What We've Learned From Sensible Medicine

Reflecting on the first three years

It is hard to believe that we are coming up to the third anniversary of Sensible Medicine, well into toddlerhood. None us could have predicted that the site would last this long or be this successful (93,000 subscribers!!!!). The three of us are getting ready to meet up in person for the first time and we thrilled to see what the future will bring. We have some exciting plans.

Three years seems a reasonable milestone to call for some reflection. So, as is our usual approach, we each wrote a short piece about what we have learned so far. Thanks for all your support.

Adam, John, and Vinay.

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Adam Cifu

I’ve learned that our readers, subscribers, and contributors are smart, generous, and kind

You have been willing to engage on issues which we all feel strongly about and sometimes disagree on. When you write on the internet most people tell you, “Don’t read the comments.” After three years, I can’t disagree more. The time and energy that our readers put into comments is amazing. I understand the topics I’ve written about better after reading your comments. Those of you that disagree with me (almost) always do so productively. Our contributors work incredibly hard on their pieces.

I’ve learned that a lot of people really hate doctors

People don’t hide their feelings in the comments. It would be presumptuous to assume to understand where this disdain originates. I expect the origin is unique to each person -- bad treatments, bad interactions, bad outcomes... I am reminded that we in medicine need to do better. Non-selectively hating doctors, and medicine serves neither doctors nor patients well.

Writing helps you think

Doing the work I do, with the colleagues I have, it is easy to come up with topics. It is when I sit down and try to turn a thought into an 800-1200 word post that I figure it out. It has becomes clear to me that every topic becomes more complicated when I sit down to write about. I love that my opinions often change as I write. My favorite chemistry professor, while trying to convince us to copy over our class notes every day, told us that “you learn through your fingers.” I now know that you think through them as well. (I should have realized that over 30 years of recognizing diagnoses only when I write my clinic notes.)

Writing is habit forming

I’ve found myself writing about a bunch of things that have nothing to do with Sensible Medicine (or, really, medicine of any kind). I am going to start putting them up another Substack. (I’ll post the first one today!) If you’re interested at all, subscribe to Baseball, Music, Art, and Other Non-medical Dalliances. I promise what goes up there will have nothing to do with what we do here.

It is a challenge to respect people you disagree with

Whether it is in my own writing, the comments, or submissions, we often extrapolate disagreeing with someone to disliking or disrespecting them. Most of us need to do better in this regard. (We try to edit the ad hominem attacks out of rebuttal articles. We have not been perfect at this.)

Only Joan Didion can write like Joan Didion (and only Vinay Prasad can write like Vinay Prasad).

We get a lot of submissions written in the meandering, thesis-less style of Didion. I often write like this too. I’ve come to realize that unless you’re a generational talent, these “essays” seldom work. Vinay also has a very specific voice – I think we all know it. Many of our submitters are inspired by his writing and try to write with his tone. This, also, seldom works.

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John Mandrola

I can’t believe it’s been three years already. Here are a few comments:

First: I am surprised

I doubted Sensible Medicine when we started. The Internet is vast; there are plenty of places for people to read medical writing. This won’t work.

But it has. Sensible Medicine has exceeded my expectations. More than a million people look at this site—per month! Pageviews, however, are not my most important metric. For me, I am happiest when an established expert comments or messages me about a post. Even if they disagree, my first thought, is holy shit, that (famous) person is reading Sensible Medicine.

My theory is that Sensible Medicine works because people are hungry for independent non-industry supported thinking. I would not say that we are unbiased, but we surely have different biases than “normal” medical sites.

We have the freedom to say, hey, the emperor really is naked. I love this about Substack and independent sites.

Second: There is dessert and there are vegetables

I knew this from my previous writing, but gosh do we see it here.

If you write about vaccines, COVID craziness, statins or anything political, the pageviews go nuts. This is Apple pie or Cheesecake.

If you write about Bayesian statistics or instrumental variable analyses, you don’t get the pop. These are vegetables.

I love that we get to do both. (And we have Vinay to save us from a slow week.)

Third: Writing is hard but editing is harder

It is fun to feature the writing of others, especially when it disagrees with one of our opinions. Some of the submitted work is superb. But not always.

I have learned that I am not a great editor, nor do I love editing. In one of my other jobs, over at theHeart.org | Medscape Cardiology, I have the benefit of a brilliant editor. We’ve got to know (and trust) each other over the years, and it is immensely valuable. She makes my writing better. Sensible Medicine has enhanced my appreciation of good editing.

Fourth: Criticism of a study is often taken personally

It should not be. I remember co-authoring a paper on the Fragility Index. I now realize that you don’t need it. If you understand power, confidence intervals and p-values, you can tell a study result is fragile without an index. At the time, however, I thought FI was a nifty way for newbies to understand statistical analyses.

Then one day on my way home on the bike, I heard Vinay just obliterate the FI. I think he called people who cited it, idiots. I laughed hard. I did not take it personally.

When I criticize a study, I know that the first author is often a young person who did a ton of work to get it published. I now realize that critical appraisal can hurt feelings. IT SHOULD NOT.

We criticize studies because that’s what science is about. In the process of arming people with bamboozle-prevention skills, we have to highlight the limitations of a study. And all studies have limitations. This is normal.

I strive to be fair, but if we were not strong than Sensible Medicine would be no different from reading editorials in medical journals or listening to late-breaking trial discussants.

Fifth: People are generous

I don’t have specifics, but nearly all of our posts are totally free. Yet so many of you choose to support us with real money.

This, too, was a surprise. Thank you to all our subscribers. Your generosity is amazing. I think we are just getting started.

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Vinay Prasad

Over 3 years of writing for Sensible Medicine, I have learned a few things.

Some people like swear words and others can go to hell ;)

I use them at times, and make no apologies. My aesthetic pursuit in writing is to most accurately transmit my thinking and these words are a part of that. I don't ascribe a moral dimension to them. Recently someone unsubscribed from my other substack Vinay Prasad’s Observations and Thoughts because of swear words. If you are that fragile, you probably should enroll in a modern day med school.

Writers are not responsible for readers.

I am constantly puzzled why anyone thinks writers are responsible for all of the comments by readers. Naturally, some readers go further and in ways that the authors don’t support.

Many people read and essay they disagree with, and email us, but refuse to write a rebuttal

I can understand reading something and hating it and moving on, or reading it, and writing a rebuttal, but I can never understand writing us a 1200 word email to complain but then saying you don’t have time to write a rebuttal.

Those that do write rebuttals find that it is can be hard to make your case

Years ago, when calling a cardiology consult, the cardiologist told me why he disagreed with my recent JAMA IM essay. I told him to write his views up and publish them. He did and spent months trying to get the essay accepted (despite it’s pro-intervention, aka favored, stance), and ultimately it appeared in a predatory journal. It was longwinded and confusing. I think many find it is harder to turn your intuitions into arguments than you may think. Still, it is worth doing.

We might be the only medical publication that publishes opposing ideas

As i wrote recently, the establishment has failed. We need Sensible medicine now more than ever! Please subscribe.

Photo Credit: Marcel Straub