The making of COVID-19 “contrarian” doctors

I thought I knew what I was going to write about until something happened that completely changed my plans for the day. My original topic is what I am going to write about today. I expanded the post to include more of a general discussion of something that I haven't written about in a while. A 13-year-old post needs to be updated in light of the COVID-19 Pandemic. The exchange is here.

Which prompted me to reply.

I might have to write an update to that old post in light of the pandemic…

— David Gorski, MD, PhD (@gorskon) October 22, 2022

It is indeed. It is a post that I am proud of. It is out of date because of what has happened since COVID-19 hit the world almost three years ago. I decided that I had to do it even if the update is not as good as the original. Jonathan Howard wrote an excellent post last Friday about another reason why doctors become contrarians, a state that has led too many of them to descend into worse than contrarianism. I will explain the reason at the end of my post. My colleagues keep expressing surprise that there are so many physicians who have turned into cranks with respect to COVID-19 and COVID-19 vaccines.

Physician social media influencers who’ve embraced COVID-19 contrarianism and antivax

I was supposed to write about why physicians become cranks and antivaxxers, but now I want to update that post. I noticed a few days before the exchange that Dr. Drew Pinsky had a pinned post on his account.

The antivax activist and leader turned general purpose COVID-19 antimasker was hosted by Dr. Drew. It only took a few days after seeing Dr. Drew throw away all pretense of not at least pandering to antivaxers, that I realized that I really needed to. I had originally planned on reviewing the movie, but decided that a review could wait, as I have downloaded a copy for when the free access to it in effect now expires, thanks to a reader. I was given an "in" to introduce my post.

RFK Jr. is an antivax activist despite his self-righteous claim that he is pro-vaccine. There is a conspiracy theory to cover up evidence that mercury in the vaccine caused theautism epidemic. There is no argument that RFK Jr. is not an antivaccine activist or that he has built an empire of fear. You should take your choice. Drew apologized for the Pandemic by the end of the year. His willingness to host an antivax conspiracy theorist like RFK Jr. on his show is one of the reasons he is worse than before. He was against vaccine passports as an attack on freedom by April 2021.

Guess who else was on his show a week before RFK Jr.

He also had Dr. Kelly Victory, an ER doctor who by the first was an antivax advocate. Alex was on the show in August. You might remember that at one time, Berenson was dubbed the "Pandemic's Wrongest Man", at least at the time, given that other people have come to contend for the title.

Take a look at the last few weeks of Dr. Drew's show.

Dr. Victory has been on the show multiple times since mid-September and seems to be a go to guest.

In the September 8 episode of Ask Dr. Drew, Dr. Drew asked if he was anti-Vaccine. I have not listened to more than a few minutes of this particular episode, but judging from the topics and guests on his show over the last few months, I am pretty sure that I will answer this question. His list goes back to August. His guests have been a lot of the same people.

It isn't my intention to pick on just Dr. Drew, he richly deserves to be picked on and his audience is many times that of SBM anyways. He was unlucky enough to be the physician social mediainfluencer who caught my attention the most recently. We have written about Dr. Damania many times. Z DoggMD went from being a skeptic who made funny videos mocking antivaxers that I used to refer to as antivax misinformation, to a laughing stock who made funny videos mocking antivaxers that I used to refer to as antivax misinformation. Dr. Marty Makary, a surgical oncologist who appeared on Tucker Carlson's show to attack the CDC Advisory Committee, is one of the physicians who have become the go to physicians for Fox News and other outlets.

I won't belabor it here, but I will ask why so many of my colleagues are still shocked that there are so many antivax and crank physicians out there. Yes, they were always there.

Reasons why physicians and scientists become “contrarians”

I believe that the conclusions of my 2009 post are still valid. I still think it's a good idea to start the discussion with a story that Richard Dawkins liked to tell. The first time I heard about it was when I watched his series on the British Broadcasting Corporation. It was about a scientist who supported a scientific hypothesis for a long time. One day a visiting professor from America came to give a talk at Oxford University, in which he presented evidence that disproved the professor's favorite theory. All eyes were on the senior scientist whose favorite hypothesis had just been messed with. The old professor strode to the podium, shook the speaker's hand, and said, "I have been wrong these fifteen years." The audience clapped uproariously. I don't know if the story is apocryphal or if it's grown with Dawkins' retelling. It's still the ideal for science.

