Blind spots

December 18, 2024

We all have blind spots in our fields of vision, that can be mapped. The optic nerves, that transmit information from the eyes to the brain, leave the back of the eye in one big nerve. In that space there are only nerve cells and no retinal cells that can receive light, and therefore no ability to receive visual information. Hence the blind spot in the visual field.

We are not usually aware of our blind spots until they are shown to us and even then, we can still persist in thinking we can see in that area of our visual field, when we cannot.

This is a known fact in Medicine. What is not so well known or accepted is that we as doctors also have blind spots, not just in our visual fields but in our perceptions of life, that are influenced by our beliefs and ideals.

We think we can see, we think we know, we are even sure that we know and that we are right, and can be quite absolute in our knowing that we know, when we do not.

We are not always willing to say “I don’t know” or “I was wrong” and this authoritative absoluteness can sometimes be hugely detrimental, to ourselves and to others.

And when we as a group insist that we know, that we are absolutely right, and that there is absolutely no room for another point of view, our collective blind spots can be immensely harmful to people and even whole populations.

Dr Marty Makary is a surgeon, Professor at Johns Hopkins University and has written a book on this subject called:

“Blind Spots: What Medicine Gets Wrong, and What It Means for Our Health.”

The following quotes are transcribed from an interview with him on American Thought Leaders. The whole interview is well worth listening to and or reading the transcript, as the detailed examples Marty provides really bring the point home.

In his words:

“When we as a medical profession use good scientific evidence to make health recommendations, we shine and we help a lot of people. But when we rule by opinion and issue these edicts based on the opinion of a small group of oligarchs in medicine, we have a terrible track record with health recommendations.”

Medicine is a very hierarchical system. As medical students and young doctors, we are not encouraged to question the prevailing dogma of the day, or even to ask for clear evidence that it is true. We are taught to learn by rote, and obediently toe the party line, and just accept that ‘this is the way it is’ and if we do not, by and large our careers do not progress very far.

It is only when we get out into the real world with real patients that we follow over time, that we realise all is not as we were told it was, or were sold it to be. And our increasing reliance on sponsored science means that we are finding out in the field what are the real side effects of drugs and other treatments, whose positive effects are promoted and negative effects minimised by the companies that make them and also sponsor the science that provides the ‘evidence’ for their use.

Marty details many examples of how we have collectively got it wrong, from the directive to not let young children eat peanuts that has led to a peanut allergy epidemic and the trial that showed this was wrong:

“Finally, the study got done, a randomized controlled trial. They took 640 kids, randomized them to peanut abstinence in the first few years of life, or early exposure to peanut butter in the first several months of life. And there was a markedly radical difference in peanut allergy development later in life. And the scientists believe it’s the same for milk and eggs and many other things that should be introduced a little bit early in infancy.

The study that was eventually published in the New England Journal was embarrassingly simple to do. They could have done it before they put out their recommendation with so much absolutism.”

I love the question that follows:

“And when you get it so perfectly wrong, where’s the humility to then issue a correction with the same vigor by which the initial recommendation was put out, really spreading misinformation?”

We as a profession have a tremendous responsibility to our patients and to humanity as a whole, to inform them how to best care for themselves, as well as treating them when needed.

We are trusted by our patients and by society as a whole to act with integrity and responsibility. We are not expected to be perfect (well, maybe we are!) but when we get it wrong, we need to let people know, so that they can take the steps they need to care for themselves in the light of that new information.

The peanut allergy story is just one of many that Marty details.

“The story of the American peanut allergy epidemic is really a broader story of the arrogance of a medical establishment saying things with such absolutism when the truth is that the right answer when people wanted to know what causes peanut allergies was, we don’t know. And you saw that during Covid and so many other different times in American modern history. The right answer from the medical establishment should have been, we don’t know.”

“We don’t know.” How different would Medicine be if we were willing and humble enough to utter these words. We are so terrified of making mistakes, of being seen to be stupid or wrong, that most of us are not able to simply tell people we don’t know, when we don’t. But how dangerous and diabolical is that? To put the health and lives of people at risk to save face and to save our own arses, when all we are really doing is making asses of ourselves and hurting people along the way. First, do no harm. There are worse things than admitting we were wrong.

We have been collectively wrong about many things over the years. In Marty’s words:

“Yes, and it’s not just the peanut allergy dogma that we got wrong for 15 years in modern medicine. We got the low-fat diet wrong for 60 years. We got opioids are non-addictive wrong for 30 years igniting the opioid epidemic. We got hormone replacement therapy wrong for, we’re still getting it wrong, for 22 years incorrectly telling women that it causes breast cancer resulting in needless suffering in the postmenopausal population… we’ve got to get back to the scientific process… You’ve got to be objective. You’ve got to have humility to recognize what you believe may be wrong.”

The trouble is that, when we are shown to be wrong, we tend to dig deeper into our beliefs, rather than having the humbleness to admit we were wrong and the willingness to review our beliefs in the light of new information. We all have biases, filters through which we see life, many of which are unconscious. We like to think that we are objective, but we are not. The more aware we are of the fact that we have biases, and that we are not perfect, the more truly scientific we can actually be. In Marty’s words:

“Well, every major scientific discovery has come from somebody challenging a deeply held assumption, challenging a dogma of the day.”

Doctors are not bad people. As far as is humanly possible, we do our best to help the people we serve. But we are trained in a system that demands superhuman perfection and does not leave space for being human and getting it wrong. And if we are found to be wrong, we are personally made an example of and crushed by the same system. The system does not care for nor serve those within it; the system serves and protects itself.

The medical system may be sick, but we don’t need to be sick in it.

We can have deeply caring professional relationships with our patients and with each other, and the more we build this true quality of relationship within the system, the more healthy the whole system will be.

We can only do what we can do. We can only be what we can be. We are not superhuman and we are not perfect and there is nothing wrong with admitting this. In fact, it is a humbling and healthy reality check! We are dedicated and caring professionals, and it is a great joy to do this job and a huge honour and privilege to serve our patients and society.

We care deeply for people and there is an art and a science to this. And it starts with being open, honest and transparent with ourselves, with each other and with our patients. Being willing to say that we don’t know, or admit when we have made a mistake and to say that we got it wrong. When we relate to people in this way, that gives them permission to also be open, honest and transparent and this builds trust between us, restoring the ancient power of the therapeutic relationship in medicine.