The Peter Attia Drive - #317 ‒ Reforming medicine： uncovering blind spots, challenging the norm, and embracing innovation

00:00:00.000 Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Atiyah. This podcast,

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00:01:04.220 My guest this week is returning guest, Dr. Marty McCary. Marty is a surgeon and public policy

00:01:10.060 researcher at Johns Hopkins University, as well as a former colleague of mine during our residency.

00:01:15.800 He's a member of the National Academy of Medicine and writes quite regularly for the Washington Post,

00:01:20.300 The New York Times, and The Wall Street Journal. He is also the author of two New York Times best-selling

00:01:25.020 books, Unaccountable and The Price We Pay. His current book, Blind Spots, When Medicine Gets It

00:01:30.540 Wrong and What It Means for Our Health, is set to be released on September 17th. In this episode,

00:01:35.860 we talk about many of the themes in his new book, including how a new generation of doctors are

00:01:40.640 thinking differently to ask new questions about the way things have been practiced in medicine

00:01:45.800 historically. We lay the foundation for the conversation by discussing cognitive dissonance

00:01:50.340 and how this theory applies to the medical community today. We discuss a few examples

00:01:55.000 of the blind spots from the book, such as the treatment for appendicitis, the peanut allergy

00:02:00.060 epidemic, the misunderstanding of HRT as it relates to breast cancer, antibiotic use, how childbirth has

00:02:06.560 evolved over the years, and more. All detailing the many scenarios in which a new medical approach

00:02:11.800 may be possible if we're able to ask different questions. We also reflect on where medicine has

00:02:16.400 done a good job over the last few decades and where Marty believes there is room to challenge

00:02:20.940 historic practices and pave a new way. So without further delay, please enjoy my conversation with

00:02:25.640 Marty McCary. Hey, Marty. Thanks for coming in. Good to be with you, Peter. Great to see you again,

00:02:35.340 as always. So you've got a new book out, Blind Spots. This is a book, I guess, I certainly remember

00:02:41.520 talking about with you as it was in the works. We've had many dinners together when some of these

00:02:46.760 topics have come up. Can I take 5% credit for the inclusion of HRT in this book?

00:02:51.660 No, you get 99% credit for that. That was incredible.

00:02:55.280 That was a late addition, right, to the book?

00:02:57.480 That tipped me off to do my own sort of investigative journalism. So I tracked down the people that made

00:03:02.860 that initial announcement saying it caused breast cancer. And I pinned them down and I went over

00:03:07.920 the stats with them hard and finally got them to confess that it did not. So thanks for tipping me

00:03:14.020 off there and helping me shape the book. So the book is a great read and it goes through a number

00:03:19.440 of situations that all kind of have this theme in common, which is an idea comes up, the idea is a bit

00:03:26.620 shaky in terms of lack of evidence, which in and of itself is not really a problem. That really is the

00:03:32.300 way medicine and science have to work. They have to start with ideas that we may or may not have

00:03:37.000 great evidence for. But what sort of goes wrong? Why is there a book about this instead of a bunch

00:03:42.720 of case studies of how everything has gone really well?

00:03:45.980 So there's a science to groupthink and that's really what's going on a lot of times. It's the

00:03:50.980 bandwagon effect. It's not just in medicine, it's in business, it's in politics, it's in relationships.

00:03:57.640 People are dead set on an idea, not because they're convinced of it, but because they simply

00:04:02.600 heard it first. And there was a psychologist named Leon Festinger, who has since passed away,

00:04:09.360 but had written a tremendous amount of material on this idea of cognitive dissonance. He really

00:04:15.540 carved this entire discipline out in psychology. And the idea is that the brain doesn't like to be

00:04:22.220 uncomfortable with conflicting ideas. It likes to settle and be lazy with one thought. And so it's

00:04:28.280 often the first thing you hear. So if something comes along that challenges your deeply held views

00:04:34.020 or just what you've happened to heard before, there's this internal conflict. So what the body

00:04:39.340 does is it will reframe the new information to make it fit what you already believe, or it'll dismiss

00:04:45.260 it completely, kind of the modern day cancel culture. So this happens in day-to-day life,

00:04:49.900 it happens in human interactions, and it happens in medicine too. We get this sort of herd mentality.

00:04:55.560 But the important thing in science is that the purpose of science is to challenge deeply held

00:05:00.560 assumptions. And so that's something that I follow as a thread in so many areas of modern day health

00:05:06.800 recommendations in this book.

00:05:08.880 And I will come back to this because I think one of the take-homes from this is not just the stories,

00:05:14.440 but what a person can do going forward. But I would also have to say that, and maybe this is

00:05:20.160 frankly just a hard thing to hear, both as the author of the book, but as a person listening,

00:05:25.160 which is how does an individual, like a normal person, navigate this? I'll use myself as an example,

00:05:31.940 not because I think I'm normal. I think I have at my disposal access to more information.

00:05:36.600 I have a research team that can help me answer questions. And yet, if I was to challenge every

00:05:43.100 idea out there that I held sacred, I'm not sure I'd get anything done. So what's the balance in

00:05:50.280 your mind between your doctor tells you something, kind of makes sense, it seems logical, at least

00:05:56.960 plausible, but technically you haven't done the thinking on it. How do you not allow yourself to

00:06:03.060 become a crazy conspiracy theorist who doesn't trust anything and throws out what's 80% good

00:06:10.660 in the pursuit of throwing out the 20% that's trash? How does one navigate that?

00:06:15.320 There are extremes on both sides. You see the pendulum swing, like with childbirth. There's this

00:06:21.220 over-medicalization of ordinary life. And then this swing back to avoid all doctors and hospitals

00:06:27.320 and deliver it home with nobody. It's a dangerous proposition. And so you see that frequently in the

00:06:32.940 history of modern medicine, and for the everyday consumer out there, I think the flag should go

00:06:38.580 up when something is put out there as a health recommendation with such absolutism as science

00:06:45.100 evidence-based, when really there's nothing to point to. That should be a flag for everyday folks.

00:06:51.920 We don't want to create hysteria. We need people to trust doctors. I need my patients to trust me

00:06:57.120 a lot of times, but asking questions should be part of the process. And I think there are times when

00:07:04.480 we are very slow as the medical community to implement scientific evidence, and it's okay to educate

00:07:12.040 the public on it. There's a non-operative protocol for appendicitis.

00:07:16.300 It's one of the things I wanted to talk about with you.

00:07:18.060 Okay. You want me to mention real briefly now?

00:07:20.400 Sure. Yeah. Let's talk about how you and I learned to treat appendicitis. And what is appendicitis,

00:07:25.380 first of all, maybe give folks a sense of this?

00:07:26.820 Yeah. So inflammation of the appendix, an infection sets in, the tight junctions break

00:07:31.500 down, and bacteria from the colon will creep in there and infect the appendix. It becomes inflamed,

00:07:37.860 gets into the blood system in late stages.

00:07:40.180 And to give people a sense of this, I mean, what's the lifetime prevalence of this and prior to any

00:07:44.900 treatment? So 200 years ago, what was the mortality from acute appendicitis?

00:07:49.860 It was over 60%. Walter Reed, a famous physician himself, died of appendicitis. The hospital in

00:07:58.060 DC is named after him. So it was a common cause of death.

00:08:01.800 And the lifetime prevalence was not that small. It was like 7% or something.

00:08:05.540 I thought it was 5%, but yeah, probably in that range.

00:08:07.680 Think about that, right? There's a 1 in 18 to 1 in 20 chance you'd get an

00:08:11.140 infection of your appendix and a 60% chance that if you got it, it would kill you.

00:08:14.920 It still is one of the most common operations performed in American hospitals. We have learned

00:08:20.720 as a reflex as surgeons. When you were at Johns Hopkins, you did this many times. We may have been

00:08:26.140 in the operating room together.

00:08:27.060 We did many together, yes.

00:08:28.840 So as a reflex, you learn to take out the appendix. You do it swiftly. You do it with

00:08:32.800 a laparoscope as of the last 30 years or so. And pre-med students know this. We'll take the

00:08:39.960 interns through the case. This is a reflex. We don't even think about it in the hospital.

00:08:43.940 So it's been one of these easy things. Diagnose, treat, diagnose, treat. Diagnosis used to be

00:08:49.240 tricky because it's going to present a lot of ways. Now the CAT scan just points out the bullseye

00:08:53.800 and you go to work. You call the team, mobilize, high-five each other after the case, talk to the

00:08:59.520 family. It's a quick, great case for a surgeon and a surgical trainee. Well, then a study came out

00:09:05.820 showing that you don't need to operate. And a short course of antibiotics is 67% effective

00:09:14.040 in patients that come in with appendicitis if the appendix is not ruptured or there's no little

00:09:19.380 stone, what we call a fecolith in the appendix, which is the vast majority of people don't have

00:09:23.820 rupture or a fecolith. So here's a discovery that really shook up the whole field of modern surgery.

00:09:31.640 So just to make sure folks are following us, the study said, look, if you're in the majority of

00:09:36.520 cases of appendicitis, it's not yet ruptured and it doesn't have an obvious mechanical cause.

00:09:41.920 Instead of taking a person to the operating room, which is low risk, but not zero risk,

00:09:46.440 you're still subjecting a person to general anesthesia. Plus there's the cost associated

00:09:50.100 with surgery. You're saying that you can get 60 to 70% the same outcome if you give them an

00:09:55.860 antibiotic. And if they don't respond to the antibiotic, then you'll take a third of those

00:09:59.600 people otherwise back to surgery? Yes, exactly. And of those who respond

00:10:04.200 well to the antibiotics, it's something like high 80% will respond to the initial course of

00:10:09.640 antibiotics. A small fraction, maybe 12%, will come back with recurrent symptoms in the first

00:10:15.320 month and say, hey, I got that pain back. And then you go to surgery for them.

00:10:18.760 So the total cure though is about two-thirds.

00:10:20.960 Two-thirds. And you don't get behind the eight ball. It's not like we give a short course of

00:10:25.440 antibiotics. Watch it. And now it's so far along, we can't do anything and the patient

00:10:29.340 is far worse. They've done the long-term follow-up. And it's not just, you made a good point about

00:10:34.560 the cost and the other thing, but the patient doesn't have to undergo an incision, anesthesia,

00:10:40.480 risk of infection, risk of hernia, all the minor risk, but they're present. The carbon footprint of

00:10:46.260 the hospital, the amount of waste produced, the nursing staffing resources. I mean, the wait list at a

00:10:52.300 hospital every night and every hospital in America has cases that are waiting to go. And typically

00:10:57.080 there's an appendix or two on that list. And sometimes these are operations that are going

00:11:02.140 to be done in the middle of the night anyway. Yeah. We've got a nursing staffing crisis.

00:11:06.240 There's so many implications to appropriately implementing this research. So I was talking

00:11:11.840 to one of my colleagues because I offered this to a kid who came in to see me. I was really in a

00:11:17.280 dilemma because I had read the study, I was convinced of it. And I thought this is at least something to

00:11:21.820 offer patients. Nobody else was really offering it at the time. The study had been a couple months

00:11:27.260 out. So I had this guy come in about 19 years old, perfect candidate, no rupture, no fecal lithe,

00:11:33.660 early appendicitis, young, healthy guy. They're already getting antibiotics when they come in and

00:11:38.460 get diagnosed in the emergency department anyway. So usually it's just running it a little bit longer.

00:11:43.340 And I offer him the surgery versus no surgery. He tells me he has a wedding the next morning in

00:11:51.300 Boston, which he has to fly to, of his sister. And I'm thinking, oh my God, what gets him to the

00:11:57.520 wedding faster? Just taking him to the operating room right now, which case he might get there in

00:12:03.500 a wheelchair. He should be able to leave the hospital in the morning and get a flight. He

00:12:07.440 might limp around. He'll be in some discomfort. Or do I do the antibiotic protocol? So I just offered

00:12:13.320 him both. And I told him what I don't know, which is, I think, the most important part of being a

00:12:18.140 doctor is understanding the unknowns and dealing with uncertainty. And guess what he chose? Between

00:12:23.960 surgery and no surgery. I'm sure he chose the antibiotic, yeah. Yeah, of course. Yeah. Do you

00:12:28.760 want to go under the knife or not? Doesn't matter. Of course he chooses no surgery. So he goes to the

00:12:34.800 wedding the next day, dances up a storm. And I become so convinced that this may be revolutionary.

00:12:41.140 And I tell one of my colleagues about it and he says, I don't buy it. I said, well, have you read

00:12:47.540 that randomized control trial? It's published in like our top journal. And he says, I need to see

00:12:53.320 two randomized control trials. So I'm like, okay, you know, they've been doing this in Europe a lot

00:12:58.120 longer than we've heard about it in the US. So a second randomized control trial comes out like a

00:13:03.320 year later. I show it to him and he says, I need to see three randomized control trials. Believe it or

00:13:09.580 not, a third one came out. I think it was like six months later, long-term follow-up. The initial

00:13:14.700 study was repeated in children's. Other studies came out that were non-randomized. And I showed

00:13:19.760 it to him and he says, I just think you're better with it out. And I'm thinking it would be unethical

00:13:26.440 to do any more research. Like this is the cognitive dissonance that Leon Festinger was describing.

00:13:32.900 Leon Festinger embedded himself into a cult to prove his theory correct. A cult that met in Chicago

00:13:41.280 believed that aliens were going to pick them up because there was going to be a great flood on a

00:13:45.980 certain day, a certain time. And he read about this in the paper that they were assembling to be

00:13:51.680 picked up by this spaceship. And he realized this is the real world example of my theory of cognitive

00:13:57.800 dissonance, why we cling to what we believe first and we're not open-minded to be objective.

00:14:03.340 The thing he wants to test is when the aliens don't come to rescue the people that are the

00:14:10.860 firm believers, how many will say, oh my God, how stupid was I to think this versus what will be

00:14:17.960 the set of stories that get spun to explain why their belief was still right?

00:14:23.300 Sounds like you somehow knew that the aliens did not come and pick them up.

00:14:26.900 I was able to make the leap of faith that the aliens indeed did not come.

00:14:30.940 So they didn't come that night and he was there in the room with all the cult members.

00:14:37.260 And somebody says at 12.05, because the pickup was supposed to happen at noon and they had

00:14:43.280 removed their belts and medals for the flight and everything. Somebody says, oh, the other clock

00:14:48.300 is wrong. It's really 11.55. And everyone gets excited. And there's this denial and denial

00:14:53.500 through the night. And then in the morning, basically, it was obvious it did not come true.

00:14:59.100 And they did not abandon their views. They dug in deeper. Those who had a little belief,

00:15:06.360 they thought this is nuts and they just left. But there was a physician that Festinger spent time

00:15:11.680 with, and he writes about it in his book called When Prophecy Fails, where the doctor said,

00:15:17.720 just openly once, almost in a Freudian way, said, I just have so much vested in this now at this point.

00:15:25.180 My job, my family, my friends, everybody knows I'm so into this. I have to hold on.

