough? No, we have to warm the baby. Turns out the data now on skin to skin time, hours of skin to skin, 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 pressure. I heard that in the studies, and I was like, that makes sense. But I don't get the glucose. Why would the glucose. There's stress hormones, cortisol. Cortisol, yeah. You figured it out quicker than I did. And I'm kind of like, what are we doing? They're sticking a metal temperature probe in the baby's rectum. And I'm like, is this a nice way to welcome a human into the world? What are we doing? Like, the baby's temperature is what the mom's temperature was because the baby just came from the mom two seconds ago. Like, what are we doing? They were just like, oh, we have to put it on the sheet. And all this probing and poking. They wash the baby. Now, they know not to wash a baby for the first 24 hours because there's kind of a proteinaceous 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, and the skin and the kisses, the grandparents. But when you're born by C section, the baby is extracted from a sterile operative field. 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.

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

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

But again, just help me anchor this to some context. Fifty 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?

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

So what was the prevalence of C sections? Pick your favorite decade when elective C section was not done. Should it be 5%? Should it be 10%? If we're only doing it for medically necessary C sections?

The obs that I've grown to really respect, really trust ethically, 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.

So we think that that probably is at least in the zip code of what is necessary. And by the way, let's go back to what we were talking about in the world of Medicine 1.0, when we barely got to our 40th birthdays and infant and 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 I know you don't think this way, but I just want to make sure people listening to us don't take away from this. C sections are bad.

C sections save lives.

I would argue C sections, antibiotics have saved more lives than anything that we're doing in medicine today. Correct?

Yes. Right.

That has doubled human lifespan.

That's right.

Because when something goes wrong in delivery, it doesn't go wrong in hours, it goes wrong in seconds. A fetus doesn't have an enormous physiologic reserve. So when their heart rate starts crashing, you've got to get that baby out immediately. So what you're basically saying, or what I think we want to discuss, is why did we go from a world in which once we had modern medicine at the early part of the 20th century and we were able to get these 12 to 15% of children born safely via a C section. How did that go to 50, 60, 70% depending on your series. What was that transition? Why did that happen?

I'm told it's a combination of a consumerist culture if you think about it. If we're being really honest here, I've talked to a lot of doctors of mine life, I think you have too. Being an OB doctor specializing in labor and delivery is one of the hardest. It is so hard, a brutal lifestyle. And so you have somebody who's been pushing in labor, it's now 10 o' clock at night, they're telling you, just cut this thing out of me. May not be medically necessary, but in the fog of the moment, I will tell you that there are OB practices that the ethical OB doctors I've interviewed and talked to tell me about this. And it drives them crazy. There are OB practices where you check out from your first prenatal visit and the receptionist, when they schedule the next.

One, is also scheduling your C section.

Would you like to schedule you pick a date for your C section. No informed consent and people. It runs in certain circles. Oh, it'd be nice to have it on her grandmother's birthday. And why don't we schedule it? It's Christmas Eve birthday and they try to schedule the birthday. There's so many factors in Brazil. There's a dogma that it changes vaginal delivery, changes one's sexual pleasure. It's unsubstantiated, but it looms large as a dogma in popular society in Brazil. So there are many reasons and I'm not in this field, but from talking to folks in it, there's a massive. I mean my cousin, I went with her when she delivered. She was by herself. And of course I'm highly attuned to this issue. And the OB docs come in and they're looking at something on the rhythm strip and they basically tell her, I think that C section might be safer for the baby. Well, even though she didn't want a C section, she of course is reasonable and open minded. You tell that to any woman in the world, they're 100% going to say, well then just do it. And so I think there's a little bit of what we call the nudge. Hey, what about this non operative protocol for appendicitis? Well, it's a little experimental, could be a little dangerous. Oh, well, heck, don't do it then. You have bone on Bone in your joint. Nothing is going to help except a knee replacement. Shit. Bone on bone. Just go ahead. Right, so we have these nudges in medicine and they're kind of well known in every field.

Look, I'm probably guilty of them myself. I would bet if I were listening to me. If I were outside of me and listening to me talk to patients, I'm sure there are many times when subconsciously I'm doing the same thing. I'm nudging them towards what I think is the right answer. Even if in cases when maybe my confidence should only be 70% instead of 99%. Do we have any evidence, Marty, that that trend is reversing? That it's coming back to more of a natural childbirth process in terms of everything from both a vaginal delivery standpoint, but also in terms of how the baby is handled post operatively. I mean, I know that for all my three kids, they had the instantaneous cord cut. We were trying to set a world record with how quickly that cord could be cut. We really, really smoked that thing. What is the trend on that now?

