This is point of inquiry for Tuesday, August 16th, 2016.
On Josh Zepps, host of We the People Live. And this is the podcast of the Center for Inquiry, a wonderful institution whose work you should support, whose work you do support merely by listening to this show that is working and probably also supporting various.
Otherwise, we’ll all know the saying, the slogan, faster, higher, stronger copier. Make sure I have been paying attention to the Olympics. But if you have cupping is back, you may have noticed, thanks largely to Michael Phelps. If you watch him smash all kinds of ridiculous records and take home embarrassingly large quantities of medals, you will also have noticed that he’s a big fan of cupping. So we thought we’d take a look at why, what it is. Is there any science behind it? What should we do? One man who knows is David Gorski, professor of surgery at Wayne State University School of Medicine. Breast cancer surgeon at the Barbara Ann Come on US Cancer Institute. And the managing editor, of course, of science based medicine that science based medicine dot org. A fantastic blog. David Gorski, thanks for being on point of inquiry.
Hey, thanks for inviting me. So I think a lot of people will have been watching the swimming at the Olympics, as I have, with a look of mild bemusement on their face as to why Michael Phelps and a lot of the other swimmers have these gigantic circular red hickeys all over them.
Someone with a very round a mouth has been has been canoodling with them.
They’re like, very, very perfect. You know what?
What are they doing? What’s coming? Let’s let’s go back to the. The genesis of the theory behind cupping.
Where did it start? Well, it’s first of all, it’s kind of funny, because when I was watching the swimming part of Sunday night, 9:00, I noticed that I was like, are those what I think they are, you know, getting closer looks? Oh, yes, they are. And then, like, my email started going crazy about this.
And by the next morning, there are a ridiculous number of stories. In any case, cupping is a practice that is indeed ancient. It’s true these days. It’s most associated with traditional Chinese medicine, but it appears to have appeared or been thought of in many cultures over many centuries, going back at least as far as the ancient Egyptians around 3000 years ago or more. And it basically involves suction. And the way the suction is achieved in a lot of cases is that, you know, these little glass cups, the air inside them is heated with a mat, you know, with a candle, a wired or whatever, what have you. And then it’s applied to the skin. And of course, as the air cools, it causes, you know, it’s suction and it pulls the skin up into the cup and they’re left in place for anywhere from five to 10 minutes. And the idea is that they are somehow drawn, you know, either drawing out the toxins or stimulating lymphatics or in some other excuses or claims is that they increase blood flow, which is a particularly ridiculous claim, which I’ll explain in a minute. In any case, there there are two kinds of cupping, wet and dry. You know, basically wet cupping actually involves making a nick in the skin after the cups in place. And it’s actually basically a form of blood letting. The other kind. Does not involve breaking the skin. And, you know, there are variants, as you may have seen. And yes, as I investigated this, I found all sorts of pictures all over social media of various athletes getting it done.
Instagram in particular was a rich source copying pictures and the original theory behind it, I guess the Chinese, at least a memory, as you mentioned, that it has it has sprung up spontaneously over the course of thousands of years and lots of different civilizations from Native Americans to to do a price to to all over the place. But the theory behind the Chinese incarnation of this had to do with the same the same theories about energy forces and cheatgrass, like the body that acupuncture removing.
Right. Right. Right.
Improving the flow of Chey that this is presumably not the rationale of Michael Phelps and his medical physicians, if you can call them that. Believe in. Do we know what they think they are doing now?
Well, there was an interview on NBC News, NBC or NBC Sports, which is particularly bad at covering this.
And I suspect the obvious reasons they don’t want to bad mouth the athletes and they all basically, you know, like.
And eyes with these incredible portraits of them overcoming a birth adversity and such. And, you know, saying bad things about them, breaks the, you know, breaks that law. Yeah. But in an incredibly credulous story that I saw Monday, I believe NBC Sports, you know, interviewed some of the athletes. They interviewed the head trainer for the U.S. swim team. I forget his name, but he you know, his rationale was kind of the same as the modern rationale, which, you know, is sledded either somehow improves lymphatic flow or it improves blood flow to injured muscles, you know, and helps decrease pain and speed healing. And unfortunately, that was the template for a lot of stories because there was a story on my local NBC affiliate that was particularly annoying that I saw Monday night where they sent one, basically sent one of their anchors to a traditional Chinese medicine clinic where he, of course, underwent cupping and was talking about how great it was. And I’m guessing that there are probably stories like that in local media all over the country now.