00:15:32.140 And Festinger watched in plain view what we all experience in a subconscious way, and that is this

00:15:39.420 resistance to new ideas. And you see it in politics and business and everything else.

00:15:45.180 And it was really amazing. It's a theory that's now well accepted as cognitive dissonance,

00:15:50.540 and it's tied closely to effort justification. That's the concept in psychology. And that is,

00:15:56.620 hey, I'm vested. I've spent all this energy on it. It must be good or justified. And we do that with

00:16:01.980 our surgical residency, fraternity hazing. It fosters this cycle of abuse. And in the examples by,

00:16:10.500 I think their name was Aaron and Mills were the two psychologists right after Festinger around that

00:16:15.780 time. And they took college students and they said, hey, we're going to have you do this task.

00:16:20.600 We're going to pay you for the task. You take little pegs and you put them in. The most tedious,

00:16:24.720 boring thing you can design. And they paid half of them 20 bucks and the other half $1 to do it for

00:16:31.540 an hour. Which group said they enjoyed doing the task more?

00:16:35.960 The group getting paid a dollar.

00:16:37.880 The group getting paid a dollar because they had to justify.

00:16:42.120 They did another experiment where they said, hey, we're going to have a sex talk and you have

00:16:46.760 to take an entrance exam. And there were three groups that took the entrance exam.

00:16:51.660 One had an entrance exam that was incredibly difficult. They didn't give them the results.

00:16:56.300 They just said, okay, you passed. The other had a moderate exam and the other one had no exam.

00:17:02.040 Then they had the talk and it was the most boring, disappointing letdown you could possibly.

00:17:06.760 They basically said, yeah, bees get together and multiply. And they're just kind of like, what?

00:17:12.460 This is what we tried hard to get in for this class. And then they asked them, did you enjoy

00:17:18.780 the class? It was designed to drive you nuts, bored. Guess which group said they enjoyed it the most?

00:17:25.020 The one with the hardest test.

00:17:25.900 The one with the hardest test. And this plays out in our lives every day. Now that I've read these studies

00:17:30.560 and have written about them, I think about this in our research meetings, when new ideas get

00:17:36.000 suggested, when people ask me if we should do it a certain way, we've got these traditions and dogmas

00:17:41.620 and medicine that can take on a life of their own.

00:17:45.300 So let's talk a little bit about peanut allergies. Probably everybody listening is no stranger to a

00:17:50.980 peanut allergy. In fact, I don't know what the prevalence is. Perhaps you do, but it's quite prevalent.

00:17:55.160 Again, the probability that someone listening to this doesn't either have a peanut allergy or know

00:17:59.600 somebody with one. It's probably close to zero. So let's talk a little bit about this. Has it always

00:18:04.820 been this way? And if not, when did this become an epidemic?

00:18:08.540 Well, it really is an epidemic and it's tragic and people can go into severe anaphylaxis just being

00:18:13.980 near a peanut without even ingesting the peanut. In 1999, Mount Sinai did a study and estimated the

00:18:21.100 prevalence to be about half of 1%. And the vast majority were very mild. There are many theories as to

00:18:27.320 why that might have crept up from zero generations prior. But the American Academy of Pediatrics

00:18:34.920 decided to address this problem by issuing a recommendation. Now, they didn't know what

00:18:40.800 to recommend. They honestly literally had no idea what to recommend. I went back and interviewed some

00:18:46.240 of the individuals who made that recommendation. It was a strong recommendation. Even if it wasn't made

00:18:52.580 with such absolutism, it was interpreted as the law of the land. And the recommendation was for all

00:18:58.820 children zero through three to avoid all peanut products, including the little peanut butter moms

00:19:04.320 would put into food in infancy. And pregnant mothers and lactating mothers should also avoid 100% peanut

00:19:11.040 abstinence. And what happened immediately after that recommendation in the year 2000 is peanut allergy

00:19:16.900 rates in the United States began to soar. And we saw a new type of allergy, which is the severe

00:19:23.360 anaphylactic reaction, the ultra allergy, where if someone used the same ice cream scooper in the

00:19:30.720 pistachio, even though they had rinsed it, that kid could end up in the emergency room. And we saw

00:19:35.000 emergency room visits skyrocket. So the medical establishment, the elites, I'll say, not the rank

00:19:40.520 and file doctors that think independently. And a lot of rank and file doctors knew they just

00:19:44.900 made this up. And some had immunology backgrounds and knew this doesn't fit with immunology. In

00:19:51.280 immunology, you need to be exposed to things early in life to be immune tolerant, something called oral

00:19:57.480 and immune tolerance. Parents had known it as the dirt theory. Sometimes you're around cats and dogs.

00:20:02.780 Kids that play in dirt. Yeah.

00:20:03.940 Yeah.

00:20:04.500 Develop a robust immune system. They're healthier later in life. Bubble kids end up getting really,

00:20:09.220 really sick later on.

00:20:10.380 There's a pediatrician named Gideon Lack, who's an allergist, who was one of these enlightened

00:20:14.740 guys early on. And he said he noticed kids that had, I think it was like iron or metal in their

00:20:21.140 teeth for dental work, were less likely to get a reaction to ear piercing later in life.

00:20:27.360 So he had done research in immune tolerance and knew this concept. If you're exposed to something,

00:20:32.660 you're less likely. Well, a bunch of pediatricians detested this recommendation, tried to speak up.

00:20:38.000 They were basically silenced or sidelined. And this recommendation took on a life of its own.

00:20:43.260 And parents were told for their kids, remember 1, 2, 3. At age 1, you can introduce milk. At age 2,

00:20:49.860 eggs. And age 3, finally, you can introduce some peanut products. So it became known as the 1,

00:20:55.460 2, 3. It took on a life of its own. It became dogma. As the peanut allergy rates soared,

00:21:00.900 the medical establishment said, what's going on here? We're telling people what to do. They're not

00:21:06.500 listening. We need to double down. We need to get people to comply. We have noncompliant parents out

00:21:13.880 there. If we can only get everyone to comply with this, we can defeat this epidemic. If you can hear

00:21:20.660 little echoes here of modern-day correlations. So this doubling down took place. And the more they

00:21:27.100 doubled down, the worse it got to the point where now there's an estimate that 1 in 18 kids has a

00:21:32.540 peanut allergy. But the severe peanut allergy is the real issue now, where it's banned in a lot of

00:21:37.360 schools. About 20% of schools in America have banned all peanut products altogether. And the

00:21:42.320 more you ban, the less exposure, the more immune sensitization, because now you have to think about

00:21:46.980 the 1 in 18 kid with an allergy. So it became a self-licking ice cream cone. It was like, more

00:21:53.420 abstinence, more abstinence. What are you doing? And the parents who were like, no, I'm going to

00:21:57.380 introduce peanut butter as my grandmother did. And for generations, when there were no peanut

00:22:02.420 allergies, they were seen as anti-science. They were ridiculed. Schools would address these parents

00:22:08.660 sometimes. I have two medical students, graduate students, doing research in my research center at

00:22:15.620 Johns Hopkins from Africa, one's from Cameroon and one's from Zimbabwe. They came to fly over to the

00:22:22.480 research meeting in their first days. And they were like, what is it with the peanut allergies here?

00:22:28.040 They're announcing it on the plane, the BWI. All these products are like, contains no tree nuts.

00:22:33.940 And they're like, what? I've never seen this before in my life. Some student invited one of them to

00:22:39.160 dinner at his house because he was a new student from Africa. And he goes, oh, would you like to come

00:22:43.420 over for dinner sometime? And he goes, yeah, sure. Do you have any peanut or other allergies?

00:22:48.640 And he's like, Marty, what the hell is it with this peanut obsession here? We have no peanut

00:22:55.540 allergies in Africa. And I was like, wow, Faith, have you ever heard of a peanut? These are public

00:23:00.840 health graduate students. No, we have no peanut allergies in Zimbabwe. Then I would call relatives

00:23:07.580 that I have back in Egypt, same thing. I've never heard of a peanut allergy, except for there was an

00:23:12.540 expat living here in Cairo. He had a peanut allergy. And you realize this is a unique American

00:23:18.200 epidemic that was created. But there must have been some index cases that caused the hysteria.

00:23:24.920 Yeah. So that incidence from Mount Sinai suggested half 1%. It might've been microbiome related,

00:23:30.340 we think. But the peanut abstinence threw lighter fluid into this fire. And it really resulted in

00:23:37.480 where we are today. So where is the American Academy of Pediatrics today on their recommendations?

00:23:42.220 So here's the thing. The study got done eventually, 15 years into the recommendation.

00:23:49.180 That Dr. Gideon Lack, I mentioned, in London published a study in the New England Journal of

00:23:54.400 Medicine with 640 kids doing a randomized control trial to early peanut butter exposure in infancy,

00:24:02.080 four, five, six months. Not as their sole diet. He's still pro-breastfeeding, right? And whole

00:24:07.500 peanuts have a choking risk. So I mean, the smart way. And then peanut abstinence and peanut

00:24:13.540 introduction in infancy. Fast forward a couple of years, radically eight-fold different rates

00:24:19.360 in peanut allergies and severe allergies. Published in the New England Journal, 15 years.

00:24:23.500 I'm sorry, what year was that study published?

00:24:25.580 2015.

00:24:26.740 Okay. Eight-fold difference. So we're talking about, that's almost like as significant as smoking,

00:24:32.580 giving lung cancer versus not. Smoking versus not smoking in lung cancer was about a tenfold.

00:24:37.500 Yeah. One of the biggest odds ratios you see in research. And then, of course, the bureaucrats

00:24:43.300 at NIAID and NIH from the National Institute of Allergy and Infectious Disease. Two years later,

00:24:49.220 they get around to putting a position paper and all this stuff. So 17 years.

00:24:53.860 But do we also understand how much has that position paper reversed the behavior in parents?

00:24:58.320 Because when it comes to kids that are born today, do we know that the amount of peanut

00:25:03.900 abstinence going on is virtually gone now?

00:25:06.020 I think it's unknown, but it's a great point you raise. Why not reverse the recommendation,

00:25:10.980 now that the science is clear, with the same vigor at which you put it out initially? Why not show

00:25:16.300 some humility? What if the leaders got out there and called CBS Mornings and other morning shows and

00:25:22.600 said, hey, we got something terribly wrong. We really need to correct the record on this.

00:25:26.780 You didn't see that.

00:25:27.620 To me, on my soapbox, that's really the beef I have with the HRT

00:25:31.780 stuff is the absolute, I mean, megaphone of fear that was promulgated through estrogen hysteria in

00:25:41.260 2001. And even though if you read the fine print today, many of those people have walked back those

00:25:47.020 recommendations of estrogen avoidance. But again, it's not only is it too little too late,

00:25:51.860 you've got a generation of women, literally a generation of women, over 20 million women who

00:25:56.580 have been deprived of HRT. But even women that are eligible to take HRT today, they're still confused

00:26:03.780 because the same megaphone that was used to say estrogen will give you breast cancer is not being

00:26:10.860 used to correct course. There's an enormous asymmetry in these information campaigns.

00:26:16.460 And one little piece, I know you've done a great job covering HRT, but one of the guys in that

00:26:20.840 committee, in the investigative journalism I did around the HRT dogma, before the announcement,

00:26:26.840 there was a committee meeting where they were hoodwinked. And the 40 investigators were basically

00:26:31.300 told, hey, throw out the agenda. We've got some breaking news on this study, causes breast cancer.

00:26:36.480 We already submitted the journal. It's coming out. And a bunch of guys there are like, this is not

00:26:41.360 how we do research. One of them, Bob Langer, who I interviewed, had said in a shouting match with the

00:26:47.620 lead investigator, he said, look, if you put something out there as sensitive as breast cancer

00:26:53.900 is caused by HRT, you will never be able to put that genie back in the bottle. And that's exactly

00:26:58.400 what happened. And sure enough, that guy had confessed to me that there were no increase in breast

00:27:03.540 cancer deaths, maybe with a gun to his head when we were, you know, I was doing the interview with

00:27:07.720 him. Yeah, not a single increase in breast cancer deaths. Unbelievable. And that was at the time of

00:27:12.600 publication. That was again demonstrated nine years later, and again demonstrated 20 years later on

00:27:19.460 the follow-up of the same cohort. I can't tell you, Marty, how many times I get asked this question.

00:27:25.420 It is probably the single most prevalent topic of discussion I have in a public setting,

00:27:31.120 like get a dinner or something like that. So it tells me how much incorrect information still

00:27:37.160 exists out there. It's amazing. There's probably no modern day medical intervention that has improved

00:27:42.360 the health of a population as much as HRT for postmenopausal. But it's not just HRT. The medical

00:27:50.160 establishment got opioids wrong for 35 years. They got heart stents wrong for 15 years. They got

00:27:56.460 the low-fat diet wrong for how many 60-plus years. They got peanut allergies wrong for 17 years. Where's

00:28:03.900 the apology? Where's the humility? That's why there's distrust right now.

00:28:09.400 This is where I really, really struggle. Because I have friends who are otherwise smart people who have

00:28:17.760 such ridiculous views in terms of where the pendulum has swung the other way. And they're convinced you

00:28:25.160 shouldn't microwave your food because microwaves are harmful. And I don't say this to be arrogant,

00:28:32.580 but there's also such a degree of scientific illiteracy that even when I try to explain to

00:28:37.840 one of these friends what a microwave is and why a microwave can't be harmful, you have to understand

00:28:44.400 what ionizing radiation is. You have to understand what a light, if microwaves are harmful, then light

00:28:49.260 is more harmful based on the wavelength. But that's a hard thing to explain to people who don't understand

00:28:54.860 science. You can't see wavelengths. It's difficult. So I think that's what bothers me is we've created

00:29:00.140 kind of a bimodal distribution of complete rejection of science and everything that medicine says is

00:29:07.560 wrong. And you should never go to a doctor and anything your doctor says is wrong to complete an

00:29:13.940 utter blind faith. And again, it comes back to my question, which I don't have a great answer to,

00:29:18.780 which is how does a reasonable person maintain skepticism, but not be paralyzed by it and not be

00:29:26.220 pushed so far to either extreme? I still come away thinking I don't know the answer to this.

00:29:31.540 Yeah, I don't have a satisfying answer either. And I feel for the everyday person out there,

00:29:38.340 a friend of mine who will come up to me and says, well, I asked about hormone therapy, but my doctor,

00:29:43.460 whom I love, said, no, it does this. You don't want to create so much skepticism where people are

00:29:50.320 denying a chest tube when they have a suction pneumothorax. So it's like, what is that balance?

00:29:55.760 I don't have a satisfying answer, but it is exactly what Leon Festinger was describing.

00:30:03.740 And the father of modern medicine, Dr. Claude Bernard, he had said, in science more than in any

00:30:11.720 other discipline, you have to recognize that we bring biases to any question. And you have to

00:30:19.040 actively suspend those biases as you take in new information so you have impeccable objectivity.

