Dr. Jonathan Howard published a letter to a medical student in the middle of my article. You are receiving an apology. I was motivated to finish this piece by it. I am a medical student like David Allely. This will serve as an introduction to my background as well as a commentary on the state of medicine as Allely and I are both entering. We are entering this profession at a time when there are many crises and I will speak about one of them today. Science and medicine have lost public trust. This loss of trust is complicated by misinformation, complicated by our sometimes problematic relationships with industry, and reinforced when we extend beyond our field of expertise as medical students. We need more than just an evidence-based medicine, which is what I call a "fundamentalist" evidence-based medicine, to tackle it. This isn't saying that evidence generated by EBM alone isn't needed, but that it is insufficient.
The stage set is where Mr. Allely presented his opinion piece. I am sure it was hard to stand in the face of perceived consensus. 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. The goal of science should be to understand the natural and social worlds as best we can. Dissent with sufficient evidence has resulted in scientific and medical breakthrough. The part that is highlighted is important. Dissenters, contrarians, and those once called "denialists" have influenced the practice of medicine. This is the same stance many would be cranks would take, and during a crisis such as a Pandemic, political decisions are charged with scientific language. The science is happening behind the scenes. I consider myself a science advocate, but trust in the science can be fraught with error in a crisis. Allely's post is full of exaggerations, but it is not making claims about COVID-19 in 2020, it is making claims about how the decisions by the CDC were made.
Early on, he was hailed ascourageous. I have had enough of the use of this word in the denialist-to-denialist adjacent spaces. This framing is used 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
I was not surprised when I read this, Dr. Prasad has become entangled in a lot of what I would call the "denialist" blogosphere. I'm not going to say if I think Dr. Prasad is a denialist or not. I'm not sure about this position. My background has given me some insights into his choice of language, which is why I am not a fan. I'm not just a medical student, I'm a formerly vaccine-hesitant individual raised by a conspiratorial anti-vaccine family. My language will be clear in the rest of this piece. People who don't trust in vaccines are referred to asVaccine hesitant. Due to a prior belief that vaccines don't work, anti-vaccination is reserved for those who create and spread propaganda.
The family that I was born into, my father/grandfather, are the ones that have been around for a long time. They believe in vitalism and it's related theories. They position themselves against medical orthodoxy by talking about their profession. Our family narrative was based on the rhetoric of courage. My father once said that.
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.
I would argue that the events are historical and that the American Medical Association is to blame for the persecution of the Chiropractor. This is not to criticize the institution of medicine, but to point out that pockets of scientific medicine's culture have a particular disdain for quackery, even as medicine itself was just beginning to collect the fruits of its relationship with science. It took until the late 19th to early 20th century for the scientific method to be widely used in medicine.
I didn't get a vaccine, thevitamin K shot was avoided at birth, and medicine wasn't used besides surgery and emergencies. When we were growing up, we would receive adjustments for high temperatures, which ranged from 104 to 105 degrees F. At the time, I was only 4 years old. My mind used to be convinced by the rhetoric of my family when I was younger. The way in which we relate to the world was established by this. The doctor and pharmaceutical world was going to be overthrown by my tribe. As they used to say, being "courageous" in the care of patients was something they used to call "stuck on the medical mill". The purpose of the descriptions was to imply that patients failed by medical treatments were cured by vitalistic chiropractors.
As I got older, my mind was already seeing errors in our constructed world. Why would scientific medicine be so popular without resorting to conspiracy theories? I didn't want to use the conspiracy theories at first. Is it possible that medicine didn't use its own science? Science, what is it?
I devoured science books even though they were full of young-earth creationist pseudoscience. I liked science more for its philosophy than anything else. It had a specific way of thinking. Evidence was gathered, claims were tested, and I was able to comprehend the world around me. I wanted to believe that the science was in my favor. It is a constant reminder that determining scientific consensus from outside the scientific community is dependent on one's view of the world. I trusted the "science" that assumed my family's and fundamentalist religious beliefs were true because I was so tied to them.
Medical students have an ethical duty to identify misinformation and respond in a way that doesn't damage public confidence. Even if patients don't trust us right now, they still trust us. If we are too casual, we may damage public trust by spreading gross misrepresentations of data which look scientific. It can be damaging if we don't speak out about vaccine harms or other things. There is a question of when enough of a consensus exists regarding benefits or harms. This bar is set by someone. Where should we talk about these things as students? Where should we talk about these things when we start practicing? This is a call to the attendings to read the piece and I don't have an answer yet. We need your assistance in learning to think and reason without making mistakes.