On that real quick. They've done studies looking at 45 seconds versus 90 seconds of delayed cord clamping. And there was a clinical, statistically significant benefit to 90 seconds. You're getting stem cells, you're getting benefit.

In what regard? What was the outcome?

I don't remember. This is a randomized controlled trial of two timings. And I'm told by the obs I respect, you want to cut it after it's done. Pulsating could go two minutes. Now we're talking about the pendulum swinging to the extreme and people taking hard line, inappropriate positions. One patient told her once, don't you dare cut that before five minutes. And she's like, oh, yeah, it's not going to pulsate after two minutes. So we don't want to create extremists here, but the C section rate has stabilized and I think it's because of awareness out there. I don't think people understand the impact of the microbiome. A study just came out in JAMA Surgery that children born by C section had higher rates of colon cancer before age 50.

How much higher?

Don't remember the odds ratio. It was JAMA surgery. Came out in the spring, 2024. I think I've got it cited somewhere in the book, but it was a large database study from Sweden. Now, again, we cannot make conclusions from that. But these are little signals on the data that we're supposed to pay attention to. I do think it's stabilizing. Dr. Will Brune tracks C section rates for healthcare organizations and he will say here's the 28 doctors at this hospital, here's their individual C section rates. As we are pulling from big data and we're not going to grade doctors shouldn't be under scrutiny for a 15% versus a 19%. But we use these data as a screening tool. If you're over 30% C section rate in your low risk deliveries, which we can do in big data, we can scrub the severe preeclampsia and the twins and all, then that is a screening tool to identify inappropriate concerning patterns that warrant a closer clinical review.

How prevalent is that type of analysis today?

We're the only group doing it that I know of. It's called global appropriateness measures. It's a consortium of physicians that I help start with Dr. Will Brune. Gameasures.com is the website and lots of groups now. GA, GA measures for globalappropriatenessmeasures.com and so health systems are saying you've got all the commercial data or nearly all the commercial Data. You got 100% of the Medicare data, a hundred percent of the Medicaid data. You can actually pull the C section rate and low risk deliveries for our doctors. I want to see what they are. And then what they do is they send a report showing doctors where they stand on the bell curve. And when you're out here as an outlier, guess what happens when you get a report. We watch in the big data, they regress towards the mean.

What's the reimbursement or the economic differences between a C section and a vaginal birth?

9,000 versus 7,000.

I really don't think it's not an economic decision.

I don't think there's any financial. I mean given again how difficult that job is of being an ob, I think it's other factors. And by the way, we're doing this for spine and hardware infusion rate during lumbar spine surgery. What's your rate? Shouldn't be over 50% in non deformity cases. We're doing it for. How often is a hernia fixed on both sides? When somebody comes in with a hernia it shouldn't be fixed on both sides more than 20% of the time. We learn the ways in which there's inappropriate practice patterns and then we profile individual docs for improvement, for quality improvement.

By the way, what percentage of inguinal hernias are repaired with mesh versus the tissue repair?

I think they're all fixed with mesh except in the famous Shaldice Clinic, where I might go someday. I got a minor hernia if it ever becomes a problem.

We've sent many patients to the Scholl Dice Clinic, and I could be just out to lunch on this. But one of the things I took away from residency that really stood out to me was how difficult a tissue repair was. Like, I just remember, technically, I still.

Don'T understand the anatomy in there.

Yeah. But secondly, how much better it was if the tissue was sound. And yet we didn't do very many tissue repairs. Pretty much everybody had mesh. Anything to say on that?

Not really. The meshes now are so lightweight. They're like a little thin net. That's what I've used. If I could do it as well as the Shoal Dice clinic, I probably would. I just like the idea of no mesh in there, and I'll offer it to patients, say, this is how I do it. If you want a no mesh repair, there's a place. I think it's in Canada.

It's in Toronto. Yeah.

Where you're from, aren't you?

Yeah. Yeah. Okay, that's interesting. So basically, if you want to get a tissue repair, venting will hernia, you got to go to the Schol Dice Clinic. But you're saying maybe mesh is getting so much less intrusive now that there's less downside to doing mesh than there used to be.

Yeah. When we used to operate together, they put these big, thick polypropylene meshes in there that I don't understand how you wouldn't feel it. And the idea was to promote scar tissue because it's actually the scarring that is the heat. But now they're lightweight, thin, like a fishnet almost.