The story is brought up for two reasons. It is true that the goal of science is for a scientist to be able to let go of a most cherished hypothesis if the evidence supports it. Most scientists wouldn't have reacted the same way that this respected senior scientist did, they would have argued with the visiting professor or tried to shoot down his hypothesis. The majority of doctors are not scientists. This isn't a criticism or insult. Clinical medicine requires a different skill set than medicine does. A good clinician doesn't need to be a research scientist in order to treat patients.

Several human qualities can lead a scientist or doctor astray. I will stick mainly with physicians and try to recreate my old post with what I see now. I admit that this is anecdotal and based on personal experience, but I think my ideas could be used in scientific studies. The three main characteristics stated more succinctly and slightly differently, that I listed back then as key to understanding cranks.

• A pre-existing belief in alternative medicine. This one is fairly self-explanatory, as alternative medicine goes together with antivax pseudoscience, quackery, and conspiracy theories like pizza and beer. Years before the pandemic, I wrote about how a culture of acceptance of alternative medicine in the form of “integrative medicine” could lead to a physician becoming antivaccine. While it’s not surprising that physicians who were antivax before the pandemic only doubled down on their antivax views applied to COVID-19 vaccines, it also shouldn’t be surprising that physicians who before the pandemic had promoted dubious ideas about, for example, diet as a panacea for virtually every health problem turned to antivax conspiracy theories. (Yes, I’m talking about Dr. Asseem Malhotra, but not just him.) In context, it’s not at all surprising that physicians who had just dabbled with antivax ideas or pandered to antivaxxers did a full heel turn after COVID-19 vaccines were released.
• Arrogance that the physician knows better than his medical profession and specialty, which I called the sine qua non of “contrarians” and “brave mavericsks.” Among medical cranks in particular, this arrogance manifests itself in the failure to acknowledge just how easily all humans, including them, can confuse correlation with causation, engage in selective memory such as confirmation bias, and are fooled by anecdotes, personal experience, and regression to the mean. I can understand how this can happen. Even among people steeped in the scientific method, it is sometimes hard not to fall prey to these shortcomings in human cognition. It is this tendency that will lead them to liken themselves to Galileo, persecuted scientists who will someday be vindicated. We frequently call this the “arrogance of ignorance,” in which a physician does not realize how much he doesn’t know. Before the pandemic, I would note that this arrogance could lead physicians to dismiss as “sheeple” the physicians who practice science- and evidence-based medicine as lacking the vision that they have, all the while making excuses for not doing rigorous clinical studies that would confirm or disprove the efficacy of their remedies over and above a placebo. Since the pandemic, the same trait appears operative, just applied to disproven cures for COVID-19 like ivermectin, disbelief that masks and non-pharmaceutical interventions do any good against COVID-19.
• Ideology. Although back in the day I used to routinely discuss how there was a stereotype that antivaxxers were hippy dippy granola crunching “liberals” and “progressives,” specifically how that stereotype was misleading because there has always been a strong right-wing contingent among antivaxxers, these days it is undeniable that the the most common ideological basis behind COVID-19 misinformation and antivax views has become overwhelmingly right wing, in fact far right wing, with antivax misinformation routinely amplified by the likes of Tucker Carlson and even conservative governors like Florida Gov. Ron DeSantis. Although physicians, as a whole profession, tend to lean slightly Democratic, certain specialties lean heavily conservative/Republican, such as anesthesiology, surgery, ENT, and ophthalmology. (Interestingly, infectious disease doctors were the most liberal of all specialties, with only 23% registered as Republican.) In any event, given how much the antivaccine movement has been captured by the right based on a shared affinity towards resisting “mandates” it should not be surprising that a number of physicians with a preexisting conservative/libertarian bent would be more likely break bad with respect to the pandemic. (John Ioannidis and Jay Bhattacharya appear to be excellent examples of this phenomenon, along with the physicians who affiliated themselves with the Brownstone Institute.)
• Ego gratification (particularly from patients) that comes with being a “brave maverick doctor” practicing medicine outside the mainstream. This derives from two things. First, it feels really, really good to successfully help a patient get better. Every physician who treats patients has felt this, and it’s a key reason why young become decide to study to become physicians in the first place. They want to help people. If a physician comes to believe that he’s discovered a treatment that helps patients whom mainstream medicine cannot, that feels even better. Notable examples from this blog include longtime cancer quack Stanislaw Burzynski, who really thinks he can cure incurable brain cancers and whose patients share that belief, and any number of “autism biomed” quacks who think that they can cure autism.) Also, never underestimate the ego gratification that can come from believing oneself to be superior to one’s colleagues, someone who has special insight that their colleagues don’t. Prepandemic, this ego gratification often led physicians to dismiss as “sheeple” their colleagues who practiced science- and evidence-based medicine as lacking the vision that they had, all the while making excuses for not doing rigorous clinical studies that would confirm or disprove the efficacy of their remedies over and above a placebo or their hypotheses that, for example, vaccines caused autism or that genetically modified organisms (GMOs). It is no coincidence that there exists a political conspiracy group disguised as a professional society, the Association of American Physicians and Surgeons (AAPS), that is basically dedicated to the idea that there exist “maverick doctors” who are not sheep and move ahead of the flock. These mavericks, not coincidentally include anyone who joins the AAPS, many of whose physicians view evidence-based guidelines as unacceptable constraints on what should be their godlike power to decide upon how to treat patients as they see fit. Also not coincidentally, the AAPS has become a major promoter of COVID-19 misinformation, although it has always been antivax.