Mm hmm. And this is apparently something that Michael Phelps has done for a while, has been doing for at least a couple of years. And he thinks that it makes him feel better.
Right. Yeah. I don’t know exactly when he started it. And I don’t know if the trainer was a true believer or if Michael Phelps talked him into learning it because he liked it so much and he wanted it. But whatever the reason, it’s a fad. It’s definitely a fad this year.
Do we know that its claims are not true? I mean, when you look into studies, I mean, like, well, alternative medicine. Well, not not like, well, whatever medicine, like some popular version incarnations of alternative medicine. The people who believe in them do experience benefits from them, at least superficially and psychologically. I know there was a study in 2012 of people with chronic neck pain and the ones who liked cupping felt better. Some claimed that their neck pain went away more than other people who didn’t get cupping. I mean, how you unpick the placebo.
Yeah. So I’m doing good, too. Are we sure that we confident that there is no medical utility?
Well, when you look at any claim, any health claim, be it conventional medicine, alternative medicine or whatever, you have to look at two things. First, is there any biologic plausibility? OK. And yes, it’s possible to be wrong about biological plausibility, although for something, for instance, like homoeopathy, you know, we’re not wrong about the utter lack of biological plausibility. But cupping actually does something physical as opposed to invoking the memory of water or, you know, saying that you dilute things to nonexistence. And they get stronger. So, first off, you know, think about what cupping does.
The claim is, for instance, that it improves blood flow. But in reality, what it’s doing is causing superficial injury that is indistinguishable from a bruise. So we know when you suck the skin up into the cops, it actually decreases blood flow. And the negative pressure causes capillaries to pop, which is where you get that lovely purple color. It’s a bruise. You know, that’s what it is. It’s a superficial bruise in the skin and superficial subcutaneous tissue. Now, yes, that provokes an inflammatory reaction after you take the cup off because it’s basically a bruise with no blood outside of the blood vessels. And the body gets rid of that with an inflammatory reaction. Whether that, you know, it’s pretty implausible that that would do anything to enhance athletic performance or speed healing. But what about the clinical evidence? You know, reviewing the clinical evidence, as I did for a couple of posts, I know it’s pretty like many alternative therapies. It’s mighty thin. You know, there’s a lot of poorly designed studies and that very well controlled systematic reviews finding, oh, maybe it does something for pain. Now, one of the messages that we try to put out at science based medicine or I’m the editor, is that if you take something with a low prior plausibility based in biology and science and combine it with tests of that modality that are equivocal, you know, or maybe weakly positive, maybe equivocal, you know, not very good or convincing. That’s basically negative studies. You know, it doesn’t work. Now, I know some people have invoked. Well, you know, like athletes are tend to be superstitious. It’s things that help them focus. You know, like they have their little rituals that they do before they compete. They you know, the very, very you know, they have their lucky socks or whatever. And it’s really. Real clear whether that actually helps or not.
Well, depends how much they believe it done it. I mean, if you believe if you believe that there’s no way that you’re going to make that I run unless you have your lucky socks on, then you’re probably not gonna make that ironic.
Well, you know, it’s possible. It’s possible. But, you know, this is nothing new.
I was talking about this the other night. Steven Novella. And, you know, for instance, do you remember what the fad was at the Olympics in 2012?
It was those those one of those tapes, you know, those colored tapes. I’m blanking on what they’re called now. Oh, it’s what I like to call a Brain Furter senior moment, but it’s Kinney’s. You’ll take Kinney’s outright, you know, things like that. Yeah. Yeah. That was a fad back then. You don’t see it and it’s still around, but you don’t see it nearly as much. These Olympics for whatever reason. And then there was a time when, you know, the magnetic bracelets were enough. Yeah.
Yeah. I mean, so there were a couple of things. Is it worth it’s worth not conflating those two things that you just alluded to. Right. One is the the sort of placebo effect of just feeling like you’re doing something that you like. Whether that’s lucky socks or whatever. And then there’s the question of believing that it actually does something. And if what if what cupping is doing is bruising, you made you believe that your muscles work better when they’re tenderized and that it’s sort of an alternative to a massage.
Maybe. I mean, isn’t doesn’t a massage also break down tendon, tendon tissue and then so on?
But in general, all that you’ve just brought up another rationale, they claim, oh, it releases you know, it’s myofascial release, you know.
The thing about a massage that’s different than cupping is cupping is almost all superficial.