Let's talk a little bit about ovarian cancer.

Yeah. Yeah.

Maybe just give folks a little bit of a anatomy of the female reproductive system so that what's an ovary? What are the little tubes that connect it to the uterus? Give folks a sense of what that anatomy is.

Yeah. So this is an incredible area where we're doing some work. 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 sits draped under the fallopian tube, and the End of the fallopian tube has finger like projections called the fimbriae. So we're talking like a millimeter. I mean they're almost really in contact. You want me to explain how this is? So it turns out, what is an.

Ovary, first of all, like, what does it make, why do women have them, where do the eggs go, all that kind of stuff.

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, you've talked about with estrogen, is involved in heart health and so many things, but it produces the eggs that go down a little circulation through the fallopian tube into the uterus. Doctors have really struggled with ovarian cancer. Really no major progress in modern medicine. 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%.

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

Yeah, there is, with the 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?

Using what? Ultrasound.

Using ultrasound. And they've done CAT scans and none were shown to improve the outcomes in people 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 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. We have taken out millions of healthy ovaries to prevent ovarian cancer. 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 with this new discovery that biologically, based on the genetics, based on a lot of good research that's emerged from Penn, Dr. Drapkin, 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 a woman's childbearing years. It's not like 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, we don't do that anymore. We remove the fallopian tubes to massively reduce your 1 in 78 chance of developing ovarian cancer. Yeah, it's that high.

1 in 78.

Yeah. I love it that you have that reaction, because 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 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? I'm like, you mean just for an everyday person? And I asked the experts. No one knew. I looked it up.

I was gonna guess 1 in 20, actually, but maybe it's less than. That's for all pancreatic cancers. You mean pancreatic adenolethal cancer?

Yes. One in 67 is. Oh, it's that.

Okay. I would have guessed even more frequent, truthfully. Okay, Yeah.

I think the fourth most common lethal GI Cancer or something.

Fifth most common lethal cancer, full stop. Not gi.

Cause of death.

Cause of death.

Okay, yeah.

Cause of death, Right. It goes, number one is lung, number two, breast and prostate, and then colon, and then pancreas.

And breast is only over pancreas because it's almost exclusively women, whereas pancreas is men and women. But it's about 40,000 for both breast and pancreas cancer. We think about. Well, if you have. And this is what the docs told me in the conference, well, if she has chronic pancreatitis, her relative risk has increased 28%. Okay, well, that's not what she's asking. She's asking what are the chances.

But again, Marty, I'm still surprised that ovarian is as high as 1 in 78, and pancreas is 1 in 67.

Most common GYN. Cause of death.

I believe that for sure. Okay, so how widely accepted is it today that ovarian cancer is a misnomer? Is that what you're basically saying, yeah, it's not ovarian cancer, it's fallopian tube cancer.

For the vast majority of these cancers, you can have other types of gonadal tumors that are much more benign, that arise out of the ovaries. There's many types of cancers in that little region. But the most common, the rank and file, what we call ovarian cancer does not come from the ovary. It comes from the fallopian tube.

And this is what we've previously thought of as serous ovarian cancers.

Serous adenosis, carcinoma. Yeah.

Is a fallopian tube cancer.

It's a fallopian tube cancer.

How is that not understood? How is the histology of. I mean, do the cells look the same? Pathologists for decades have examined this because when a woman gets ovarian cancer, she doesn't die from the ovary, she dies from where it spreads to. Right. She's dying from the spread of that cancer to another part of her body. So when they take those cells and they're looking at them under a microscope and they're staining them, why did it take so long to figure this out?

Because of medical group think. And when I interviewed the scientists that were involved in this discovery, the resistance that they encountered was the same old story of the people who challenged the low fat diet and opioids are not addictive and HRT and all this other stuff. It's the same story at UCSD San Diego. A pathologist there wrote a very bold essay in one of the medical journals where he said, I'm telling you, the cells we're looking at do not look like ovarian cancers. These ovarian cancer cells, they don't look like ovarian cells. And he got, of course, you know, attacked and piled on like the H. Pylori causes ulcer guy, he just got destroyed. And his courageous step actually led some researchers to say it was the Netherlands to say, actually we're going to explore this a little bit. And they did a little bit more of an analysis. It was like 15 years ago. And they affirmed him a little bit. They were like, yeah, we are seeing the same thing. They did a series of people who had BRCA mutations. And then this guy, Ronnie Drapkin and Chris, I can't remember his last name at Brigham and Women's Hospital. They decided, and it was incredible. Chris had a mentor at Brigham and Women's and he goes, when everyone's laughing at an idea in science, that's a signal. You should look into it. Your curiosity should kick in.