00:30:26.220 And it's a lesson for everyone today. Unfortunately, I think we're going the other direction in science

00:30:30.900 right now. We've got policing of misinformation. We've got this culture of obedience in medical

00:30:37.680 school that goes right down to your first day of medical school. So I'm optimistic on the future

00:30:43.160 of healthcare because enough people now are sort of anti-central authority, anti-corporate,

00:30:48.720 and they're questioning things they didn't before. But this culture of just get in line and do what

00:30:53.360 you're told is still a powerful force. Yeah. I mean, I'd love to spend some time when we get

00:30:58.720 through a few more of these interesting examples talking about how to at least change medical education.

00:31:03.540 And to me, one of the most important changes I would make if I were medical education czar would

00:31:10.700 be a very dedicated track of statistics and probability theory. And I think this is important

00:31:17.780 for all of science. I know you would agree with me, I think, but there are no proofs in science. I've

00:31:22.780 said this many times before. So nothing is a hundred percent certain. So science is not a thing,

00:31:28.380 it's a process. And what is highly probable today is probably a better way of describing something

00:31:35.500 that we think is true. So new information should always be obtaining probability. So if you think

00:31:40.780 about that framework, if people are trained in the mathematics of uncertainty, which is what

00:31:46.600 statistics and probability theory are, and I feel very fortunate because I was a math major before I

00:31:52.400 went to medicine. So that came a little more naturally to me to think that way. You could look at some

00:31:56.760 index cases of peanut allergies in the nineties and you could say, well, my hypothesis is this is

00:32:02.760 due to being exposed to peanuts as a child. Now that turns out to be wrong, but that would be your

00:32:07.800 hypothesis. But you wouldn't cling to that hypothesis with absolute certainty because you would

00:32:12.740 understand that it's a probability distribution and you might assign it a probability of 50%. And you would

00:32:19.360 say, well, if this is true, how would I test it? I would test it. And then based on information,

00:32:25.900 as it's coming in, I'm updating that probability. Is it now more than 50% or less than 50%?

00:32:31.340 And I know that sounds very mechanical, but I can't really think of another way. And I know we're

00:32:37.440 going to try not to talk about COVID today because the world's COVID fatigue is rampant, but COVID

00:32:42.720 offered so many lessons in this, which is, hey, did this virus come from a lab or did it come from a

00:32:48.080 wet market? I don't know. I'd say 90% it came from a wet market because we have a precedent of

00:32:54.720 viruses coming out of wet markets. Okay. Well, it's three months later. We have some more

00:32:59.760 information. We found out about this research being done there. Should we update the probability?

00:33:04.740 Okay. Maybe it's 80-20 now. Great. That's an update in probability. Six months later, hey, we still

00:33:10.740 haven't found the vector. Okay. Maybe it's 50-50 now. But if we thought about it that way, I think

00:33:16.680 it's easier to change your position because you're not wed to a binary outcome, yes or no.

00:33:22.200 So you're thinking about it as a probability distribution function, which is constantly

00:33:26.940 getting upgraded and updated and improved. And it's theoretically converging on what is true as we

00:33:33.900 go. And that's true of everything. I've lost track of all the other things. Fortunately,

00:33:38.760 I've purged most of them from my brain, but like ivermectin, all of these things. I mean,

00:33:43.700 all of these are reasonable things to have assumed that what became unreasonable was to not go through

00:33:49.860 this process. Both sides, the sides that clung to them and the sides that morally oppose them.

00:33:55.280 We should probably revisit that. Let's shift gears a little bit and talk about antibiotic use. So this

00:34:01.060 is something that probably doesn't get that much attention. I know, Marty, when I was in the hospital,

00:34:07.120 we did talk a lot about this. In particular, we talked a lot about it in the ICU, which was the idea

00:34:12.140 of antibiotic resistance being a real problem. But as a person who lives outside a hospital now,

00:34:19.300 I don't hear much about it. So that makes me think one of a couple scenarios. Scenario one is

00:34:24.960 it was greatly exaggerated in the early 2000s when I was a resident because it hasn't materialized.

00:34:30.180 Resistance you're talking about.

00:34:31.020 Resistance, yeah. It was real and it's still real, but more and more drugs are being developed to keep

00:34:37.460 the bacteria at bay. I could walk through several other machinations, but give us a sense of what

00:34:42.960 this means, what the implications are, and what can be done about it.

00:34:47.180 So about 100,000 people in the US die a year, roughly, from resistant bacteria that are resistant

00:34:55.020 to the antibiotics we've had. The time period it took for bacteria to develop resistance through

00:35:01.980 their natural evolution was about 23 years when antibiotics were first mass-produced in the 1950s

00:35:08.640 and 60s. Then it shrunk down to 14 years, and now it's about one year. Within a year,

00:35:14.480 bacteria will mutate around an antibiotic and it'll be a blank, say, methicillin-resistant

00:35:20.160 staphylococcus. We're now seeing C. diff, one of those common bacteria, take the life of somebody

00:35:26.900 every other month or so in the hospital. In most hospitals, you tend to pick it up in the hospital.

00:35:32.800 Sadly, you look back and you say, oh yeah, they took ANSEF for this tiny little thing they didn't

00:35:36.860 need to take the ANSEF antibiotic for. About 60% of outpatient antibiotics are unnecessary,

00:35:42.960 according to several studies. And inpatient antibiotics, I'm not sure it's much better.

00:35:48.240 I personally have given thousands of unnecessary antibiotics because I've been forced to.

00:35:55.680 When I say I give them, the operations that I do, there's this protocol that you give every

00:36:01.720 single operative patient antibiotic before the incision.

00:36:05.000 Yeah, Marty, I don't think I ever cut a person's skin in my life without an antibiotic being on board,

00:36:11.640 except for a certain trauma case where you're literally putting a knife on them the second

00:36:15.080 they walk in the door because they're going to die. But yes, we used to give ANSEF. I don't know

00:36:19.540 if that's still the case, right?

00:36:20.820 That's a common one, yeah.

00:36:21.560 Okay. And again, the reason was there are bacteria on the skin. And even though we scrub

00:36:26.640 the skin, you can't get every bacteria out. So we're going to give you an antibiotic that has

00:36:32.440 to be in your system. It's going to be given to you intravenously. And usually the anesthesiologist

00:36:36.700 still does it in pre-op or before you cut skin, so that by the time that incision goes through,

00:36:42.180 whatever bacteria are on the edge of that skin aren't going to potentially get in. So again,

00:36:45.700 makes a lot of sense. I never questioned it. There must have been studies that demonstrated

00:36:50.220 lower incidence of wound infections. I can't imagine something that prevalent

00:36:53.760 was implemented without an RCT, was it?

00:36:56.700 There were studies and there were RCTs in major abdominal operations that were done open. Well,

00:37:02.460 most surgery is done minimally invasive now, and people have inappropriately extrapolated those

00:37:07.280 findings to minimally invasive surgery. I mean, have you ever heard of an infection after a

00:37:12.700 laparoscopic inguinal hernia? Maybe like a case report. I've never seen it.

00:37:17.360 But isn't that because we're giving them antibiotics potentially?

00:37:20.180 I don't think so, because you would see at least some. I don't think it would be 100% effective.

00:37:24.660 You don't see that with abdominal surgery. I mean, it reduces the incidence of infections a little bit.

00:37:29.700 I just don't think there's any mechanism in some of these procedures. I don't think it

00:37:33.700 works. I don't think it gets to this. Well, for whatever reason, with no data,

00:37:38.220 the research from open abdominal GI cases got extrapolated broadly. And I remember asking,

00:37:43.980 I was actually in practice a little bit before the broad recommendation. I remember asking this

00:37:49.620 guy, Patch Dellinger, who was involved in these recommendations. It's called the Antibiotic

00:37:54.860 Society of America. You know, one of these, there's all these niche meetings. We have the

00:37:59.720 Pancreas Club. It's like all these meetings. It's more fun than the Spleen Society, by the way.

00:38:04.540 They're boring. And so, I remember asking him, why is it the antibiotic recommendation at the time

00:38:09.860 of incision? For every operation, I've never seen or heard of an infection for these minor procedures.

00:38:18.300 And he said, well, you know, we thought a lot about that on our committee, and we decided

00:38:22.060 making it easy to remember to do it for every operation would ensure that the big operations

00:38:27.480 get it. And I thought, well, we may have a blind spot in American medicine. Now, it's very obvious

00:38:33.960 to me, based on some research I've been seeing out there, that not only could we be breeding

00:38:38.720 resistance, but what are these antibiotics doing to the gut microbiome? And it turns out that a new

00:38:44.720 theory, which has emerged out of the University of Chicago, is suggesting that surgical infections

00:38:50.800 don't come from the skin bacteria crawling in. It comes from the gut, some sort of weakness in the

00:38:57.280 gut, and there may be a transposition of some bacteria. And they've actually done studies now

00:39:03.880 in mice where they alter their gut microbiome prior to surgery, and they have found that there's some

00:39:09.780 reduction in infection. So, there may be sort of probiotics preoperatively that may reduce the risk.

00:39:16.680 This is a big area of ongoing research. There's nothing definitive. We've learned that people

00:39:21.820 should chug a Gatorade three to four hours before surgery is mostly for the glucose, but what's it

00:39:27.820 doing to the gut? Is the patient coming in in a starvation state, and is that doing something

00:39:32.140 to the microbiome? We've had all this dogma in the operating room. You got to wear your hats like

00:39:38.220 here. You got to cover your shoes. Some places don't cover your shoes. And then you go overseas,

00:39:42.200 as you may have as well. You go to Africa, and you realize they're not wearing anything. They're not

00:39:47.920 even wearing masks when they're doing surgery, and their infection rate is no different.

00:39:52.880 Really?

00:39:53.140 Yeah.

00:39:53.700 That's surprising to me.

00:39:55.140 Yeah. And you think, well, what is the mask doing? Is it preventing sweat from dripping in? Is it

00:40:01.500 preventing the airborne particles? Because the airborne particles are just coming out of the side of your

00:40:07.000 mask. This University of Chicago research is challenging a lot of deeply held assumptions.

00:40:11.800 in operating room protocol. But one of the things I feel bad about, and I don't do it anymore now,

00:40:17.220 is going in for a minor laparoscopic procedure. Anesthesiologist says, you want me to give ANSEF?

00:40:23.740 And I say, no, you can hold off. The average 10-year-old in America has taken 11 courses of

00:40:30.640 antibiotics, and the average three-year-old has taken two and a half courses of antibiotics.

00:40:35.880 We think that zero to three age group, the microbiome, is the most sensitive to antibiotics.

00:40:41.080 But antibiotics are like carpet bombing your microbiome, these millions of bacteria that

00:40:47.080 live in harmony. And this study, I don't know if I can mention this, but this Mayo Clinic study,

00:40:53.120 this is what I was telling you before I was dying to tell you about this study,

00:40:55.880 incredible study out of the Mayo Clinic that came out. I think maybe the most significant study

00:41:01.400 of the modern era in that it's shattering our deeply held assumptions about chronic diseases.

00:41:07.360 And the Mayo Clinic researchers took the 14,000 children that live in Olmstead County,

00:41:13.960 the area of Rochester, Minnesota, and they looked at kids who took an antibiotic course in the first

00:41:19.860 two years of life and tracked whether or not they developed asthma, learning disabilities,

00:41:26.540 overweight, obesity later in childhood. And what they found were these incredible correlations.

00:41:32.400 There were about 10,000 kids who had taken an antibiotic course and 4,000 who had not,

00:41:37.220 and they matched them to the best of their ability statistically. A 20% increase in obesity among kids

00:41:43.820 who had taken an antibiotic in the first two years of life. 21% increase in learning disabilities.

00:41:49.480 These were all the statistically significant findings. 32% increase in attention deficit disorder.

00:41:54.620 A 90% increase in asthma and a 289% increase in celiac. Other studies have shown a correlation between

00:42:02.760 antibiotics early in childhood and ulcerative colitis and Crohn's disease. Makes sense. We're changing

00:42:08.020 the microbiome. We may be carpet bombing the microbiome with the dogma that there are no downsides

00:42:13.720 to antibiotics. You got some sniffles. It probably won't help you, but it won't hurt you. Not true.

00:42:18.900 Now, how do we know in this study, Marty, that the 4,000 kids who were in the control arm that didn't

00:42:24.900 get antibiotics weren't healthier kids, which is why they never needed the antibiotic, and that it

00:42:32.200 wasn't some other factor about the 10,000 who did get the antibiotics. Either they were just naturally

00:42:39.180 less healthy kids. There was something about them that was less robust. There were other factors that

00:42:44.220 couldn't be corrected for that actually explains those differences.

00:42:48.420 I love it. That's how a scientific mind should think, because there could be confounding variables.

00:42:52.960 For example, maybe it's the infection that they were treating that is the cause that led to.

00:42:59.560 That's right. Yep.

00:42:59.800 Right? So those are all good questions. Now, first of all, we cannot make conclusions from this study,

00:43:05.920 but this study is an incredible signal that I think we should pay attention to for two reasons.

00:43:10.380 Number one, it's been repeated in a Danish study of about a million children. Number two,

00:43:16.140 there was a dose-dependent relationship. The more courses of antibiotics a child took-

00:43:21.120 The more significant the delta.

00:43:22.740 The higher the odds ratio.

00:43:24.420 Worth maybe pausing and explaining to folks how you can increase the probability of a finding being

00:43:32.920 real in an epidemiologic study. So again, it always comes back to this, what's the probability what

00:43:37.600 you just said is causal. Causality is the single most important force in science. I'm convinced of

00:43:43.260 that. If you don't have causality, you have nothing. It's what makes the universe what it is,

00:43:47.540 in my view. So you stated a correlation. It's only interesting to us if there's causality.

00:43:53.740 And now the question is, how probable is the causality? And various factors defined by a

00:43:59.900 statistician named Austin Bradford Hill speak to the strength of the association and the probability

00:44:07.160 or likelihood that that association is causal. And you've outlined a couple. So one of them is,

00:44:12.320 what's the strength of the association, period? So if I knew nothing else, was the asthma the 289%?

00:44:20.220 Celiac.

00:44:20.820 Celiac. So the fact that that had such a strong hazard ratio, that's a hazard ratio of 2.9 versus

00:44:26.360 the others that are like 1.2, you would say, well, just on the basis of strength of association,

00:44:31.160 that one's more likely to be causal. You then stated another factor, which was reproducibility.

00:44:36.160 There's another study that's done the same analysis, and it's coming up with the same

00:44:39.660 answers. So that makes it a little more likely to be causal. And then you talked about the dose effect,

00:44:44.280 even within the association. For example, all of this was figured out during the kind of smoking

00:44:50.220 cholera epidemics when people were trying to understand causality. And then you'd say, well,

00:44:55.320 if smoking is causally related to lung cancer, then theoretically, my correlations should get

00:45:02.060 stronger and stronger, the more cigarettes you smoked. If that's not the case, it becomes very

00:45:06.640 hard to make the case that smoking is causing lung cancer. So you're saying that there was a dose

00:45:12.020 effect. The more antibiotics you took, the more strongly you were having these associations.

