This is one of those posts inspired by an exchange on Twitter. In brief, the exchange led me to a 14-year-old post that—or so it rapidly became apparent to me—desperately needed updating in light of the COVID-19 pandemic and the bumper crop of COVID-19 “contrarians” (a.k.a., antivax cranks, quacks, and grifters).
Here’s the exchange, which suggested a way to come at the answer:
Which led me to respond:
And it’s true. That old post is one that I’m particularly proud of. At the same time, I realize that it’s spectacularly out of date, given what has happened since COVID-19 hit the world nearly three years ago, hence my thought that I really do need to update it. So, after having thought about it for a day, I decided that I had to try to do it, even if I take the risk that the update is inferior to the original. Also, Dr. Jonathan Howard published an excellent post a week and a half ago about another possible reason why doctors gradually become “contrarians”, a state that has led too many of them to descend into worse than contrarianism, such as openly peddling antivax conspiracy theories. That reason is audience capture, and I will elaborate on it near the end of my post. Moreover, even nearly three years into the pandemic, my colleagues keep expressing surprise that there are so many physicians who’ve turned into cranks with respect to COVID-19 and COVID-19 vaccines, I’d like to discuss why they shouldn’t be so surprised and the factors that lead to this seeming transformation.
Physician social media influencers who’ve embraced COVID-19 contrarianism and antivax
How is my desire to update a previous post about why physicians become cranks and antivaxxers related to what I had originally planned on writing about? It turns out that a few days before the exchange above, I noticed this Tweet by Dr. Drew Pinsky, which as of my writing now is still his pinned Tweet nearly two weeks after his interview with antivaccine leader Robert F. Kennedy, Jr. (RFK Jr.):
That’s right, radio and TV personality who’s now a podcaster, Dr. Drew, hosted longtime antivax activist and leader turned general purpose COVID-19 antimasker, anti-“lockdowner”, and antivaxxer, Robert F. Kennedy, Jr., on his podcast to promote the new “documentary film” adaptation of his conspiracy theory extravaganza book, The Real Anthony Fauci: Bill Gates, Big Pharma, and the Global War on Democracy and Public Health, first published nearly a year ago. Seeing the Tweet about my old post just a few days after having seen Dr. Drew throw away all pretense of not at least pandering to antivaxxers—if not going antivax himself—after having been seemingly semi-reasonable in years past only told me that I really did need to discuss how so many physicians who were once seemingly reasonable turned into outright COVID-19 minimizers, antimaskers, and antivaxxers in such a short period of time. (I had originally planned on reviewing the movie, but decided that a review could wait, as I’ve downloaded a copy for when the free access to it in effect now expires, thanks to a reader who managed to bypass the countermeasures designed to prevent download of the video file.) Rather, Dr. Drew had unwittingly given me an “in” to introduce my post.
Before I go on, it is important to emphasize that there is absolutely no doubt that, despite his self-righteous assertion that he is “fiercely pro-vaccine” (ironically enough, on The Dr. Oz Show), RFK Jr. is an antivax activist and has been since before 2005, when I first deconstructed an article published in both Rolling Stone and Salon.com (to the eternal shame of both publications). His article, “Deadly Immunity“, posited a conspiracy theory to “cover up” evidence that mercury in the thimerosal preservative used until around 20 years ago in some childhood vaccines had caused the “autism epidemic”. In other words, there is no arguing that RFK Jr. is not a diehard antivaccine activist or that he has built an empire fearmongering about vaccines. Having such a person on one’s show is evidence of either utter naïveté about “telling both sides” with a grifting conspiracy theorist, sympathy to antivax views, a willingness to promote antivax views to profit, or being an antivaxxer oneself. (Take your pick.) Interestingly, early in the pandemic in 2020, Dr. Drew minimized the pandemic but then apologized for it by year’s end when he caught COVID-19. Of course, it didn’t take him long to start backsliding, as by April 2021 he was railing against vaccine passports as assaults on freedom. Now, nearly two years later, he’s way worse than he ever was in promoting COVID-19 minimization and antivax views, as evidenced by his willingness to host an antivax conspiracy theorist like RFK Jr. on his show.
A week before RFK Jr. was on Dr. Drew’s show, guess who else was on his show?