It’s just the skin and, you know, immediate subcutaneous tissue. Whereas when you’re doing a massage, you’re actually massaging the muscles, because when you when you put those cups on all, it doesn’t suck the skin and a little bit of subcutaneous tissue into the cup.
And that’s where the tissue injury happens. So they are different. And in general, a good massage should not cause tissue injury, you know, which means being done. You’ve got a really inexperienced masseur.
Yeah. So, okay, so then people the next point that people will tend to raise is, well, okay, so it may not work, but it makes them feel a little bit better. So where’s the harm?
And I think we could probably divide the harm into two potential categories. Right. The first being physiological harm.
And I know that you can speak to cases where this has been conducted, where I caused real harm. And then after that, I think we can also get to just the the philosophical and psychological harm to the scientific method that is incurred by the by widespread practices that make no sense.
Well well, for friends, you know, yes, it can cause harm. Now, people say, oh, that’s incompetently done and maybe that’s true. But, you know, there are examples of if you leave the cups on too long or if the negative pressure is too much, you can actually cut the blood flow off to the skin to a point where the skin actually dies.
And when the skin act, when the skin dies, it’s basically indistinguishable from a burn because, you know, thermal injury to the skin is basically the skin is burned until it dies. But, you know, in terms of how they heal, they’re very, very similar, you know, a burn versus killing off the skin. And, you know, I wrote about a case from Australia in June or July where this guy was so enthusiastic about cupping that, you know, he insisted on having it done this, you know, in the same locations over and over again and, you know, for long periods of time. And he actually did have these cup shaped dead patches of skin on his back.
I mean, the photos are horrifying. People can look them up if they want. I, I hesitate to tell you to include a link, a link to it just because his basically his back has a half dozen cup sized third degree burns with holes poking through his skin into his flesh. And he has sepsis of some kind, seemingly. So he’s also got an infection. I mean, the reason why you have to keep burns clean. Right, right. Is because they’re susceptible to infection, which he seems to have gotten.
So. So there’s that. And, yes, that’s uncommon. You know, the reason that made the news is it’s uncommon, you know, but but it’s it exists. And you can argue. Well, yes. You know, if there’s no benefit, no discernible, objectively demonstrable benefit and there is this risk, then it’s all risk and no benefit. You know, that’s one way to argue it. Now, as you say, there’s the there’s another problem. And this brings into the springs into play. You know, one thing that we’re about on the science based medicine blog and that. Is how pseudoscience has infiltrated medicine, and particularly in some large academic institutions, in the form of, you know, what they used to call complementary and alternative medicine, but now prefer to call integrative medicine. As in, you know, integrating these methods with science based medicine. And as I like to say, integrative medicine departments are popping up like kudzu all over the place and basically very little to no evidence that a lot of this stuff works and some of it is outright quackery. And so where do reporters go when they see something like Michael Phelps and his cupping marks? Where do you know where to? Where is a reporter going to go for an expert to give him a quote? They’re going to go to these integrative medicine departments. And so they did. You know, I saw quotes from. The head of integrative medicine at Duke University who said he was happy to see the marks and Michael Phelps because it meant that his integration of this was becoming so mean. He saw it as an indication that he, you know, integration was becoming more popular and mainstream, even as he admitted that there is no evidence that it really does anything.
And both he and the head of integrative medicine at the Mayo Clinic and the Mayo Clinic is big into this stuff, too. Agreed that cupping alone is is not you know, what the athletes are doing is like cupping in isolation is not ideal to them. They view the cupping. They said, well, if Michael Phelps had come to us, we would have been able to give him cupping. But we would have done it as part of a full integrative medicine consultation and a complete holistic approach that would involve traditional Chinese medicine and all these other things, which are like ninety nine percent pseudoscience. And so it’s like cupping is the gateway, the gateway Wu, if you will, is for us. And that’s how they viewed it. And the worst offender of all that I’m aware of so far, the Cleveland Clinic, which tweeted a link to a video on its media page of an acupuncturist talking about cupping and how it’s done and doing a demonstration and going on about how great it is.
And they posted this to their Facebook page and they post and they they tweeted the link. And unfortunately, the Cleveland Clinic is one of the worst as far as integrating pseudo science into medicine. It’s a shame because it’s generally a great place otherwise. For instance, it offers all sorts of stuff and it’s integrative medicine department from traditional Chinese medicine, I think cranial sacral acupuncture, etc.. It has a traditional Chinese medicine herbalist that, you know, unstaffed, that it made the news a couple of years ago. For that it has a functional medicine center figure headed by Mark Hyman, who is like the guru of functional medicine, which, you know, I like. Functional medicines are a hard one to explain, but it’s basically it involves measuring pretty much everything and trying to correct pretty much everything with supplements it’s or whatever. And there’s not a heck of a lot of evidence from much of it at all.
