I was in the middle of writing this article when Dr. Jonathan Howard published Letter to a Medical Student: You Erred. You Are Owed an Apology. It couldn’t have come at a better time as it motivated me to finish this piece. Like David Allely, a third-year medical student and author of the piece Dr. Howard critiques, I am a medical student. Today my intention is to have this serve as an introduction to my personal background as well as a commentary on the state of the medicine profession Allely and I are both entering. As fate would have it, we are entering this profession at a time marked by many crises, one of which I’ll speak about today. Public trust in science and medicine has declined. To complicate matters, this loss of trust is mediated by misinformation, complicated by our sometimes problematic relationships with industry, and, as I will attempt to show, reinforced when we extend beyond our field of expertise as medical students without doing our due diligence. To tackle it, we will need more than what I’ll call a “fundamentalist” evidence-based medicine (EBM), which I, along with others, contend is not sufficient to guide modern medicine. Note, this is not to say that evidence generated by EBM alone is not necessary, merely that it is insufficient.

It’s with this stage set that I want to first applaud Mr. Allely for writing and presenting his opinion piece. I’m sure it was difficult to stand in the face of perceived consensus, this blog, and what many affectionately call the “liberal Twitter mob”. For now, I urge the readers of SBM to continue giving Allely some grace; often, we as medical students are not given the room to dissent against either perceived or real consensus, nor are we taught, as some argue we should, to dissent effectively and productively to move EBM forward. After all, the goal of science should be, at least in an ideal world, to understand the natural and/or social worlds as best we can. I would also hope that most if not all the readers of this blog remember that dissent with sufficient evidence has resulted in scientific and medical breakthroughs. The underlined portion is key. From Semmelweis to David Sackett (one of the fathers of evidence-based medicine), the practice of medicine has been influenced by dissenters, contrarians, and those once called “denialists.” The issue is, this is the same stance many would be cranks take, and during crises such as a pandemic, political decisions are charged with scientific language. Nevertheless, the actual science is occurring in the background. While I consider myself a science advocate, “trusting the science” can be fraught with error in a crisis, as consensus usually cannot occur without significant debate. However, Allely’s post is not making claims about COVID-19 in 2020, it is making retrospective claims about what his risk was, how the decisions by the CDC were made, and, even more concerning, it is also full of exaggerations.

The grandiosity of his piece is exemplified early with him hailed as “courageous.” Frankly, I’ve had enough of this word as of late as I’ve seen it used in the denialist-to-denialist adjacent spaces to somehow give one clout. As one might expect, Dr. Vinay Prasad uses this framing for Allely’s piece, Failing our kids: Myocarditis in young boys:

Mr. Allely is a medical student, but a courageous one. I am glad he is joining our profession

My “Courageous Background”

When I read this, I was not surprised, Dr. Prasad has become entangled in much of what I might call the “denialist” blogosphere, using phrases I know at a visceral level. For now, I will not comment on whether I think Dr. Prasad is a denialist; honestly, early in the pandemic I vehemently disagreed with Dr. Gorski regarding labelling him as such. I’m now unsure about this previously held position. However, one opinion I hold to strongly, my background has given me some key insights here regarding his choice of language, which is why I’m not a fan. You see, I’m not just a medical student, I’m a formerly vaccine-hesitant individual raised by a well-meaning but conspiratorial anti-vaccination family. In the rest of this piece, I will be clear in my language. “Vaccine hesitant” is used when referring to individuals who lack trust in vaccines. “Anti-vaccination” is reserved for those actively creating and disseminating propaganda and/or sloppy science due to a prior belief that vaccines do not work.

In my case, the family I was born into, namely my father/grandfather, are your “old guard” of chiropractors. They believe wholeheartedly in vitalism and hence, subluxation theory. Additionally, they talk about their profession as one does a religion, positioning themselves against medical orthodoxy. This rhetoric of “courage” was central to what a sociologist (and my therapist) would call our family narrative. I recall my father once saying (paraphrasing here):

Son, I became a chiropractor because I’ve always seen myself as bucking the trend when the evidence suggests otherwise, even if they throw me in prison. Remember, chiropractors were once jailed for practicing medicine without a license.

