White Coat Underground

I had a nice dinner last night with a group of medical bloggers and journalists (I don’t recommend the scallops). One journalist, a veteran of many years, asked me, “is your goal to convince people, or are you preaching to the choir?”

It’s a simple question, one that I probably should ask myself daily but don’t. Rather than extracting an answer from my behind, I decided to think about it for a while.

The answer, I think, is both and neither. It’s hard to judge given that the percentage of readers who comment is low, but the question wasn’t “are your readers convinced”, but “do you intend to convince them?”

Blogs are an odd beast existing in an in-between world of “not journalism”, “not editorial”, and other “not” phrases. It’s whatever the blogger wants it to be, although it’s becoming clearer to me that if I’m going to stay serious about writing, I’d better understand what these other things are that I’m “not”. Not being a professional journalist, I can’t devote myself to a story in the same way as someone who gets payed to research and write stories. Instead I write about what I already know, or what my narrow expertise allows me to learn quickly. And because I write what I know, I often allow my own passions to come through in the writing, especially my reverence for patient care and my abhorrence of snake oil and other “alternative” flimflam. When I write with a passion about how little I respect CAM and its boosters, am I really going to convince anyone? Or am I just another random guy with a strong opinion?

I like to think the answer is both and neither. I do come at this with a unique perspective as a writer. Most medical journalism is not done by medical professionals (and most medical writing is not done by people who can write). Sometimes I take a strident tone which is probably going to rally the troops, but is less likely to win me any converts. But I also try to tell real stories of real people looking for answers. Sometimes medicine has these answers but fails to communicate them. Sometimes we don’t. And this is a group I hope to reach more an more.

People with difficult medical problems for whom there is no simple solution don’t stop looking for answers when they leave the doctor’s office. People come to me because they want help, and if I don’t give it to them, they’re going to vote with their feet. As a physician, I must try to help my patients understand their illness, and sometimes that means helping them change their expectations. Lots of doctors, either because they don’t want to “take away hope” or because they want to make a buck, will give patients the answers they want to hear, rather than the truth. It’s difficult, but possible, to tell patients the truth and help them continue to hope. That’s hard, and not particularly profitable–and it’s the essence of medicine. Anyone can prescribe an antibiotic for an infection; it’s really not that difficult. But telling patients the truth and helping them retain hope is hard work. Part of being a doctor is giving bad news, and those who would rather avoid it shouldn’t be doctors.

A recent commenter asked my why I would use the language of morality to talk about the antivaccination movement. After all, can’t we have disagreements without impugning each others’ moral character?

Given my responsibilities as a doctor, morality and ethics are central to what I do. They’re unavoidable. What my journalist colleague taught me (or reminded me) was that it’s helpful to have a goal in mind when you write. Sometimes my goals are clear to me, sometimes not, but one of these goals is to communicate to a wide audience that real medicine, practiced ethically, is hard, messy, and and in a very profound sense, real. Offering people hope based on your own ideas rather than the bulk of medical evidence may be easy, but it’s not medicine, and it’s not moral. If I don’t convince everyone about a particular scientific fact, fine, but I want you, dear reader, to understand the reason behind the passion, to help you understand that sometimes the best medicine is not the medicine you want, but the medicine you need.

Comments

#1 Ryan
November 9, 2009

In my view, your blog helped recruit me to the choir, and now by preaching to me, you are giving me eloquent ways to construct an argument to evangelize others.
#2 Colin
November 9, 2009

Yepp I’d agree with Ryan. Or rather: I was in the choir, but excellent blogs like yours encouraged me to start my own.