But let's be clear, and I want to keep coming in back to this. Maybe 19 out of the 20 things that we laugh at, we should be laughing at. I mean, this is the thing. I just want to make sure we're not giving people a license to assume that every dumb idea is right. Most dumb ideas end up being dumb and wrong.

Yeah, we don't want to promote snake oil here on the drive, but it is interesting.

This is the challenge is the signal to noise ratio is still incredibly low. And the examples that are most remarkable always looked a little foolish at the outset. But I think what we want to do is just make sure that people understand that just having a crazy idea is not sufficient. You have to have a means of stating what a hypothesis is, determining how to test that hypothesis, and above all else, having the ability to update your hypothesis based on new emerging information. Because again, most crazy ideas end up being wrong.

That's right.

Just full stop wrong.

Yeah. Most ideas end up being wrong.

Yes. It's very challenging. Where are we right now in terms of rolling this insight out into broader oncologic care? So you said at Hopkins, if a woman wants to get a tubal ligation tying of the fallopian tubes, she is told, we'll happily take your fallopian tubes out. But if we're going to go in there, we might as well make sure you never get cancer, massively reduce the risk. Where else do we see this? How ubiquitous is the acceptance of this? And is there any uncertainty that remains here, or is this basically now a fait accompli as far as our understanding of that physiology?

There is uncertainty because I think as early as we are in something like this, there always will be. But it is now standard of care in Germany and most of Canada that when a woman comes in for any abdominal surgery, elective abdominal surgery, even a.

Lap cholecystectomy, is you're taking your gallbladder out.

Yes, Even a lap coli, most commonly a lap coli, actually. Woman comes in, because that's more common in women and they're finished having children, they will be offered to remove the fallopian tubes, sparing the ovaries, as during the procedure, as a concomitant surgery.

And the general surgeon does this.

So the general surgery, I'm doing this now in my practice. Woman comes in, done having kids. Rebecca Stone, who is our gyn oncologist, who's one of the national nurses, she.

Comes in and does the salping.

Yeah, I don't want to Be taking out the round ligament or something.

Yeah. And tell me, what is the probability of taking out the fallopian tube and damaging an ovary such that a woman ultimately needs an oophorectomy as well, which would be a disaster, an absolute disaster for a woman to lose her ovaries if she's premenopausal and still relying on those for hormones.

Yeah. And I think you've touched on a big unknown there, which is the single reason why this is not a broad recommendation for any woman and everyday person to come in for just their fallopian tube removal. It is only offered as a concomitant procedure. Obs are very good at this. They say it's a simple procedure. But here's the issue. If you make a broad recommendation for every woman who's done having kids to come in and have this done, what if 1 in 20 surgeons is going to have a complication rate of 5%? You've canceled out all the public health benefit of reducing ovarian cancer. So that's why for now, the recommendation, and this is a recommendation that not even all of our surgeons at Hopkins are aware of, is that when we're in there doing another elective abdominal procedure in a woman who's finished having children, and generally on the younger side, not over 67, I think, is the average age for ovarian cancer. So after that, you're benefit diminishes. So in that window of done having kids before they're in their mid-60s or, and this is, we're just using our best judgment here, that's the group where we're offering now that, hey, I can have you talk with our OB GYN doctors. They can come in and reduce your 1 in 78 chance of her. In Canada, they've done giant studies now and they're showing actually lower rates of ovarian cancer long term. And so we're waiting for some of that data to come out, but it's pretty wild. And the pathologist, Dr. Vallakuz at Johns Hopkins has actually said, marty, we haven't made progress with chemotherapy on ovarian cancer. And maybe this is why we may have been targeting the wrong type of organ tissue. So it's pretty interesting. It's an opportunity. It's also an opportunity for people to be aware of this best practice out there. Like the guy who needs to see three randomized controlled trials to do the non operative protocol for appendicitis. It's going to take time. I mean, only some doctors in the United States outside of GYN are doing this. The American Academy of OBGYN has actually put out a statement recommending women who come in after they're done having kids. So there's actually a national guideline on it. But it takes a long time for people to understand, become aware, learn the best practice. I hope it can address the ovarian cancer incident. In my mind, it's in the bucket of challenging certainty. If you're 100% certain that this cancer must come from the ovary, be open minded to the fact that, hey, there's some things here that we haven't understood in the past. For example, tubal ligation has resulted in a lower risk of ovarian cancer. Hmm, interesting. Maybe it's blocking off some of the cells that could have caused cancer and migrated down. Maybe it's killed off some of the lining. There's an understanding that ovarian cancer is more likely to spread, more likely to be discovered after it's spread. Well, there's a little gap between the fallopian tube and the ovary, so maybe it's disseminates in early stages because of that gap. So there's some interesting things that are now fitting together again.