00:45:17.740 Yeah. And this is the first formal study I've seen like this on an epidemiologic basis that

00:45:22.980 fits a hypothesis that to me makes sense. The cephalosporins had a higher correlation.

00:45:29.240 They're generally considered to be a little more damaging to the microbiome than the NCEFs and

00:45:34.660 penicillins. Is that because they target gram negatives more or anaerobics more? I'm so far out

00:45:40.860 of my life on antibiotics, I don't even remember why that would be the case.

00:45:45.100 I don't know, but there are other observational data. For example, farmers have used antibiotics to

00:45:52.240 fatten animals for food production for decades. And the world expert on the microbiome, Marty Blazer,

00:45:59.040 who was the chief of medicine at NYU. His daughter developed chronic abdominal diseases

00:46:04.460 and obesity. They feel terrible because they gave her a bunch of antibiotics in childhood and they

00:46:09.940 thought there was an association. He's a laboratory scientist. He started doing all these mice

00:46:14.680 experiments. If antibiotics are making animals more obese, what are they doing to humans?

00:46:21.280 That, by the way, is another one of the Bradford Hill criteria. Do you have experimental evidence

00:46:26.160 that also supports this? Which, of course, in the case of human epidemiology, you would look at

00:46:30.380 animals. So, of course, someone listening to this might say, well, okay, Marty, but there's got to

00:46:36.100 be some bad luck involved here. I mean, let's go back to the Rochester, Minnesota study. You got 4,000

00:46:41.580 kids who never took an antibiotic, 10,000 kids who did at least a course or two. Well, those 10,000 kids

00:46:48.300 weren't just given antibiotics for no reason. They must have had ear infections. They must have had

00:46:52.600 tonsillitis. They must have had appendicitis. They must have had something. What were we supposed to

00:46:57.820 do? How do we draw the line between what was medically necessary? Because as unfortunate as

00:47:02.920 those consequences are, they pale in comparison to a life-threatening infection that could have

00:47:08.700 killed a kid. So, how do we decide what the minimum effective dose is, what's absolutely medically

00:47:15.180 necessary versus what is superfluous and potentially just exposing a kid to these complications

00:47:22.060 later in life? Antibiotics save lives. You've seen it and I've seen it right in front of our eyes.

00:47:26.600 They're amazing medications. They ushered in the white coat era. As I wrote in my book, Marty,

00:47:32.200 it's what took us from medicine 1.0 to medicine 2.0. We died like dogs for 250,000 years of human

00:47:41.680 existence. We died like dogs. You got an infection. Life expectancy was 38. It's not the only thing that

00:47:49.500 made the difference, but it was arguably the single most important difference with sanitation

00:47:54.740 and antimicrobial therapy in the transition from medicine 1.0 to 2.0. That's right.

00:47:59.340 So, we don't want to throw the baby out with the bathwater.

00:48:01.440 This is the nuance, which if people want just sort of a simple dumb message and all or nothing,

00:48:06.260 which is where our echo chambers of media and politics take us in life and social media, right?

00:48:11.500 You want this all or nothing absolutism. Antibiotics save lives, but they are also massively abused and

00:48:18.320 overused, at least 60% in all the studies.

00:48:21.600 40% of antibiotic use is justified?

00:48:25.760 Yeah, and I even question that number because they would say that I should be giving antibiotics

00:48:29.500 before my minor procedures. But there's also epidemiologic data over time that,

00:48:36.700 look at all these chronic diseases. Now, I know they're multifactorial, especially obesity,

00:48:41.340 but look at all the increases we've seen in these exact diseases that they've seen increase

00:48:47.120 in the antibiotic group after the broad administration of antibiotics in the 1940s and 50s. In the 60s,

00:48:54.480 it just went up even further. The discoverer of antibiotics, Alexander Fleming in 1922,

00:49:02.000 he had warned after he got the Nobel Prize about the massive overuse of antibiotics. He had written

00:49:09.500 in his diary that I found in my research that these mass factories producing penicillin, it blew him away.

00:49:16.840 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.

00:49:23.520 It's unknown, but somebody left the window open in his lab where he was growing staph in an auger gel.

00:49:29.600 And some of that mold landed and formed a circle around the mold where all the bacteria were killed.

00:49:37.760 And he had discovered what's considered to be the greatest discovery of modern medicine.

00:49:42.020 And so, you're right. It took us from being surgeon barbers where we had a lancet and an axe to do

00:49:48.940 amputations and maybe digoxin, which didn't help. And that was it. And doctors weren't disrespected,

00:49:55.840 but they were respected like a priest or a barber. And then with the mass production of antibiotics,

00:50:01.340 now we had the power and control the substance where only we could give you a magic pill.

00:50:07.540 Doctors began to wear white coats. They had an unquestioned authority. We kept people in the

00:50:13.160 hospital.

00:50:13.840 I'm a little disappointed you're not wearing a white coat today, Marty.

00:50:16.660 I'm not a white coat kind of guy. We held babies in the hospital for 10 days,

00:50:24.780 routinely. Normal, healthy babies.

00:50:26.520 I was in the hospital for 14 days when I was born.

00:50:29.460 Normal?

00:50:30.040 Yeah.

00:50:30.380 That term?

00:50:31.080 Yeah.

00:50:32.860 14 days.

00:50:33.960 It's crazy.

00:50:34.840 You could be out of the hospital with an aortic root replacement in half that time.

00:50:38.940 I remember my little sister was born around 1980s. Mom came home from the hospital after

00:50:45.280 delivering her. My brother and I were like, hey, we have a sister. Every day we'd ask,

00:50:50.180 dad, when is our little sister coming home from the hospital? Well, the doctors haven't released

00:50:54.860 her yet. She's totally normal, right? She's sitting in there for days and days. You go in

00:50:59.780 there with some big glass window. They'd be like, there she is, third row from the back,

00:51:04.660 six one over. You see this little head of hair. Looking back on it, this is the medical

00:51:11.100 paternalism. This is that white coat era. This never happened before in history.

00:51:15.720 People will stay in the hospital for two weeks after a cataract. They'd measure their toe

00:51:20.140 diameter. They'd probe and poke and put babies in the NICU and feed them formula. And mother would

00:51:27.700 be like, can I still hold the baby? No. As a student, I was in the OB rotations, my first

00:51:32.980 rotation. I'm nervous. I'm not even almost shaking thinking about it. They give me the scissors.

00:51:39.200 Go, room six. You know, there's some moaning. You go in there and all sorts of chaos.

00:51:42.700 Okay. As soon as you see the umbilical cord, you cut it. And I'm holding the scissors. I want to

00:51:50.480 learn about the process of childbirth, but I've blocked out everything because I have one job.

00:51:55.860 And I'm holding these scissors and then there's chaos. And then all of a sudden this baby,

00:52:01.000 and I can barely see this slippery cord and they're putting clamps on it. Cut it! You know,

00:52:05.820 and I'm like swooping in to cut it. And then they take the baby off to the back table. What are we

00:52:10.960 doing? Oh, we have to re-warm the baby. Okay. So, they put the baby under this table with the

00:52:17.080 French fry light. And I'm thinking, baby... The French fry light.

00:52:21.680 The baby... The irony... The baby was getting a warm blood transfusion from the mother with a

00:52:30.860 pulsating umbilical cord, which was actively pulsating when you clamped it and told me to cut

00:52:36.120 it. But I don't say anything. I want to get a good grade. And I'm like, the mom wants to hold the

00:52:41.580 baby. Wouldn't that be warm enough? No, we have to warm the baby. Turns out the data now on skin-to-skin

00:52:48.260 time, hours of skin-to-skin. That's the best incubator. There's all kinds of incredible

00:52:53.000 data now on how the baby has more normal blood pressure and heart rate and more normal glucose

00:53:00.020 levels when the baby is held by the mother. And the heart rate and blood pressures, I heard that

00:53:05.560 in the studies. And I was like, that makes sense, but I don't get the glucose. Why would the glucose...

00:53:09.360 They're stress hormones or not. Cortisol. Cortisol. Yeah. You figured it out quicker than I did.

00:53:13.380 And I'm kind of like, what are we doing? They're sticking a metal temperature probe in the baby's

00:53:19.420 rectum. And I'm like, is this a nice way to welcome a human into the world? What are we doing? Like,

00:53:25.440 the baby's temperature is what the mom's temperature was because the baby just came from mom two seconds

00:53:30.960 ago. Like, what are we doing? They were just like, oh, we have to put it on the sheet and all this

00:53:35.080 probing and poking. They wash the baby. Now they know not to wash a baby for the first 24 hours because

00:53:41.880 there's kind of a proteinaceous coat. And again, C-sections, they save lives. But C-sections like

00:53:48.820 antibiotics are also massively overused. And it turns out, as the head of the microbiome unit at

00:53:54.300 the NIH explained to me when I did the research for this book, she said in a vaginal delivery,

00:54:00.180 the baby's gut in utero is sterile. And so it's seeded, the microbiome is seeded from the bacteria in

00:54:07.060 the vaginal canal and then augmented by bacteria from the colostrum, the early breast milk and the

00:54:13.480 skin and the kisses of the grandparents. But when you're born by a C-section, the baby is extracted

00:54:18.080 from a sterile operative field. What may seed the baby's microbiome are the bacteria that normally live

00:54:23.860 in the hospital. And when she explained it to me that way, I thought, my God, you know, it makes sense.

00:54:28.820 So what is the prevalence of C-section today? And how close are we to peak C-section versus what was

00:54:36.520 it 50 years ago? We're about 30% in the United States. Private hospitals in Brazil are at 90%.

00:54:43.220 Overseas, it's sometimes even worse. The individual doctor C-section rate ranges from 12% to we've seen

00:54:53.260 100%. So we have a big project at Johns Hopkins and through our consortium. On the appropriateness

00:54:58.800 care where we look at practice patterns of physicians and we basically can profile a

00:55:03.860 physician on their pattern of doing something where there's known to be a lot of inappropriate

00:55:08.560 overuse. But again, just help me anchor this to some context. 50 years ago, presumably they were

00:55:15.820 not doing elective C-sections. A C-section was done because it was medically necessary. Is that a safe

00:55:21.980 assumption? Yeah, there's definitely more unnecessary C-sections. Right. So what was the prevalence of

00:55:25.620 C-sections pick your favorite decade when elective C-section was not done? Should it be 5%? Should

00:55:32.080 it be 10% if we're only doing it for medically necessary C-sections? The OBs that I've grown to

00:55:38.900 really respect, really trust ethically on, they talk passionately about the overuse of C-sections

00:55:45.620 and they have impeccable judgment. They have C-section rates in the 12% to 15% range.

00:55:51.480 So we think that that probably is at least in the zip code of what is necessary. And by the way,

00:55:59.540 let's go back to what we were talking about. In the world of medicine 1.0, when we barely got to our

00:56:05.020 40th birthdays and infant and maternal mortality were sky high, every one of those kids that would

00:56:12.800 be getting a necessary C-section, they'd be dying and probably the moms are dying. So this is a huge

00:56:18.120 advance. The fact that we could do this operation, and I know you don't think this way, but I just

00:56:23.940 want to make sure people listening to us don't take away from this, C-sections are bad.

00:56:27.980 C-sections save lives.

00:56:29.600 I would argue C-sections, antibiotics have saved more lives than anything that we're doing in

00:56:35.940 medicine today, correct? Yes.

00:56:37.780 Right? That has doubled the human lifespan.

00:56:40.160 That's right.

00:56:40.660 Because when something goes wrong in delivery, it doesn't go wrong in hours. It goes wrong in

00:56:46.580 seconds. A fetus doesn't have an enormous physiologic reserve. So when their heart rate

00:56:52.260 starts crashing, you've got to get that baby out immediately. So what you're basically saying,

00:56:57.900 or what I think we want to discuss is, why did we go from a world in which once we had modern medicine

00:57:04.460 at the early part of the 20th century, and we were able to get these 12 to 15% of children born

00:57:12.180 safely via a C-section, how did that go to 50, 60, 70% depending on your series? What was that

00:57:21.020 transition? Why did that happen? I'm told it's a combination of a consumerist culture. If you think

00:57:27.960 about it, if we're being really honest here, I've talked to a lot of doctors in my life. I think you

00:57:33.520 have two. Being an OB doctor specializing in labor and delivery is one of the hardest. It is so hard,

00:57:40.980 a brutal lifestyle. And so you have somebody who's been pushing in labor. It's now 10 o'clock at night.

00:57:49.400 They're telling you, just cut this thing out of me. May not be medically necessary, but in the fog of

00:57:55.740 the moment, I will tell you that there are OB practices that the ethical OB doctors I've interviewed

00:58:02.540 and talked to tell me about this, and it drives them crazy. There are OB practices where you check

00:58:08.180 out from your first prenatal visit, and the receptionist, when they schedule the next one-

00:58:13.480 Is also scheduling your C-section.

00:58:15.140 Would you like to schedule? You pick a date for your C-section, no informed consent,

00:58:19.420 and people, it runs in certain circles. I'd be nice to have it on their grandmother's birthday,

00:58:25.060 and why don't we schedule it Christmas Eve birthday, and they try to schedule the birthday.

00:58:29.320 But there are so many factors in Brazil. There's a dogma that it changes. Vaginal delivery changes

00:58:35.700 one's sexual pleasure. It's unsubstantiated, but it looms large as a dogma in popular society

00:58:43.360 in Brazil. So there are many reasons, and I'm not in this field, but from talking to folks in it,

00:58:49.960 there's a massive... I mean, my cousin, I went with her when she delivered. She was by herself.

00:58:55.580 And of course, I'm highly attuned to this issue. And the OB docs come in, and they're looking at

00:59:02.600 something on the rhythm strip, and they basically tell her, I think that C-section might be safer

00:59:08.980 for the baby. Well, even though she didn't want a C-section, she, of course, is reasonable and

00:59:14.260 open-minded. You tell that to any woman in the world, they're 100% going to say, well, then just do

00:59:19.420 it. And so I think there's a little bit of what we call the nudge. Hey, what about this non-operative

00:59:24.840 protocol for appendicitis? Well, it's a little experimental, could be a little dangerous. Oh,

00:59:30.100 well, heck, don't do it then. You have bone on bone in your joint. Nothing is going to help

00:59:34.840 except a knee replacement. Shit, bone on bone, just go ahead. So we have these nudges in medicine,

00:59:41.360 and they're kind of well-known in every field.

00:59:43.100 Look, I'm probably guilty of them myself. I would bet if I were listening to me, if I

00:59:48.040 were outside of me and listening to me talk to patients, I'm sure there are many times

00:59:51.640 when subconsciously I'm doing the same thing. I'm nudging them towards what I think is the

00:59:56.940 right answer, even if in cases when maybe my confidence should only be 70% instead of 99%.

01:00:04.840 Do we have any evidence, Marty, that that trend is reversing, that it's coming back to more of

01:00:11.500 a natural childbirth process in terms of everything from both a vaginal delivery standpoint, but also

01:00:17.200 in terms of how the baby is handled post-operatively? I mean, I know that for all my three kids,

01:00:23.120 they had the instantaneous cord cut. We were trying to set a world record with how quickly

01:00:28.780 that cord could be cut. We really, really smoked that thing. What is the trend on that now?

