By BENJAMIN MAZER, MD

Doctors can be two-faced. This isn’t necessarily a negative attribute. Doctors have distinct personas for our patients and our colleagues. With patients, doctors strive for a compassionate but authoritative role. However, with each other, doctors often reveal a different demeanor: thoughtful and collaborative, but also opinionated and even sometimes petty. These conflicts are often the result of our struggle with evidence-based medicine. The modern practice of evidence-based medicine is more than the scientific studies we read in journals. Medicine doesn’t just change in rational, data-driven increments. Evidence-based medicine is a dialectic, a conversation. Doctors are being continually challenged to reconcile personal experience, professional judgment, and scientific data. Conflict can naturally result.

This struggle has been ongoing since the rise of evidence-based medicine decades ago. There are factions in medicine who are skeptical of clinical trials as the answer to all of medicine’s important questions, while other factions are wary of authority and consensus-driven medicine. These battles have traditionally been confined to the doctor’s lounge, both literal and in the figurative “safe spaces” of academic journals and conferences. But now the doctor’s lounge is going public. Social media is enabling doctors to rapidly communicate with each other. The heated public arguments that often result are in turn raising new questions about the effect of public discourse on the medical profession and the patients we serve.

I think the social media platform that’s doing the most to influence public debate about medicine is Twitter. Twitter, with its character limits, bandwagons, and trolls may seem inhospitable to nuanced medical debate, but the power of Twitter to broadcast physicians’ instinctive and abbreviated thoughts is underappreciated. “What does my doctor really think?” For too long, patients have asked this question in vain. Despite an ever-expanding evidence base, physicians have always relied on rapid, slippery judgments. Carefully edited debates in journals reveal the logical side of physician thinking, but they mute this more common aspect.

As a trainee, I remain awestruck by the intellect and erudition of my colleagues. However, like Twitter, disorganization and abuse are also native to the medical training process. While this chaos often breeds burnout, it also selects for passion and dedication. It shouldn’t surprise us that this nerdy, boisterous culture has translated so easily to Twitter.

For example, a clinical trial called ORBITA was recently published in the The Lancet. It pitted percutaneous coronary intervention against a surgical placebo to see if this invasive procedure could truly reduce anginal chest pain. In the study, PCI did not outperform placebo, with an accompanying editorial asking whether this was “the last nail in the coffin” for this expensive, widely-used medical procedure.

The study was heavily covered in the mainstream press, but the most heated debates have taken place on Twitter. Dr. Vinay Prasad, an oncologist who often stokes controversy on the platform, had suggested in his 2015 book “Ending Medical Reversal” that a placebo-controlled PCI study could show just these results. He took to Twitter to defend the trial with biting bromides, tweeting, for example, that “Criticizing ORBITA is akin to cavemen sitting in the dark for millennia suddenly complaining about the brightness of the first torch.” One of the study’s authors, Dr. Darrel Francis, also created an account and proceeded to call out misguided criticism of the study with signature irony. At one point, he even asked, “Which type(s) of cognitive bias has been nicely displayed by those seeking to undermine ORBITA? Please reply with the name of the bias and a quote exemplifying it.” These conversations are providing insight into the tentative way new research findings are integrated into physician thinking.

Medical debates on Twitter can also turn personal. Last December, Dr. Lisa Rosenbaum published an essay in the New England Journal of Medicine pushing back against the “less is more” movement in medicine, claiming that evidence doesn’t support the more heavy-handed elements of this campaign. In response, Dr. Prasad tweeted a chart showing America’s unprecedented healthcare costs accompanied by the ironic tagline “Damn you, less is more.” Dr. Jerome Kassirer, a former editor of the New England Journal of Medicine, tweeted “It’s not her first dumb analysis of health care; probably not the last.” Some doctors felt that this harsh rebuke of Dr. Rosenbaum’s essay had taken on a gendered tone. One radiologist suggested many criticisms were “ad feminam” attacks rather than substantive counterpoint. While the debate generated by this essay was often enlightening, it was nevertheless infused with some of our more partisan urges.

What mix of trust and honesty does the doctor-patient relationship require? When does public bickering help patients, and when does it merely stoke animus? In an environment that pays heavy lip service to shared decision-making, how muddied should doctors let their public messaging get? On one hand, we can imagine a fully informed patient would want to hear about the heady conversations taking place in the profession. Yet if doctors are unsure, how is a patient – naïve and ill – supposed to sort through these arguments? Perhaps people will just tune out, as they often do with politics.

And what of the effect on doctors? To some extent, the idea that medicine’s most obstinate quarrels can be sorted out in public is a pretentious fantasy much like thinking a debate between William Buckley and James Baldwin sorted out racism. In contrast to the egoism most associate with public displays, I think there is something vulnerable about presenting an argument in public. On social media I have had my arguments made easily threadbare by a physician with a different perspective.

This isn’t to say it’s easy being a public firebrand. Prestigious academics, largely male, dominate medicine’s public conversation. A sociologist named Dr. Tressie McMillan Cottom recently drew attention to what results when people of color, women, and second-tier academics attempt to enter public debate. Speaking out doesn’t always generate thoughtful responses. It can lead to “orchestrated outrage,” where intolerant internet-dwellers hound employers to penalize or silence outspoken scholars. Marginalized academics remain far more vulnerable to this assault than white or male Ivy league doctors.

A nineteenth century German pathologist named Rudolf Virchow wryly observed that “Medicine is a social science, and politics nothing but medicine at a larger scale.” I envision a new role for the “public intellectual” in medicine in response to the rise of social media. I want to see heated debates contextualized, not sanitized, for the public. In our discussion of medical truth, we often lose the “truthiness” that drives so much physician behavior, to borrow a phrase from comedian Stephen Colbert. The public conversation has long accepted this dichotomy in politics – we discuss high-minded policy goals alongside the skullduggery and pettiness. In the age of free-wheeling social media debates, medicine will have to catch up.

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Dr. Benjamin Mazer is a resident in pathology at Yale-New Haven Hospital. His opinions are his own and do not represent tho