It shouldn't be a surprise to anyone that there are a large number of antivax physicians who are behaving badly over COVID-19. The physicians were always with us. They were given the excuse to reveal themselves.

What about the audience?

“Audience capture” or just “capture”?

On Friday, Dr. Howard wrote about something. It was similar to my experience years before Dr. Howard discovered the antivaccine movement.

Over the ensuing decade, I observed something interesting about the anti-vaccine movement. When I first encountered it, anti-vaccine influencers could gain attention by claiming vaccines caused autism. That was once cool and edgy. After a few years, however, this bogus claim was merely the price of entry into Anti-Vaxx World. Since there was nothing to be gained by merely saying vaccines caused autism, in order to gain attention, anti-vaccine influencers like Dr. Brogan were forced to blame vaccines for all manners of maladies, such as the “epidemic” of SIDS (even though SIDS rates have decreased markedly). Other anti-vaccine doctors compared vaccines to rape, and RFK Jr. compared vaccinations to the Holocaust. Attacking pediatricians became commonplace.

He is also correct...mostly. Antivaxxers blame vaccines for everything from SIDS to rape and call for doctors to be put to death for their role in it. The increasing radicalization of the antivax movement, to the point where what was once considered fringe is now mainstream, is exactly what Dr. Howard gets right. Why? I believe Dr. Howard was correct when he wrote about audience capture.

I think this [audience capture] perfectly describes what I’ve observed before the pandemic with anti-vaxxers like Dr. Brogan and during the pandemic with contrarian doctors, several of whom I once admired as defenders of evidence-based medicine. However, they’ve since become trapped by their followers. After 2.5 years of minimizing COVID and discouraging pediatric vaccination, they’ve cornered themselves into positions they knew to be quackery prior to the pandemic. Echoing Dr. Brogan and anti-vaccine tropes about measles and HPV, they write pro-virus articles titled “The Triumph of Natural Immunity” and argue that it’s “natural and healthy” when children get sick with COVID.

I agree but have a different opinion. I define the "audience" that has captured once reasonable physicians more broadly than just their social media presence. This is how you think of it. When it was founded in 2006 it didn't take off for a long time. In 2009, social media was dominated by Facebook. The audience capture happened before I wrote my post. Think of it this way because this example doesn't include physicians. I once wrote about how parents with doubts about vaccines would become radicalized and turn into antivaxxers, subjecting their children to all sorts of quacky in order to cover up their doubts. Doctors are under a lot of social pressures.

I define the audience of physician influencer as including their patients, if they have any, even if they don't practice medicine. Although Dr. Marty Makary has nearly 190K followers on the social networking site, he doesn't have a show or a substack. His fame comes from his appearances on Fox News, where he casts doubt on public health interventions and vaccines. Dr. John Ioannidis, who brags about having no social media presence, but who is frequently quoted by the media about the Pandemic and now has a hagiographic YouTube "documentary" out to see that, is another example.

I pointed out the faux profundity in the movie, which, I suppose, I will have to watch at some point, as much as it is likely to nauseate me.

Antivax sentiment has been undergirded by classic Eugenicist thinking.

The professor predicts that if we survive as a species, the virus (sc2) will probably kill billions of us. Just the kind of belief in research and progress I expect from a scientist in medicine, lol. pic.twitter.com/0GmKwyhjec

— Hypoautonomic (@hypoautonomic) October 21, 2022

It's my favorite.