I think this speaks to something that we can talk about it at an arm's length from any situation, and it all makes sense. But now you want to think about how difficult this is to put into practice. 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 in anything. You have 99.9% certainty that this cancer is coming from these ovaries. And 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. That's a really low number. That's a one in a thousand 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 your practices and say, well, maybe that's now a 1% chance at some point. If that's a 10% chance, I really need to pay attention. If there's a 10% chance I'm wrong, I really need to pay attention to this. I need to pause. We're not trained to do that. So how do we go about thinking about this? I already said what I would do if I were czar of medical education. I don't know enough about medical education today. It's been 25 years for me. But you're closer to it because you're still part of a university system. Is medical education significantly different today when it comes to this? Like, how does a medical education today at Hopkins differ from what it was 25 years ago?

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

Is it still that way?

It's still that way. You might even say it's worse. I was talking this morning to Dr. Will Brun, who just graduated, 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, wrote memorization stuff. He said it was like 50% of his medical education. This bacteria is catalase positive, catalase negative, it says a branched chain bacteria. This is a straight chain. It's mind numbing. Memorizing the names of enzymes he Sundays was like 20% 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. And we do this to this incredible generation. We spit them out seven, eight years later. They're different people. They're robotic, they're sometimes emotionally disconnected. They've learned a 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.

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

Yes. Yeah. That is the private organization.

AAMC is the entity that also regulates the USMLE licensing exam. Yes, got it.

They collect a lot of money from these students. It's a private organization. One of the cool things that we get to do is talk to a lot of people out there in America and get a bit of a bird's eye view on things. And I was talking to conference of medical school deans and later on I had met the dean of 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. Regurgitate 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 rate. 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 got to pay us two to three hundred dollars every two years or so and take a quiz that we give you. And they're out there making a ton of money off this new thing. 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?

I went to college in Canada, okay?

Imagine your college called you and said, hey, your degree, you don't have it anymore. You got to 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. 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 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 need more research in them. They want to think differently.

But who would fund this research, Marty? I mean, I think when I talk about the pillars 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 would be like a sort of waste bucket of everything else that may or may not have benefit, like sauna, cold plunge, red light therapy, 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 residency, right? You learn about procedures and medications very well. That's what we learn. And I think we do learn that quite well. But to your point, we learn nothing about exercise, sleep, nutrition, and emotional health and, well, being part of that, 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 pillar, you take the placebo. 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 outside of philanthropic and government causes such as the nih, it's very difficult to get any of that research funded. So how would we create a new medicine around something for which it would be so difficult to really gather the right evidence? Or would you argue, look, we already know enough today that we could teach off the current practice.

The NIH could not be more broken. They've got these siloed funding centers, as you suggested. You know, unless your research falls under kidney cardiovascular disease. And it's what the old 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 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. 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 or 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.

What is the rationale for doing this?

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 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 and sometimes the side of the tongue and the frenum under the tongue? 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 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.

Is it being tested?

No. I'm not saying it's bad or wrong, but I'm saying this desperately needs a randomized controlled 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 going to fund that study? Big Pharma?

No.

Fat chance. The nih? Not one of their clinical centers. The American Academy of Pediatrics, with their thousand dollars a year membership of all these, $130 million in revenue they take in a year? No. No interest. This is the Bermuda Triangle of healthcare in the United States and worldwide. We desperately need to fund things where there are 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. I hate to mention Covid. We saw this during COVID All those Covid controversies could have been answered in three weeks or a month or two. They could have done the clinical study immediately, done the randomization, answered the question. Instead they. Everyone went on TV and opined about it. It's easier. The NIH controls $80 billion. What are they funding? They were funding this cruel dog experiment at the University of Iowa, trapping these dogs and having these sandflies bite their heads in these cages. And concluding in the article that is published, leishmaniasis can spread from dog to dog via sandfly bites. Who gives a shit? This is where our tax dollars are going and then we're not funding basic clinical research out there.

