A year ago, I got myself in trouble on Twitter. I tweeted a video of a man dunking on a basketball hoop. The young man took a big dribble and leapt into the air. The camera panned outward. He appeared to soar, defying gravity like Lebron James. He raised the ball up high and brought it down in a monster jam on the hoop. The camera continued to pan outward, and it became clear -- the hoop was not the regulation 10-foot rim, but something much smaller. The man appeared to be dunking on a 7-foot hoop. My tweet went something like this "Dunking on alternative medicine is like dunking on a 7-foot hoop; let's raise it back up to 10 feet."
To my surprise, my tweet struck a nerve. My impression is that it was irritating to folks who, for the most part, spend time debating and debunking alternative and complementary claims or self-identify as doing so. Their objections to my tweet were twofold -- first, some felt that they also spent time criticizing conventional medicine, and second, alternative medicine topics -- like cupping and acupuncture -- are important ways people waste their own time and money and are worthy of debunking. I hope that my thinking through this topic has the potential to inspire the next generation of skeptics to pursue the topics we need more activism on.
Let me start by acknowledging a truth of the cosmos: time is a fixed commodity. If one spends most of one's time critiquing acupuncture or homeopathy -- those are hours not spent critiquing robotic surgery, prostate-specific antigen screening, or a new prescription drug. Of course, any single person may have written on a variety of topics, but every hour spent on one activity is time taken from another. If you wrote 5,000 words on homeopathy, there is some other topic you did not write 5,000 words on. And, the truth is, there is waste -- i.e., things that don't work -- in all domains: 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 topics to spend our debunking energy? I wish to offer a framework that will help you decide what deserves your critical eye versus what can be put on the backburner.
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 in the tens and thousands of dollars per use or month, and conventional healthcare is a nontrivial portion of the U.S. gross domestic product. Conventional medicine is like alternative medicine in terms of budget impact, but add one or two more zeros.
2. Harm and invasiveness. All things being equal, we should focus our time on interventions that have greater harms -- death, perforation, cardiac arrest -- than those that offer minor harms -- cutaneous bruising. We should focus more on things that are invasive -- placed inside or within -- that those that are merely superficial.
3. Does it affect other people? This is an important factor. Topics that affect others -- the spread of contagious infections -- are fundamentally different than topics that affect only ourselves -- e.g., cupping for pain. We should give extra attention, all things equal, to practices that have implications for others -- like infectious diseases.
4. Who pays? I think it matters who pays for a therapy. Individuals are free to use their own money as they see fit. An individual might spend money on a lavish car or golf clubs, or even furniture, wallpaper, or décor. Wearing a copper bracelet for arthritis or wearing a silver one for beauty are both things we do because they make us feel better. Ultimately it is impossible to tell someone how they ought to spend their own money. At the same time, practices covered by health insurance are all of our concern. Through tax subsidies, government funded healthcare, these are things we all pay for; thus, we have a special responsibility to think critically about them.
5. Ability to persuade. This is a difficult prerequisite to articulate, but not all issues have as many "swing voters" as others. A new drug or device or screening test has a massive number of healthcare providers who simply have not taken a stand. People who have not formed an opinion. A practice that is long-standing and entrenched has many stubborn adherents, though trainees may remain open-minded. All things being equal, our focus should be topics with the most swing votes.
Issues that are deeply challenging are those that wed 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 argument can no longer persuade. In these cases, if the cause is sufficiently important -- such as MMR vaccination -- I think we should move towards randomized trials of different persuasion strategies to find what actually works. If, however, a topic fails by several aforementioned metrics, I think we might just have to let it go.
6. Your unique skill set. In deciding what you should spend your time on, it is important to think about what you are uniquely qualified and able to comment on. If you are a practicing orthopedic surgeon or allergist-immunologist, you are part of a tiny guild of people who have the knowledge to even identify the excesses in your field. Sure, you can talk about vitamin C, but so can many others. Why not focus on what few can do?
7. Unmet need. You as a skeptic should take stock of which fields have unmet needs. My research team is doing some ongoing work to identify places in medicine where no one is a critical third party. These places desperately need you. Just like investigative journalism, sometimes the best stories emerge from domains where no one is looking (e.g., local politics). I worry that some topics have oversized interests -- acupuncture -- while others are neglected entirely -- base of skull surgery.
8. Excessive concern with likes, RTs, and followers. Above all else, the goal of skepticism is to encourage better healthcare choices. In the world of Facebook and Twitter it is easy to be misled. Absolute and blanket condemnation may be popular amongst people already inclined to oppose complementary and alternative medicine, but perhaps unlikely to persuade anyone who sees value in the practices. The modern information ecosystem encourages preaching to our choirs, rather than broadening our base. We must be careful to avoid this temptation.
Putting it all together, I think skepticism is one of the most important things we do as scientists, and put myself firmly in the long tradition of skeptics. I am not sure I have always maximized my own time, but the moment I saw the logic of this prioritization, I began to continually reassess where I spend my energies, and encourage others to do the same.
Social media algorithms encourage us to chase the popular, faddish and, dare I say, 7-foot topics -- like homeopathy -- and perhaps not the topics where we are desperately needed. Topics that cost a lot, impact budgets, are paid for by insurers, have serious harms, are invasive, affect others, where there are lots of undecided people, where there is unmet need, and where we, with our unique skillset can help. Those are the 10-foot issues. I think it's time we raise the hoop.
is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of .