01:00:33.760 On that real quick, they've done studies looking at 45 seconds versus 90 seconds of delayed cord

01:00:38.460 clamping. And there was a clinical statistically significant benefit to 90 seconds. You're

01:00:42.920 getting stem cells.

01:00:44.160 Benefit in what regard? What was the outcome?

01:00:46.080 I don't remember. This is a randomized controlled trial of two timings. And I'm told by the OBs,

01:00:52.740 I respect, you want to cut it after it's done pulsating. Could go two minutes. Now, we're talking

01:00:58.660 about the pendulum swinging to the extreme and people taking hard line, inappropriate positions.

01:01:03.660 One patient told her once, don't you dare cut that before five minutes. And she's like, okay,

01:01:09.560 it's not going to pulsate after two minutes. So we don't want to create extremists here. But

01:01:13.460 the C-section rate has stabilized. And I think it's because of awareness out there. I don't think

01:01:18.240 people understand the impact of the microbiome. A study just came out in JAMA surgery that children

01:01:24.900 born by C-section had higher rates of colon cancer before age 50.

01:01:29.440 How much higher?

01:01:29.920 I don't remember the odds ratios. JAMA surgery came out in the spring of 2024. I think I've got

01:01:35.720 it cited somewhere in the book, but it was a large database study from Sweden. Now, again,

01:01:40.820 we cannot make conclusions from that, but these are little signals on the data that we're supposed

01:01:45.180 to pay attention to. I do think it's stabilizing. Dr. Will Bruhn tracks C-section rates for healthcare

01:01:51.140 organizations. And he will say, here's the 28 doctors at this hospital. Here's their individual

01:01:57.360 C-section rates as we are pulling from big data. And we're not going to grade. Doctors shouldn't

01:02:03.680 be under scrutiny for a 15% versus a 19%. But we use these data as a screening tool. If you're over

01:02:12.800 30% C-section rate in your low risk deliveries, which we can do in big data, we can scrub the severe

01:02:19.660 preeclampsia and the twins and all that. Then that is a screening tool to identify inappropriate

01:02:25.780 concerning patterns that warrant a closer clinical review.

01:02:29.480 How prevalent is that type of analysis today?

01:02:32.440 We're the only group doing it that I know of. It's called Global Appropriateness Measures. It's a

01:02:36.740 consortium of physicians that I helped start with Dr. Will Bruhn. GAMEasures.com is the website.

01:02:42.420 Lots of groups now. GAMEasures for globalappropriatenessmeasures.com. And so health

01:02:48.980 systems are saying, you've got all the commercial data or nearly all the commercial data. You've got

01:02:53.880 100% of the Medicare data, 100% of the Medicaid data. You can actually pull the C-section rate

01:02:59.160 and low risk deliveries for our doctors. I want to see what they are. And then what they do is they

01:03:03.380 send a report showing doctors where they stand on the bell curve. And when you're out here as an

01:03:08.940 outlier, guess what happens when you get a report? We watch in the big data, they regress towards the

01:03:14.700 mean. What's the reimbursement or the economic differences between a C-section and a vaginal

01:03:19.300 birth? 9,000 versus 7,000. I really don't think-

01:03:22.780 So it's not an economic decision.

01:03:23.400 I don't think there's any financial. I mean, given again, how difficult that job is of being an OB,

01:03:28.700 I think it's other factors. And by the way, we're doing this for spine and hardware infusion rate

01:03:34.000 during lumbar spine surgery. What's your rate? Shouldn't be over 50% in non-deformity cases.

01:03:41.420 We're doing it for how often is a hernia fixed on both sides. When somebody comes in with a hernia,

01:03:48.480 it shouldn't be fixed on both sides more than 20% of the time. We learn the ways in which there's

01:03:54.160 inappropriate practice patterns. And then we profile individual docs for improvement,

01:03:58.440 for quality improvement.

01:03:59.200 By the way, what percentage of inguinal hernias are repaired with mesh versus the tissue repair?

01:04:05.200 I think they're all fixed with mesh, except in the famous Scholdeis Clinic,

01:04:09.740 where I might go someday, I got a minor hernia if it ever becomes a problem.

01:04:14.980 We've sent many patients to the Scholdeis Clinic, and I could be just out to lunch on this,

01:04:19.700 but one of the things I took away from residency that really stood out to me

01:04:23.020 was how difficult a tissue repair was. I just remember technically,

01:04:27.720 I still don't understand the anatomy.

01:04:29.640 It's spooky in there.

01:04:30.060 Yeah. But secondly, how much better it was if the tissue was sound. And yet,

01:04:35.900 we didn't do very many tissue repairs. Pretty much everybody had mesh. Anything to say on that?

01:04:42.120 Not really. The meshes now are so lightweight. They're like a little thin net. That's what I've

01:04:47.260 used. If I could do it as well as the Scholdeis Clinic, I probably would. I just like the idea of

01:04:53.020 no mesh in there. And I'll offer it to patients, say, this is how I do it. If you want a no mesh

01:04:57.820 repair, there's a place, I think it's in Canada, right?

01:04:59.940 It's in Toronto, yeah.

01:05:00.420 Yeah.

01:05:01.020 Where you're from, aren't you?

01:05:02.040 Yeah.

01:05:02.420 Yeah.

01:05:03.520 Okay. That's interesting. So basically, if you want to get a tissue repair of an

01:05:07.180 little hernia, you got to go to the Scholdeis Clinic. But you're saying maybe mesh is getting

01:05:11.680 so much less intrusive now that there's less downside to doing mesh than there used to be?

01:05:16.340 Yeah. When we used to operate together, they put these big, thick polypropylene meshes in there

01:05:21.260 that I don't understand how you wouldn't feel it. And the idea was to promote scar tissue because

01:05:25.720 it's actually the scarring that is the heat. But now they're lightweight, thin, like a fishnet almost.

01:05:31.980 Let's talk a little bit about ovarian cancer.

01:05:33.720 Ah, yeah.

01:05:34.680 Maybe just give folks a little bit of an anatomy of the female reproductive system so that what's

01:05:40.440 an ovary? What are the little tubes that connect it to the uterus? Give folks a sense of what that

01:05:45.380 anatomy is.

01:05:46.520 Ah, yeah. So this is an incredible area where we're doing some work. Our research team at Johns

01:05:51.240 Hopkins is dedicated to studying the big issues in healthcare that we are not talking about,

01:05:56.020 that we should be talking about. Where research is taking off, new science is pointing to things

01:06:01.040 that like, hey, pay attention. And there's not a lot of attention or NIH dollars. And one of those

01:06:05.680 areas is the true origin of ovarian cancer. The ovary sits draped under the fallopian tube. And the

01:06:16.040 end of the fallopian tube has finger-like projections called the fimbriae. So we're talking like a

01:06:21.300 millimeter. I mean, they're almost really in contact. You want me to explain how this works?

01:06:25.840 So it turns out-

01:06:27.120 What is an ovary, first of all? Like, what does it make? Why do women have them?

01:06:30.680 Where do the eggs go? All that kind of stuff.

01:06:32.340 So it used to be thought that the only purpose of the ovary is to produce sex hormones, but it's

01:06:37.420 not true. It produces, you've talked about with estrogens involved in heart health and so many

01:06:42.540 things, but it produces the eggs that go down a little circulation through the fallopian tube into

01:06:48.340 the uterus. Doctors have really struggled with ovarian cancer. Really no major progress.

01:06:55.840 In modern medicine. Most of the cases are lethal or present in late stages. There's almost nothing

01:07:02.880 you can do. Very little surgical intervention. There are some cases where it's early enough,

01:07:07.760 but overall the fatality rate is over 50%.

01:07:10.340 And there's a strong association between certain types of breast cancer and ovarian cancer.

01:07:14.800 Yeah, there is with the hereditary predisposition. So some people get tested, but a big study was just

01:07:20.820 done in the UK looking at screening tests for ovarian cancer. Should we have mass population

01:07:27.560 screening?

01:07:28.700 Using what? Ultrasound?

01:07:30.060 Using ultrasound and they've done CAT scans and none were shown to improve the outcomes in people

01:07:36.020 and detecting ovarian cancer. None. Total failure. They abandoned the entire idea of ovarian cancer

01:07:42.680 screening based on this big UK study. So here we are with a cancer with almost no advances, a ton of

01:07:48.640 money. It's not for lack of funding at the NCI. And what is going wrong here? Well, I love this blind spot

01:07:55.920 of medicine because it shows how when you're certain of something in medicine, you can still benefit from

01:08:02.400 challenging deeply held assumptions. It turns out that there was a recent discovery that ovarian cancer

01:08:09.000 does not come from the ovary. The most common and lethal type comes from the fallopian tube and the

01:08:16.360 cells float onto the ovary. We have taken out millions of healthy ovaries to prevent ovarian cancer

01:08:23.320 during abdominal surgery, during a hysterectomy. The ovaries will be removed to so-called prevent

01:08:28.460 ovarian cancer. It turns out we were targeting the wrong organ. With this new discovery that

01:08:34.080 biologically, based on the genetics, based on a lot of good research that's emerged from Penn,

01:08:40.900 Dr. Drapekin, a guy at Johns Hopkins, one of my colleagues, there's a gynecologic oncologist now,

01:08:46.840 this is her entire career focus, is that we have to increase public awareness that this is really not

01:08:53.080 ovarian cancer the vast majority of time. It's fallopian tube cancer. And we can prevent it because

01:08:58.460 the fallopian tube serves no function after a woman's childbearing years. It's not like even

01:09:04.960 after menopause, there's very low levels of estrogen that can trickle out of the ovary for a while.

01:09:10.100 But after a woman's done having kids, if they come in and say, I want my tubes tied,

01:09:15.420 the new answer at Johns Hopkins is, we don't do that anymore. We remove the fallopian tubes

01:09:20.480 to massively reduce your 1 in 78 chance of developing ovarian cancer in the future.

01:09:25.660 Is that high?

01:09:26.420 Yeah, it's that high.

01:09:27.340 1 in 78?

01:09:28.920 Yeah, I love it that you have that reaction because I had the same reaction. I realized we don't think

01:09:33.140 like that in clinical medicine. Like at the pancreas cancer conference once, I asked,

01:09:38.620 this patient was asking, what is her lifetime chance of developing pancreatic cancer?

01:09:43.600 And I said, well, you have no risk factors. And she goes, well, what is it? I'm like,

01:09:47.620 you mean just for an everyday person? And I asked the experts. No one knew. I looked it up.

01:09:53.840 I was going to guess one in 20 actually, but maybe it's less than that. That's for all

01:09:57.880 pancreatic cancers. You mean pancreatic adeno lethal cancer?

01:10:01.520 Yes. One in 67 is what we found.

01:10:04.680 Okay. I would have guessed even more frequent, truthfully. Okay.

01:10:07.380 Yeah. I think the fourth most common lethal GI cancer or something.

01:10:10.700 Fifth most common lethal cancer, full stop, not GI.

01:10:13.920 Cause of death?

01:10:14.620 Cause of death.

01:10:15.220 Okay.

01:10:15.480 Yeah. Cause of death, right? It goes, number one is lung, number two, breast and prostate,

01:10:22.020 and then colon, and then pancreas.

01:10:24.400 And breast is only over pancreas because it's almost exclusively women, whereas pancreas is men

01:10:31.380 and women, but it's about 40,000 for both breast and pancreas cancer. We think about, well, if you

01:10:37.960 have, and this is what the docs told me in the conference. Well, if she has chronic pancreatitis,

01:10:42.400 her relative risk has increased 28%. Okay. Well, that's not what she's asking. She's asking,

01:10:47.720 what are the chances?

01:10:48.900 But again, Marty, I'm still surprised that ovarian is as high as one in 78 and pancreas is one in 67.

01:10:56.920 Most common GYN cause of death.

01:10:59.740 I'd believe that for sure. Okay. So how widely accepted is it today that ovarian cancer is a

01:11:07.220 misnomer? Is that what you're basically saying?

01:11:09.780 Yeah.

01:11:09.980 It's not ovarian cancer. It's fallopian tube cancer?

01:11:13.440 For the vast majority of these cancers. You can have other types of gonadal tumors that are

01:11:19.120 much more benign that arise out of the ovaries. There's many types of cancers in that little

01:11:24.120 region. But the most common, the rank and file, what we call ovarian cancer does not come from

01:11:29.000 the ovary. It comes from the fallopian tube.

01:11:30.760 And this is what we've previously thought of as serous ovarian cancers.

01:11:35.360 Serous adenosis carcinoma, yeah.

01:11:37.940 Is a fallopian tube cancer.

01:11:40.780 It's a fallopian tube cancer.

01:11:42.160 Well, how was that not understood? How is the histology of, I mean, do the cells look the same?

01:11:47.960 Pathologists for decades have examined this because when a woman gets ovarian cancer,

01:11:53.140 she doesn't die from the ovary. She dies from where it spreads to, right? She's dying from the

01:11:58.680 spread of that cancer to another part of her body. So when they take those cells and they're looking at

01:12:03.380 them under a microscope and they're staining them, why did it take so long to figure this out?

01:12:08.440 Because of medical groupthink. And when I interviewed the scientists that were involved

01:12:14.100 in this discovery, the resistance that they encountered was the same old story of the

01:12:19.580 people who challenged the low-fat diet and opioids are not addictive and HRT and all this other stuff,

01:12:24.560 it's the same story. At UCSD, San Diego, a pathologist there wrote a very bold essay in one

01:12:33.700 of the medical journals where he said, I'm telling you, the cells we're looking at do not look like

01:12:39.680 ovarian cancers. These ovarian cancer cells, they don't look like ovarian cells. And he got,

01:12:45.240 of course, attacked and piled on like the H. pylori causes an ulcer guy. He just got destroyed.

01:12:53.020 And his courageous step actually led some researchers to say, I think it was the Netherlands,

01:12:59.160 to say, actually, we're going to explore this a little bit. And they did a little bit more of an

01:13:02.520 analysis. It was like 15 years ago. And they affirmed him a little bit. They were like, yeah,

01:13:08.340 we are seeing the same thing. They did a series of people who had BRCA mutations. And then this guy

01:13:15.080 Ronnie Drapekin and Chris, I can't remember his last name, at Brigham and Women's Hospital.

01:13:20.680 They decided, and it was incredible, Chris had a mentor at Brigham and Women's. And he goes,

01:13:27.040 when everyone's laughing at an idea, in science, that's a signal you should look into it.

01:13:32.140 Your curiosity should kick in.

01:13:34.400 But let's be clear, and I want to keep coming in back to this,

01:13:37.240 maybe 19 out of the 20 things that we laugh at, we should be laughing at. I mean,

01:13:42.040 this is the thing. I just want to make sure we're not giving people a license

01:13:45.540 to assume that every dumb idea is right. Most dumb ideas end up being dumb and wrong.

01:13:52.840 Yeah, we don't want to promote snake oil here on the drive, but it is interesting.