Some of the quotes from Ioannidis sound like they were written by Jack Handey.

Audience capture is a question. The Perils of Audience Capture is the same article that Dr. Howard did, and it starts with an example of aninfluencer named NicholasPerry, who discovered that uploading mukbang videos of himself consuming various dishes while talking to the camera was a form of audience capture.

These new videos quickly found a sizable audience, but as the audience grew, so did their demands. The comments sections of the videos soon became filled with people challenging Perry to eat as much as he physically could. Eager to please, he began to set himself torturous eating challenges, each bigger than the last. His audience applauded, but always demanded more. Soon, he was filming himself eating entire menus of fast food restaurants in one sitting.

In some respects, all his eating paid off; Nikocado Avocado, as Perry is now better known, has amassed over six million subscribers across six channels on YouTube. By satisfying the escalating demands of his audience, he got his wish of blowing up and being big online. But the cost was that he blew up and became big in ways he hadn’t anticipated.

As a result of being thin and health-conscious before, she became morbidly obese.

Where Perry was mild-mannered and health conscious, Nikocado is loud, abrasive, and spectacularly grotesque. Where Perry was a picky eater, Nikocado devoured everything he could, including finally Perry himself. The rampant appetite for attention caused the person to be subsumed by the persona.

It is usually the ideology that comes first when it comes to antivax and crank beliefs. It would be easy to attribute audience capture to grift and the desire to make more money, but it is actually more complicated than that.

Audience capture is an irresistible force in the world of influencing, because it’s not just a conscious process but also an unconscious one. While it may ostensibly appear to be a simple case of influencers making a business decision to create more of the content they believe audiences want, and then being incentivized by engagement numbers to remain in this niche forever, it’s actually deeper than that. It involves the gradual and unwitting replacement of a person’s identity with one custom-made for the audience.

To understand how, we must consider how people come to define themselves. A person’s identity is being constantly refined, so it needs constant feedback. That feedback typically comes from other people, not so much by what they say they see as by what we think they see. We develop our personalities by imagining ourselves through others’ eyes, using their borrowed gazes like mirrors to dress ourselves.

When humans were living in small communities where most people knew each other, it was not a bad thing. That is no longer the case. A social mediainfluencer is able to interact with people all over the world without ever meeting them in person.

Before the rise of social media, physicians who advocated for certain quackery or antivax ideas got more patients, but also more approval from those patients. When the Texas Medical Board tried to hold Dr. Stanislaw Burzynski accountable for his quackery, he used his patients as a weapon. Burzynski's story is an example of how difficult it is to stop medical misinformation.

Doctors go into medicine because they want to help people, and helping people through diseases and medical conditions can feel really, really good. There is a culture among physicians in which we tend to view ourselves as more important than anything else. When science shows that gifts, even small ones, can have a profound influence on behavior, physicians often proclaim that gifts from pharmaceutical representatives have no effect. Many of my coworkers consider themselves above such considerations. This type of arrogance can blind colleagues who develop large social media followings.

When influencers are analyzing audience feedback, they often find that their more outlandish behavior receives the most attention and approval, which leads them to recalibrate their personalities according to far more extreme social cues than those they’d receive in real life. In doing this they exaggerate the more idiosyncratic facets of their personalities, becoming crude caricatures of themselves.

The caricature quickly becomes the influencer’s distinct brand, and all subsequent attempts by the influencer to remain on-brand and fulfill audience expectations require them to act like the caricature. As the caricature becomes more familiar than the person, both to the audience and to the influencer, it comes to be regarded by both as the only honest expression of the influencer, so that any deviation from it soon looks and feels inauthentic. At that point the persona has eclipsed the person, and the audience has captured the influencer.

Or, as Dr. Howard said, the dynamic between social media doctors and their audience is different.

Their fans often lavish them with praise, telling them they are “fearless” for challenging the orthodoxy. And you can see how some doctors get cornered by their followers and are forced to adopt more extreme positions. The cardinal rule is to never stop being “heterodox”, no matter what. This is how doctors end up praising viruses.

Doctors who are science-based can be prone to such attractions, but in their case it becomes an internal battle over which aspect of their personality and/or brand is more important, their dedication to science- and evidence-based medical care or their desire, conscious or unconscious, to satisfy their I think that this sort of dynamic is a big part of how many people like Z DoggMD are on social media. It is true that everything old is new again, and that the new school contrarians are coming to resemble the old school antivaxers. I think that physicians who were already social media stars before the Pandemic hit were more prone to audience capture than those who weren't. Being a contrarian is nothing more than a waste of time and attention.