If there’s not a lot of evidence for these things, why are y. Who’s paying? I mean, like, if it were just very rich people paying out of pocket, then I would it wouldn’t really bother me. But why are health insurance companies presumably paying?
Well, health insurance companies will pay for some things, like some health insurance companies will pay for acupuncture. I don’t know too many that would pay for copying.
So why are these clinics doubling down on this, presumably? I mean, I guess I guess the subtext behind my question is a little bit about the way that the American healthcare system works in the first place, because I know that in my home country of Australia, where we have Medicare for all, Medicare will only pay for things that are verifiable.
It’s not gonna it’s not gonna blow finite taxpayers resources on things that don’t work.
This is true. And yet Australia does not lack for this sort of stuff.
That’s right. But you would never you you’d never see it from an equivalent of the Mayo Clinic or the Cleveland Clinic in Australia.
I don’t think you’re saying there are no universities, medical schools there that offer it.
I I’d take that bet immediately. This is a slice of every medical school. Don’t worry.
I’ll have to decide when I have time that all but I would be I’d be very surprised if they were I’d be very surprised if they were they were enthusiastic integrative departments in hospitals in Australia. Because that’s essentially what you’re talking about, right? The Cleveland Clinic.
Right. But in any case, I mean, here it’s some of the biggest hospitals. Like I said, Duke, Cleveland Clinic, Mayo Memorial Sloan Kettering. Although to its credit, Barry Cassilis, who runs the Integrative Medicine Program at Memorial, has said that cupping is nonsense. So if it did, they kind of vary in how far down the rabbit hole they go. You know, it is with some of them very, very far down and some of them, you know, dipping their toes in. But it is disturbing.
Now, I mean, part of it is a perception of patient demand. Yeah, part of it is kind of philosophical. I think there is American. Medicine is suffers from a number of issues, but one issue is that a lot of the primary care doctors are feeling unfulfilled just because it’s really hard to stay. Keep your head above water without seeing a whole lot of patients. And that means you don’t get to spend that much time with them and you feel less and less like the total doctor.
And here is integrative medicine saying we give you the tools to be the doctor to the whole person.
The holistic doctor. You know how we treat the whole patient now?
It’s a false dichotomy, of course. You do not have to embrace pseudoscience to be a holistic doctor, a good internist, family practitioner or pediatrician, whatever primary care specialty. You are a good doctor. A good primary care doctor is a holistic doctor. And you don’t have to embrace acupuncture. Reiki, you know well the apathy or naturopathy, because a lot of doctors, you know, know that homeopathy is nonsense. Okay. But, you know, they’re blind to what, you know, what a lot of these things are. For instance, a couple of years ago, I wrote an article about integrative oncology in and in, and I talked about homoeopathy. Well, one of the criticisms was we don’t use homoeopathy. You know, it came from the Society of Integrative Oncology. They were very ticked off at me because I wrote a review article and a, you know, an opinion piece in a very high impact journal that Nature reviews cancer and basically calling a lot of this quackery. So they say we don’t use homoeopathy. We know homoeopathy is bonke. So I said, OK, my response. Do you use naturopathy? And the answer is, of course, yes. In fact, natural past’s could be members of ASIO. And in fact, Matra Path wrote some clinical guidelines for the supportive care of breast cancer patients that I had criticized. You know, there were natural path there.
I said, OK. You have natural paths.
Well, naturopathy, although it encompasses a whole lot of wew, as I like to say. One key component, naturopathy is homoeopathy. Every natural path learns homoeopathy. They don’t all practice it, but many of them do. So if you have, as I like to say, in states where naturopathy is unfortunately licensed, there is a test called The End Plex, which is their licensing exam. There’s a big section on that exam on homoeopathy. I would love to get those questions, but see what they are.
What type of water would you prescribe for headaches? Different type of water, would you, to prescribe for irritable bowel syndrome?
And then I pointed out that one of the coauthors of their of their clinical guidelines on breast cancer actually has in clinical trials dot gov.
A clinical trial on homoeopathy and on a homeopathic remedy. It’s so like you guys don’t even know what you’re getting in bed with, I think.