01:13:57.040 This is the challenge, is the signal-to-noise ratio is still incredibly low. And the examples

01:14:04.200 that are most remarkable always looked a little foolish at the outset. But I think what we want to

01:14:09.320 do is just make sure that people understand that just having a crazy idea is not sufficient.

01:14:15.520 You have to have a means of stating what a hypothesis is, determining how to test that

01:14:22.480 hypothesis, and above all else, having the ability to update your hypothesis based on new emerging

01:14:29.960 information. Because again, most crazy ideas end up being wrong.

01:14:34.000 That's right.

01:14:34.380 Just full stop wrong.

01:14:35.940 Yeah. Most ideas end up being wrong.

01:14:37.740 Yes. It's very challenging. Where are we right now in terms of rolling this insight out into

01:14:45.440 broader oncologic care? So you said at Hopkins, if a woman wants to get a tubal ligation,

01:14:52.700 tying of the fallopian tubes, she is told, we'll happily take your fallopian tubes out. But if we're

01:14:58.980 going to go in there, we might as well make sure you never get cancer.

01:15:01.800 Massively reduce the risk.

01:15:03.060 Like, where else do we see this? How ubiquitous is the acceptance of this? And is there any

01:15:08.780 uncertainty that remains here? Or is this basically now a fait accompli as far as our

01:15:12.560 understanding of that physiology?

01:15:14.440 There is uncertainty because I think as early as we are in something like this, there always will be.

01:15:19.700 But it is now standard of care in Germany and most of Canada that when a woman comes in for

01:15:26.960 any abdominal surgery, elective abdominal surgery.

01:15:30.520 Even a lap cholecystectomy. If you're taking your gallbladder out.

01:15:33.680 Yes. Even a lap chole. Most commonly a lap chole, actually. A woman comes in because that's more

01:15:38.780 common in women. And they're finished having children. They will be offered to remove the

01:15:44.400 fallopian tubes, sparing the ovaries during the procedure as a concomitant surgery.

01:15:49.840 Okay. And the general surgeon does this?

01:15:51.460 So, the general surgery, I'm doing this now in my practice. A woman comes in, done having kids.

01:15:57.560 Rebecca Stone, who is our GYN oncologist, who's one of the national leaders.

01:16:01.580 She comes in and does the salping.

01:16:03.620 Yeah. I don't want to be taking out the round ligament or something.

01:16:06.640 Yeah. And tell me, what is the probability of taking out the fallopian tube and damaging

01:16:11.460 an ovary such that a woman ultimately needs an oophorectomy as well, which would be a disaster,

01:16:16.720 an absolute disaster for a woman to lose her ovaries if she's premenopausal and still relying

01:16:21.920 on those for hormones.

01:16:23.580 Yeah. And I think you've touched on a big unknown there, which is the single reason why this is not

01:16:28.660 a broad recommendation for any woman and everyday person to come in for just their fallopian tube

01:16:36.100 removal. It is only offered as a concomitant procedure. OBs are very good at this. They

01:16:41.420 say it's a simple procedure. But here's the issue if you make a broad recommendation for every woman

01:16:47.960 who's done having kids to come in and have this done. What if one in 20 surgeons is going to have

01:16:54.240 a complication rate of 5%. You've canceled out all the public health benefit of reducing ovarian

01:17:00.640 cancer. So that's why for now, the recommendation, and this is a recommendation that not even all of

01:17:07.400 our surgeons at Hopkins are aware of, is that when we're in there doing another elective abdominal

01:17:13.640 procedure in a woman who's finished having children, and generally on the younger side, not over 67,

01:17:19.900 I think, is the average age for ovarian cancer. So after that, your benefit diminishes.

01:17:25.600 So in that window of done having kids before they're in their mid-60s, and this is, we're just

01:17:30.920 using our best judgment here, that's the group where we're offering now that, hey, I can have you talk

01:17:36.960 with our OBGYN doctors. They can come in and reduce your 1 in 78 chance of her. In Canada, they've done

01:17:42.600 giant studies now, and they're showing actually lower rates of ovarian cancer long-term.

01:17:47.400 And so we're waiting for some of that data to come out.

01:17:49.900 But it's pretty wild, and the pathologist, Dr. Vallecuz at Johns Hopkins, has actually said,

01:17:57.280 Marty, we haven't made progress with chemotherapy on ovarian cancer, and maybe this is why. We may

01:18:03.040 have been targeting the wrong type of organ tissue. So it's pretty interesting. It's an opportunity.

01:18:09.580 It's also an opportunity for people to be aware of this best practice out there. Like the guy who

01:18:15.940 needs to see three randomized controlled trials to do the non-operative protocol for appendicitis.

01:18:21.080 It's going to take time. I mean, only some doctors in the United States outside of GYN are doing this.

01:18:29.320 The American Academy of OBGYN has actually put out a statement recommending women who come in after

01:18:35.560 they're done having kids. So there's actually a national guideline on it, but it takes a long time

01:18:40.480 for people to understand, become aware, learn the best practice. I hope it can address the ovarian

01:18:47.940 cancer incident. In my mind, it's in the bucket of challenging certainty. If you're 100% certain

01:18:54.040 that this cancer must come from the ovary, be open-minded to the fact that, hey, there's some

01:18:59.660 things here that we haven't understood in the past. For example, tubal ligation has resulted in a lower

01:19:06.440 risk of ovarian cancer. Hmm, interesting. Maybe it's blocking off some of the cells that could

01:19:12.160 have caused cancer and migrated down. Maybe it's killed off some of the lining. There's an understanding

01:19:16.840 that ovarian cancer is more likely to spread, more likely to be discovered after it's spread.

01:19:21.800 Well, there's a little gap between the fallopian tube and the ovary. So maybe it disseminates

01:19:26.900 in early stages because of that gap. So there's some interesting things that are now fitting

01:19:32.240 together. Again, I think this speaks to something that we can talk about it at an arm's length from

01:19:39.620 any situation and it all makes sense. But now you want to think about how difficult this is to put

01:19:44.420 into practice. You're a doctor and this is what you do. You have 99% certainty, which means you're a

01:19:51.760 good doctor because you don't have 100% certainty in anything. You have 99.9% certainty that this

01:19:58.060 cancer is coming from these ovaries and everything that you do in your practice is predicated around

01:20:03.940 that. But now you have to somehow work with a 0.1% probability that everything you believe about

01:20:10.880 this is wrong. That's a really low number. That's a one in a thousand delta. How do you not squash that

01:20:18.340 and allow that to remain open and flexible while you continue to do your best work here

01:20:25.620 and periodically come back to revisit this? Assuming you're not even the one who's doing

01:20:31.080 the primary work, but you're just trying to keep update on your practice and your practices and say,

01:20:35.900 well, maybe that's now a 1% chance. At some point, if that's a 10% chance, I really need to pay

01:20:40.760 attention. If there's a 10% chance I'm wrong, I really need to pay attention to this. I need to pause.

01:20:45.180 We're not trained to do that. How do we go about thinking about this? I already said what I would

01:20:51.520 do if I were czar of medical education. I don't know enough about medical education today. It's

01:20:56.280 been 25 years for me, but you're closer to it because you're still part of a university system.

01:21:01.920 Is medical education significantly different today when it comes to this? How does a medical

01:21:05.760 education today at Hopkins differ from what it was 25 years ago?

01:21:09.980 Well, one of the most important qualities of a physician is

01:21:15.180 humility, knowing your limits and having the awareness, the self-awareness that you could

01:21:20.400 be wrong as you said. And when you are wrong, when it's clear you might be wrong, feeling bad about

01:21:25.960 it and offering the patients, hey, you know, we got this wrong. I thought this is the best way to

01:21:31.120 approach it. One thing I love about Rebecca Stone and so many of the doctors I work with at Hopkins is

01:21:36.340 they don't say you need to have your fallopian tubes out. They say we have some data that is suggesting

01:21:41.200 that if we take the fallopian tube out, we can reduce your risk of ovarian cancer significantly.

01:21:47.180 The danger in medicine, one of the poisons today is the absolutism that's out there. And when we go

01:21:52.600 through medical school, you're just memorizing and regurgitating. And it's this terrible, robotic,

01:21:59.180 dogmatic training.

01:21:59.920 Is it still that way?

01:22:00.920 It's still that way. You might even say it's worse. I was talking this morning to Dr. Will Bruhn,

01:22:05.200 who just graduated, a buddy of mine I'm working with on the appropriateness work. And he just

01:22:10.260 graduated from Oklahoma University School of Medicine. We were talking about all the useless,

01:22:16.900 dumb, rote memorization stuff. He said it was like 50% of his medical education.

01:22:22.560 This bacteria is catalase positive, catalase negative. This is a branch chain bacteria.

01:22:29.020 This is a straight chain. It's mind-numbing. Memorizing the names of enzymes, he says,

01:22:35.120 was like 20% of his medical education. What are we doing to these kids? They come to us in medical

01:22:43.340 school, bright, creative, altruistic. They want to do good. Social justice is a generational value.

01:22:51.340 And we beat them with the rote memorization of these enzymes and stuff you can look up. We have

01:22:57.000 phones nowadays. You don't have to know the Krebs cycle on demand in the trauma bay. And we do this

01:23:02.960 to this incredible generation. We spit them out seven, eight years later. They're different people.

01:23:09.860 They're robotic. They're sometimes emotionally disconnected. They've learned a reflex as a survival

01:23:15.320 mechanism in order to do what we tell them to do, which is get through the exams.

01:23:19.980 And the thing that kills me, and a lot of students, they see the tension, they feel it,

01:23:25.540 they hate it. They're fighting it. We do have incredible students that are able to stay normal

01:23:30.660 through the process. But it's a struggle because the culture of medicine says obey. And it's one

01:23:36.700 private company that controls the medical education in every medical school in America,

01:23:41.400 the double AMC, a small group of people get to decide what every doctor learns in their medical

01:23:48.620 education. And these people are dinosaurs. They're forcing these kids to memorize the names of all

01:23:55.100 these.

01:23:55.400 And what's the relationship between the AAMC and the company that administers the USMLE and the

01:24:02.740 accreditation? Are they linked in some way?

01:24:04.840 Yes. Yeah. That is the private organization, double AMC.

01:24:08.800 Is the entity that also regulates the USMLE licensing exam?

01:24:12.400 Yes. Got it.

01:24:13.100 They collect a lot of money from these students. It's a private organization. One of the cool

01:24:18.240 things that we get to do is talk to a lot of people out there in America and get a bit of a

01:24:22.100 bird's eye view on things. And I was talking to conference of medical school deans. And later on,

01:24:27.900 I had met the dean of medical school in San Antonio, University of the Incarnate Word, UIW,

01:24:34.440 it's called. Great Medical School, San Antonio. And she's like, gosh, Marty, you're so right.

01:24:40.160 Why do we have to teach all this rote memorization and just beat them to regurgitate?

01:24:45.460 I would love, she's told me, to teach self-awareness and understanding uncertainty and

01:24:52.400 focus on applied statistics and the critical appraisal of research and the fact that there

01:24:58.260 are nerves that extend to every aspect of the hand without having to name 50 nerves in the hand

01:25:03.880 regurgitate on the exam. I would love to have a modern day education, but I can't because the

01:25:11.560 double AMC dictates what we teach and we have to teach to a test and our test score pass rates.

01:25:18.440 So it's this terrible system and it's connected to the American Board of Medical Specialties,

01:25:24.380 which issues board certification. And recently they've basically said, in order to keep your

01:25:29.820 board certification, you got to pay us $200 to $300 every two years or so and take a quiz that

01:25:35.820 we give you. And they're out there making a ton of money off this new thing. They're telling hospitals

01:25:42.460 you have to require current board certification and unless they've paid us, we're a private company,

01:25:47.620 they're not currently board certified. Imagine your college, UCSF or no, Berkeley. Where'd you

01:25:53.880 go to college again?

01:25:54.360 I went to college in Canada.

01:25:55.460 Okay. Imagine your college called you and said, hey, your degree, you don't have it anymore. You

01:26:00.120 got to pay us every year to keep your degree. That's exactly what the American Board of Medical

01:26:04.320 Specialties is doing. They're private organizations, a monopoly. My buddy Will was telling me at Oklahoma

01:26:09.600 University School of Medicine, I probably shouldn't say this, but what the heck, eight hours on

01:26:16.000 transgender sensitivity training, two hours on nutrition. The two hours on nutrition, he said,

01:26:22.880 we're so pathetic, it might've been better to have zero hours. HDL is good. You know, it's like the

01:26:28.980 most basic. And I see this awareness among a generation of doctors and students that they

01:26:35.360 know something is missing. This isn't right to just be memorizing. They're smart people.

01:26:40.360 And that's why you've got a huge number of people, doctors who are learning from you as you learn.

01:26:45.020 Talking about evolving your position. You're out there learning, reading, talking to people.

01:26:50.480 People are learning with you and they're hungry for this kind of honesty with where medicine's going.

01:26:56.560 Maybe we should be talking about more chronic diseases differently. Maybe we should be talking

01:27:02.060 more about treating diabetes with cooking classes than just throwing insulin at people.

01:27:06.080 Maybe we should talk about school lunch programs, not just putting kids on Ozempic. Maybe we should

01:27:10.360 talk about sleep medicine when we treat high blood pressure, not just throwing antihypertensives

01:27:14.940 at people. First line, second line, third line. Maybe we should talk about ice and physical therapy

01:27:20.160 instead of just surgery and opioids when somebody comes in with pain. Food is medicine, the microbiome,

01:27:26.500 general body inflammation. These are the topics that a generation of doctors are starving to talk

01:27:33.020 about. We need more research in them. They want to think differently.

01:27:36.380 But who would fund this research, Marty? I mean, I think when I talk about the pillars of medicine,

01:27:42.180 right, we have nutrition and exercise and sleep and emotional health and then molecules. So that's

01:27:49.100 roughly five things. Then you could really add a sixth pillar, which would be like a sort of waste

01:27:53.580 bucket of everything else that may or may not have benefit like sauna, cold plunge, red light therapy,

01:27:59.240 all that kind of stuff. Okay. Now, one of those buckets is really taught well in medical school.

01:28:05.180 We really do learn, and by medical school, I mean medical school and residency, right? You learn about

01:28:10.720 procedures and medications very well. That's what we learn, and I think we do learn that quite well.

01:28:15.720 But to your point, we learn nothing about exercise, sleep, nutrition, and emotional health and

01:28:21.360 well-being. Part of that, if you're trying to be as uncynical as possible, is at least when it comes

01:28:28.340 to molecules and procedures, the way to study it is straightforward. The interventions are easy.

01:28:34.280 You take this pill or you don't take. You take this pill or you take the placebo. And then on top of

01:28:38.280 that, there's a financial engine that supports the use of that, which justifies the cost of the studies.

01:28:45.940 But when it comes to doing research on many of these other things, outside of philanthropic

01:28:51.860 and government causes such as the NIH, it's very difficult to get any of that research funded.

