As I’ve been writing I’ve been very fortunate to have a lot of my peers and mentors read my work and give me feedback.
One of them1 has been very supportive, but also has tried to persuade me that I should not be publishing my work here. Instead arguing that I should be submitting my essays to academic journals. We had a good discussion about this and I thought it was worth expanding out into a full post; both so I can think out-loud about my decision-making and also to explain to people on the internet why I’m doing what I’m doing.
Honestly, it feels to early to write this whole “why I write” thing - I’m not popular enough for anyone to care. Buuuuuuut part of the reason I decided to start a blog was to escape editors telling me “sorry we’re just not looking for a piece like this right now.”
So, you know, deal with it2.
Why Are You Even Here?
I first had an inkling that I might like to write when I started reading Scott Alexander’s Slate Star Codex3 sometime in college4. At that point in my life, online prose5 was represented in my mind by 4chan greentext, angry/angsty Tumblr posts, the World of Warcraft forums, and things written by obscure and (literally) schizophrenic authors like TIME CUBE6. The internet was emphatically not a place where Smart People wrote Interesting Things. Those writings only existed in scientific journals, newspapers, and books; they might be reproduced online, but that was not where they came from.
SSC really inverted my view about what I might find on the internet. In retrospect… no shit. Ender’s Game, perhaps my favorite book as a teenager7, published in 1985, rather presciently predicted a future where the internet was a grand stage for intellectual debates; that the possibility of this idea did not sink in probably had something to do with where I was spending my time online.
It took a little while reading SSC for it to set in that there were indeed other blogs that were also very interesting, very good, and seemed to be written by smart people with actual credentials who did not appear to be schizophrenics. Still, as an undergrad student, my world of acceptable facts existed almost exclusively in books, journal articles, and other “reputable” publications.
Then, I graduated college and worked as a research assistant for 2 years. This was the metaphorical equivalent of deciding to inject your Suboxone it instead of letting it dissolve under your tongue like you’re supposed to. Instead of getting high on the beauty of participating in the Scientific Method, the politics of scientific research threw me into a state of withdrawal89. I don’t think anything I experienced would be viewed as particularly shocking by anyone working in academic research, but I became much less confident that the sciences were so much more special and unique than other areas of inquiry in terms of immunity from bias. I do think the scientific method makes them less so, just not as much less so as I thought. Thus, I started treating them with the same sort of skepticism that I did other institutions. Again - no shit - I should’ve thought about this before, but ya know, the innocence of youth blah blah blah.
Conversely, this experience made me much more open to the idea that blogs like SSC could actually be treated as serious works of scholarship instead of just interesting novelties.
It was around this time that I tried my hand at starting my first blog. It mostly consisted of me attempting to explain the data behind things I felt people didn’t understand very well - usually due to some ideological blindspot. I fell off of it pretty quickly, mostly because I couldn’t convince myself that I was qualified to comment on my chosen topics despite significant research. In fact, it was doing the research that made me feel even less qualified once I realized just how little I really knew!
I also realized how much work writing is for me.
I am an excellent writer. It’s one of those pieces of praise that I’ve been given consistently throughout my life. It also happens to be one of those things that I am able to say about myself without feeling like I am being immodest. However, it is rare that I enjoy the process of writing. It has always felt like a chore in the same way that exercise does. I can be glad that I am getting into the routine, I am usually proud of my efforts once it’s over, but it is often a very frustrating, demoralizing, and self-doubt generating exercise filled with a lot of uneven progress and plenty of dread at picking up where I left off.
Once I abandoned my blog, I pretty much gave up on the idea of writing. It was just something for other people. People with more confidence in their ideas, more expertise in their subjects, and who actually enjoyed doing the damn thing. It wasn’t until residency that I seriously considered writing again.
Starting this new blog took a solid 2 years of: Enjoying teaching. Realizing that staying current with the literature is not something every physician does. Running into a lot of medical mythology, and when I gave pushback getting the (positive) response of “oh, I didn’t know that, let’s do it that way!” My program director asking me at every 6 month review, “have you thought about writing yet?”
At some point in that process I started to feel like I actually had something to say that was meaningful, useful, and (best I can tell) true. My first few essays here are really just topics that I’ve spent an unreasonable amount of time thinking about in residency and finally putting them to (digital) paper.
Why Here? Why Not Publish In Academia?
My flip answer - not too long ago mind you - would’ve been, “Because I really don’t care about academia.” This, as I discovered, is only half true.
The true half is that I really, truly, have no desire to become a high-powered researcher who pumps out papers, chases grants, and plays the game of academic politics. Does that mean I would never dip my toes into the water if some particularly appealing opportunity comes along? Of course I would - I just know that I am not the sort of person who would enjoy that being my entire career.
The remaining part is that I have become just delusional enough to think that maybe I can at least nudge the ivory tower of psychiatry a few tenths of a degree in the right direction. At the very least I am confident that I can prevent at least one resident from giving a delirious grandmother lorazepam to treat their agitation.
As such, my answer to that question has become more nuanced:
It’s Their Fault, Really
First, the shine has really come off of academic journals for me. Part of this was seeing the research sausage get made. Another has been seeing how poorly even very well respected academic journals police themselves when it comes to errors. My Exhibit A10 for this sort of behavior is the article Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study published in the American Journal of Psychiatry (AJP), one of the most prestigious psychiatry journals in the world. This study concluded that:
the longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them.