Yes, he had Dr. Vinay Prasad, the oncologist turned COVID-19 minimizer and antivaxxer parroting antivax tropes that were old when I started blogging, just repurposed for COVID-19 vaccines and children, and Dr. Kelly Victory, an ER doctor who by the first summer of the pandemic had become a veritable cornucopia of COVID-19 misinformation and only got worse from there. In August, Dr. Drew even had Alex Berenson on his show. You might remember that Berenson was once dubbed—and accurately so, at least at the time given that others have come to vie for the title—the “pandemic’s wrongest man“.
In fact, just take a look at the last several weeks of his Ask Dr. Drew podcast. For example, in his most recent Ask Dr. Drew, Dr. Drew has Edward Dowd, a “former Wall Street analyst and BlackRock portfolio manager” that Dr. Drew credulously touts as a “numbers guy”—in other words, someone with zero relevant expertise in epidemiology, pharmacovigilance, infectious disease, vaccines, or any other discipline that would allow him to come to any scientifically plausible conclusions based on the datasets he examined but possessed of lots of hubris and Dunning-Kruger—claiming that there has been an epidemic of sudden deaths in 2021 and 2022; i.e., since the COVID-19 vaccines rolled out. Together with Dr. Kelly Victory, he discusses “Sudden Adult Death Syndrome” (SADS). I was way ahead of him on this, having thoroughly discussed why “SADS” is nothing new and vaccines have nothing to do with it.
Then I looked at the list of most recent episodes of Ask Dr. Drew:
As you can see, Dr. Victory has been on the show multiple times since mid-September and seems to be a go-to guest, along with COVID-19 minimizers and antivaxxers like Harvey Risch, Dr. Jay Bhattacharya, and, of course, RFK Jr. He promotes antivax conspiracy theories and lies, such as:
- The awful study by anonymous scientists for the Florida Department of Health that Dr. Joseph Ladapo tried to represent as showing that the vaccines are more dangerous than the disease in men under 40;
- The distortions around the old news that the Pfizer mRNA-based vaccine trial “never tested the ability of the vaccine to prevent transmission”, disinformation that I discussed in detail last week;
- Misguided attacks against California law AB 2098 as some sort of horrific affront to free speech;
- Anti-mask propaganda;
- Fear mongering about the nanoparticles used in mRNA vaccines, a topic that once led me to dub lipid nanoparticles in mRNA vaccines the “new mercury to antivaxxers“;
- Mass delusional psychosis, the discredited idea promoted by Dr. Robert Malone and Dr. Mark McDonald that the pandemic caused an epidemic of “delusion” that qualified as a “psychosis”.
Indeed, I can’t help but be amused by a September 8 episode of Ask Dr. Drew in which Dr. Drew asked the question, “Is Dr. Drew Anti-Vaccine?” Even though I haven’t listened to more than a few minutes of these particular episodes, judging from the topics and guests on his show over the last few months, I’m hard-pressed not to answer—and most emphatically—”yes” to this question. I mean, just look at his list of topics going back to August! By and large, his guests have been a veritable laundry list of COVID-19 deniers and antivaxxers.
Before I move on to discussing why so many physicians seemingly turned into cranks after COVID-19, let me just mention that it isn’t my intention to pick on just Dr. Drew—although he richly deserves to be picked on and his audience is dozens of time that of this blog and many times greater than that of my other blog. He just happens to be unlucky enough to have been the physician social media influencer who happened to catch my attention the most recently. Here at SBM we’ve written about so very many others, including Dr. Zubin Damania (a.k.a. ZDoggMD), an E.R. physician and long-time social media influencer who went from being a skeptic I used to cite, particularly his funny YouTube videos mocking antivaxxers, to a font of COVID-19 minimization and even antivax disinformation regarding COVID-19 vaccines and children himself; the aforementioned Dr. Vinay Prasad, an oncologist with a large Twitter following before the pandemic who had previously made reasonable criticisms of medical reversals and the oncology drug approval process but turned to COVID-19 misinformation fairly early in the pandemic, even once likening public health nonpharmaceutical interventions to incipient fascism; and so many more who can be found on Substack, which has become the new wretched hive of scum and quackery for COVID-19. Then there are some who are not so much social media influencers but have become the go-to physicians for Fox News and other outlets promoting COVID-19 disinformation, such as Dr. Marty Makary, a surgical oncologist who most recently appeared on Tucker Carlson’s show to attack the CDC Advisory Committee on Immunization Practices (ACIP) when it was considering adding COVID-19 vaccines to the childhood immunization schedule, and Dr. John Ioannidis, arguably the most highly published living scientist and a former hero of mine who has been reduced to promoting awful “science” that incompetently and deceptively used a satirical publication index to attack critics of Great Barrington Declaration-style “let ‘er rip” pandemic policies intended to reach “natural herd immunity.”