But I think part of the problem here in selling this way of thinking is, you know, and when you say that this sort of appeals to doctors who are sick and tired of the narrowness of their profession and want to feel like they’re doing the right thing by treating the whole human being in a holistic manner, is that it is addressing it’s addressing a problem that does exist insofar as medicine and the pharmaceutical industry can seem overly narrowly focused on particular diseases and particular symptoms and particular cures and insufficiently focused on the entirety of the human being.
So, you know, how often do you go to the doctor and and do they really try to get serious with you about what you’re eating and about, you know, how much you’re drinking? Well, maybe drinking they do. But, you know, there’s you don’t get the impression in a hospital that you’re being cared for and nourished as some kind of spirit, having an experience on planet Earth.
Now, I take your point that the correct response to that is not to dove into woo woo. The correct response to that is to have a more profound connection, I suppose, between the people who are supposed to who we entrust without our health care.
But that’s a complicated argument to try to make to people when they have just a gut feeling that there’s something to reductionistic about the way things are.
Right. But there is another side to this, too. For instance, one of the slams that is made by integrative practitioners against regular doctors is, oh, well, you don’t deal with diet and lifestyle and such.
They kind of do.
I can’t remember you ever since I hit middle age. I can’t remember a time I’ve gone to the doctor where I haven’t been. Know. We’ve been trying to get me to lose weight and exercise more. ET cetera, et cetera.
Look, I know, isn’t it? I mean, I’ve never had a doctor suggest, for example, that mindfulness meditation might help me get my cortisol levels down or anything.
I mean, it’s not like they have a particularly broad view of human wellbeing.
But but but my point is, if you talk to a lot of the some of these primary care doctors, patients, you know, changing your lifestyle and exercising and changing your diet hard.
Yeah. I don’t want to hear and I don’t want to do it.
They want a pill like. Can I. Can you just give me a pill and I’ll lose weight, you know, or you know it’s.
Yeah. No, I get it. But I mean, I think that we’re at risk because there’s something I my concern and it’s a concern about anti vax is it’s a concern about homeopathy. It’s a concern about all kinds of which is that there’s something instinctively appealing to people about the idea of treating things in a nuance, in what they what seemed to be a nuanced way where you’re treating the more like an art than a narrow science.
Well, you know what? Yes. But the keyword there is seems because if you actually look at a lot of these, there’s nothing really that any less assembly line about a lot of this alternative medicine. And I like to say, well, in the absence of standards, in the absence of science, personalizing your treatment is basically making it up as you go along. Yeah. And there’s no way to test whether what you’re doing, you know, is working because you do it differently every time.
But, David, that strikes a lot of people in the gut as big as sounding reasonable, like I’ve had these conversations with him, homeopaths who who say, like you’re you’re just not grasping the broad and nuance of what we’re doing. We’re communicating with the whole person.
It reminds me a little bit of the conflict in in moral philosophy where people will say, I just don’t think that Peter Singer is right in his position on abortion and infanticide. Well, that’s fine for you to feel that way.
But the whole point of moral philosophy is to not on the basis of feelings. The whole point of it is to logically unpack it and see what works best in the same way. That’s what medicine should be like. But it’s really hard to win this communication battle with people who increasingly seem to feel that there’s something true and persuasive about about practitioners operating from their guts and seeing you as a as a special little butterfly instead of just as a series of symptoms. And I’m not sure how to how to win that communication battle, because I’m not sure that we are.
Oh, it’s also it’s not just patients wanting that. They’re there is for instance, you know, you may or may not be aware of this.
There’s a there’s a segment of the medical community of physicians who are very resistant to evidence based medicine because they view it as what they call cookbook medicine, which it really is.
And if you look at it or are they dismiss it as algorithm medicine, which it is to a point, but not there’s a lot of freedom in that algorithm. What they don’t like is being told what to do and how they feel like they are the doctor. And it should be whatever I feel is correct for the patient. And sometimes what they feel is correct for the patient is supported by evidence, but sometimes it’s not. And it’s one of those things where there is a segment and integrative medicine, I think actually does appeal to that sort of doctor who is like I am the whole doctor. I will do everything, whether it’s from conventional medicine or from traditional Chinese medicine. Right. Well, the good of my patient.
It’s almost a doctor who feels are more of a shaman than than a a scientist.
