COMMENTARY

On Twitter, and in Life, Aim to Persuade the Swing Voter

Too Much of Our Discourse Focuses on 'Rallying the Base'

Vinay Prasad, MD, MPH

Disclosures

June 13, 2019

Spirited, public discussions of medicine are happening everywhere these days: conference presentations, newspaper editorials, and even on #MedTwitter, the growing community of attending physicians, fellows, residents, interns, nurses, mid-levels, students, and other affiliated healthcare workers on Twitter. In all of these settings, the best discussions persuade or enlighten the audience. The worst are mostly virtue signaling or preaching to the choir.

Of course, people use these forums for diverse reasons, but let me humbly suggest that medical discussions would be better if we catered more to the swing voter and left the job of "rallying the base" to politicians. I will focus on Twitter, but these observations extend to other media as well.

What Is a Swing Voter?

The swing voter is the Twitter follower who genuinely has not made up his or her mind. Is the trial supporting the use of the factor Xa reversal agent, andexanet alfa, persuasive? Are the data supporting annual mammographic screening for women over age 40 strong? Do the trials of resident-physician work hours utilize a reasonable margin of noninferiority?

In cases like these and many others, #MedTwitter shines. We see arguments and counterarguments, and the audience—many of whom are undecided swing voters—can evaluate the merits and limits of the case being made. This collection of threads by cardiologist Venk Murthy about the downsides of using the Apple watch to detect atrial fibrillation is a great example.

These discussions tend to have a few things in common. We all tacitly agree to the ground rules. It is about evidence, data, and reason. Those with strong points, apt references, and succinct delivery can reach a broad audience of open-minded individuals. In these discussions, I have been both debater and audience member—depending on my knowledge of the topic—and in both cases I have learned something. Of course, the eternal truth about debate is also true on #MedTwitter: It's about changing the mind of the audience, not the other debater.

Enlightening the audience is another strength of #MedTwitter: Lengthy #tweetorials explain why abdominal aortic aneurysms are more common than thoracic ones. #Threads guide readers through the intro, methods, results, and conclusion of a new paper from JAMA Internal Medicine. Here, too, Twitter excels. I find myself scrolling back through the feeds of some gifted teachers, asking, "Has she explained anything else?"

Rallying Your Base

At other times, I see tweets that I call "rallying your base." For instance, I doubt that the crisis of misinformation around childhood vaccination will be solved (or helped) by an angry pro-vaccine tweet from a physician. And yet, this is much of my Twitter feed.

The vast majority of physicians support childhood immunization and immunize their own children.[1] A pro-vaccine message by healthcare workers to healthcare workers is arguably preaching to the choir. For those who disagree, research suggests that factual corrections regarding vaccines may have counterproductive results.[2] Condemning and insulting those who disagree with vaccination is common on Twitter but is no better than rallying one's base. Of course your colleagues and followers agree. But is the comment helpful? Does it change the minds of anyone who harbored doubts or does it merely harden their views?

Similarly, while surveys suggest that physician attitudes toward complementary and alternative medicine extend across a range of views,[3] I am aware of no physician who takes the extreme position that patients with serious medical illness should decline all conventional therapies and pursue solely alternative healing strategies. In fact, more physicians likely embrace the view of Drs Phil Fontanarosa and George Lundberg that "There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking."[4]

And yet, on Twitter, doctors sharply criticize rogue accounts that promote acupuncture, alkaline water, or chiropracty. Of course, nearly all of the claims in these accounts are unproven, implausible, or worse; but the better question is, "Whose mind are you changing?" Believers in these remedies are often attracted to the beliefs or worldviews embodied by such therapies.[5] At times, they seek a solution to an unresolved problem.[6] Many state that they will still return to conventional therapy if they need it.[6] Those of us who practice medicine in places where complementary remedies are favored grimace at these sharp rebukes. A good doctor learns to accommodate patients' preferences for complementary practices as long as they are not expensive and do not impinge upon conventional therapies. This practice helps develop a long and durable therapeutic relationship with a patient who needs you today or may someday need you.

At times, self-righteous doctors quote tweets that were doing a fine job of being forgotten, pointing out errors or insulting the authors. This occurs when the quoted tweet is from an account with fewer than 100 followers and the critic has greater than 1000. What is the point of this? A previously ignored message has now been amplified, and it is doubtful that this will persuade anyone who is genuinely on the fence.

Tweet and Debate Better

Of course, rallying your base gets a lot of retweets from people who agreed all along. It feels good and signals that you hold accepted and popular views. It does not require effort. You don't need to read any papers or review the history of aortic aneurysms to chime in. But, as an observer, it is dull and tiresome. It tells me nothing that I did not already know, and I'm not on Twitter to see who can get the most angry about a topic that healthcare professionals essentially agree upon.

Here is how to debate better. First, pick topics for which there is disagreement among members of the profession. Next, state the position you disagree with, ideally more clearly than it was stated by the person with whom you disagree. Finally, say what is wrong about that position. What is missing? What is inaccurate? Why does the conclusion not follow from the premises? Educate the audience about what is wrong—patiently, clearly, and maybe with a little bit of zing. That's all it takes.

In life and on Twitter, I want to learn things I did not know, to be persuaded on topics where I have not made up my mind, and to stay abreast of science and medicine. Rallying your base may be an effective strategy for politicians, but in medicine it's the swing voter we should care about.

Follow Vinay Prasad on Twitter: @VPrasadMDMPH

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