However, subsequent analysis of the paper revealed that their statistical analysis was flawed. A correction was issued stating:
…the results demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts in that comparison. Given that the study used neither a prospective cohort design nor a randomized controlled trial design, the conclusion that “the longitudinal association between gender-affirming surgery and lower use of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them” is too strong.
And yet, if you go to the page of the article I linked above, the text of the correction appears nowhere in the article. The conclusion that was admittedly “too strong” remains. As far as I can tell there have been no edits to the text of the article. There is a link at the top indicating that a correction was issued, and an addendum at the bottom that says:
After this article was published online on October 4, 2019, some letters containing questions on the statistical methodology employed led the Journal to seek statistical consultations. The results of these consultations were presented to us and we concurred with many of the points raised. The letters (35-41) and our response to them (42) appear in the Letters to the Editor section of the August 2020 issue of the Journal.
I think you can see how this might undermine my previous notion that academic journals are primarily interested in giving their readers the most objective and unbiased look at the data.
I think there are some decent arguments about why I should try and publish in a journal anyway: It’s more prestigious and will likely carry more authoritative weight in the scientific community. I might change my mind about wanting to be a high-powered researcher and really regret publishing all of my good ideas on a blog. More people will see it in a journal, etc.
I think most of these things can be overcome with careful citations, passing drafts through other experts, and a frank and open discussion about errors and mistakes. Not unhelpful has also been a huge shift towards internet self-publishing in the past decade or two - plenty of serious public intellectuals in just about every field you can think of publish blogs that are treated as serious works of scholarship.
I Need to Be (Able to Be) Honest
I dread the idea of having to write a paper like this one from Beach et al.. They conclude that IV haloperidol doesn’t prolong the QTc relative to placebo, but were apparently forced to contradict the logical conclusion of their findings and still recommend ECGs and telemetry in certain patient populations receiving the drug. As I alluded to at the end of my essay on QTc prolongation, sometimes the evidence brings you to unequivocal conclusions. I think my role as an educator is to say those things unequivocally instead of hedging my bets.
I also want to be able to find out that I was wrong about something, go back, and make sure that you can see exactly what it was and how I messed up. Usually that will be an in-article correction with preservation of my original error - like in my trazodone essay - but I’m sure that at some point I will have to write a whole ‘nother post explaining how I was horribly wrong. Either way, it’s not going to be an addendum at the bottom of a 25-minute read.
It Needs To Be Fun For Both Of Us
I like being able to write in my own voice. I like including a few paragraphs on odd pieces of trivia without caring about the word count. I like having footnotes11. I like making jokes. I may derive some pleasure from forcing you to read them. I like playing with the structure of the text on the page; and using semicolons where they don’t technically belong. I like nobody being able to tell me, “a scientific essay just isn’t the right place for those sort of things.”
I think that all of those things are a big part of what makes my writing good and in turn makes people like you want to12 suffer read through a few-thousand word essay on why Trazodone is not a good sleep drug, and maybe even enjoy it a little bit. I hope that when you read my work, you go “wow this guy really must think that this stuff is pretty cool, and he’s right, it is pretty cool!”13.
Selfishly, but perhaps most importantly, being able to write this way is also what makes it enjoyable enough that I keep coming back. The way I see it, we’re in this together - I tell you some interesting things, you tolerate bad metaphors about Suboxone.
Thanks, as always, for reading.
Hi Dr. Q
I may have a slight problem with authority
I would like to continue to apologize to Scott for shamelessly fawning over his work as I suspect it makes him mildly uncomfortable. Unfortunately, I regret to inform him that I will not stop any time soon.
I swear it feels like I’ve been reading it since high school, but the oldest post is from 2013 and I graduated HS in 2011.
A term I use so loosely that it may represent a true thought disorder
Which, uh, if you want a great example of the schizophrenic thought-process, you can’t ask for better.
It still holds up as an adult - go read it if you haven’t. Even if you don’t like SciFi.
For those of you who don’t get the metaphor but would like to: don’t bother, it’s not that funny.
For those of you who don’t care and want to get it anyway. Ok, fine.
Suboxone is a medication for people with opioid addiction to help control cravings. It contains buprenorphine which partially stimulates the opioid receptors and prevents cravings and opioid withdrawal, but can also get you high if you take enough or inject it right into your veins. To prevent people from doing this, suboxone also includes a drug called naloxone which blocks the opioid receptors and will throw you straight into opioid withdrawal. This is a very unpleasant experience. Fortunately, buprenorphine is well absorbed through the membranes of your mouth and GI tract, while naloxone is barely absorbed. So, as long as you don’t try to inject it, you’ll just absorb the buprenorphine and won’t go into withdrawal.
There are dozens of other examples of this sort of thing - this one has just stuck in my mind.
Shout out to the Bartimaeus books.
This is too embarrassing to put in the body of the essay, but I’m the sort of biology nerd who is literally brought to tears by things like this music video which is a parody of Despacito all about the field of evolutionary developmental biology, just because of how beautiful and complex I find nature to be.
Or at least tolerate
Amen brother, publishing in journals requires going through editorial boards, a process that has become substantially dilutive and like you say requires hedging strongly worded conclusions.
Looking forward to more deep dives here, you are certainly having an impact on my practice
Dr Wendel, I think that you should begin publishing in journals specifically so I don’t have to read any more suboxone metaphors.