No, no, no. It is it’s shaman. It’s that I’ve called I’ve even done a post on that. I’d have to look it up where I talked about. It’s basically a form of shamanism. You know, it was dressed up with a little bit of conventional medicine thrown in. But, yeah, it’s the shaman healer. And of course, doctors are not quite you know, there’s a wide feeling in the medical profession that doctors are not as respected as they once were, that we’re no longer as independent as we once were, which is that part is true because a lot more of us work for a large health systems now and as opposed to being private practice.
I mean, I work for a university. You know, I have an employer. I’m not my own. You’re not my own practice. So.
So, I mean, let’s wrap up by thinking about how we how we sort of steer this ship in a different direction then, because, as I mentioned, I’m not sure that.
What I’m certain that the media is not doing a good job of communicating good medicine and fighting quackery as well as it could. And I’m not even sure that we’re winning the broader cultural war here. And I think part of it has to do with the fact that people don’t like being talked down to or being perceived to be talked out to. And I’d like NoDoz wagging their fingers at them and telling them that their favorite strategy or technique is wrong.
How do we how do we spread reason without sounding like we’re bossy?
And given given my reputation for sarcasm, that’s that’s always a tough one. But I mean, one area is there’s this this can work with at least vaccine averse parents. I kind of like to divide this into two groups, you know, like and I do this for anti vaccine people. There’s the group that are the hardcore anti vaccines. Nothing’s going to persuade them ever. You know, they’re they’re experts, motivated reasoning and being anti-tax as part of their personal identity now. You know, there’s no way you’re going to change their minds. What you can do is minimize their influence on the fence sitters.
And you work try to work within, you know, the fence sitters to persuade them. And, you know, you can appeal to shared values that you can point out the evidence. If you can put the evidence in the right form of context, it can be persuasive to someone who has not gone so far down the rabbit hole that you can’t pull them back out. Yeah. And I think some of the same can be said for a lot of this, you know, as far as integrative medicine and the integration of pseudoscience and into medicine.
And I tend to take a pragmatic view of it. You know, one on one, I’m kind of forced to take a pragmatic view on it. It’s like if one of my patients says she wants to do acupuncture, I’m not going to, like, make fun of it. I’m not going to say no. But if she asked me what I think of it in terms of the evidence, like, does it work? I am quite honest.
But, you know, as far as I’m, you know, looking at the evidence, I see no evidence that it works. It’s mostly if if at all, placebo effect, and it’s not entirely risk free, you know, that sort of thing. But you are an adult if you want to pursue it. In addition to conventional therapy. Fine. You know, because what I’m dealing with cancer. So it’s like I’ve got to get them to have their surgery and chemotherapy and radiation and alienating them by bashing, you know, telling them, well, they’re idiots is probably not gonna help. I mean, when I’m you know, I like I like to put it this way. It’s when I’m writing for the blog, I’m entertaining myself. I’m trying to educate and I’m hopefully entertaining the people who are reading. It’s a totally different thing than when you’re out one on one with a patient. So I would never, ever speak to patients.
You know, one on one the way I kind of make fun of these things on the blog. That’s a good point.
I mean, I never know as a as a you know, as a media person who wants to be as reasonable as possible. I feel like Dr. Jekyll and Mr. Hyde is one half of me that wants to write the piece that’s entitled. Michael Phelps is an Idiot and cupping doesn’t work.
And then there’s another part which wants to be Michael Phelps as a hero, but he may be in slightly incorrect about this one.
Well. Well, there’s one thing I’ve learned after doing this for about 11 years now is, you know, you’ll get crappy the way you do it. Yes. Yes. I mean, welcome to humanity when I’m when I’m too. You know, when I when I’m when I really let my full sarcasm flow. Yeah. I’ll get I’ll get these emails about how can you be so mean. You’re not you’re driving people away. But even when I do things that are less sarcastic, I’ll still get some of those. And look at Steven Novella, for instance. I like to hold him up as an example. He is like one of. He goes out of his way to be like one of the least offensive advocates for science that you can imagine. And he gets people suing him, you know.
Yeah. And also, as you dial down the stridency and become more tactful. Then you also start copping flak from the other end of people saying that you’re obfuscating and being insufficiently right.
You’re you’re defensive. And we see this in particular, you know, to take another example, outside of medicine in the whole militant Athie ism versus Ramit alienists life.
Yes, exactly. Exactly. David Goreski, thanks so much for being with us. I want to go and uncouple myself and go for a swim.
Oh, I’ll have fun. Thanks for inviting me. You got it.