Dear Dr. Vinay Prasad,
I knew you before COVID. Like you, I am a practicing medical oncologist. I first discovered your name years ago when I stumbled upon your oncology podcast. Later on, I proudly converted to Medical Conservativism after embracing your mission statement: The Case for Being a Medical Conservative. I have read your book as well. We have never actually met, but I have been following you across various media formats for a long time. During my journey, I have been repeatedly in awe of your ability to critically appraise the oncology medical literature. The methods that I have learned from you continue to inform the way that I evaluate new data and teach my medical students.
While listening to you shred (a compliment) the latest oncology journal article on your podcast, I have often found myself wondering how you practice medicine in your cancer clinic. With perhaps one exception, I have yet to hear you whole-heartedly endorse a completed clinical study. Instead, you are quick to point out methodologic flaws and second-guess the latest FDA approvals. If I took every word literally, I would predict that you do not prescribe any of the cancer treatments that you have previously eviscerated on your podcast. But, I know that is not reality.
I recognize your brand of frenetic bluster – you are a contrarian. Contrarians are needed. In my oncology practice, I am inundated with pharmaceutical salespeople and email advertisements promoting the latest oncology medications (with new price tags upwards of $200,000 per year). You correctly point out when there is only a marginal benefit to be obtained at very high societal cost. I find value in questioning the status quo, even if it is only while listening to your weekly 30-minute podcast on my drive home. Listening to a contrarian viewpoint every now and then does not paralyze me. In fact, I believe it makes me a more well-rounded physician. My oncology patients continue to receive the latest treatments even when the underlying study is partially flawed. I am sure that you treat your patients similarly.
More recently, I have watched you apply your brand of flippant contrarianism to COVID. As a result of your new content and continued flare for delivery, your audience has grown well beyond the smaller world of medical oncology. You have surely noticed that your new audience is now more likely to be politically motivated than medically oriented. As a result, they may not be properly equipped to place your indignation within the broader scope of traditional medical opinion. For them, the script is likely flipped, with the contrarian viewpoint replacing the standard of care.
While you might see that as a positive, I worry that hearing primarily contrarian viewpoints can be paralyzing. How else does one explain the decreased COVID vaccine uptake in the Red States? I respect the ability of my patients to make informed decisions in my home state of Alabama. However, when that decision process is cross-pollinated by politics my confidence wanes. By not fully recognizing how your audience has changed, I fear that you may have unintentionally contributed in some small way to these worse outcomes. Thankfully, there is still time to recalibrate your messaging for the next slate of public health decisions.
As I write this, your influence is at a new high and the future looms large. Your friends are accepting important government positions. You are likely fielding some flattering and influential employment offers as well. Whether you change jobs or not, please recognize that you are now influencing the national public health policy. Your role in the public square has evolved in a significant way, whether you intended this or not. I hope you understand that being in authority is a very different job than simply questioning authority. You no longer have the luxury of being the bombastic underdog contrarian; your audience is too large and the stakes are too high.
I am watching with interest to see how you will respond in your new role. Unfortunately, the early returns are not great. An article you recently penned in The Free Press attempts to “draw distinctions” on a multitude of potential policies that Robert F. Kennedy, Jr may try to implement. You make the reader aware that some of RFK Jr’s controversial recommendations are currently implemented in other countries. On casual inspection of the article, I do not see any overt factual errors. You correctly point out that “all European countries recommend using MMR vaccines in children” and accurately state that “no country I am aware of warns against using it because it leads to autism”.
Later in the article, the ground gets a little shakier when you make the seemingly reasonable statement that “vaccines are like drugs. We need more evidence.” But, the benefit of vaccines extend beyond the simple evidence-based calculation of number-needed-to-treat that you proselytize. Even in situations where the individual benefit of vaccination is low, vaccines often have an additional benefit – they keep our neighbors healthy, too. If I decide not to take a cholesterol medicine, that decision only affects my risk of stroke and heart disease. But, when someone declines a vaccine, it raises the risk of an outbreak within the entire community. There is a public, and dare I say, patriotic component to vaccination that makes it very different from the cancer therapies that you and I administer in our clinics.
And of course, we always “need more evidence” to inform our medical practice. Like you, I am usually in favor of ethically collecting more data. However, we must continue to care for our patients while we wait (indefinitely). As I alluded to above, a lack of perfect evidence is not an excuse to be paralyzed and do nothing. The inherent public health benefit of vaccines further raises the stakes of inaction. I believe there is legitimate reason to hold each vaccine to a lower evidence standard than the expensive and highly toxic chemotherapy treatments that we prescribe. Of course, you know all of this already. In “The Case for Being a Medical Conservative”, you list vaccines as one of the penultimate examples of high-value care.
I suspect that you would counter that your article is not actually taking a stance on vaccination or any of the other controversial topics. You may continue to insist that “if other nations are doing it, we should be willing to look into it”. I take issue with that seemingly benign sentiment as well, but will let it pass for the time being.
Ultimately, it is not the existence of this article that surprises me. What bothers me is that you are the author. I have never heard you parrot government public policy with the implicit assumption that if someone else is doing it, it might be okay. Where is the in-depth critical analysis of the evidence that you are so well known for?
Reading an article like this opens the door for me to question your biases and perhaps even your motives. Because I used to see you as above politics, I believe this article is beneath you.
Despite my ongoing admiration for you in the oncology space, I am now nervous. Your vaccine communication and your latest article have given me pause. I always thought that your superpower was unbiased critical appraisal of the medical evidence. I hope that you can quickly rediscover your superpower and put it to responsible use. Perhaps it will again lead you back to your evidence-based roots as we confront a future of trying to fact-check Make America Healthy Again.
Sincerely,
Jonathan Storey, MD
P.S. Please beware falling victim to the human biases that you so astutely identify in others. Specifically, I hope that you are being vigilant to avoid motivated reasoning in the form of confirmation bias and audience capture.