debate – The Early Career Voice

In my previous blog, I shared five lessons about the way we practice medicine, which I believe were highlighted by the unprecedented circumstances of the COVID-19 pandemic. I would like to share five more COVID-19-inspired reflections, but this time it’s about the way we, as physicians, debate our medical opinions and the thought processes through which we form these opinions to begin with. While these thoughts came as a result of following scientific debates on social media, I believe they apply to all sorts of debates in other contexts as well:

Opinions are not principles. Principles are ethical codes we live by and cherish for our whole life. Opinions, on the other hand, are impressions and ideas that we make as we go, based on information that is available to us (with some emotional influences as well). That being said, while it might take a major life event for someone to change their principles; opinions can, and should, change quite often. There is nothing wrong about changing one’s opinion based on new information or on changing circumstances. In fact, this only reflects a healthy and dynamic thought process. Keeping that in mind makes it easy for us to admit when we’re wrong and to accept that others are allowed to change their position without being accused of hypocrisy.
Debate is not an aim. With the urge to prove our point and support our convictions, we often forget the real aim of any debate; reaching the truth through exploring alternative interpretations. Social media has opened unprecedented venues for endless debate, and the field of medicine has remarkably caught up to this. Unfortunately, we sometimes forget that proving our point often gets in the way of actually finding the truth.
Absence of evidence is not evidence of absence. As physicians, we adopt a scientific thought process. We always strive to find evidence to support any medical claim. Nonetheless, it is important to remember that just because something is not supported by evidence, it does not necessarily mean that it’s not true. It often only means that “we don’t know”. In the midst of scientific debates, we tend to forget this simple fact and start to proclaim that a certain medical intervention doesn’t work simply because it hasn’t yet been assessed by clinical trials. The more accurate way to address this is to say that we don’t know if it works or not, otherwise, we would be committing the same error we were criticizing in the first place.
Bias is vulnerability. Bias and prejudice are human flaws. And we are all human. We tend to be a lot less rigorous in our scrutiny of the methodology and the validity of the results of an article (scientific or otherwise) when the findings are consistent with our own bias. We tend to drop our most important defense mechanism against gullibility—our ability to think systematically and to critically appraise the evidence. This becomes particularly obvious on social media where we are quick to enthusiastically share (and sometimes praise) studies that support our viewpoints, without properly examining the content. Eliminating this bias requires a conscious effort when assessing data that align with our opinions to be even more careful.
We know very little, so be humble. Every day, nature shows us that no matter how much our medical knowledge increases over time, we still know relatively very little about the world we live in. COVID-19 is just another reminder. It’s true that some of us know more than others, but in the big scheme of things, none of us is in a position to brag or be condescending. So no matter whom or what we’re debating, let’s remember to be humble, be kind, and be respectful.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

Disagreement, dissent, challenges to commonly held positions? Cool. Ad-hominum attacks, sexist language and images, name-calling? Not cool.

Critique and dissent can be eloquently expressed, and often they are. I have read thoughtful letters to the editor and received constructive, if painful, reviews of my work (side note: learn how to write constructive reviews!). There are well-established professional norms in these contexts. On social media, however, discourse is less measured and formal. A benefit of this democratization of publication means that ideas challenging power structures and status quo can propagate more easily, cross-pollination among disciplines flows naturally, and historically underrepresented voices can gain a wide audience. But a downside to this lack of gate-keeping is sometimes the deterioration of debate.

Scientists and clinicians use Twitter for education and conversation (for great examples, see #FOAMed— free open-access medical education). Many of us use the platform to communicate ideas and research findings to a wide audience, both other scientists and the public. Social media offers a channel to interact with people whose work you admire, too. It’s a great way to share your hard work, comment on debates, ask questions, and yes, disagree.

But Twitter isn’t without its downsides, one of which is immediacy: the second you hit publish, your words are out there, associated with your name. It’s too easy for something you dashed off in a fit of pique to come to represent your professional self. It’s also easy to forget that there are people behind the hashtags and handles: if you wouldn’t say something to a human in front of you, it’s likely not wise to tweet it, either— but the sense of anonymity encouraged by social media platforms can embolden some people. In combination, these factors can create conditions where bullying and other bad behavior, rather than reasoned debate, take over.

Take a recent online kerfuffle involving cardiology trainee Danielle Belardo, MD, and Jeff Nelson, who owns the website VegSource.com. Dr. Belardo recommends olive oil to her patients as part of a plant-based diet, and she shares this information on her social media channels. She bases her advice on scientific evidence and the recommendations of professional bodies such as the American College of Cardiology. There is plenty of conflicting evidence on dietary approaches to reduce risk of heart disease, and many disagree on the conclusions, including Nelson. Dietary patterns stir up lots of dissent, and that’s good. But rather than engage in conversation about the differing viewpoints on the science, Nelson posted an inflammatory meme including blatantly sexist imagery, in an apparent attempt to ridicule discredit Dr. Belardo. This behavior is, unfortunately, not unusual. People, especially women, who voice controversial ideas online are frequently subject to this kind of bullying and often to sustained harassment also. Outside of social media, a physician who promotes an evidence-based but controversial idea will likely have fans and detractors, but on twitter, she has trolls and bullies. Suddenly, rather than an intellectual back-and-forth focused on difference of opinion and evaluation of evidence, we have the digital equivalent of name-calling, schoolyard insults, and stalking.

This behavior isn’t only bad for the targets, it’s also bad for science. Unfortunately, incivility online can have a chilling effect of innovation and conversation. Afraid of triggering flame wars, some may hesitate to ask excellent probing questions. Afraid of trolls, some may hesitate to speak controversial truths. And fearing aggressive bullying, some (especially women, who are the targets of much egregious behavior) may resist speaking altogether. Diversity of methods, opinions, identities, and backgrounds should always be welcome in science, and it’s hugely detrimental to progress when brilliant people are silenced.

How can we promote civility and dissent, which are good for science? I don’t know that there’s an easy answer, but I will leave you with these words from social scientist Amy Cuddy, who has weathered her share of online incivility: “The only way to elevate the civility and quality of scientific debate is to radically depart from personal attacks and public shamings. We have to replace fear and indignation with excitement and curiosity. If there’s a genuine interest in understanding any complicated scientific phenomenon, there is a way forward. It requires openness, listening, trust, and collaboration.” (source: https://amycuddyblog.com/2017/11/29/civility-in-science-is-not-a-luxury-its-a-necessity/)

How can you contribute to openness, listening, trust, and collaboration?

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