The reckoning of medicine in the post-fact world

“Our son doesn’t get the flu shot, no one in our family does,” she said, with some emphasis on the “no one,” inviting me to take a swing. Anticipating futility, I reminded myself that our pediatrics clinic was already forty-five minutes late. This was a scrap better deferred.

“Alright,” I said flatly as I moved on with the encounter. This was of course not explicitly, but indeed, implicitly, approving the mother’s choice.

The boy above has persistent severe asthma. We saw him in our ER just a couple of months ago on IV steroids for an exacerbation with the intubation cart at the ready. I know the flu could kill this child. Yet, he remains unvaccinated.

Did I fail this child by not exploring his mother’s assertion further? I certainly did. Could I have convinced her to give him the flu shot? Probably not. How often are these physician-versus-patient interactions taking place? Daily.

The reality is that we are now practicing medicine in a post-fact world. Facts — individual bytes of knowledge whose discussion time is over — are being debated. Patients’ trust of allopathic medical advice is eroding, sometimes leading to poor outcomes and always to poor encounters. People are spending money they don’t have on outrageously priced homeopathic products. Folks are putting coconut oil on their genitals to eradicate yeast infections. And whooping cough is back.

The nails in the coffin for reasoned discourse and truth-seeking were pounded on an undignified Taco Tuesday, September 26, 2006. Facebook opened its doors to 1.8 billion people shouting as loud as they can over the din of alt-right fake news, millennial-left Buzzfeed BS, cat videos, and, “Dermatologists hate her! Local mom reveals the one WEIRD trick to her stunning results!” There is no accountability here. There is no recourse for those who create falsehoods that resemble truths and mortar them blindly into our general direction.

Blatant misinformation is bad, but it’s a superficial wound. The underlying epistemological disease process affecting society is much more contagious, insidious, and dangerous. Intentional disregard for the truth, that is, choosing to believe something that is demonstrably false, renders reason and science meaningless.

Charlatan cures and quackery are nothing new. The difference is that they were previously used in the absence of scientific health care. Now, they are used in rejection of it.

Social media reinforces this departure from reason with “filter bubbles.” As you interact (like, share, read) with content, the Internet shows you more of that content in a positive-feedback cycle. The reader only sees more of what they want to believe, giving the false impression of consensus. These bubbles are custom-fit confirmation bias.

It’s easy to blame the patient for their wrongness. But when you pause and take your attention off the bicarb/microscope/Stryker rep and take a critical look at the flow of scientific knowledge, it’s obvious that something is amiss.

The research carried out at hospitals and universities around the world is funded mostly by taxpayer money, higher education, and donations from individuals or businesses. The researchers generate the knowledge and then share it with the world via an academic publisher. These mahogany-desked fat cats charge the researcher — who pays with public money — a couple grand for the privilege. Their so-called “value add” lies in their reputation and peer review process, which is usually done by volunteers. When the research finally goes to print — occasionally on paper — hospitals and universities pay through the nose to access journals because they need it to function. Journals are just too expensive for individuals.

So, academic publishers gain ownership of the science the public has already paid to produce, add minimal value, and then make them pay again to see the results. This racket to the tune of $25 billion per year for the industry’s largest player, Elsevier. And physicians shouldn’t start throwing stones in a glass house — articles from our professional association journals are $20 to 30 per read or a few thousand dollars up-front to the author to have it published open-access.

You see, it’s not that the public is intentionally avoiding the facts — they don’t even have access to them. Government exists to correct market failures, and this is a critical situation where the invisible hand needs a hand. Cheaper access to the research makes it easier for cash-strapped traditional news outlets to report on. More importantly, it makes the research open to new media science bloggers, the truth-seeking equivalency in the filter bubble space who will disseminate findings in an appealing way for the average reader. The appetite is there — 66 percent of online adults report an interest in health and medicine content per the Pew Research Center.

“But the lay public doesn’t have adequate training to interpret original research in context!” You exclaim, from your very tall and expensive soapbox built from all the unopened textbooks in your 16-year post-secondary journey to your MD-PhD in Nephrology. The fact that we still refer to the laity is offensive, and, of course, this ivory tower argument is bullshit. Researchers should attach a public-friendly summary with their manuscripts. And if Aunt Margaret’s access to more information about her disease makes you nervous, perhaps you should take your CME a little more seriously.

The real danger is not in the ignorance of my asthmatic patient’s mother, but the current post-fact environment that makes it acceptable, even commendable, for her to ignore truth and put the life of her child at unnecessary risk. This environment developed out of the complete lack of accountability for Internet content creators and the filter-bubbles that perpetuate and self-affirm the lies. That is out of our control. But just as critical to the development of this post-fact environment was the sequestration of scientific knowledge by a broken industry. This is something we must change if we are to restore public faith in medicine and enthusiasm for scientific advancement.

Perhaps then, in a world where the public can easily access and share new research, we can get back to cooking with coconut oil.

Maxwell Luke Armstrong is a medical student.

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