Now, however, I find myself asking the same question. I think that at the moment I’m trying to speak to people who don’t necesarily have the same scientific background as I do. The problem is that as soon as I start preaching to the choir my views go up tremendously…
#3 Denise
November 9, 2009

Please keep it up, PalMD. I, for one, use your blog constantly as a counterpoint to all the wooMercolaShit that my friends post to their facebook. I love your tone. I love your style. You are REAL (your mad-dad-crush on your baby girl) and you are SMART (you know, that whole you-actually-practice-medicine thing). I’m a fan, and I try every day to win you a few more.
#4 antipodean
November 9, 2009

It’s the same when you write editorials or papers.

What’s your message?

I tend to try to think of a pithy sentence at the beginning of the process and keep that in mind (and in sight) while writing. Everything is building toward that message and the message is repeated and reinforced throughout.

I personally don’t think your tone is too strident to communicate with the middle ground readers. But then I read whitecoatundergraound right after respectfulinsolence, so that might colour my judgement…
#5 Caroline
November 9, 2009

hey there,
I check out your blog pretty frequently– i like the tone of your writing; its a really approachable way to find get med news. This made me laugh: “Most medical journalism is not done by medical professionals (and most medical writing is not done by people who can write)”And its funny because its true.

One thing I really admire about certain preachy projects, is that the most effective ones do not preach. I worked for a while filming for those anti-smoking Truth Ads (I was a smoker at the time, wah wah waaaahh) and a few years later I come to find out that those things are proving really effective! the makers attribute this to 2 things: they present facts rather than stating behavior change, and they present the facts in a way that encourages discussion and thought, so that people will really mull them over. When people think about an issue they will come to their OWN conclusion, and THAT ownership of an idea is what will form the basis of their behaviors.

I’m still doing freelance stuff –filming and illustration, actually, right now I’m working on an up-start project called SpeakHealth.org. we are really going for that same goal, of presenting facts in a way that makes people think and discuss, rather than preaching. I guess I will let this comment serve as a shameless plug, but we could always use the traffic!

Keep up the good work- you are doing a great job!
~c
#6 Becky
November 9, 2009

Same here. Your expertise arms me with salient objections. Recently, a mother of two asked me if I was getting the H1N1 shot. I sensed that her reason for asking wasn’t to start an argument, but to help her figure out just what to do. I don’t work in the medical field. I’m an English teacher. I told her all that I know, much of it coming from the science blogs, including this site (and my own critical thinking abilities). I can’t say for sure that she’ll vaccinate her kids, but I’d be surprised if she didn’t.
I want to add that the type of “argument” being waged by the pseudo sciences and especially by the anti-vaccine group demand, I think, a “strident” tone. In this “debate” there really isn’t a “side.” That would suggest that the anti-vac people have anything of substance to back up their claims. They don’t. They have feelings and hunches. So, I think you’re right to assert this vociferously, or else those who are on the fence, or are simply confused by it all (the mom with two kids) could fall into that rabbit hole of doubt and fear.
#7 Andy
November 9, 2009

Oh my, Asking a English teacher opinions on vaccine.. Seriously. Unfortunately teachers are some of the least educated. When you dont know what to major in or you want to ride through college people choose elementary education. PLEASE people, ask somebody with a bit more relevant education about vaccines or look the information up yourselves….
#8 Donna B.
November 9, 2009

aw, Pal. Do you think I’d still be reading this blog every day if I thought you weren’t effective at presenting your viewpoints (some of which I disagree with?)

In a way, I consider myself a front line warrior against woo. I understand my daughter’s fear of thimerosol even though it isn’t rational, and I try my best to help her overcome that fear. It’s difficult dealing with a pregnant woman’s hormones and the fear of harming one’s child, born or unborn.

To a woman who would rather have a week-long headache rather than take something that *might* harm her baby… it’s hard to explain how beneficial the swine flu vaccine is.

(Fortunately, I’ve not had to convince her of the benefits of the regular schedule of vaccinations for her first child.)

Then there are my elderly relatives who suffer from the pains of arthritis (a family affliction) and who are willing to try almost anything legal. Legal includes, in some cases, useless surgery that sometimes, at best, leaves the pain not worse.

