Editorial: Ezetimibe and Etiquette

This is an editorial or rant, I guess it depends on your perspective. I have been contemplating for a few days if I should bother with this post. However, as a wise friend once counselled: “the standard that you walk past, is the standard that you accept.” So I have decided to write this in order to have a place to direct folk in the future when confronted with rude or unprofessional behaviour in the electronic environment.

In recent times I have been writing a column for the Royal Australian College of GPs. This came about after I started the “Old Doc, New Drug” series on the blog. The editors of the NewsGP College magazine thought that my attempts to make pharmacology fun would be popular their readers. I have enjoyed writing these articles and received a lot of positive and useful feedback.

Last week my article on the cholesterol medication ezetimibe was published. Ezetimibe is not a “new drug”, it has been on the market for 15 years. However, as a remote GP working in ED and Anaesthesia it is a medication that I don’t prescribe. I felt that there was a gap in my knowledge which I needed to rectify.

This has always been the ethos of the BroomeDocs blog: wondering aloud into the ether and exploring new ideas. My very public demonstration of ignorance and learning has resulted in a lot of great educational opportunities for myself and hopefully the readers too. The basic contract is this: I spend my spare time researching and writing stuff I hope is helpful to other doctors – the readers can take it or leave it but it is all for free! Nobody loses.

Putting oneself “out there”, online requires a thick skin. I have certainly had my share of colourful debates in the comments section! On some occasions I have argued aggressively to make a point. However, the argument is always with the science, not the person.

A few days ago I got a text message from a close friend and fellow GP who was sitting in her office in Victoria reading the latest NewsGP. When she scrolled to the comments section she was quite annoyed by one particular comment and brought it to my attention. In the eternal world of the internet – here it is as written in a public professional forum:

Jon   1/05/2019 9:55:19 PM Respectfully, how is this a “new” drug? It’s been on regular use for years. A brief Google search finds that it has been on the PBS since 2004 https://www.researchgate.net/publication/310587922_Ezetimibe_Use_costs_and_adverse_events_in_Australia. In fact, it was the subject of an NPS RADAR bulletin in 2004 as well. If “only one class of drugs” has been used to lower cholesterol for “the majority of” you career, and it ezetimibe has only recently made its way onto your radar 15 years after its PBS debut, then I guess you’ve hard a long career – and one that didn’t involve a great deal of ongoing CPD. What’s next? An article about that new-fangled metformin you’ve started hearing about?

This is clearly not the worst thing ever written upon the internet. However, I would like to use it as an example of the sort of behaviour that makes me worry about some in our profession. Let me take you through it….

Firstly, if you are a healthcare professional and would like to make a comment then you should never do so anonymously. Anonymous comments are the academic equivalent of childhood “ding-dong ditch” pranks. If you have a point to make; please own it and have the courage to use your full name.

Remaining anonymous is argumentation cowardice. Much of what is wrong with online society would be resolved if we were all required to make comments in our own, identifiable voices. My guess is that the trolls would rapidly disappear once unveiled. Few people are truly jerks to your “face” even when it is only a unique, identifiable avatar.

Anonymity removes the other person’s ability to engage in a true, reasoned debate. I am certainly not going to argue with; or explain myself to an egg emoji.

Second point. Opening with ‘respectfully’ is a red flag for rudeness. In the comment above the tone becomes increasingly less respectful as it progresses. As professionals, we should assume ‘respectfully’ as a given. If you need to say it (or write it) then I am not surprised that you are full of vitriol, ready to bubble over. Please don’t use the term if your goal is to be the opposite.