It was put in 2009.

The other point that is worth emphasizing is that being a contrarian is not in and of itself particularly impressive because scientists are so often wrong. There are far more hypotheses that are falsified than hypotheses that stand up to experimental and observational scrutiny. Indeed, I find “contrarian” scientists who won’t support their doubts of the established consensus with good science (and sometimes not even good logical arguments) of their own to be particularly annoying, like a two-year old who says “No!” to everything. Being “contrarian” is only productive if the contrarian scientist can produce actual evidence using sound experimental and observational methodology suggesting that the consensus is seriously wrong. That’s one reason why “intelligent design” creationists (or, as I’ve increasingly started calling them, evolution denialists) are not taken seriously and should not be taken seriously. They point out what they see as “shortcomings” in evolutionary theory, some valid but most based on gross misunderstandings of what evolutionary biology actually says, and do no research. Indeed, they don’t even try to do any research that might suggest alternatives. The same is true of cranks of all stripes, including “alt-med” cranks, HIV/AIDS denialists, and many other varieties.

It's not desirable to be a contrarian. One thing to be a contrarian who finds fault with existing science based on evidence is not the same as being a contrarian for the sake of being. It isn't hard for the latter to be the former. That is the reason why physicians like Dr. Ioannidis and Prasad were able to get into COVID-19 contrarianism. The quality of clinical trials used to justify interventions had been criticized before the Pandemic hit. Many big fat, juicy targets for their previous skills were provided by the appearance of a novel virus, where the science evolved quickly and was initially confusing or even misleading. It was the "in." The randomized clinical trial is the only valid method of clinical investigation due to arrogance and audience capture. These once respected doctors are no longer the same. They can be asked if they have changed or if they have always been this way. My answer is yes. I think they have become more like this than they have been. They have changed, but that change was not a change in character.

Avoiding audience capture and the temptation to become a “contrarian” for the sake of being a “contrarian”

I found an echo of my thoughts in this passage, when Bhogal asked if they had been captured by their audience.

I’m no authority on the degree to which my mind has been captured by you, my audience. But I do suspect that audience capture affects me far less than most influencers because I’ve taken specific steps to avoid it. I was aware of the pitfall long before I became an influencer. I wanted an audience, but I also knew that having the wrong audience would be worse than having no audience, because they’d constrain me with their expectations, forcing me to focus on one tiny niche of my worldview at the expense of everything else, until I became a parody of myself.

It was clear to me that the only way to resist becoming what other people wanted me to be was to have a strong sense of who I wanted to be. And who I wanted to be was someone immune to audience capture, someone who thinks his own thoughts, decides his own destiny, and above all, never stops growing.

And.

In this way I ensured that my brand image—the person that my audience expects me to be—was in alignment with my ideal image—the person I want to be. So even though audience capture likely does affect me in some way, it only makes me more like the person I want to be. I hacked the system.

My brand image is, admittedly, diffuse and weak.

I think so as well. I don't know if I have a real "brand image." It isn't something I've consciously cultivated, but I must have cultivated it over the last couple of decades. I felt like an audience captured something early in my career, before I joined. A British science fiction show known for its cantankerousness and impatience with humans led to many of my early posts being sarcastic and even nasty. My readers liked that and wanted more, but I mellowed over time. I can still be sarcastic, but I just have to compare what I write now to what I wrote in the past.

Too much praise makes me very leery and sometimes even uncomfortable; when I encounter it it is just as likely to make me question myself and what I've written as it is to reinforce my beliefs. People who have met me in person at skeptical conferences have noticed that too much attention and praise makes me uncomfortable. There have been comments on it. It might lead me to seriously question my views and writings if I received a lot of feedback telling me how "fearless" I am for speaking out.

That may be the key to avoiding audience capture. I don't think I have a financial motivation to get more traffic in a long time, and I don't care nearly as much about growing my audience as other people do. I am obsessed with questioning my beliefs and actions presented to the public. It has been enough for almost two decades, but I don't think it will be enough for two more, if I keep doing this for two more.

It's worse to have the wrong audience than it is to have no one to watch it. It has corrupted and radicalized physicians because they attracted the wrong audience during the Pandemic.