It has taken me over 3 years to convince my father that taking hydrocodone at bedtime so that he can sleep somewhat pain free is a good thing. During this time he was willing to try anything that offered a “cure” but unwilling to reduce his pain with narcotics.

He’s finally realized that good night’s sleep reduces his pain tremendously, even if he does have to use a narcotic to get it.

Then there is one of my aunts who is convinced that drinking a cup full of apple cider vinegar a day will cure her diabetes. I don’t think a cup of vinegar is going to hurt her unless she stops taking metformin and monitoring what she eats. However… I have to fight other relatives that tell her the metformin is interfering with the “goodness” of the vinegar.

And then there’s my step-mother and her family who freely admit they visit what they openly call “witch doctors” and buy every quack medicine there is available. And they have a plethora of MDs they visit also. The last time I did an “audit” of my step-mother’s medicine, she had three prescriptions for xanax from three different doctors.

(I will admit to thinking that either my step-mother must take the xanax, or I must…)

I do these medicine “audits” because my father was prescribed blood pressure medicine by several different doctors and ended up in the hospital with a BP of 80/40.

What I cannot stop my father from doing is going to doctor after doctor after doctor looking for cures. He’s 86 and threatened to fire his very capable primary care physician because he was told that aches, pains, and lack of physical capability was a part of aging.

So… yeah, you’re preaching to the choir sometimes. But you’re also giving the non-medical part of your choir enough knowledge to tell others “you really should check that out with your doctor” at the very least.
#9 Diane
November 9, 2009

I learn so much here. And you give me stuff to think about. You wrote earlier this year, or maybe last year, that every patient needs an advocate. I made sure I was there for my mom in her dreadful hospitalization and eventual death, knew that that was what I was doing, entirely because you wrote it. Your blog, and Orac’s, has shown me how complicated and messy medicine can be, and that easy answers aren’t always possible. Your two blogs have made me more comfortable with not having all the answers to medical problems, and how that is an honest assessment. How often does an alt-med provider send a possible patient away saying “You know, I really can’t find anything wrong with you”? Thanks for blogging.
#10 CanadianChick
November 10, 2009

preaching to the choir, but it’s a choir that wants to learn more.

at least in my case.

I LOVE your blog. I read it before any other ScienceBlog these days. I love the mix of humour, intelligent commentary and where needed, a little bit of ass-kicking.

I like being able to get the information here that helps me articulate my opinions on REAL medicine when someone starts to try to peddle woo to me (I have a lot of medical issues, it’s rare that I can go a week without someone trying to suggest some alt-med nonsense).

Keep doing exactly what you’re doing, and I’ll keep reading!
#11 Bridget
November 10, 2009

I’ve always been skeptical and mistrusting of doctors – probably because of a few bad experiences beyond their control. (I mean people do die and sometimes there’s not much that can be done.) This blog has shown me the other side and I appreciate that.

Also, the advocate post was excellent as I have several family members going through heart surgery and a daughter who just had a baby.

I also admire your attempts to improve your BMI. I don’t think that the medical establishment understands obesity, addiction and all that stuff, so it’s helpful to see medical personnel struggle with the same problem. It’s better than a skinny nurse or doctor saying, just quit eating, or just follow this food plan.

It must be hard to find time to blog with your busy schedule, but I think you are doing a good job.
#12 daedalus2u
November 10, 2009

Zuska had a recent post on religion and science where I left a comment. I won’t go into the details here, other than to point out my perspective which I think is related to why PalMD posts. It involves morals, knowledge, ethics and most of all the actions that one takes to remain being a responsible human being.

I think that religious-type thinking comes from the same human place that privilege-type thinking comes from (to learn about privilege, read Zuska’s blog). Many people who are religions consider themselves to have privilege, the supreme ultimate privilege of having an infinitely powerful, omnipotent and omniscient BFF. Those of us without an infinitely powerful, omnipotent and omniscient BFF don’t consider ourselves privileged (at least not in that way).