The list goes on and on; I won’t belabor it here, although I might mention more later and ask again why so many of my colleagues are still shocked that there are so many antivax and crank physicians out there. Spoiler alert: They were always there. It is also not an unreasonable criticism to state that some of these doctors, through their presence on social media—and even old media—had become de facto entertainers or social media influencers who just happened to have MDs. Certainly, that is arguably true for Dr. Drew, Dr. Oz, and ZDoggMD, the last of whom recently shed all pretense of being a clinician and quit to build his media empire full time. However, the same can’t be claimed for Dr. Prasad , who prepandemic was clearly an academic physician who just dabbled in social media. He even said in an interview four years ago:
I guess I would say that, although I tweet about things often, I do not believe I have made any arguments on Twitter that I have not first made in the peer reviewed literature. I have some arguments that I purposely do not make on Twitter, because the paper is under review. I’m actually cognizant of that, although I think Twitter is … let’s be honest, why do I use Twitter?
Number one, I find it fun. I find it fun to use Twitter, it’s enjoyable, it’s interactive, you get to hear from interesting people. I do not use Twitter to debut ideas, I use Twitter to get ideas out that were published in peer reviewed journals.
That doesn’t sound like someone who had become social media influencer first and left his career as an academic physician to be his second concern. Oddly enough, though, a few months later Dr. Prasad quit Twitter around the time he started his podcast, which before the pandemic tended to cover mostly more mundane medical topics related to oncology and clinical trials. Obviously, he came back to Twitter before the pandemic, but he came back under a different handle. Then after the pandemic hit he started two Substacks. After he started going “COVID-19 contrarian,” his paid subscriptions to his Substack grew markedly, and his social media presence ballooned.
Dr. Makary is another example. Although he has a large Twitter following now (~190K), before the pandemic it was nine-fold smaller (a very respectable, but not huge, Twitter following), and he mostly used his Twitter account to promote his books. Since he “went contrarian,” his Twitter following has ballooned, and it now seems he’s on Fox News at least once or twice a week. He’s still a clinical surgeon, though, who operates on complex hepatobiliary cancers; indeed, I kind of dread going back to in-person surgical meetings, as it’s quite possible I could run into him at the Society of Surgical Oncology or the American College of Surgeons meeting next year, or even maybe at a more general cancer meeting like the American Society of Clinical Oncology.
John Ioannidis is a weird one in that he actually routinely brags about having no social media presence. However, it now occurs to me in retrospect that, for all his bragging about not being on Twitter, Instagram, Tik Tok, and other platforms, he does seem quite aware of social media discussions about him, which makes me strongly suspect that he does lurk a lot on Twitter at least. His path to this probably came from his having been almost universally acclaimed for his skeptical takes on the evidence base supporting various medical interventions; he seems genuinely surprised that he hasn’t gotten the same reaction from his COVID-19 takes. Of course, before, most of his takes were not so politically charged.
Let’s move on to the concept of audience capture, which I didn’t consider in my 2008 post.
Reasons why physicians and scientists become “contrarians”
Rereading my 2008 post on this topic, I believe that its conclusions are still largely accurate, just incomplete now. As mixed as my feelings about evolutionary biologist Richard Dawkins are these days, nonetheless I still think that that a good way to start this part of the discussion is with a probably apocryphal story that he liked to tell. (The first time I heard it was watching his BBC documentary series The Root of All Evil?.) It was about an elderly and esteemed scientist who had supported certain scientific hypothesis for many years. One day a visiting professor from America came to give a talk at Oxford University, in which he presented evidence that conclusively refuted this professor’s favorite hypothesis. As the lecture concluded, all eyes were on the esteemed senior scientist whose favorite hypothesis had just been roundly falsified. According to Dawkins, the old professor strode to the podium, shook the speaker’s hand, thanked him profusely, and said, “I have been wrong these fifteen years” In response, the audience applauded uproariously. Whether this story is apocryphal or not or whether it’s grown with Dawkins’ retelling it over time, I don’t know. It is nonetheless the ideal towards which science strives.
