A year ago, I got into trouble on Twitter. I tweeted a video of a man diving on a basketball hoop. The young man made a big dribble and jumped into the air. The camera turned outward. He seemed to hover, defying gravity like Lebron James. He lifted the ball high and dropped it into a monster on the hoop. The camera continued to pan outward and it became clear that the hoop was not the regulation 10-foot rim, but something much smaller. The man appeared to be diving on a 7-foot hoop. My tweet went something like this: “Immersing yourself in alternative medicine is like immersing yourself in a 7-foot hoop; let’s raise it up to 10 feet.
To my surprise, my tweet struck a chord. I feel like it was irritating to people who, for the most part, spend time debating and debunking alternative and complementary claims or who identify as doing so. Their objections to my tweet were twofold: first, some felt they were also spending time criticizing conventional medicine, and second, topics related to alternative medicine – like cupping and acupuncture – are important ways for people to people wasting their time and money and deserve to be talked about. demystification. I hope that my thoughts on this topic have the potential to inspire the next generation of skeptics to pursue topics on which we need more activism.
Let me start by acknowledging a truth of the cosmos: time is a fixed commodity. If most of one’s time is spent criticizing acupuncture or homeopathy, those are hours not spent criticizing robotic surgery, prostate-specific antigen screening, or a new prescription drug . Of course, any person can have written on a variety of topics, but every hour spent on one activity is time taken on another. If you’ve written 5,000 words on homeopathy, there’s another topic you haven’t written 5,000 words on. And the truth is that there is waste, that is to say things that do not work, in all areas: alternative and complementary medicine, but also conventional medicine. In other words, skepticism has an opportunity cost.
Next, we must apply skepticism to skepticism itself. How should we prioritize which topics to spend our debunking energy on? I want to offer a framework that will help you decide what deserves your critical eye versus what can be put on the back burner.
1. Cost. All things being equal, we should focus our energies on interventions that cost more (per unit) and have greater budgetary impact (total cost for all units). Some medical devices and pills cost tens and thousands of dollars per use or per month, and conventional health care represents a sizable portion of the U.S. gross domestic product. Conventional medicine is like alternative medicine in terms of budgetary impact, but add an extra zero or two.
2. Damage and invasiveness. All things being equal, we should focus our time on procedures that result in greater damage – death, perforation, cardiac arrest – than on those that result in minor damage – skin bruising. We should focus more on things that are obtrusive – placed inside or inside – than on those that are merely superficial.
3. Does this affect other people? This is an important factor. Topics that affect others – the spread of contagious infections – are fundamentally different from topics that only affect ourselves – for example, cupping for pain relief. We should pay particular attention, all things being equal, to practices that have implications for others, such as infectious diseases.
4. Who pays? I think it’s important to know who pays for therapy. Individuals are free to use their own money as they see fit. An individual may spend money on a lavish car or golf clubs, or even on furniture, wallpaper or decor. Wearing a copper bracelet for arthritis or a silver bracelet for beauty are two things we do because they help us feel better. Ultimately, it’s impossible to tell someone how they should spend their own money. At the same time, practices covered by health insurance are all our concerns. Thanks to tax subsidies and government-funded health care, these are things we all pay for; we therefore have a special responsibility to think critically about it.
5. Ability to persuade. This is a difficult prerequisite to articulate, but not all issues have as many “sway voters” as others. A new drug, device, or screening test attracts a huge number of health care providers who simply haven’t taken a stand. People who haven’t formed an opinion. An old and well-established practice that has many stubborn followers, although trainees can remain open-minded. All things being equal, we should focus on the issues that generate the most tie-breaking votes.
The issues that pose the real challenge are those that combine politics, identity and tribalism. Topics like herbal medicine, chiropractic, and (sadly) even masks during COVID-19 may have become so deeply polarized and tied to identity that the argument can no longer convince. In these cases, if the cause is important enough – like the MMR vaccination – I think we should look to randomized trials of different persuasion strategies to find what actually works. However, if a topic fails on multiple criteria mentioned above, I think we may just have to leave it aside.
6. Your unique skill set. Before deciding what you should spend your time on, it is important to think about what you are particularly qualified and able to comment on. If you are a practicing orthopedic surgeon or allergist-immunologist, you are part of a small guild of people who have the knowledge to even identify excesses in your field. Of course you can talk about vitamin C, but so can many others. Why not focus on what few people can do?
7. Unmet need. As a skeptic, you should take stock of areas of unmet needs. My research team continually works to identify areas of medicine where no one constitutes a critical third party. These places desperately need you. Much like investigative journalism, the best stories sometimes emerge from areas where no one is looking (e.g., local politics). I fear that some topics have inordinate interest – acupuncture – while others are entirely neglected – the basis of skull surgery.
8. Excessive concern for likes, RTs and followers. The purpose of skepticism is, above all, to encourage better choices in health care. In the world of Facebook and Twitter, it’s easy to make a mistake. Absolute, blanket condemnation may be popular among people already inclined to oppose complementary and alternative medicine, but it may be unlikely to convince anyone who sees value in these practices. The modern information ecosystem encourages preaching to our choirs, rather than broadening our base. We must be careful to avoid this temptation.
In summary, I think skepticism is one of the most important things we do as scientists, and I stand firmly in the long tradition of skeptics. I’m not sure I always optimized my time, but once I understood the logic of this prioritization, I began to continually reevaluate where I was spending my energy and encourage others to do the same.
Social media algorithms encourage us to seek out the popular, trendy, and, dare I say, 7-foot topics – like homeopathy – and perhaps not the topics we are desperately needed for. Topics that are expensive, have an impact on budgets, are paid for by insurers, cause serious damage, are invasive, affect others, where there are many undecided people, where needs are not met and where we , with our unique skills, can help. These are the problems of the 10 feet. I think it’s time to raise the hoop.
Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California, San Francisco, and author of Smart: How bad policy and bad evidence harm people with cancer.
