In the webcomic The Oatmeal, illustrator Matthew Inman tackles the backfire effect. He goes on to discuss how the part of one’s brain called amygdala “makes us biologically wired to react to threatening information the same way we’d react to being attacked by a predator.”1 Inman’s comic was a popular statement in anticipation for the 2016 election and presently remains relevant due to its wry humor and ongoing significance on why people are so resistant to hearing contradictory facts. However, many political scientists found it hard to replicate as a large-scale peer-reviewed study could not reproduce the findings.2 I felt myself backfiring from reading the backfire effect. This phenomenon is the epitome of how debates begin, of how medical ethics are handled, of how scientific research is initiated.
The motivated reasoning and confirmation bias that Inman discusses in the backfire effect can be manipulated in medicine, similar to the “truthiness” model. Dr. Jeffrey Matthew from the University of Wisconsin adopts Stephen Colbert’s illustration of the “truthiness” model as “Truth that comes from the gut, not the book.”3 The backfire effect and the “truthiness” model are some of the reasons as to why trusting the knowledge that professors, peers, or anyone else impart is so difficult for me. From one angle, I could see the controversial information that was taught to me as something that is just testing the resistance in my amygdala.
I observed the bleak reality of clinical based medicine as something that has been anecdotally passed down to form “truthiness” yet have no evidence-based methodology. For example, we were taught the five most common causes of postoperative fever with one of the causes being atelectasis (partial or complete collapse of lung). However, the relationship between atelectasis and postoperative fever is unsupported. This ongoing tug-of-war between what is factual and what is practiced is the foundation of curiosity in medicine. It’s why I was interested in this profession in the first place.
I was looking for answers. I did not want to look for them in books. That is why I consider our clinical rotations, known as the Longitudinal Integrated Clerkship (LIC) a perfect program for students like myself. TCU & UNTHSC School of Medicine’s LIC incorporates multiple specialties in one longitudinal rotation for approximately 40 weeks. This type of integrated learning allows us to test controversial information such as indication for which diabetes medication to prescribe in the various specialties. These experiences allow us to decide upon our self if these “clinical pearls” are a part of the backfire phenomenon or a form of “truthiness”.
Several patients one day presented with evidence-based urgency hypertension, something I had recently read about but had not yet seen in my patients. These patients had blood pressures well over 180/100 such as 191/106 and 185/103, whereas normal blood pressure is 140/90. Proper protocol from my notes would suggest “oral antihypertensive agents, including β-blockers, angiotensin-converting-enzyme (ACE) inhibitors, or calcium channel blockers.”4 Proper protocol in my clinic: perform the HPI for the patients concerns and not address the hypertension. Talk about backfire.
I began to question if evidence-based medicine is preferential over clinical based medicine. I asked my internal medicine preceptor her thoughts on the difference between clinical based and evidence-based medicine in this scenario and she stated “What evidence-based medication does not always take into consideration are the social factors such as patient compliance and adherence along with socioeconomic disadvantages. When those factors arise, that is when clinical based medicine becomes preferential to evidence-based medicine.
This is where I had to start learning the difference between clinical based practice and academic based practice. I found several articles on UpToDate that both supported and contradicted the clinical based practice in measuring high blood pressure in the clinic. My realization from this search was exactly what Dr. Jeffrey Matthews touched on in his lecture: “evidence is elusive.” Proper protocol depends on what year of research does the physician base their protocol on, the type of medicine (clinical or evidence-based) the physician practices, and just the physician her/himself. Now that I have learned, seen, and practiced the difference, this is a lesson that will never be forgotten.
By any circumstance, this narrative piece is not me passing judgement. This reflection is about me ultimately realizing how medicine is fluid with waves of preference in evidence-based medicine or clinical based medicine. As a naïve medical student, I supposed the two would be one. Oh, understanding that the two types of medicine are rarely unified backfired on me- and my amygdala, the emotional cortex that hosts our core beliefs!
1 Inman, Matthew. “You’Re Not Going to Believe What I’m about to Tell You .” Comic strip. The Oatmeal, 2016. https://theoatmeal.com/comics/believe.
2 Haglin, Kathryn. “The Limitations of the Backfire Effect.” Research & Politics 4, no. 3 (2017): 205316801771654. https://doi.org/10.1177/2053168017716547.
3 Truth and Truthiness in Surgery . Truth and Truthiness in Surgery , 2016. https://youtu.be/swYKy_u3If0.
4 “Emergent Hypertension.” USMLE-Rx. Accessed June 2, 2021. https://usmle-rx.scholarrx.com/rx-bricks/brick/CP_CAR0087.