Tiny Bubbles

Mikkael Sekeres, MD, MS
Director of the Leukemia Program at the Cleveland Clinic in Cleveland, Ohio, and editor-in-chief of ASH Clinical News

“Double, double toil and trouble;
Fire burn and caldron bubble…
For a charm of powerful trouble,
Like a hell-broth boil and bubble.”

William Shakespeare, “Song of the Witches” (from Macbeth)

The bubbles in which we live came into focus during the last U.S. presidential election, when the East and West Coast press were accused of completely missing the coming of Trump (or was it a second coming?) because they couldn’t see beyond the reassurances of people in their own liberal bubbles. I am myself a product of the East Coast liberal press (my dad having been a political reporter for the Providence Journal-Bulletin in Rhode Island) and thus lived in such a bubble during my formative years. Having been a resident in the Midwest for the past 15 years, though, I must say I was not as taken by surprise.

I was reminded again of the false consolation of bubbles during a recent conversation with my 13-year-old daughter.

“Come over here and see this,” I said to her, as I sat at the kitchen table scrolling through my Twitter feed on my phone. It was a typical Sunday morning: I made breakfast for the kids and we had reached that precious hour between our coming together briefly as a family and my chauffeuring them to various extracurricular activities.

She ambled over slowly, her curiosity piqued (but not wanting to admit that it was piqued, lest she be accused of finding her middle-aged father vaguely interesting).

“Look!” I pointed to a recent tweet of myself with some other hematologists at a meeting. “I sent this last night, and it got 17 likes!”

“Mmmmhmmm,” she mumbled, in as noncommittal a way as humanly possible.

“What? That’s not so bad!” I said. “How many likes does one of your photos typically get on Instagram?”

“Usually about 350,” she answered, ever so casually. I think she may have even tossed her long, brown hair – the body-language equivalent of former World Wrestling Federation star Jimmy “Superfly” Snuka jumping from the top of the ropes to pin me to the mat.

“The trick is in recognizing when we are making decisions, or interpreting reality, from within our bubbles.”

“Well, it may not be 350 likes, but the people who did like it are impactful!” I countered anemically, my bubble now fully burst. Her job done, she left the kitchen and the deflated carcass of my ego for the flies and jackals to consume.

Bubbles can be dangerous, because they trick us into thinking we are more correct than we may be, more influential with our self-selected captive audience, and they reassure us that we are surrounded by like-minded views.

Social media outlets such as Twitter, Instagram, and Facebook are ready-made for bubble construction: We choose whom to follow (and even who follows us), allow ourselves to have our confidence stroked by numbers of followers (even as some can be purchased to enhance the perception of our popularity), and estimate our impact by numbers of likes. Yet, I would consider the 17 people who liked my photo to be friends more than colleagues, while the 350 people who like my daughter’s posts are all members of her 8th grade class, in which the culture is to “like” indiscriminately (sorry to break it to you, honey). It’s all too easy to think we’re famous, but our fame has been self-constructed. Those likes don’t represent a championing of my viewpoint, nor a tacit agreement to promulgate my opinion, nearly as much as I’d like them to.

Bubbles exist in the health-care workplace, also. Within a disease team, we may standardize our approach to treating conditions such as leukemia, initially acknowledging which aspects of our care are based on well-designed studies and which aren’t. Over time, those standards become codified, though, as if handed down directly from The Mount. Then, we marvel at those who practice differently outside of our bubble and the “reckless” way they treat their patients. Of course, it’s not truly reckless; it’s just not what we do. For leukemia, this could refer to post-remission therapies, treatment of relapsed or refractory disease, clinical application of next-generation sequencing results, and (in the most egregious data-free zone) neutropenic precautions. Yes, on our leukemia floor, we allow patients to have fresh flowers and even fruit.

Have you ever heard of anything so reckless?

Research bubbles are the worst. We often choose our collaborators as we choose our friends, or those we follow on Twitter. We attend the same meetings, read the same journals, and check with each other before adopting a new practice – sometimes before we have made an independent decision about its value. As a result, we decide which research is valid and which studies are flawed, even when the methodology, power, and conclusions may be similar. One randomized trial demonstrating a survival advantage for maintenance therapy in acute myeloid leukemia (AML) is ignored in the U.S., while another showing a survival advantage in an AML subtype that never knew it needed a special treatment approach gets the nod from guideline panels, in part because the latter study included investigators from our bubble.

And bubbles are probably unavoidable. In his book Being Mortal, Atul Gawande, MD, MPH, wrote about the aging process, and how we progressively narrow our circle of friends and family, the people with whom we want to have contact, as we approach death. Essentially, we are reducing the size of our bubbles, and taking solace in the reassuring warmth and familiarity they provide.

I suspect we do this throughout our medical careers too. The trick is in recognizing when we are making decisions, or interpreting reality, from within our bubbles and either acknowledging that fact, or bursting out of our small, safe universes to encounter other worlds and the discomfiture of new opinions.

But not necessarily the opinions of 350 8th graders.

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