Next up… “a brief Google search“. Condescension is never a great look. If Jon had read the article then he (or she) would realise that I actually did quite a bit of research in its production. Of course, if Jon had done a brief Google search for “Casey Parker” they might have discovered that I am either:

• A Panamanian pornographic actress
• A hunky cast member of the medical drama Grey’s Anatomy
• A rural GP, author of the BroomeDocs blog and podcast

For the record, I am the latter. If Jon had checked then he/she would have realised that the series “old Doc, New Drug” is not about cutting edge pharmacology. Rather, it is about disseminating useful knowledge for other doctors in what I hope is an engaging and easily read style. I am the Old Doc, the Drugs are new to me!

Now in fairness Jon is, in a strange way, complaining that the drug that is being discussed is ‘not new’. It has been on the market since 2004. He / she is entirely correct as the Google search confirms. If this is the point Jon wishes to make – then it is clearly correct – he/she wins the debate (which I was not aware I was a party of until this point).

Whilst this article is nominally about an old drug, it is actually about the recent evidence that has emerged about ezetimibe. The trials that were analysed were published quite recently in 2015 and 2017. So it seems that Jon either did not actually read the article or has judged it entirely on the title which is at best laziness.

I suspect though that Jon’s real motivation for tilting at my written windmill arises from vanity. Jon is attempting to demonstrate to other readers that he/she is smarter than the chap whom the editors asked to write the article. Hence, he must be very smart indeed, right?

Sadly I must pull that rug out from under Jon’s feet and assure him/her that I am not particularly smart. My IQ is likely around 100 and as such he/she stood a 50% chance of being smarter than me before demonstrating this in writing.

The part of the comment that really bothered me [ I am not counting the spelling or grammatical errors] was this low blow towards the end. “it [if ] ezetimibe has only recently made its way onto your radar 15 years after its PBS debut, then I guess you’ve hard a long career – and one that didn’t involve a great deal of ongoing CPD. “

There are a few things going on in this sentence. A direct attack on your opponent’s intellect is argumentum ad hominem (an argument against the man). This is widely considered the basest form of argumentative error.

The inference is that I must have been living under an educational rock to be so ignorant of this drug. Well, possibly true, I have spent little time on this particular agent, but it is a logical error [ hasty generalisation or inductive fallacy ] to generalise my specific ignorance of ezetimibe to my broader education or knowledge.

The myth in play here is that we doctors have (or should have) a perfect understanding of everything we do in medicine. This is born from the ridiculous culture of medical school where we all strive for 100% and feel like a failure at any less. This myth is both wrong and harmful.

The facade of the ‘perfect doctor’ is comical at best. More importantly it gives rise to the kind of arrogance that prevents one from questioning the “old truths” and exploring better ways to do the best by our patients. This myth perpetuates the kind of bullying, pimping and abuse of power that still plagues our profession. I do worry about our professional culture when I read comments such as these. This was largely my motivation for responding

Finally, in response to Jon’s parting shot… I will write that article about “new-fangled metformin“. I have prescribed it for many years and yet I know that there are many things to learn. I am perennially fascinated by what I learn every day. Medicine is complex. The science changes every year. Our minds must remain open if we are to provide the best care that we can.

One of my favourite talks from the SMACC conferences was by Dr Jenny Rudolph. In it she espouses the re-framing of the “WTF” moment. That is, when you see something that seems dumb, ludicrous or plain wrong and you begin to ask … WTF?… rethink the situation as “What’s Their Frame?”

Instead of assuming that the person making the obvious error is somehow inferior or incompetent – take a step back. Convert your righteous indignation into genuine curiosity. Ask yourself: “what lead this person to this situation?” or “where is this person coming from, what is their motivation?” Then, and only after discovering the source of the error should you interject and give feedback. After doing so – I am still at a loss to understand Jon’s frame.

So, please, when writing comments on professional websites, blogs or Facebook groups please spent a moment examining your motivations before hitting “enter”. I suspect that most trolls may have a valid point. A moment examining one’s posture may allow that point to be made in a truly collegial manner.

If you see bad behaviour online that does nothing to expand our knowledge or progress the profession – call it out. Respond and comment in turn. Or at least send them to this page!