How “Blind Spots” are driving up medical costs – and worse

Yes, I just finished Marty Makary’s new book, the topic of which is clear from the subtitle, “When Medicine Gets It Wrong and What It Means for Our Health,” and the story he tells is grim.  It’s a slim book and probably available for checkout at your local library (though I had to wait for it to come off hold) and honestly I don’t understand why his nomination for a cabinet position in the Trump administration was treated as suspicious — Dr. Makary has been a consistent advocate for a better healthcare system, and is nothing remotely like JFK Jr.’s anti-vax nuttery.  The largest part of the book is a set of brief reports on ways in which the groupthink of medical professionals got things wrong, with deadly/costly consequences.

Here’s a short list:

Peanut allergies:  in 1998, based on a total misinterpretation of a 1996 study, the UK health department recommended “peanut abstinence” for high-risk young children to avoid peanut allergies.  In 2000, the American Academy of Pediatrics (AAP) went even further, and said that no child should be given peanuts before age 3.  This caused peanut allergies among children to climb dramatically – resulting in high costs due to EpiPens and serious medical harm to allergic children when they are exposed, as well as an upheaval as classrooms became “peanut-free.”  It took until 2015 for a researcher to look at the available evidence (including much smaller rates of allergies outside of the US and the UK, even in places such as Israel where a common baby food, Bamba, is made of peanuts), conduct a study (despite heavy criticism) and publish the results — the discovery that peanut exposure in infancy results in an 86% reduction in peanut allergies compared to following the AAP recommendation.  But it took 2 further years for the AAP to reverse its guidance.

HRT:  Hormone Replacement Therapy for women suffering from symptoms of menopause was pretty much the norm, until a 2002 study announcing that HRT increased a woman’s risk of breast cancer.  Now women are told to take hormones in menopause for the shortest dose and the least time needed to alleviate symptoms such as hot flashes.  The truth is actually that the “proof” of breast cancer risk didn’t pass statistical significance tests, and at the same time HRT has been proven, at rates that pass statistical significance tests, to reduce risks for heart disease, Alzheimer’s, and more.  But the influence of the first study, and the power of the lead researcher (who, it seems, simply disliked HRT and wanted to find reasons to end the practice), means these positive benefits can’t get traction.

Antibiotics:  It’s generally known that antibiotics cause short-term tummy troubles, but it turns out that there are long-term consequences to frequent doses of antibiotics, with associations with higher rates of obesity, learning disabilities, ADHD, asthma,  and celiac disease.  (It’s not 100% clear whether this is a matter of children whose doctors overprescribed antibiotics, say, for ear infections or viral illnesses, vs. the cause potentially being having illnesses which required more frequent antibiotics, but Makary is so concerned about appropriate statistical analysis that I would be pretty disappointed if he made this mistake.)  It’s also the case that Crohn’s disease and ulcerative colitis didn’t really exist before the 1940s, coinciding with the advent of antibiotics.

Cholesterol:  This chapter was the least surprising because it is now common knowledge, I think, that dietary cholesterol does not cause blood cholesterol, and that fat in one’s diet is not the cause of being fat.

Blood from HIV-infected donors:  Yikes!  The Red Cross did not begin screening donated blood until 1985, despite the existence of a test years earlier, based on an almost-magical belief that blood was safe.

Ovarian Cancer: The norm for the last 70 years has been that women past childbearing age who are having surgery for any other reason, have been encouraged to also have their ovaries removed, as protection against ovarian cancer.  Apparently, “hundreds of millions” of women have had the procedure.  But it turns out that even after menopause, the ovaries still produce hormones, just at a smaller level, and what’s more, ovarian cancer is not what it seems, but it’s really “fallopian tube cancer” which quickly spreads to the ovaries, so that fallopian tube removal, a much less invasive procedure which doesn’t impact women’s health or well-being afterwards.  Scientists are now conducting trials as to the impact of this procedure as a purely preventive measure.

Silicon breast implants:  Silicone breast implants became very popular, but then came to a screeching halt when, in 1990, news anchor Connie Chung reported on “breast implant illness.”  One thing led to another and in 1995, Dow Corning paid $3.2 billion to 440,000 women to settle claims, leading to the company’s bankruptcy.  But it turns out that there was never any evidence and in 1999, an Institute of Medicine report by independent scientists concluded that the claims that these breast implants caused diseases such as autoimmune disease, were false.

What’s the cause of these failures?  “Groupthink” is a pat answer, but a large part of it is in fact a “don’t rock the boat” mindset.  Getting along with colleagues, playing by the rules of orderly paper submission, maintaining the existing paradigm — the medical and scientific world simply doesn’t like dissent.

And Makary concludes with “what else are we getting wrong?” — as potential items to rethink include flouride in drinking water, the supposed harmlessness of marijuana, the use of tylenol for fevers (that is, bringing down low-grade fevers rather than enabling the body to use fever as an infection-fighting mechanism), certain types of early cancer detection, so-called “gender affirming care” for children, and more.

So what’s to be done?  I don’t know. But the book’s overdue at the library and I wanted to write down the key points.