I bring this story up for two reasons. First, it is indeed true that the goal of science is for a scientist to be able to let go of even a most cherished hypothesis if the evidence refutes it, something that human nature leads us to find very, very difficult to do. Indeed, most scientists would probably not have reacted quite the same way that this respected senior scientist did; instead, most probably would have argued with the visiting professor or tried to shoot down his competing hypothesis. Second and more importantly, the vast majority of physicians are not, in fact, scientists. It is not a criticism or insult to state this. Medicine is a different discipline, and clinical medicine requires a different, albeit overlapping, skillset. Medicine is, as I like to say, applied science, and a good clinician does not have to be a research scientist to be competent—or even excellent—at diagnosing and treating patients.
In my original post, I listed several human traits that can lead a scientist or physician astray. This time around, I’m going to stick mainly with physicians and try to synthesize my old post with what I see now, after nearly three years of pandemic and 14 years overall. I admit that this is all anecdotal and based on personal experience, but I suspect that my ideas could provide hypotheses to test in scientific studies. That shortcoming in my speculation aside, the three main characteristics, stated more succinctly and slightly differently, that I listed back then as key to understanding cranks were:
- 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 mavericks”. 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, and 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 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 pre-existing 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, such as its Scientific Director Martin Kulldorff.)
- 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 people 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 long-time 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 some special insight that their colleagues lack. 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 or genetically modified organisms (GMOs) caused autism. 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.
As I discussed before, it shouldn’t surprise anyone that there are a disturbingly large number of antivax physicians who are behaving badly over COVID-19 out there, to the point where everything antivax is old again. These physicians were always with us, as anyone in medicine knows; COVID-19 just gave them the excuse to unmask themselves.
But what about audience capture?
“Audience capture” or just “capture”?
I’ll finish up by elaborating on what Dr. Howard wrote about on Friday. Specifically, this passage echoed my own experience years before Dr. Howard (mainly because I’m a lot older than he is and thus discovered the antivaccine movement before he did):
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’s right, too…mostly. In actuality, antivaxxers blamed vaccines for all those things long ago; it’s just that blaming vaccines for SIDS, for example, comparing vaccines to rape, and calling for doctors to be tried and hanged, guillotined, or otherwise executed for their role in promoting vaccination programs (now falling under the rubric of “Nuremberg 2.0“) were considered fringe even among antivaxxers. What Dr. Howard gets right is the increasing radicalization of the antivax movement, to the point where what was once considered fringe—embarrassing, even, to antivaxxers who liked to consider themselves more “reasonable”—is now mainstream, to the point where a popular pundit like Tucker Carlson even approvingly featured RFK Jr. in his Fox News special about how society, GMOs, vaccines, and other things he doesn’t like are going to result in the “end of men”, who apparently need “bromeopathy” and testicular tanning as tools to restore their flagging testosterone levels. But why? I think Dr. Howard was on to something when he wrote about “audience capture”:
I think [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 with one difference. I define the “audience” that has captured once-reasonable physicians (or at least seemingly reasonable physicians) more broadly than just their social media presence. Think of it this way. Twitter was only founded in 2006 and didn’t really take off for a few years. Facebook hadn’t yet come to dominate social media discourse in 2009. Before I wrote my post, blogs and discussion forums were about it, but audience capture still arguably happened. Although this example does not include physicians, think of it this way. 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 “autism biomed” to “recover” their autistic children after becoming active in antivax online discussion forums. Doctors are not immune to these sorts of social pressures.