01:28:57.740 So how would we create a new medicine around something for which it would be so difficult

01:29:02.880 to really gather the right evidence? Or would you argue, look, we already know enough today

01:29:08.060 that we could teach off the current practice?

01:29:10.500 The NIH could not be more broken. They've got these siloed funding centers, as you suggested.

01:29:18.100 Unless your research falls under kidney, cardiovascular disease, and it's what the

01:29:22.640 old belts and suspenders professors there want to fund, it's a legacy system where if the senior guys

01:29:29.960 who've done the research and made a name for themselves on an idea like it, they throw money your

01:29:34.800 way. I think the disruption is happening right now. Private industry, you're seeing private industry

01:29:40.340 fund research on different probiotics and bacteria you can introduce. We're seeing private industry

01:29:46.060 fund research. They funded our research on price gouging and predatory billing, another big blind

01:29:51.300 spot in medicine. A lot of our work is not funded by the NIH. And people come up and say, my gosh,

01:29:58.180 it makes sense what you're saying. Why don't we have a big study on natural immunity? And we could draw

01:30:03.020 the blood of these people. I mean, how many studies have you put out there where you've said,

01:30:06.220 this study needs to be done? It's not what falls in line with the NIH silos, but it needs to be done.

01:30:12.040 The classic example, a practice right now that is surging in the United States is taking a newborn

01:30:18.520 and cutting the frenulum under their tongue, either routinely or if it's a foreshortened tongue.

01:30:25.100 Some people believe in routine and other people believe in only in foreshortened and other people

01:30:29.920 believe never should be done. I don't know what the truth is. I have good ENT friends.

01:30:34.000 What is the rationale for doing this?

01:30:36.980 The rationale, the claim is that it'll improve breastfeeding and lactation rates,

01:30:42.260 that it may help. There's claims out there that it may help with sleep apnea,

01:30:46.900 with speech impediments. I think they're outrageous claims when it goes that far. These are

01:30:52.600 people who are also cutting the frenulum under the upper inside lip and sometimes the side of the

01:30:59.740 tongue and the frenulum under the tongue. Yeah. So there's been babies that don't breastfeed,

01:31:03.980 because they're in pain from this. And this practice is taking off like crazy. It's driven

01:31:10.020 a lot in dentistry. It's in that lactation world of lactation consultants could refer you to somebody.

01:31:17.020 And it's this dogma that has never had any scientific evidence to support the claim.

01:31:23.760 Is it being tested?

01:31:25.220 No. I'm not saying it's bad or wrong, but I'm saying this desperately needs a randomized control

01:31:30.920 trial. Desperately. Just like the peanut allergy study, just like the antibiotic study. Do it in

01:31:36.960 a cohort of a couple hundred, randomization, follow them, take a look, five years or whatever

01:31:41.960 that study design is needed. Who's going to fund that study? Big Pharma? No, fat chance.

01:31:49.780 The NIH? Not one of their clinical centers. The American Academy of Pediatrics? With their

01:31:55.900 $1,000 a year membership of all these $130 million in revenue they take in a year? No. No interest.

01:32:03.320 This is the Bermuda Triangle of healthcare in the United States and worldwide. We desperately need

01:32:09.260 to fund things where there are ideas, people are doing things, and they're doing them in a black

01:32:15.240 hole with no scientific evidence. We need to do the appropriate study. We could answer the controversy

01:32:20.640 in less than a year. I hate to mention COVID. We saw this during COVID. All of those COVID controversies

01:32:26.820 could have been answered in three weeks or a month or two. We could have done the clinical study

01:32:32.160 immediately, done the randomization, answered the question. Instead, everyone went on TV and opined

01:32:37.320 about it. It's easier. The NIH controls $80 billion. What are they funding? They were funding this cruel

01:32:47.520 dog experiment at the University of Iowa, trapping these dogs and having these sandflies bite their

01:32:55.860 heads in these cages, and concluding in the article that is published, leishmaniasis can spread from dog

01:33:03.720 to dog via sandfly bites. Who gives a shit? This is where our tax dollars are going, and then we're not

01:33:10.220 funding basic clinical research out there. Why do you think that is?

01:33:14.880 I don't think it's diabolical. I think people get set in their ways. I think it's Leon Festinger's

01:33:21.360 cognitive dissidence. I think people think, oh, this would be interesting. Find out whether or not

01:33:26.180 what's the average diameter of stones on Thames Street. That would be interesting. No, it's not

01:33:31.580 interesting. I'm seeing it a lot now with health equity. I think describing disparities in health equity,

01:33:37.640 in my personal opinion, is not interesting at all. We know there are massive disparities in health

01:33:44.020 equity saying, oh, there's also a health disparity and chronic myelogenous leukemia. That's not

01:33:50.440 interesting. That's known. What's interesting is what you're doing to reduce disparities in health

01:33:55.560 equity. And yet, half of the papers now, when I go to these conferences, are on differences and so-and-so

01:34:02.460 by race and socioeconomic status. Yeah, it's been known since the beginning of time, the number one

01:34:08.200 driver of health status overall in a population is the socioeconomic status of that community.

01:34:13.780 I think it's just, I don't know, intellectual laziness, the old guard. There are fresh ideas

01:34:20.920 in medicine. But when you show up in medicine, and you've done this, you show up in the academic world

01:34:27.140 as a resident, or you get a peek of it as a student, you have big ideas. Hey, this thing about the

01:34:33.280 microbiome and the rates of this, and it all fits, and maybe chronic diseases have gone up with

01:34:37.620 antibiotics. Whatever the big idea is, you're told, no, no, you need to pick one narrow area

01:34:43.140 and work on an incremental little scientific paper that'll go to the abstract of the Southern

01:34:48.640 Surgical Society or whatever it is. And that's how the NIH funds their research, little small ideas.

01:34:54.880 We need big ideas. They don't fund that. We need new ideas on cancer. What's the ROI on our cancer

01:35:01.800 funding? Paper at ASCO showed that Avastin increased glioblastoma survival rates by two months. Well,

01:35:11.120 patients want to know, what's the cure? Did you cure anyone else that you haven't cured before?

01:35:15.560 If that's the top paper at ASCO, our investment on research has a terrible ROI. And I think it's

01:35:20.460 because we're not funding big ideas. But we need Ben Franklin thinkers. Ben Franklin, intellectually

01:35:26.440 curious. Starts thinking about ophthalmology, invents bifocals, is interested in electricity,

01:35:33.360 invents the lightning rod, invents a stove called the Pennsylvania stove. He's a true scientist.

01:35:40.080 We don't have Ben Franklin thinkers today in medicine. I think Vinay Prasad is one. I think

01:35:45.040 you're one. You think we don't have them or you think we don't have a vehicle to fund them?

01:35:49.460 We don't have a vehicle to encourage them. I think, and I'm just saying this because I've said

01:35:55.260 this to other people. You're one of those Ben Franklin type thinkers. You think broadly about

01:36:00.200 healthcare. That's what we do on our research team is you're told in med school day one,

01:36:05.900 hey, here's the Netter textbook of anatomy. Pick an organ. You're going to have to focus on just one.

01:36:11.680 Which one do you like? Do you like kidney? Do you like brain, heart? You have to pick one.

01:36:16.100 You're like, well, what if I'm interested in the whole body or the system or the way we deliver care

01:36:22.520 or the way we fund research or approve drugs? Or what if I'm interested in all of it? What if I'm

01:36:28.340 interested in gun control and violence prevention and I'm interested in trauma and everything?

01:36:35.200 You're basically told, no, no, stop thinking like that. You got to pick an organ. I mean,

01:36:39.760 I went to the gym as a medical student and there were some docs that were also used at the gym and

01:36:44.900 they would ask me every day, what are you going into again? And I want to be like, I'm a second year

01:36:50.180 medical student. I don't know. Is that okay? I don't know. And I think you can get a specialization

01:36:56.600 and then come around and get off the hamster wheel. There's a lot of these docs now saying,

01:37:01.680 I don't care about my RVU bonus. I want to do something more meaningful. And they're starting

01:37:06.360 businesses. 50% of our medical students at Johns Hopkins are getting a second degree with their

01:37:12.240 medical degree. They don't want to live the life that they see. These guys who are like,

01:37:18.280 I got four NIH grants and presented, you know, I got 60 papers. I mean, I hit that point where I was

01:37:25.380 like, okay, I've published 300 scientific peer review articles. Nobody's reading them. I don't

01:37:32.360 think I've made beyond maybe a couple meaningful contributions. Like what are we doing? We've got

01:37:38.160 to focus on impact. So everything we do now in our research group focuses on impact. And that's how

01:37:44.140 we got into the science of medical errors, frailty as a condition, predatory billing and price gouging

01:37:52.140 in medicine. 62% of Americans say in a Harvard survey, they don't trust the medical profession

01:37:58.660 to bill them fairly and they avoid care or delay it for fear of the bill. So you can now have the

01:38:05.320 cure for pancreas cancer, but that cure is only, instead of being 100% effective, it's only 38%

01:38:10.760 effective because you've lost that connection. Rebuilding trust is the hottest topic right now

01:38:17.220 in medical journals, essays. So speaking of that, in 2020, the New England Journal of Medicine broke

01:38:23.880 with a 208 year tradition and it endorsed one of the candidates for presidency, which again,

01:38:31.300 this is the most esteemed journal in all of medicine that for 208 years was decidedly

01:38:36.940 apolitical. It chose to break that. Now, regardless of a person's political stripes,

01:38:43.400 why do you think that's a bad idea?

01:38:46.000 I think there is a political narrative and in politics, everyone sticks to the same talking

01:38:51.240 points. But in science, science is based on a civil discourse of different ideas among experts.

01:38:59.320 And so they're directly in conflict. The journal decided to endorse a presidential candidate

01:39:04.900 for the first time. Okay. Other journals have said, here are some issues. We're not going to be

01:39:11.120 both sides-ing. Okay. Well, what if you said that about peanut allergies back in the days? What if you

01:39:16.840 said that about people who are suggesting opioids are very addictive? They've seen it. The New England

01:39:22.740 Journal is the one, is the place that published that study that out of 30,000 cases of people taking

01:39:29.560 narcotics, there was only one patient who developed dependence, and that became the dogma. And dogma

01:39:34.800 takes on a life of its own. I think the journals are in a bubble. I think just like we need term

01:39:41.600 limits for politicians, just like presidents should turn over after eight years, journal editors should

01:39:48.180 not serve terms like monarchs in Europe or African presidents. They're there for life. And it's they're

01:39:54.940 loading these journal editorial boards with their buddies. It's cronyism. Everyone in the field

01:39:59.880 knows it. It's hard to criticize because we all need the journals to publish our research.

01:40:04.180 The New England Journal of Medicine, just a couple of years ago, out of 51 editors, had one African

01:40:10.440 American. Now, you can only find one African American to serve in the editor. What's going on is

01:40:16.700 it's their buddies from the Brigham and Women's Hospital and Beth Israel Deaconess and Mass.

01:40:22.640 Oh, it's my buddy from... I remember meeting the editor of the New England Journal when he came

01:40:27.000 to visit Hopkins. Jerry Cacera, I think was his name. I don't know why I'm mentioning these names.

01:40:33.820 These guys will probably all send me some hate mail, but what the heck. And I said, oh, I got a chance

01:40:39.280 to meet your predecessor at a conference. We actually had a nice time together talking about issues.

01:40:44.320 He goes, oh yeah, he was my roommate when we were cardiac fellows together. And so you have all these

01:40:50.820 internal medicine doctors who look alike, think alike, they're buddies from one institution,

01:40:58.540 from one part of the country, deciding what should go through the gates for the rest of the doctors

01:41:04.220 of the world to see. It's changing. Vinay Prasad and John Mandrola and Adam Sifu and I and some others

01:41:11.480 started a new newsfeed called Sensible Medicine, where we're publishing our thoughts in real time

01:41:17.860 when we see articles that look flawed, when there's a bandwagon effect, when we call things out.

01:41:24.260 Yeah, like 100,000 subscribers to this thing now. We're starting a new journal now, which is designed

01:41:29.760 to be objective, and it's called the Journal of the Academy of Public Health. Jay Bhattacharya and

01:41:36.260 Martin Kulldorff and I and a bunch of others.

01:41:38.580 But how do you know you won't fall into the same trap of the New England Journal of Medicine,

01:41:44.020 science, science, nature? I want to bring it back to this thing, which is the biggest journals in the

01:41:48.780 world became political in 2020. They made a very concerted, conscious decision to weigh in on

01:41:58.080 politics, to endorse presidential candidates. And again, I don't think it matters who they're

01:42:04.820 endorsing. I don't think it matters what party you're in. I'm amazed more people don't look at that

01:42:10.860 and say, oh no, that is awful. That is awful. We cannot have science and politics. We can't have

01:42:20.600 those things commingle. Again, it doesn't matter if they're endorsing your party, you should be just

01:42:25.600 as concerned as if they're endorsing the other party. That's right.

01:42:29.560 There's an objectivity that can't be commingled there. I think as much as I respect Martin and Jay

01:42:37.280 and you, I don't think I have a sense of what the answer is here and why just coming up with the

01:42:43.080 new rogue journal is the answer, because I still don't understand systemically what's going on.

01:42:49.540 Anyway, I don't mean to sound pessimistic. All the terms for kind of the non-conventional

01:42:53.920 thinking world, is the goal of that to be a little bit more provocative in the other direction,

01:43:00.480 even if it's deliberately provocative? But I just want to be careful that we don't

01:43:04.720 create disagreement for the sake of disagreement.

01:43:07.280 That's right. We are prone to the same bandwagon groupthink as the JAMA and New England Journal

01:43:12.660 editors. They're a bunch of like-minded friends. We are at risk of that. We have to be constantly

01:43:17.240 aware of it. And we've invited people who disagree. In Sensible Medicine, we love publishing

01:43:22.760 pro-con articles on the same issue, the same topic. And you'll see that. Fanai Prasad is wrong.

01:43:30.300 Adam Sifu is wrong on this topic. They're sparring in the spirit that we should have in academics.

01:43:35.940 Remember, when Obama first ran for president, he was asked, what is your favorite book? He said,

01:43:41.520 Team of Rivals, how Lincoln brought together all these different opinions. No, don't go to war. Do

01:43:46.640 that. And he wanted them on his cabinet. He wanted to moderate a civil discourse.

01:43:51.620 It wasn't just different opinions. Lincoln's cabinet was composed of the people who had attacked him

01:43:56.540 and run against him during the election. It was, these are the people who have just spent the past

01:44:03.120 six months telling the American public why Lincoln is an idiot and should never be president. And that's

01:44:10.620 the team that he assembled his cabinet from. We need to stay humble, avoid celebrity worship

01:44:18.440 in medicine. We do that a lot. It's the culture of how we create the greatest, highest attainable

01:44:26.840 achievement you can have as a physician is to be the chief of a department. And the way you do that is-

01:44:31.600 Is that really true though, Marty? Like there was never a day when I wanted to be the chief of anything.

01:44:36.280 I think you're unique. I mean, in the culture of academics, it dominates. Get your NIH grant. Oh,

01:44:42.760 you have a grant, but it's not NIH. Try harder. Maybe you'll get a K award.