Now, these events are historical, chiropractors were jailed and persecuted, sometimes even unjustly I would argue (as does Dr. Harriet Hall), by the American Medical Association. Note, this is not to denigrate the institution of medicine, only to point out that pockets of scientific medicine’s culture have had a particular disdain for anything labelled quackery, even as medicine itself was just beginning to collect the fruits of its relationship with science. After all, medicine didn’t consistently embrace use of the scientific method until the late 19th to early 20th century, with an even longer period of time until that method extended to the clinical domain full-scale via clinical epidemiology (i.e., evidenced-based medicine) in the 1970s.

As one might expect, I was not vaccinated, the vitamin K shot was avoided at birth (because natural), and medicine was shunned besides surgery and/or emergencies. Growing up, we would receive cervical chiropractic adjustments for high fevers (those bordering on 104 to 105 degrees Fahrenheit), with powerful anecdotes developing about fever breaking after manipulation. (I can’t verify these claims completely as I was only 4 at the time.) Once I became older, maybe 6 or 7, my young mind was convinced by the rhetoric of my family. To me, this established a clear “us versus them” way of relating to the world. The enemy, the physician and pharmaceutical world, was about to be ousted by my tribe; heroes standing up against giants. I recall vivid language regarding being “courageous” in the care of patients “stuck on the medical mill” as they used to put it. Such descriptions were intended to imply that patients failed by medical treatments like back surgery were “cured” by vitalistic chiropractic.

Soon though, confusion set in; while young, my mind was already spotting errors (I was as precocious as they come) in our constructed worldview. The first hole was to genuinely ask the question: why would scientific medicine be so widely embraced without resorting to illogical conspiracy theories? After all, I didn’t want to resort to said conspiracy theories at first, they seemed far-fetched. Could it be that medicine just wasn’t using its own science? What even is science?

What is still so odd to me looking back (ok not really that odd considering my views today) I devoured science books, albeit ones full of young-earth creationist pseudoscience. Honestly, I loved science (what little I got in a homeschooled education) more for its philosophy than anything else. It had a particular way of thinking. Claims were tested, evidence was gathered, and I could truly understand the world around me. Honestly, I wanted to believe that the science was on my side and my family’s. Such vivid emotional recollections now serve as a constant reminder that determining scientific consensus from outside the scientific community is mediated by one’s worldview. Because I was deeply tied to my family and fundamentalist religious beliefs, I only trusted the “science” that assumed these beliefs were true.

Today, I see this as a justification for our ethical duty as medical students regarding identifying misinformation correctly and responding in a way that does not damage public confidence. Patients trust us, even if such trust is low right now, and that shouldn’t be taken lightly. We must ensure we are arguing well and using our “courage,” however, if we are too flippant, we may damage public trust by spreading gross misrepresentations of data which appear scientific and well-formulated. Likewise, if we avoid speaking out about identified vaccine harms or otherwise appear to be suppressing information, that too can be damaging. The question becomes, when is there enough of a consensus regarding benefits or harms? Who sets this bar? When and where should we discuss these things as students? When and where should we discuss these things when we enter practice? Again, I don’t have an answer today as I claim no current expertise, rather this is a call to the attendings reading this piece. We need you to help us learn to think and reason with our “courage,” without making gross errors.

Anyways, back in my adolescent years, my workaround was to grant that modern medicine was only useful during emergencies, a move that later gained my family’s approval to become an EMT and paramedic in my late teens. Thus, they came to see the views we all formed as, “integrative and complementary,” and probably a bit progressive for their more outdated chiropractic philosophy. It’s something talked about often on this blog. So-called CAM is usually nothing more than a scapegoat for finagling in non-scientific, pre-scientific, or pseudoscientific therapies.