My family approved me to become an EMT and paramedic in my late teens after I granted modern medicine was only useful during emergencies. They came to see that the views we all formed wereintegrative and complimentary. It's something that's talked about a lot on this site. Non-scientific, pre-scientific, or pseudoscientific therapies are often the reason why so-called CAM is a scapegoat.
Critical thinking shows how ignorant I was when I said that modern medicine was only good for emergencies. As fate would have it, the rising tide of Christian Nationalism swept me away, even though I had a normal childhood. I was placed firmly in right-leaning echo chambers as a child. The connection between vaccines and death camps was the first conspiracy. The existence of FEMA death camps assumes that they will fake a disaster, advertise a vaccine, and then people will die because of it. It sounds familiar? In the COVID Pandemic, the same thing happened again. Conspiracy, not just bright and shiny pseudoscience, became the core of our belief around the role of medicine in society. My life was ruled by the decisions of Joe Mercola, Del BigTREE, RFK Jr., and Jim Baker.
In my adolescence, I was asked to remain brave as we prayed for the healing of diseases, all the while consuming the "evidence" released from the above sources and feeling as if the world was against me. I spread the information and embellished it, like most of those trapped near the top of the anti-vaccine movement. This was caused by a combination of ignorant and fearful people. I remember walking into my father's office and seeing re-stockings of the "dangers of thorium" papers.
How do you get to a first-year medical student who is passionate about science, philosophy of science and medicine? It was slowly, painfully, and with a lot of inner work. The medical misinformation piece was always close behind the religious deconversion lens that I believe I did well on this show. There is a lot of overlaps between the positions of fundamentalists on religion and anti-vaccine propaganda.
My story is not to belabored, 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. I was livid by the change. My anger is similar to Mr. Allely's. It wasn't the big bad liberals in medicine who did this, it was my family. I realized that I was endangering society and putting myself at risk unnecessarily.
I have done my time in the anti-vaccine community in the U.S., but I have never written about it. I struggle to see the worth in my voice as I see myself as a student of science and medicine. I have to speak out after seeing medical students like Allely write in a way that addresses medical misinformation. Ten years ago, these words from Allely would have encouraged my vaccine hesitancy.
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.
This should be seen as asinine by anyone who has studied the most basic philosophy of science. Allely's trust in institutions may have been blind, but that doesn't mean his arguments are now cogent. He has a duty to look at the evidence to see if it supports his beliefs. I almost think he's implying that science and evidence should bring high certainty. There are reasons to believe that science is reliable, but it is not a monolith of certainty. In medicine, this becomes even more important as the evidence is often used on patients who don't look like the ones we studied in the randomized controlled trials As the disease moves, this becomes more dangerous. When Omicron arrived, variant emergence changed the risk of hospitalization/death.
This error shows the importance of science in policy. In the modern age, science is concerned with making projections and understanding the natural world. The goal in a crisis is to make pragmatic decisions about projection, but certain methods can give a picture of what the world looks like right now or in the past. It is necessary for a democratic society to use its science and politics to make good decisions. Allely uses a "retrospectoscope" to critique decisions made based on projections. The models and evidence are different. Allely confuses them, probably because she is ignorant. His editors didn't catch the conflation.
Being clear about my position, I would like to ask ourselves if we could have done things better. It would encourage better policy if it was removed from the rant, railing, and whine about the CDC. I don't think a substack article by an angry medical student is helpful. What could it possibly be? If it were a well-written piece, we would see a rebuttal of the opposing argument. I think the most important social value in science is the desire to try to prove yourself wrong.
Allely doesn't handle this conversation with care because he chose his substack as his domain. His dissent isn't unethical in and of itself. He feeds into our problems with medical misinformation instead of addressing them. You don't know, you disagree with a widespread booster mandate, and you wait for more data.
I think there are two things going on here, one of which is that Allely is firmly set in the philosophy of medical conservatism, and the other of which is that he is reacting to the fundamentalists. We want to respond to the right-wing populism in the street. It is reasonable to believe that the migrants will bring crime, that we will be wiped out by the government, and that these things are true. The phenomenon of public trust in institutions is split between party lines due to fearmongering in our politics. David HIcks is a cognitive scientist.
