Why should I trust you?

On call one night as a medical student, I was presenting a case to my intern. As I recounted the patient’s ER course, the intern stopped me and said, “Pal — trust no one.”

That sounded a little harsh to me, but the intern was nice enough to explain further.

“Look, you’re going to be taking calls from doctors and nurses the rest of your career. They are going to give you information about a patient, but it’s you who will be responsible for everything that goes right and wrong. Do you want to hang yourself on someone else’s evaluation?”

As any internist knows, there is a perpetual tension between ER and internal medicine docs. ER docs need to save lives and move meat. The snapshot the ER doc gets is sometimes inconsistent with the bigger picture the internist sees, leading to some conflict. It’s inevitable, really, that how the patient looks in the ER will differ from how they are up on the floor several hours later. And this is what my intern was conveying to me.

Patients will often complain about the parade of students, interns, residents, and attendings who seem to ask the same set of questions, but this was my intern’s point: things change, stories change, clinical facts change, and you better make sure the facts you report are the facts you verified.

(As an aside, it’s a not infrequent occurrence that a patient’s story will change significantly with the length of the white coat. The indigestion the student hears about becomes the crushing sub-sternal chest pain the attending rushes to the cath lab.)

I also remind patients that they don’t know which one of us might be called to their bedside in the middle of the night, so it’s best tolerate us all.

Anyway, this is my long-winded way of getting to the issue of trust. There are ER doctors who I’ve worked with for years and I know pretty well. I know their quirks, and I know that what they tell me is how it is (at that particular moment).

If I get an ER call from someone I don’t know, I will listen politely, but I’m probably going to see that patient first and re-check everything myself.

So “trust no one” isn’t precisely the dictum, but it’s a start. Clearly level of trust is influenced by many different factors.

At January’s ScienceOnline09 conference, Terra Sig’s Abel Pharmboy and I will be hosting a session on blogging and anonymity. It’s a topic particularly important to us as bloggers of medical science. A number of months ago, I “unmasked” myself and never really explained to anyone why. Pseudonyms are a big part of blog culture, and I preferred to keep mine while no longer guarding my real identity (for various reasons).

I would argue that in the blogosphere, there are three levels of identity: real name identity, pseudonymity, and anonymity. Real name identity is still not the “real person”. People write and behave differently online. Pseudonymity (my particular choice) involves using a pseudonym, but having one’s true name generally known or available. Anonymity is just that—the attempt to keep your real life identity completely secret. Each of these levels has different implications on both how the writer behaves and how the reader perceives.

Abel has brought the issue of trust forward—both the reader’s trust of the blogger, and the blogger’s trust in the reader. At our session (which we’d love to have you at, but will probably blog about, or better yet, maybe we’ll live blog it and take questions) I’m sure we’ll address lots of these issues, but we’d like to hear from denizens of the blogosphere. Abel’s question was, “do you trust me?” My question to you is, “Do you consider blogger identity when reading, and if so how? And do you find there to be a difference in the three levels of identity?”

Or of course, ignore my question, and say whatever you wish.


  1. I can only speak to my own circumstance…I prefer to blog anonymously because I have reason to be concerned my medical condition, if known to my current or potential future employer(s), would keep me from keeping my job or getting a new one. Otherwise I wouldn’t mind if people knew the ‘real’ me, since pretty much everyone IRL knows about my condition.

    When it comes to online interactions I always think of Reagan’s great maxim: “Trust, but verify.”

  2. I try and consider the argument more than I do whether or not it’s made using a ‘nym.

    That being said, if it’s a (consistently) crappy argument I try to find the source. I still haven’t found who Gribbit really is and that enforces my disdain for his shit.

    Finding Orac was relatively easy, but the power of his arguments really didn’t drive me to find out who is.

  3. Richard Eis

    Since online names are such a part of the culture, i have never considered blogger identity as defining what i think of someones writing.
    Finding out that pharyngula was a big cuddly soft spoken teddybear of a man (not a bad thing 🙂 was rather weird though. You never can tell.

  4. When I see PZ in january, i will personally buy him a drink and convince him to let me check his scalp for horns.

  5. As I read this and wrote my own post last night, I thought about how some actual board-certified MDs have bastardized the hard-earned title by serving as purveyors and promoters of fraudulent supplement products and various moneymaking practices, workshops, and such, that are based on marketing and deception with nary a bit of science to be seen. So even formal titles meant to confer authority and medical knowledge and ability do not always mean that information provided is trustworthy.

  6. I’ve seen PZ up close. I promise, no horns. Not even any telling scars. But why trust me?

    I haven’t quite figured out what determines whom I trust online. (Trust? I don’t trust anyone. Except when I do.) But I do think looking to people who have made transitions between the three levels would provide interesting information both about why they adopt the level they do and about reactions to the different levels.

  7. I was reading Rubor Dolor Candor Tumor just now, and I left him the following comment. Then it occurred to me how you had asked the trust question over here, and I thought I should repost:

    “I so love reading doctors’ blogs! It has really given me a better appreciation of the medical profession, and as contradictory as this might sound, hearing about mistakes like this from the doctor’s perspective has led me to trust the medical profession and the diagnostic system more. It has brought it more down to earth for me, humanized it, and made it seem less impersonal. Blogging by doctors really does a great service for the profession IMO.”