Even basic critical thinking reveals how ignorant my previous view on “modern medicine being only good for emergencies” was; after all, modern medicine has seen its best success with preventative measures such as vaccines, not solely emergency care. Looking back, had my childhood been “normal,” these contradictory views might have been deconstructed earlier; however, as fate would have it, the rising tide of Christian Nationalism swept me away. (I was homeschooled from 2nd grade on, placing me firmly in right-leaning echo chambers.) First came the conspiracies surrounding the Obama Birther movement, then the connection between vaccines and “death camps”. The logic is fuzzy, but basically the existence of FEMA death camps presupposes that the proverbial “they” will fake a disaster, advertise a vaccine, and then folks will die because of it. Sound familiar? This same trope came up again in the COVID pandemic. For someone precocious such as myself, I grew increasingly anxious because conspiracies, not just bright and shiny pseudoscience, became the core of our belief surrounding the role of medicine in society. From faith healing to corrosive end-times theology (we prepped for the end of days actively), my life became ruled by the whims of Joe Mercola, Del Bigtree, RFK Jr., and Jim Baker.

To recall a day in my adolescence, I was asked to remain “courageous” as we prayed for the healing of diseases, all the while consuming the “evidence” released from the above sources and generally feeling as if the world was against us. Like most of those trapped near the top of the anti-vaccination movement, I did not solely consume the information, I spread it and embellished it. At the time this was due to a combination of ignorance and fear. Walking into my father’s office, I recall re-stocking the “dangers of thimerosal” papers, sharing them like gospel tracts.

How does a person go from that to a first-year medical student who is passionate about science, philosophy of science/medicine, and science communication? Slowly, painfully, and with a lot of inner work. This is probably better explained through a religious deconversion lens which I believe I did well on this podcast; however, the medical misinformation piece was always close behind. While what I’m about to say is mere opinion, there is lots of overlaps between fundamentalist positions on religion and anti-vaccination propaganda.

Not to belabor my story—I invite anyone willing to talk about it to reach out—but the deconstruction of fundamentalist religion, my exposure to society as an EMT and then paramedic, and the work of SBM were critical in righting my path. However, such a radical change left me livid. Ironically, my anger is like that of the other subject of this piece, Mr. Allely. Like him I felt robbed, except it wasn’t the CDC, FDA, or the big bad liberal attendings in medicine who did this, it was my family. To put it mildly, I realized that I was actively harming society, and that I had been put at risk unnecessarily.

The Politics of Fear and Angry Angsty Medical Students

As one can clearly see, I’ve done my time in the actual anti-vaccination subculture of the U.S. Nevertheless, I’ve rarely written about this topic, mostly because I’ve been focused on learning medicine. Personally, I’ve struggled with seeing the worth in my voice as I see myself as a student of science, medicine, and society. But after these years of COVID-19, the bitter political polarization, and seeing medical students like Allely write in a way that I believe inappropriately addresses medical misinformation, I must speak out. Some 10 years ago, these words (taken from Allely’s article) would have sat well with me, encouraging my ongoing vaccine hesitancy (italics my own for emphasis):

I’ll admit I feel some anger when I think about Covid policy and vaccine requirements, etc. I am a healthy, 25-year-old male. I took Moderna, which by all accounts has a higher risk of myocarditis than even Pfizer. I trusted our public health and medical institutions blindly in the early pandemic, based on my perception of an impressive track record and rigorous peer review.

To anyone who has studied even the most basic philosophy of science this should strike one as asinine. Allely’s trust in institutions might well have been blind, but that in no way guarantees that his reactionary arguments are now cogent. Furthermore, he isn’t a common citizen anymore, he has a duty to identify the evidence which disconfirms his beliefs and see if it holds water. Even worse, I almost think he is implying that science and the evidence it generates should bring 100% or at least high certainty. Indeed, there are good reasons to think that science is reliable, but it is by no means a monolith of certainty; we will never be 100% certain. In medicine, this becomes even more important to decision-making as the evidence is often used on patients who don’t look like the ones we studied in the randomized-controlled trials. In a pandemic, this becomes even more dangerous as the target (i.e., disease) is moving. Variant emergence, for example, changed the risk of hospitalization/death when Omicron arrived, a key pillar in Allely’s article and something Dr. Howard immediately pointed out.