Why do you think that is?

I don't think it's diabolical. I think people 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 what's the average diameter of stones on Thames Street? That would be interesting. No, it's not interesting. I'm seeing it 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 chronic myelogenous leukemia. That's not interesting. 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 differences in so and so by race and socioeconomic status. 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. 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 glioblastoma survival rates by two months. Well, patients want to 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 because 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. 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.

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

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 focus on just one. Which one do you like? Do you like kidney? Do you like brain? Heart? 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 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 were also used at the gym. And they would ask me every day, what are you going into again? And I want to 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 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 want to 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 don't want to live the life that they see. These guys who are like, I got four NIH grants and presented and 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 got to 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. 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 that connection. Rebuilding trust is the hottest topic right now in medical journals, essays.

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

I think there is a political narrative, and in politics, everyone sticks to the same talking points. But in science, science is based on a civil discourse of different ideas among experts. And so they're directly in conflict. The Journal decided to endorse a presidential candidate for the first time. Okay. Other journals have said, here are some issues. We're not going to be both sides, inc. Okay, what if you said that about peanut allergies back in the days? What have you said that about people who are suggesting opioids are very addictive? They've seen it. The New England Journal is the one is the place that published that study, that out of 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 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 because 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 Beth Israel Deaconess and Masjois, my buddy from. I remember meeting the editor of the New England Journal when he came to visit Hopkins. 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, from one part of the country deciding what should go through the gates for the rest of the doctors of the world to see it's changing. Vinay Prasad and John Mandrola and Adam Sifu and I and some others started a new news feed called Sensible Medicine where we're publishing our thoughts in real time. When we see articles that look flawed, when there's a bandwagon effect, when we call things out. Yeah, like 100,000 subscribers to this thing now. 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. Jay Bhattacharya and Martin Koldorff and I and a bunch of others.

How do you know you won't fall into the same trap of the New England Journal of Medicine, Science, Nature? I want to 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.

We cannot have science and politics. We can't have those things commingle again. It doesn't matter if they're endorsing your party. You should be just as concerned as if they're endorsing the other party.

That's right.

There's an objectivity that can't be commingled there. I think as much as I respect Martin and Jay and you, I don't think I have a sense of what the answer is here and why just coming up with the new rogue journal is the answer Because I still don't understand systemically what's going on.

Yeah.

Anyway, I don't mean to sound pessimistic. All the terms for kind of the non conventional thinking world. Is the goal of that to be a little bit more provocative in the other direction? Even if it's deliberately provocative. But I just want to be careful that we don't create disagreement for the sake of disagreement.

That's right. We are prone to the same bandwagon group think as the jam in the New England Journal Editors. There are a bunch of like minded friends. We are at risk of that. We have to be constantly aware it and we've invited people who disagree in Sensible Medicine. We love publishing pro con articles on the same issue, the same topic. And you'll see that Vinay Prasad is wrong. Adam Sifu is Wrong. On this topic. 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.

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. Yes, 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 team that he assembled his cabinet from.

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

That's really true, though, Marty. Like, there was never a day when I wanted to be the chief of anything.

I think you're unique. I mean, in the culture of academics, it's dominates. Get your NIH grant. Oh, you have a grant, but it's not nih. Try harder. Maybe you'll get a K award.

But what percentage of physicians today are academic physicians versus community physicians?

Well, it's blurring. What's an academic center nowadays with the acquisitions and mergers.

If we just define academic as people who have some funding for research and. Or are involved in the education of students and residents beyond. I'm not talking about Sinai, where you're a community surgeon who once in a while has a resident scrub with you. I'm not talking about that. But if we define academic a little bit rigorously, it can't be more than 10% of physicians would fall into that bucket, right?

Probably. Probably. So at the end of the day, a lot of the cases.

Well, so that's the question, right, Is what do they control? And how much do the community physicians look to them? And I think that just kind of comes back to everything we've been talking about. But ultimately, what matters is what are the community physicians doing? What are the workhorses doing? What are the people who are taking care of the majority of the patients? And let's be clear, even if that number is right, I'm making it up 9010. But directionally, I'm sure that's in the ballpark. It's 9010 in headcount, it's not 9010 in patient touch, it's more than that, because the academic physician has many other responsibilities that don't involve patient care. So it might be 95.5. In other words, the majority of people listening to us are going to get the bulk of their medical care from people who are not academic physicians. And therefore the most important thing in delivering exceptional care to the majority of people is making sure that community based physicians are able to think independently or able to think clearly in that regard. I just don't know that the answer lies in the hierarchy of the academic institution. I don't know that that is really where the problem is. I don't know where the problem is, but I don't think it's where 5 to 10% of the attention lies.