    I no longer fret about those 15 minute appointments, for instance, knowing what I do about how hard it is for docs to make a living under current reimbursement rules. Also, you blogging doctors are funny and thoughtful and generally awesome– I know you’re really in this profession to help people. It comes through in the writing. It makes me feel good to read it.

    Medical and sciencebloggers have been talking a lot about how alternative sCAMs have a great frame for their snake-oil peddling, because they can project certainty and comfort to their clients. I used to be really put off by what I perceived as a cold impersonal-ness of the medical profession. Well, these past few years that I’ve been reading doctor blogs have done SO MUCH to increase my confidence that my doctors really do care and want to help, and wouldn’t be in the profession otherwise! I feel that doctor-written blogs effectively increase the amount of “face time” we, the public, get with doctors. I just cannot say enough about how much I love reading the blogs of doctors and medical researchers. I feel my health, and the health of my family, is in good hands.

    I feel that blogs by all scientists are doing a LOT to make the process of scientific research much more accessible to the public. This is a wonderful, wonderful thing!

    This whole comment has done nothing to address the issue of anonymity and trust… the only thing I can say is that I didn’t know the real identities of my favorite bloggers for years, but I trusted them because their pseudonymous writing seemed really heartfelt, I guess.

  8. I would argue that in the blogosphere, there are three levels of identity: real name identity, pseudonymity, and anonymity. Real name identity is still not the “real person”.

    Why not? I’m Dale Husband and I’ve been using my real name for years and always try to be as real as possible, holding none of my true self back. With me, what you see really is what you get. Even my distinctive Circle H logo is not an attempt to hide my identity, it IS my identity, as much so as any actual picture of my face or body could ever be.


  9. I post under a pseudonym, but anything and everything I post I would post under my actual name. Usually I only get snarky with people who (I feel) deserve it, and then usually to counter disinformation that can harm other people. I only use the one pseudonym, and if anyone really wanted to find out who I am, it isn’t very difficult.

    I post a lot on the topic of autism, and there are some real wacko individuals in the anti-vax community. Some individuals such as Paul Offit have received death threats from them. That is a plenty good reason to remain anonymous.

    Who I am has nothing to do with the quality of the facts and logic that I present. I only want people to base their assessment of the facts and logic I am using on those facts and logic themselves, not on my “reputation”, or any other irrelevancies.

    If you can’t evaluate an argument based on its facts and logic, then adding personalities and reputations and other extraneous and superfluous information doesn’t increase your ability to evaluate it. I have Asperger’s, so adding personalities and reputation really just confuses things. Usually I have a hard time keeping track of who the authors are of even extremely important and critical papers. The facts are easy to keep track of, the personalities much more difficult.

    In the fullness of time I think my ideas will be confirmed and accepted as mainstream. Until that happens, most people are simply unable to understand them. That is what Thomas Kuhn pointed out. Hanging out on skeptic boards, where people do use high level and rigorous argument techniques does help me refine my ideas. It is frustrating that people don’t understand what I am saying, but I understand why it is happening. It isn’t about me, other than about my inability to communicate my understanding to someone else.

    Looking at someone’s motives for posting can be useful. My motive is to disseminate information. I am not selling anything (yet), I am trying to commercialize my NO discoveries, but only in ways that are ethical, consistent with my values and which I know how to do. I don’t know how to sell snake-oil, or to use arguments or marketing techniques other than those based on facts and logic. I understand that to those who don’t understand NO physiology, what I am saying sounds like CAM.

  10. Off Topic (but can’t resist)

    Just heard in a drug commercial:

    “Common sideeffects are runny nose and decrease in semen, get the picture?”

  11. I think that if you blog under a pseudonym or anonymously, it can be somewhat easier to refer to your personal life. E.g. if I blog about my brother, people can fairly simply find out who he is, but if I blogged under a pseudonym, it could be any man living in Denmark, who has a father.

    That’s why I don’t blog about friends and family. They are not the ones blogging, so I have no right to involve them in my blogging.

    I also don’t blog about my work, since I am a consultant, and there is something called client confidentiality.

    If I didn’t blog under my own name, I wouldn’t need to take these things into consideration – at least not theoretically. In reality, I’m not sure it’s quite true.

    Back to the issue of trust – for me it doesn’t make a difference. Duncan Black, of Eschaton, blogged as Atrios back when he was the biggest powerhouse among the liberal blogs – he was pretty much instrumental in forcing Trent Lott to step down from his leadership position after all. Until recently, we didn’t even know that Digby was a woman, and we still don’t know her name. Yet, I trust either of those much more than I would ever trust a person like Matt Dudge, who blogs under his own name. It’s a simple matter of looking at the track record.

  12. RebekahD

    When I found Orac and PalMD through the Skeptics’ Circle, it never occurred to me to care what their real names were. It was the quality of their arguments and the way they back them up with sources I can check that earned my trust.

    There are so many possible reasons for anonymity, such as the one written above by Kathy, that anonymity shouldn’t automatically cause distrust. Often, it is about self-preservation rather than shady motives.

  13. When I found Orac and PalMD through the Skeptics’ Circle, it never occurred to me to care what their real names were. It was the quality of their arguments and the way they back them up with sources I can check that earned my trust.

    I came to ‘know’ these folks from scienceblogs, and they seem to be what they say they are, and they back up there stuff with references to actual sources.

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