This error demonstrates something critical about the role of science in policy. Science is concerned not solely with understanding the natural world, but also, at least in the modern age, with making projections. Certain methods (i.e., classic clinical epidemiology/EBM) can give us a picture of what the world looks like right now or in the past, but the goal in a crisis is to make pragmatic decisions about projection (i.e., what things will look like in the future given a degree of uncertainty) that balance potential benefits and risks. Such projections require a democratic society to utilize its science and its politics to come to reasonable decisions. Thus, Allely is using what I’ll call a “retrospectoscope,” to critique decisions made based on projections using empirical data. To put it differently, there is a difference between models and evidence. Allely confuses these, probably out of overt ignorance rather than intent to deceive. His editors should have caught this conflation; they didn’t.

Being clear about my position, I’m all for dissecting our pandemic response and asking ourselves: “could we have done things better here?” That would encourage better policy and remove it from the ranting, railing, and whining about how terrible the CDC is or is not. However, I don’t think a substack article by an angry medical student is really helping anything. How could it? It’s not a well-written and vetted piece, which, if it were, we would see a takedown of the opposing argument. While admittedly formed through my own academic pursuits, I think the most important social value in science, one which needs fanned constantly, is the desire (I would argue duty) to attempt to prove oneself wrong.

Allely not only chooses his substack as his domain to avoid this duty, he also does not handle this conversation with care. Admittedly, his courageous dissent is not unethical in and of itself. Instead, I see him as feeding into our problems with medical misinformation rather than addressing them. Why go to these lengths when you can simply admit you don’t know, you disagree with say a widespread booster mandate, and you await more data?

As I will explain, I think there are two things going on here: (1) Allely is firmly set in the philosophical position of medical conservatism/medical nihilism which is bound to fundamentalist EBM to a degree (methodolatry as some call it); and (2) he is reacting to the politics of fear. In today’s world we want to have a response to the right-wing populism in the streets. They warn us that the migrants will bring crime, that we will be exterminated by our government, and that somehow, it’s reasonable to believe these things. Indeed, the phenomenon of public trust in institutions is largely split among party lines these days, largely because of the fearmongering we see in our politics. As cognitive scientist David Hicks writes:

Trust in scientific expertise is itself a partisan phenomenon. Survey studies by the sociologist Gordon Gauchat and the Pew Research Center show that over the past five decades, liberals have had steady or even increasing trust in science and scientists, while conservatives have gradually lost trust. But even this is an oversimplification, as conservatives have maintained trust in what the sociologists Aaron McCright and Riley Dunlap call “production science” (science as used by industry) and lost trust only in “impact science” (science as used by regulatory agencies for goals such as restricting pollution and protecting human health).

We could come at this problem like Prasad and Alley, communicating far less about the benefits of new pharmaceuticals (in this case a vaccine) and exaggerating harms, believing this will lead to more public trust (the latter premise has little to no empirical support that I’m aware of), or we can choose to be honest about the evidence both at the bedside and in policy discussions. To do so, we must learn to understand the politics of fear and meet it with humanism at the bedside and careful communication publicly. It honestly was inspiring to see chiropractic, the field my family has used to justify their anti-vaccination views, begin to combat COVID misinformation. Regarding the bedside, fact correction alone is probably not going to work with hesitant patients, as a cohesive narrative of fear has been spun in public. They’ve been told that science which disagrees with their political values is to be critiqued, while science in service of industry’s libertarian values escapes without critique. Oddly enough, the pandemic turned this on its head, as conservative values became twisted towards denialism of industry science as regulators moved to approve these products swiftly.