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 communicate less about the benefits of new pharmaceuticals and more about exaggerating harms, believing this will lead to more public trust, or we can. We need to understand the politics of fear, meet it with humanism at the bedside, and communicate carefully. It was inspiring to see that the field my family used to justify their anti-vaccine views was beginning to fight false information. Fact correction alone isn't going to work with hesitant patients as a cohesive narrative of fear has been spun in public. Science which disagrees with their political values is critiqued, while science in service of industry's libertarian values escapes critique. As regulators approved these products quickly, conservative values became twisted towards denying industry science.
As we enter medicine, Mr. Allely and I will have to face this lack of trust head on. We need to find a way to bridge the gap because we are not trusted by a lot of people. I think we're on the same page. 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 strong claims. I'm open to the idea that the risk-benefit of the vaccine isn't appropriate in some age groups. I don't think that critique is off-limits. We need to hold our institutions to the fire of science when necessary. To identify uncertainty in the science to policy transition we need cogent arguments that do not misstate facts. Policymaking is not easy, it involves tradeoffs, and waiting for perfect evidence in a pandemic is not as easy as fundamentalists think. The following argument is pushed by Allely's writing.
I don't agree with a firm prior belief. The problems of industry bias, failures to share data, and the hidden harms of some therapies are not fixed by sloppy science alone. We need to make people aware of the roles of science and policy. I don't think a prior vaccine hesitant belief is necessary. How we communicate about science is the solution. We need to be clear about what we know and what we don't know. My third premise is formal.
We need to be able to acknowledge uncertainty without being hyperbolic about it. This isn't saying we can't critique our institutions. One of the main tasks of science is to critique institutions to uncover errors. It is possible to act other than what Mr. Allely shows. We can and should be moved to dissent with our anger instead of being blinded by it. It can and should be done in a rational way. Dr. Paul Offit was a member of the Vaccines and Related Biological Products Committee. What's the reason? He didn't see any evidence of safety or benefit when he saw Pfizer/Moderna data comparing monovalent to bivalent, but he did see human data at the meeting. Dr. Howard didn't critique Dr. Offit as strongly as he should have. What's the reason? When Dr. Offit dissents on vaccine policy, he usually does so with evidence and arguments. He referred to the decision as "overselling" instead of railing about it.
The speed at which new evidence must be absorbed is one of the hardest parts of making policy. It was important for COVID science to be quick to inform policy. This wasn't a case where science wouldn't catch up. We needed evidence fast. The Pandemic would show us the limits of the over reliance on randomized trials which are better suited to diseases with stable definitions and incidence. It was sloppy, but that is how science works. It's not a good idea to look back and pick apart our response. Slow science is being performed by us. We have a lot of time to argue over data. Allely extends retrospective critiques that are not cogent into the future with more exaggerated statements.
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
He sees the problem in front of us, the problem of public distrust in medicine, but his solution seems to be to misspeak or be ignorant of the facts when arguing for his position. He did not face a higher risk of being hospitalized. Even if we grant Allely the 1 in 10,000 risk of hospitalization for vaccine-related myocarditis, he fails to account for the risk over time and what happened in the omicron wave. The politics of fear are played into his argument. It makes a view worse and worse for public discourse. Is Allely in the wrong for writing about science and policy in the public domain?
It is my opinion that medical students need to be involved in these conversations. His critical error was that he failed to understand that medical conservatism still requires a lot of debate. We need to understand how these decisions are made and how data affects our patients. We must not be timid like I was. It is a violation of professional ethics for Allely to misstate obvious facts. If there is one thing I have learned from transitioning from baseline vaccine hesitant to scientifically informed it is to find those who disagree with you. Go out and find the experts who disagree with you if you think you're right about a lot. See what comes up when you push against their argument. Send them a letter, email them, or call them. If you still don't agree with their arguments, mention them. If you have clarity of thought, you can be a skeptic.
I contend that medical students should learn to be more efficient in their studies because they are often full of repetition. What's the reason? It gives one time to write, to research, and to truly learn about the differences between a fundamentalistEBM position and the methodolatry spoken of here in 2009. If modern medical students pay attention, they will eventually see that there is a need for a solution to the problem. I don't know what the solution is, but I bet it's similar to the one pictured. The medical school is in dire need of contributions from the philosophy of science to tackle this critical challenge.
I want anyone who reads this piece to help us understand modern medicine's debates about the state of EBM and where it needs to go from here. Encourage us to be critical thinker while also teaching us to be compassionate with our patients. The politics of fear are not going to go away soon. To make it out, leave the world better than we found it, and become great clinicians and academics, we must brave the storm, have tough conversations, and vet our work thoroughly before dissent.
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