Believing that you know something to be “true” is like having privilege. You consider yourself to have a privileged view of reality such that you “know” what is true. Those of us who are scientists know that there is no way of knowing that gives anyone a privileged view of reality. That is why scientists try and keep each other honest by pointing out mistakes that creep into the thinking of human beings when they are not careful. It is human nature to begin to assign oneself privilege and think that you know better than someone else, just “because”.

It comes down to human nature. It was Nietzsche who said

He who fights with monsters should look to it that he himself does not become a monster. And when you gaze long into an abyss the abyss also gazes into you.

The surest way to corrupt a youth is to instruct him to hold in higher esteem those who think alike than those who think differently.

That is why preaching to the choir isn’t very helpful, unless that choir is ready to look for and to call you out on your mistakes. A choir that calls you on your mistakes and sloppy thinking is infinitely better than an echo chamber. Who is it who only “communicates” with an echo chamber? Not people who want real answers to real questions.

I think that is part of why PalMD blogs. He does fight with monsters; monsters who exploit vulnerable patients who are dying; monsters who exploit the fears that mothers have about how best to protect their children from infectious diseases. Monsters who lie to patients and to themselves to make money off the misery of others.

Just as all of us have privilege, all of us have a tendency to think of our ideas as privileged too. As scientists we have to put aside our thinking that we have privileged ways of thinking and instead focus on the data and on the logic that strings the data together. Facts and logic we can share and have tested verified and confirmed by others in ways that subjective experiences and privileged thinking can’t be.

Religion and privilege all derive from “top-down” social hierarchies. The leader at the top dictates how it is for everyone below. Science is not like that; it derives from the bottom-up, from facts strung together with logic.

When honest people don’t know the answer, they try and find out, they don’t just make shit up. You have to be very privileged to think that you can just make shit up and it will be correct.

I think that PalMD is blogging in part to try and get the answers to difficult questions, answers they don’t teach you about in school; answers that are too complicated to derive just from facts and logic. Questions I don’t even know how to ask.
#13 James Sweet
November 10, 2009

I was a convert via Orac, so I can’t give PalMD the credit… but I’d like to echo the same sentiment as some other commenters: You will (almost) never convince people who are hostile to your message, but people who are receptive but ignorant (and I mean ignorant in a neutral manner here, as will be seen in a moment) will be convinced in droves.

Before stumbling on Orac’s blog, via PZ’s blog, my position on vaccines could be summed up as, “The cost-benefit is almost certainly a positive, but who knows, maybe there is something to this autism thing, and that ought to be researched more thoroughly.” I was less sympathetic, but still not utterly without sympathy, for some forms of alt med. (I always thought homeopathy was beyond absurd, but that one ain’t hard to figure out )

I felt this way because, despite a natural skepticism, my sole source of information on these topics had been the mainstream media, who, as we all know, in their misguided attempts at “balance” wind up preventing a severely skewed picture of reality.

In short, I was “receptive but ignorant” in regards to the truth about anti-vax paranoia and some types of alt med. I am not an ignorant person in general, and I wasn’t willfully ignorant; it was just something that wasn’t a priority for me (especially before becoming a parent) and which was covered poorly by the mainstream media.

These are the folks you are converting. And goddamn, that is important.
#14 Stacey C.
November 11, 2009

I’m another of the ‘found you through Orac’ crowd. I like that you are willing to tell stories about the people you actually meet in your practice. I think it really helps to show that you’re not just a guy with strong opinions but someone who is actually dealing with these medical facts on the ground every day.
I must admit that you’re blog would probably be a better introduction to science based medicine than Orac’s for the type of person who’s been swimming in the sea of CAM and Homeopathy etc. I think your approach is very personable and easily allows the reader to feel like you’re sincere and really trying to give people the best answers you have, even if that answer is messy and ambivalent.