The Task We Face: Public Trust in Modern Medicine

The task Mr. Allely and I will face at the bedside and in the public domain as we enter medicine is to face this lack of trust head on. To do so, we must acknowledge that we are not trusted by a significant portion of the population along party lines, and we must find a way to bridge that gap. I believe that he and I are on the same page there. The difference, as far as I can tell anyways, is that my past life experiences and subsequently developed views on science, society, and the need for a more science-based medicine, have instilled a sense of cautious skepticism when communicating using strong claims. To be clear I remain open to being convinced that the risk-benefit of COVID-vaccination is not appropriate in certain age groups regarding boosters. Additionally, I do not believe that critiquing institutions is totally off-limits. We, that is those of us learning and working in medicine, need to hold our institutions to the fires of science when necessary. However, to do so effectively, we must make cogent arguments that do not misstate facts so we can appropriately identify uncertainty in the science to policy transition. After all, policymaking is not easy, it involves tradeoffs, and waiting for perfect evidence in a pandemic is not as simple as fundamentalist EBM suggests. Broadly speaking, I see Allely’s writing as pushing the following argument regarding public trust in medicine:

  • The politics of fear elevates tensions which may obscure facts, politicizing science and leading to intense disagreements
  • Such tensions lead to less trust in medicine, science, and other institutions
  • The solution is to remain skeptical of new pharmaceuticals, always paying attention to harms which are often dismissed and exaggerating these risks to protect public trust

I take issue with a firm prior belief anchored in #3. While we have uncovered industry bias, failures to share data, and the hidden harms of some therapies, such problems are not remedied by performing sloppy science ourselves. Instead, we need to ensure that folks understand the role of science and the role of policy. While we agree on the first two premises, I am not convinced that a prior “vaccine hesitant” belief is necessary. Instead, I think the solution lies in how we communicate about science. We must be clear about what we are sure about, what we are unsure about, and where values come into play. Put formally, my third premise is this:

  • The solution does not lie in misstating facts, rather we need to discuss uncertainty, remain honest about the risks, and make reasonable decisions in real-time. Above all, we need to show empathy to our patients, invite critique, and perform good science in a free society.

To truly be great communicators about policy, we must also be able to acknowledge uncertainty without ranting and railing against institutions with hyperbolic language. Again, this is not to say we cannot and should not critique our institutions. Indeed, one of the key duties of science, and in extension a science-based medicine, is to critique institutions to uncover errors. However, there is another way to act other than that shown by Mr. Allely. Instead of summoning our anger and being blinded by it, we can and should be moved to dissent with that anger while also remaining aware of the human tendency to err. That can and should be done rationally and poignantly. Take Dr. Paul Offit, who voted “no” to approval of the ancestral strain + BA.4/BA.5 (omicron sub-lineages) bivalent boosters while on the Vaccines and Related Biological Products Committee (VRBPAC) in August 2022. Why? Because he did not see evidence of safety nor of benefit in June 2022 when shown the Pfizer/Moderna data comparing monovalent to bivalent (ancestral strain + BA.1 (omicron)) and had yet to see human data at the VRBPAC meeting. I also want to point out to readers that Dr. Howard, who has been very critical of Vinay Prasad, failed to critique Dr. Offit as strongly. Why? Because when Dr. Offit dissents on vaccine policy, he usually does so with evidence, well-founded arguments, and without sowing distrust to the same degree. Instead of ranting about the CDC, he directly speaks about the decision at hand, referring to it as “overselling.”

On the Need to Understand Fast Science Versus Slow Science

One of the hardest parts of making pandemic policy has been the sheer speed at which new evidence must be assimilated. Obviously, COVID science had to be fast to inform policy. This wasn’t a case where science could lag. We needed evidence and we needed it quickly. Indeed, Trisha Greenhalgh predicted that the pandemic would show us the limits of EBM’s over-reliance on randomized trials which are much better suited to diseases with stable definitions and incidence. Instead, our basic and clinical sciences had to become fast, and admittedly it was sloppy, but that’s how fast science works. To look back and pick our pandemic response apart is a different matter. We are now performing slow science. We have the time to go back, pick apart our response, and argue over data. Allely does this, but then extends retrospective critiques—ones that I argue are not cogent—into the future with more statements containing exaggerations:

That record (the CDC) is being tarnished and trust betrayed by sloppy science and overly broad mandates. I faced a far higher risk of being hospitalized with the vaccines I was mandated to take than if I had simply been infected with Covid

To his credit, he sees the problem in front of us, the problem of public mistrust in medicine; however, his solution seems to be to misspeak or otherwise remain ignorant of the facts when arguing for his position. He did not face a higher risk of hospitalization; he is wrong on that fact as Dr. Howard showed. Even if we grant Allely the 1 in 10,000 risk of hospitalization for vaccine-related myocarditis which he cites, he underestimates the COVID-19 risk by a large margin, failing to account for its risk over time and what happened in the omicron wave. Furthermore, his argument plays into the politics of fear. It amplifies a view which is at its best poorly articulated and at its worst harmful to public discourse. The next question should be, is that par for the course in writing about science and policy in the public domain, or is Allely in the wrong?

While merely opinion, it’s my view that medical students need to be involved in these conversations, the key is how we go about them. It wasn’t wrong for him to write this piece, his critical error was in failing to understand that medical conservatism is a philosophical position which still requires much debate. We need to see the way these decisions are made, what data “counts,” and how that affects our patients. But we must not be only “courageous” as I did while vaccine hesitant. That is what Allely is doing here, and it led him to misstate obvious facts, which is arguably a breach of professional ethics. Honestly, if there’s anything I’ve learned from transitioning from baseline vaccine hesitant to scientifically informed it’s to find those who disagree with you. Assume you are probably wrong about a lot, and then go out and find the experts who disagree with you. Push against their arguments and see what comes up. Write to them, email them, or zoom call with them. Cite their arguments when attempting to take them down if you still disagree. It’s only with such clarity of thought that you can be the skeptic you pretend to want to be.

Indeed, zooming out for a second, I contend that medical students should learn to become efficient in their studies, which are often full of rote memorization. Why? Because it gives one time to write, to research, and to truly learn about the philosophical differences between a fundamentalist EBM position (i.e., the methodolatry spoken of here as early as 2009) and SBM. The modern medical student will eventually, if they are paying attention, see that EBM has its flaws and that a solution is needed. What that solution is, I don’t yet know, but I bet it looks something like SBM. As some philosophers of medicine have pined, the medical school EBM education is in serious need of contributions from the philosophy of science/medicine to tackle this critical challenge.

I invite anyone reading this piece to help us as medical students to grow in this mission to understand modern medicine’s debates regarding the state of EBM and where it needs to go from here. Encourage us to become critical thinkers while also teaching us to be empathetic while communicating about misinformation and general health literacy with our patients. The politics of fear and these large philosophical disagreements between fundamentalist EBM and SBM are not going away anytime soon. To make it out, leave the world better than we found it, and become great clinicians and academics we must brave the storm, dare I say with the “courage” to be skeptical, to have tough conversations, and to vet our work thoroughly before dissenting.

Author

  • Judah Kreinbrook is currently a first-year medical student at Duke University. His interest in science-based medicine arose after deconstructing the anti-vaccination beliefs of his parents. Prior to medical school, Judah worked as a paramedic, a formative clinical experience which revealed the difficulties of clinical practice. His current academic interests include the philosophy of science/medicine, empirical research on medical misinformation, quantifying diagnostic error appropriately, and always trying to prove himself wrong. Clinically he is interested in cardiology, critical care, and emergency medicine.

Posted by Judah Kreinbrook

Judah Kreinbrook is currently a first-year medical student at Duke University. His interest in science-based medicine arose after deconstructing the anti-vaccination beliefs of his parents. Prior to medical school, Judah worked as a paramedic, a formative clinical experience which revealed the difficulties of clinical practice. His current academic interests include the philosophy of science/medicine, empirical research on medical misinformation, quantifying diagnostic error appropriately, and always trying to prove himself wrong. Clinically he is interested in cardiology, critical care, and emergency medicine.