I don't disagree with you. I've got my perspective. Being in the towers of the ivory tower, the top at Hopkins, it's all about this. Fabian Johnson just went to be chair at Wake Forest. He just got this job. Great. You know, we're having a big reception for him. It's a big deal. It's kind of, you know what we do, we create chairs to go out there. So I have a, do have a skewed perspective. But every doctor gets trained in an academic medical school in this culture. Every student tends to come through this culture where we tell them it's a privilege to hold a retractor for six hours instead of come and watch me talk to a patient's family afterwards and learn self awareness and how to be perceptive and empathetic. So I don't have a solution. But do you see things where you say we are actually moving more in the direction of everybody get in line than we are in the freedom of the rank and file doctor in America to speak how they would speak creatively. For example, I'll talk to a doctor and say, what do you think about, let's say hormone replacement therapy postmenopausal? Someone will say, well, you know, I've heard this, but I tend to question that. I know some people are saying this. I'm not sure that's a good doctor. A doctor who says, according to this US Preventive Service Task force, you must do this. You're like reciting a catechism. That's not the doctor that we want to create. And how do you teach humility? John Cameron and I did this thing where when he operated next door to me, I would pause and I'd say, this is a really interesting scenario. Can the scrub nurse run over or the tech run over and get out of Cameron and Take a look at this. And he'd come in and he'd say, ah, it's really interesting, Marty. In the past, I've done it this way or that way. I know exactly what he's going to say. But I want to model humility to the students and residents in the room. When he gets as maybe one of the most famous surgeons in the world, he gets a situation like that, he calls me in, hey, can the tech run over, grab Dr. Makary to come in, take a look, get his thoughts on this? He didn't need my thoughts. He knows my thoughts. Anyway, we've worked together for 25 years. I go in there and I say, oh, that's interesting. Yeah. So you're going to do it this way? Yeah, that's what we're thinking. Thanks, Marty. He's trying to model humility and I think that's one way we can teach it. But it's an uphill battle. I mean, the policing right now in modern medicine is at an all time high. I gave grand rounds for our ob GYN department at Hopkins and it went great and it was awesome. And they helped me shape some of these ideas and the research that I've worked on that we discussed. And when I filled out the CME form, I've coined this ICD9 diagnosis code called send us your slides in advance. Harassment syndrome. Starts off in the hallway with, hey, Peter, would you be interested in giving us a talk sometime? Yeah, sure. And then the harassment and the email and we need your fill out these forms and these. Write four questions for our CME and send us your slides. We have to have your slides. No, you don't have to have my slides. Okay, I'm going to work in current events from that morning of my talk. Sometimes I've realized the kryptonite for the send us your slides and harassment syndrome.

What if you don't use slides?

I'm not going to use. I'm not going to use slides. Oh, well. Well, then I guess we don't need you to send them, but okay. And then you show up with a thumb drive. Hey, I got some graphs. I was going to throw up. Is that okay? Oh, yeah, sure. The AV guys in the back. But anyway, one of those forms I had to fill out for this cab. Continuing medical education requirement for any time you give grand rounds was, I hereby agree that everything I say will comply with generally accepted norms and standards recognized by consensus within the medical profession. And I'm looking at this and I'm like, no, what I put out there is. I like to cite research that challenges deeply held assumptions and I'm going to be talking about that. And I'm not going to sign to some catechism here that yes, I will obey and only say things that are in line with consensus. If you look at our track record in modern medicine, when we use good scientific studies before we make massive health recommendations, peanut allergies, whatever, when we have good science, we shine as a profession. When we wing it, when an elite small group of medical establishment folks decide what the world is going to do based on their own gut feeling or dogma, they have a lousy track record.

What are you most proud of? That the medical institution in this country. Let's just keep it simple. What do you think medicine has done the best job of in the last decade?

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

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. Where else are we hitting it out of the park?

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 new best practices of skin to skin time delayed cord clamping, encouraging breastfeeding early on, reducing C sections when not necessary. Those are in the last 10 years, those best practices. But we're at a pretty good point where the system is humming on a lot of 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 U.S. hospital. We have the best care in the world. If I break a bone, I'm going to go straight to a doctor. But when it comes to telling me 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 didn't know what to do. 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 whipples. And it's a tour de force of science and technology and advancements. And we do something called a pancreas transplant with eyelid 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 proud of that my dad 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, some people find it hard to take their medications as prescribed. How are you doing with it? It's far less head to head. And so it's an incredible profession. And teaching these little pearls and gems, citing research, 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 why we've called on them to have ethical billing and pricing practices. But 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 get into it.