01:44:46.640 But what percentage of physicians today are academic physicians versus community physicians?

01:44:51.820 Well, it's blurring. What's an academic center nowadays with the acquisitions and mergers?

01:44:56.720 If we just define academic as people who have some funding for research and, or are involved

01:45:04.920 in the education of students and residents beyond, I'm not talking about Sinai where you're a community

01:45:11.700 surgeon who once in a while has a resident scrub with you. I'm not talking about that. But if we define

01:45:15.480 academic a little bit rigorously, it can't be more than 10% of physicians would fall into that bucket,

01:45:20.400 right? Probably, probably. But they control a lot of the gains, right?

01:45:24.300 Well, so that's the question, right? Is what do they control and how much do the community

01:45:27.900 physicians look to them? And I think that just kind of comes back to everything we've been talking

01:45:31.380 about. But ultimately what matters is what are the community physicians doing? What are the work

01:45:35.580 horses doing? What are the people who are taking care of the majority of the patients? And let's be

01:45:40.880 clear. Even if that number is right, I'm making it up 90-10, but directionally I'm sure that's in the

01:45:45.680 ballpark. It's 90-10 in headcount. It's not 90-10 in patient touch. It's more than that because the

01:45:52.200 academic physician has many other responsibilities that don't involve patient care. So it might be 95-5.

01:45:58.220 In other words, the majority of people listening to us are going to get the bulk of their medical care

01:46:03.500 from people who are not academic physicians. And therefore, the most important thing in

01:46:11.200 delivering exceptional care to the majority of people is making sure that community-based physicians

01:46:17.180 are able to think independently or unable to think clearly. In that regard, I just don't know that the

01:46:23.540 answer lies in the hierarchy of the academic institution. I don't know that that is really

01:46:29.080 where the problem is. I don't know where the problem is, but I don't think it's where 5% to

01:46:34.080 10% of the attention lies. I don't disagree with you. I've got my perspective being in the towers

01:46:42.140 of the ivory tower at the top at Hopkins. It's all about this. Fabian Johnson just went to be chair at

01:46:49.080 Wake Forest. He just got this job. Great. We're having a big reception for him. It's a big deal. It's

01:46:53.980 kind of what we do. We create chairs to go out there. So I do have a skewed perspective. But

01:46:58.680 every doctor gets trained in an academic medical school in this culture. Every student tends to

01:47:04.980 come through this culture where we tell them it's a privilege to hold a retractor for six hours instead

01:47:09.740 of come and watch me talk to a patient's family afterwards and learn self-awareness and how to be

01:47:16.280 perceptive and empathetic. So I don't have a solution, but you see things where you say,

01:47:23.080 we are actually moving more in the direction of everybody get in line than we are in the freedom

01:47:29.820 of the rank and file doctor in America to speak how they would speak creatively. For example,

01:47:35.260 I'll talk to a doctor and say, what do you think about, let's say, hormone replacement therapy,

01:47:40.920 post-menopausal? Someone will say, well, you know, I've heard this, but I tend to question that. I know

01:47:44.620 some people are saying this. I'm not sure. That's a good doctor. A doctor who says, according to this

01:47:50.680 U.S. Preventive Service Task Force, you must do this. You're like reciting a catechism. That's not

01:47:56.140 the doctor that we want to create. And how do you teach humility? John Cameron and I did this thing

01:48:02.440 where when he operated next door to me, I would pause and I'd say, this is a really interesting

01:48:07.740 scenario. Can the scrub nurse run over and, or the tech run over and get Dr. Cameron to take a look

01:48:13.340 at this? And he'd come in and he'd say, ah, it's really interesting, Marty. In the past, I've done it

01:48:18.000 this way or that way. I know exactly what he's going to say, but I want to model humility to the

01:48:24.300 students and residents in the room. When he gets, as maybe one of the most famous surgeons in the

01:48:29.320 world, he gets a situation like that. He calls me and, hey, can the tech run over, grab Dr. McCary

01:48:35.520 to come in, take a look, get his thoughts on this. He didn't need my thoughts. He knows my thoughts

01:48:40.760 anyway. We've worked together for 25 years. I go in there and I say, oh, that's interesting. Yeah.

01:48:45.780 So you're going to do it this way. Yeah. That's what we're thinking. Thanks, Marty. He's trying

01:48:49.440 to model humility. And I think that's one way we can teach it, but it's an uphill battle. I mean,

01:48:55.300 the policing right now in modern medicine is at an all-time high. I gave grand rounds for our OBGYN

01:49:01.980 department at Hopkins and it went great and it was awesome. And they helped me shape some of these

01:49:07.560 ideas and the research that I've worked on and that we discussed. And when I filled out the CME form,

01:49:14.160 I've coined this ICD-9 diagnosis code called, send us your slides and advance harassment syndrome.

01:49:27.980 It starts off in the hallway with, hey, Peter, would you be interested in giving us a talk sometime?

01:49:34.440 Yeah, sure. And then the harassment and the email and we need your, fill out these forms and these

01:49:40.940 write four questions for our CME and send us your slides. We have to have your slides.

01:49:46.300 No, you don't have to have my slides. Okay. I'm going to work in current events from that morning

01:49:49.600 of my talk. Sometimes I've realized the kryptonite for the send us your slides and harassment syndrome.

01:49:55.600 What if you don't use slides?

01:49:56.760 I'm not going to use, I'm not going to use slides. Oh, well, uh, well then I guess we don't

01:50:03.000 need you to send them, but okay. And then you show up with a thumb drive. Hey,

01:50:06.860 I got some graphs I was going to throw up. Is that okay? Oh yeah, sure. The AV guys in the back.

01:50:11.960 But anyway, one of those forms I had to fill out for this C of B continuing medical education

01:50:18.040 requirement for any time you give grand rounds was, I hereby agree that everything I say will

01:50:24.600 comply with generally accepted norms and standards recognized by consensus within the medical profession.

01:50:31.420 And I'm looking at this and I'm like, no, what I put out there is I like to cite research that

01:50:37.920 challenges deeply held assumptions. And I'm going to be talking about that. And I'm not going to sign

01:50:43.160 to some catechism here that yes, I will obey and only say things that are in line with consensus.

01:50:48.260 If you look at our track record in modern medicine, when we use good scientific studies,

01:50:52.980 before we make massive health recommendations, peanut allergies, whatever you, when we have good

01:50:58.240 science, we shine as a profession. When we wing it, when an elite small group of medical establishment

01:51:05.340 folks decide what the world is going to do based on their own gut feeling or dogma, they have a lousy

01:51:13.380 track record. What are you most proud of the medical institution in this country? Let's just keep it

01:51:18.340 simple. What do you think medicine has done the best job of in the last decade? Well, I think you look at

01:51:24.880 cardiac surgical care. I think you look at line infections in hospitals. I mean, there have been

01:51:30.180 some really big wins here that don't get maybe as much attention as they deserve. Where else are we

01:51:35.400 hitting it out of the park? Obstetrical care. I think we've not only now have is the infant mortality

01:51:41.500 rate as good as modern medicine can deliver it, but we've now accepted these new best practices of

01:51:46.740 skin-to-skin time, delayed cord clamping, encouraging breastfeeding early on, reducing C-sections when not

01:51:52.700 necessary. Those are in the last 10 years, those best practices. But we're at a pretty good point

01:51:58.640 where the system is humming on a lot of acute care. And there's a video I saw on social media the other

01:52:05.380 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

01:52:10.240 world. If I break a bone, I'm going to go straight to a doctor. But when it comes to telling me what I

01:52:16.480 should be eating or how to live my life, I don't think I trust modern medicine. If you come in with

01:52:23.280 chronic abdominal pain, sometimes our sophisticated system doesn't know what to do. So I think the

01:52:29.700 acute care has been mastered. And I think about the operations I was a part of, these laparoscopic

01:52:36.580 whipples. And it's a tour de force of science and technology and advancements. And we do something

01:52:45.160 called a pancreas transplant with islet cells now for people with chronic pain. So I think

01:52:50.400 good stuff is happening. We have good people. People go into medicine, nursing, every aspect

01:52:57.200 of healthcare united by one common thing. And that is everybody wants to help other people

01:53:03.960 who are in need. And that's an incredible bond that we have. It's a profession we should all be proud

01:53:10.320 of. It's a heritage I'm proud of that my dad was a part of. And I get to do the things he encouraged me

01:53:19.520 to do, little tips, ways to connect with patients. I still think of the time he said, don't ask

01:53:27.160 somebody, are you taking your medication? Instead, say, some people find it hard to take their medications

01:53:34.320 as prescribed. How are you doing with it? It's far less head-to-head. And so it's an incredible

01:53:41.020 profession. And teaching these little pearls and gems, citing research, calling out the importance

01:53:47.720 of good scientific methodology, it's still, I think, the best job in the world. And medical centers are

01:53:54.640 still some of the most respected institutions in America, which is why we've called on them to have

01:54:00.060 ethical billing and pricing practices. But we can correct course. And I think, all in all,

01:54:06.700 it's an incredible privilege to be a part of the medical profession. I encourage anyone to get into

01:54:11.320 it. You would still encourage someone who's sitting here listening to us, who's in college, who's

01:54:16.740 on the fence about going into tech, going into business, going into law, going into medicine.

01:54:23.280 You'd still give them the nudge to do medicine if it's something they're partially considering?

01:54:26.820 Yes. Where else can you put a knife to someone's skin within seconds of meeting them just because

01:54:33.260 you're the doctor? People will tell you secrets they've never told their spouse within minutes

01:54:38.560 of meeting you because you're the doctor. And so there's an incredible heritage in the profession.

01:54:45.700 And so I think it's the best job in the world. Now, you got to be okay with memorizing enzyme names

01:54:51.000 over and over again. I mean, hundreds of names of useless molecules that you could look up on Google.

01:54:57.400 That's just part of the old system. But, you know, I think the bigger issue isn't so much that you have

01:55:02.680 to memorize those names. It's that you're sort of lacking the context and why. I mean, Marty, I still

01:55:07.780 memorize names of complex enzymes and pathways, but the difference is I'm doing it because it's feeding

01:55:13.820 my interest. It's like I'm reading papers and I'm learning new things and I have to draw diagrams.

01:55:19.660 I mean, I'm doing the same thing I was doing 25 years ago. I also don't want to let people suggest

01:55:25.180 that it's not important to have knowledge. Like it is important that I know these things,

01:55:29.360 even if they seem a little bit esoteric. But it's just easier to know it when you understand why,

01:55:35.180 when you have a scaffolding around why. While I can't tell you every step of the Krebs cycle,

01:55:41.020 I still remember in great detail how metabolism works because it really matters to what I do.

01:55:47.520 So I think if anything, I just hope that medical education can major in the major and minor in the

01:55:53.300 minor. Because while I think it matters that you understand these things, and again, maybe this is

01:55:58.900 already the case because I'm so far from it. But if you understand why the Krebs cycle matters and why

01:56:04.420 when the Krebs cycle isn't working, every disease in the body gets worse, why is it that a person with

01:56:11.940 cardiovascular disease, type 2 diabetes, Alzheimer's disease, why do they have defective

01:56:15.940 Krebs cycle? That's what I want medical students to be understanding and learning.

01:56:20.540 Yes.

01:56:20.760 So anyway, I don't know where I stand on it, truthfully. If I do get asked from time to time

01:56:25.840 by young people, hey, would you do it all over again? And of course, for me, the answer is

01:56:30.340 undoubtedly yes. But I also realize there are a lot of other exciting fields in the world today

01:56:34.580 that maybe weren't available to me. And I don't know.

01:56:37.720 How about surgical residency? Would you do that part again?

01:56:41.320 Yeah, it's interesting. Knowing what I know today and knowing where I ended up today,

01:56:44.520 would I have been better off doing an internal medicine residency? The answer is probably yes.

01:56:50.040 I think it would be more logical. But look, I wouldn't know you. I wouldn't know Ted Schaefer.

01:56:55.220 I wouldn't know a lot of the amazing people that I've gotten to know through my surgical training.

01:57:00.640 And I think in many ways, surgical training, especially the way we did it so long ago when you

01:57:06.200 didn't have regulations on work hours and stuff, it was so hard. It really gave me an appreciation

01:57:13.040 for how much easier my life is today and how lucky I have it to not be woken up every 14 minutes when

01:57:20.840 I sleep and things like that. So I'd probably be reluctant to change anything. I think it all

01:57:25.880 worked out okay. And I'm really grateful for the folks I met along the way. And I do hope that someone

01:57:31.700 listening to this who's contemplating medical school. As you said, I agree with you completely.

01:57:36.660 Anybody who chooses to be anywhere within the vicinity of this field, you want to be a nurse,

01:57:40.660 you want to be a radiology tech, you want to be a phlebotomist, you want to be a doctor.

01:57:44.060 The one thing that unites all of those people is they're doing it for the right reasons.

01:57:49.860 The sort of kid in high school when asked, what do you want to go into? And they say,

01:57:54.800 I don't know, I'm thinking about being a nurse. They're different from their peers.

01:57:58.900 It's a calling really to be in medicine. So we attract these great folks. I think our challenge

01:58:05.280 in the academic towers is how can we keep the focus both on the technically sophisticated

01:58:11.360 pieces of metabolism so they understand it, but at the same time, not lose sight of the overall person.

01:58:17.900 Yeah, I agree. You have to preserve the humanity of the field while harnessing critical thought

01:58:24.260 and doing it around this scaffolding of purpose.

01:58:28.020 Classic example of this. The Pima Indians in New Mexico along the Gila River,

01:58:32.220 they had been cut off with their water supply, farmers and ranchers and settlers. And so this

01:58:38.280 nation of Indians all of a sudden weren't able to grow crops and the healthy foods they'd been

01:58:44.720 eating for centuries. So the US government recognizing how they were being depleted of

01:58:50.700 food and the starvation that was happening. They started shipping food. This wasn't whole food

01:58:55.900 stuff. This was spam and potato chips or whatever else. And they started developing massively high

01:59:03.000 rates of obesity. Diabetes quickly ensued. And so you had this population that was massively obese

01:59:09.140 and with diabetes. And the NIH decides to swoop in and address this problem by looking for

01:59:15.820 a predisposing gene for obesity and diabetes. And they tested the blood of all these poor Indians.

01:59:21.920 And it's like, we can't see the forest from the trees sometimes, right? We've been feeding them shit

01:59:27.320 for decades. That is what's been driving the obesity and diabetes. It's not that they have a gene.

01:59:34.160 They've had spontaneous mutations of the FTO gene that have now produced rampant obesity.

01:59:38.920 Yeah. Well, Marty, thanks for making time to come by and talk. Always a pleasure. And congrats again

01:59:45.640 on your new book. I'm sure many people are going to get a kick out of it. We barely touched on,

01:59:51.740 I think, a third of the stories that are in it.

01:59:54.320 Oh, it's great to be with you, Peter. Great to see you.

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The Peter Attia Drive - September 16, 2024

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

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