That’s why I define the “audience” of physician influencers as including potentially not just their social media followers, but their patients (if they have any, that is—Drs. Ioannidis and Bhattacharya, for example, do not practice clinical medicine, and Dr. Vinay Prasad appears to have a minimal clinical practice and mostly does research) and followers of any sort. For example, although Dr. Marty Makary does have nearly 190K followers on Twitter, he appears not to have a podcast or a Substack (although he frequently appears on other people’s podcasts). His main fame appears to come from his regular appearances on Fox News and other conservative traditional media outlets to cast doubt on public health interventions and vaccines for COVID-19. Another example is Dr. John Ioannidis, who, as I mentioned before, brags about having no social media presence but who is frequently quoted by the media about the pandemic and now has a hagiographic (and very painful to watch) YouTube “documentary” Out To See that portrays him as the classic “brave maverick doctor” who in early 2020 saw everything that his colleagues did not, was unjustly “persecuted” for it, and now accuses his fellow physicians and scientists of currying political favor—a classic case of projection, if ever I saw one.
As I pointed out on Twitter about the faux profundity in the movie, which, I suppose, I’ll have to watch at some point (I’ve only watched part of it so far), as much as it is likely to nauseate me:
Ioannidis also voices classic eugenicist thinking that has long undergirded antivax sentiment:
And, my favorite:
As I said, some of these quotes from Ioannidis sound like bad facsimiles of Jack Handey’s “Deep Thoughts” applied to medicine.
Why does audience capture do this? I refer to the same article by Gurwinder Bhogal that Dr. Howard did, “The Perils of Audience Capture“, which starts with the example of an influencer named Nicholas Perry, who discovered that “uploading mukbang videos of himself consuming various dishes while talking to the camera, as if having dinner with a friend” got him a lot of attention that his previous videos did not, noting:
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.
Basically, Perry, who had been thin and health-conscious before, became morbidly obese and also:
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.
I’ve often said that antivax and crank beliefs are often about grift, but it is usually the ideology that comes first. While it would be easy to attribute audience capture to grift and the desire to make more money (and certainly greed and grift often play a role), as Bhogal explains, it’s actually more complicated than just financial incentives to be ever more outrageous and radical:
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.
He further notes that such a process was not necessarily a bad thing when humans were living in small communities where most people knew each other, as it helped social cohesion. However, that’s not the case anymore. A social media influencer can interact with people all over the world, nearly none of whom he’s met in person, and they can exercise this influence online.
I would argue that this same process also applied to physicians before the rise of social media who discovered that advocating certain quackery or antivax ideas gained them not just more patients, but more approval—adulation, even—from those patients. Just look at Dr. Stanislaw Burzynski’s adoring patients, whom he wielded as weapons against the Texas Medical Board and the FDA whenever any regulatory or law enforcement bodies tried to hold him accountable for his quackery and tell me that such adulation doesn’t have an effect. Indeed, there’s a reason why I’ve invoked Burzynski’s story as an example of how difficult it has always been to halt medical misinformation.
Again, the vast majority of physicians go into medicine because they want to help people, and helping people through diseases and medical conditions can feel really, really good and be deeply rewarding. This is particularly problematic because there is a culture among physicians in which we tend to view ourselves as above such seemingly petty influences as ego gratification or audience capture. This phenomenon can be seen in other contexts, such as in the way that physicians frequently proclaim that gifts from pharmaceutical representatives have no effect whatsoever on their clinical behavior or judgment, when science overwhelmingly shows that gifts, even small ones, can have a profound influence on behavior. Again, many of my colleagues consider themselves above such considerations. This is the same sort of arrogance that can potentially blind colleagues who develop large social (or even traditional) media followings to this possibility:
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 described the dynamic between social media influencer physicians who go “contrarian” and their audience:
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.
Physicians 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” predominates, their dedication to science- and evidence-based medical care or their desire, conscious or unconscious, to satisfy their audience. In any event, I rather suspect that this sort of dynamic is a major part of how so many social media influencers like ZDoggMD, Dr. Drew (who has been both a traditional media influencer and social media influencer over the years), Dr. Prasad, Dr. Bhattacharya, and the like started out just somewhat contrarian with respect to the pandemic and are now parroting antivax talking points retooled for COVID-19 vaccines, whether they realize these talking points are old antivax talking points or not. Everything old is new again, indeed, and “new school” COVID-19 contrarian “antivaxxers” are, more and more, coming to resemble “old school” antivaxxers. I also suspect that physicians who were already social media influencers before the pandemic hit, like ZDoggMD, Dr. Drew, and Dr. Prasad, were likely far more prone to audience capture resulting in their turning into COVID-19 contrarians than those who were not, but, as the case of Drs. Ioannids, Makary, Bhattacharya, and Kuldorff demonstrate, even doctors who had little social media (or media presence) before the pandemic have not been immune. Moreover, no matter how much attention being a contrarian brings a physician, there is nothing particularly admirable in just being a contrarian.