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 still give them the nudge to do medicine? If it's something they're partially considering, 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 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.

But, you know, I think the bigger issue isn't so much that you have to memorize those names, it's that you're sort of lacking the context. And why? I mean, Marty, I still memorize names of complex enzymes and pathways, but the difference is I'm doing it because it's feeding my interest. It's like I'm reading papers and I'm learning new things and I have to draw diagrams. I mean, I'm doing the same thing I was doing 25 years ago. I also don't want to 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, 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 think, if anything, I just hope that medical education can major in the major and minor in the minor. Because while I think it matters that you understand these things. And again, maybe this is already the case because I'm so far from it. 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, 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.

Yes.

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

Me, and I don't know, how about surgical residency? Would you do that part again? Yeah.

It's interesting, knowing what I know today and knowing where I ended up today, would I have been better off doing an internal medicine residency? You know, the answer is probably yes. I think it would be more logical. But look, I wouldn't know you. I wouldn't know Ted Schaefer. I wouldn't know a lot of the amazing people that I've gotten to know through my surgical training. And I think in many ways, surgical training, especially the way we did it so long ago when you didn't have regulations on work hours and stuff, it was so hard. It really gave me an appreciation for how much easier my life is today and how lucky I have it to not be woken up every 14 minutes when I sleep and things like that. So I'd probably be reluctant to change anything. I think it all worked out okay, and I'm really grateful for the folks I met along the way. And I do hope that someone listening to this who's contemplating medical school, as you said, I agree with you completely. Anybody who chooses to be anywhere within the vicinity of this field, 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 they're doing it for the right reasons.

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

Yeah, I agree. You have to preserve the humanity of the field while harnessing critical thought and doing it around this scaffolding of purpose.

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 weren't able to grow crops and the healthy foods they'd been eating for centuries. So the U.S. government, recognizing how they were being depleted of food and the starvation that was happening, they started shipping food. This wasn't whole food stuff, this was 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 with diabetes. And the NIH decides to swoop in and address this problem by looking for a predisposing gene for 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. Right. We've been feeding them shit for decades. That is what's been driving the obesity and diabetes. It's not that they have a gene.

They've had spontaneous mutations of the FTO gene that have now produced rampant obesity. Right, yeah. Well, Marty, thanks for making time to come by and talk. Always a pleasure. And congrats again on your new book. I'm sure many people are going to get a kick out of it. We barely touched on, I think, a third of the stories that are in it.

Always great to be with you, Peter. Great to see you.

Thank you for listening to this week's episode of the Drive. It's extremely important to me to provide all of this content without relying on paid ads to do this. Our work is made entirely possible by our members and in return, we offer exclusive member only content and benefits above and beyond what is available for free. So if you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription premium membership includes several benefits first, comprehensive podcast show notes that detail every topic, paper, person and thing that we discuss in each episode and the word on the street is nobody's show notes rival hours. Second, monthly Ask Me Anything or AMA episodes. These episodes are comprised of detailed responses to subscriber questions typically focused on a single topic, and are designed to offer a great deal of clarity and detail on topics of special interest to our members. You'll also get access to the show notes for these episodes, of course. Third, delivery of our premium newsletter, which is put together by our dedicated team of research analysts. This newsletter covers a wide range of topics related to longevity and provides much more detail than our free weekly newsletter. Fourth, access to our private podcast feed that provides you with access to every episode, including AMAs, sans the spiel you're listening to now and in your regular podcast feed. Fifth, the Qualys, an additional member only podcast we put together that serves as a highlight reel featuring the best excerpts from previous episodes of the Drive. This is a great way to catch up on previous episodes without having to go back and listen to each one of them. And finally, other benefits that are added along the way. If you want to learn more and access these member only benefits, you can head over to Peterattiamd.com subscribe. You can also find me on YouTube, Instagram and Twitter, all with the handle Peterattiamd. You can also leave us review on Apple Podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional healthcare services, including the giving of medical advice. No doctor patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously. For all of my disclosures and the companies I invest in or Advise, please visit PeterAttiamD.com about where I keep an up to date and access active list of all disclosures. It.