As I put it 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.
Being a contrarian, in other words, is not in and of itself desirable. It’s one thing to be a contrarian who finds faults with existing science based on evidence (and not the cherry picked misinterpretations of evidence most commonly used by the COVID-19 contrarians that we routinely write about here); it’s quite another to be a contrarian for the sake of being a contrarian. Unfortunately, I suspect that it’s not difficult for the latter to lapse into being the former. That could well describe why physicians like Dr. Ioannidis and Prasad so easily lapsed into COVID-19 contrarianism. Before the pandemic hit, their entire “brands” had been based on criticism of the evidence base for various medical interventions and the quality of clinical trials used to justify those interventions. Naturally, the appearance of a novel virus, where the science evolved rapidly and was initially often confusing or even misleading, provided many big fat, juicy targets for their previous skills. That was the “in”. Unfortunately, arrogance and audience capture appear to have done the rest, along with methodolatry, also known as the obscene worship of the randomized clinical trial as the only valid method of clinical investigation. Now these once-respected doctors are pathetic shells of their former selves, scientifically speaking. One can ask whether they’ve changed or if they were always like this. To that, my speculative answer is yes. I suspect that they were always “like this,” but not nearly as much as they have become. In other words, yes, they’ve changed, but that change was an amplification of existing traits, not a change in character.
Avoiding audience capture and the temptation to become a “contrarian” for the sake of being a “contrarian”
Bhogal asks himself the question that all influencers should, namely whether they have been captured by their audience, and I found an echo of my thinking in this passage:
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.
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.
Me too—I think. To be honest, I’m not even sure that I have a true “brand image.” If I do, it’s not something I’ve consciously cultivated, although no doubt I must have cultivated something like it over the last couple of decades. On the other hand, I did feel something akin to audience capture early in my blogging career. I had started out on previous versions of this blog with a brand based on a pseudonym named after an all-knowing computer from an obscure (in the US, anyway) forty-year old British science fiction show. This computer was characterized by extreme cantankerousness and impatience with humans, which led many of my early posts to be particularly sarcastic and sometimes even nasty. My readers seemed to like that and want more, but, oddly enough, over time I actually mellowed. I can still be quite sarcastic, to be sure, but just compare posts from here (and previous incarnations of this blog) from c.2005-2010 to what I write now if you want to see. Even as late as 2012, I was not above some extreme sarcasm every now and then.
Also oddly enough, too much praise actually makes me very leery and sometimes even acutely uncomfortable; when I encounter it, it’s just as likely to make me question myself and what I’ve written as it is to reinforce my beliefs. Those who’ve met me in person at various skeptical conferences have likely noticed that too much attention and praise actually make me noticeably uncomfortable, particularly when that attention is a lot of praise. (People have commented on it.) I sometimes think that, were I to receive a lot of feedback telling me how “fearless” I am for voicing heterodox opinions, it might actually lead me to seriously question my views and writings.
Another key strategy to avoid audience capture is an openness to considering legitimate criticism. I don’t claim to be perfect on that score, but I do try. One example that comes to mind is from last year, for which I must make a mea culpa. Before the kerfuffle over the positive review of Abigail Shrier’s Irreversible Damage, the not-so-secret other blog for which I serve as editor had been oblivious to the pseudoscience and conspiracy theories regarding gender dysphoria, transgender adolescents, and gender-affirming care. Since then, we have tried to remedy that longstanding oversight with science- and evidence-based discussion and analysis.
Maybe these are the keys to how I’ve (mostly, I think) avoided audience capture. I seem never to have cared nearly as much about growing my personal audience as many influencers do, and there hasn’t been anything resembling a financial motivation for me to garner more traffic in a long time. I also obsessively question my beliefs and actions presented to the public, possibly even more than is healthy. It’s been enough for almost two decades, but I never assume that it will be enough for two more; that is, if I even continue doing this for two more given how old I will be then.
Mr. Bhogal was quite correct when he pointed out that it is worse to have the wrong audience than to have no audience. During the pandemic too many physician social media influencers attracted the wrong audience, and it has corrupted and radicalized them.