Rae Woods: From Advisory Board, we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. Today I am thrilled to bring you a conversation with Dr. Aaron Carroll. If you don't know who Aaron is, be prepared to be blown away. He is a pediatric physician. He's the chief health officer for Indiana University. He's a popular New York Times contributor, he's the editor in chief of the health policy blog, the Incidental Economist, and he makes videos for his YouTube channel Healthcare Triage, not to mention the fact that he has authored or co-authored several books, including his latest, The Bad Food Bible. All this means that I could have talked to Aaron about a million things, but I wanted to bring him to Radio Advisory, to speak directly to you about how you can combat all of the myths and misinformation that exists today. Rae Woods: Make sure you stick around for the very end of the episode for a breakdown of my conversation with Aaron. I bring on two colleagues, Solomon Banjo, and Pam Divack. Because I wanted to get their take on the delicate role that clinicians play when it comes to sharing information online and with each other. But for now, let's go to the conversation with Aaron Carroll. Okay. I have to admit that I'm trying really hard, not to fan-girl too much here. Truly. I have been following you for years. In fact, I have a Healthcare Triage mug. Dr. Aaron Carroll: Oh, good for you. Oh, that's very nice. Rae Woods: This was actually a gift from my brother for Christmas or my birthday. So he is just as excited that I'm speaking to you as I am. So little shout out to my brother. Dr. Aaron Carroll: Oh, you're making my day. This is very nice. Thank you. Thank him for me as well. Rae Woods: I will definitely do that. Now Aaron, what are the big focus areas for your career? And there are a lot. Is teaching real people about medical myths. This was obviously a problem long before COVID-19, but I'm curious what kind of feels different for you right now? What feels different about this moment? Dr. Aaron Carroll: I think the stakes to be very honest with you is the biggest difference. People who are buying into misinformation or myths at the moment are not just putting others at risk they're putting their own lives at risk. And most of the time when I'm talking about medical myths, it's small ball, it's things which might make a slight difference at the edge, or might make a tiny quality of life difference. Or even if we're talking nutrition, it might make a broad years or decades long difference. But right now buying into the wrong stuff could be impact or mortality. And like in the very short term, it's a whole different game. Rae Woods: Absolutely. Is there a moment where you started noticing more of this misinformation creeping in either in your own practice right as a physician, or in your broader career? Is there a moment where you went, "Hmm, I'm getting a lot more questions from people that just don't make sense or completely rooted in misinformation or maybe even disinformation?" Dr. Aaron Carroll: I think things felt like they got tense when the country started the lockdown last year, up until that point in January and February, the pandemic was something over there. It wasn't even affecting us. And in March it was still hard to raise alarm bells. It wasn't a big deal, but by the time we got to April when it felt like a lot of the country was locking down and people were taking it seriously, that's when I think is just starting to see pushback because people's lives and livelihood were being really affected. And if you don't see it every day, and if you weren't in the healthcare system, you did not see it every day back then. It was hard to understand why we were doing that. And I feel that's when things started to pick up, it's when you just started seeing protests around lockdowns or protests around masking that was when it felt like things were getting worse. Rae Woods: I also feel like in the world of myths and misinformation, there's just some particular vulnerability in the medical and healthcare space, because it is so complex and misunderstood even by the folks within it, that it just becomes really hard to battle. Dr. Aaron Carroll: People in general have no appreciation of how much uncertainty there is in medicine. That I think about the time one of the dirty secrets that we don't tell anyone is how much we're just making it up. The number of things for which there's rock solid, randomized controlled trial evidence is really small. A lot of the times we're going with best guess, best practice and we sometimes get it wrong, but we speak with the same level of authority, no matter what that level of evidence is. And so this felt like a time when a lot of people were all of a sudden exposed to how much uncertainty we often have to deal with in medicine, but it was playing out right before their eyes and people freaked out. Rae Woods: Yeah. They didn't know how to deal with it, in their mind. It's, "You're changing the goalposts on me. See, you don't know what you're talking about, so why should I trust you this time?" But not realizing this is inherent to the way that we study and ultimately practice medicine. Dr. Aaron Carroll: I remember being on a podcast in, I want to say April or may, I can't remember exact, but it was about masks. And the host was like, "How can you live with this level of uncertainty?" And I'm like, "This is every day." Rae Woods: This is my job. Dr. Aaron Carroll: I'm totally comfortable with this. I'm always playing small odds in one way or the other and understanding that the best treatments have stopped, what number needed to treat of like one in 100, one in 1,000, everything is incremental. And there's often a fair amount of uncertainty. And so at the beginning, when we were talking about masks, it was focused on masks to protect you, meaning M95s that they weren't short supply. And we needed the hoard them for the healthcare system who were at highest risk. And so I remember even saying, or tweeting one point, like if you're wearing a mask thinking M95, at this point, you're wasting a mask. And then months later it was like, okay, no, no, no, no. Now we know it's it's airborne everyone should wear it nine months later, maybe a month later, everyone should wear cloth mask. And people are like, "Well, you said," and I'm like, well, different masks in a different circumstance. And yeah, we're learning as we go. Rae Woods: Yeah. And this is why I think it is so unbelievably difficult to nudge or ultimately change behavior. And you've pointed out before that one of the biggest reasons why this is a problem is because the very people with the least understanding of science tend to be the ones that oppose it the most. Right? That's why large scale efforts to educate the public tend to fail. I think we know what really doesn't work. We know that bombarding people with facts, figures, data is not going to be that effective. Do we have any understanding of what does work to nudge behavior? Dr. Aaron Carroll: I mean, there is some, unfortunately it's hard. Obviously if messages come from trusted voices in the community, they work better, but that's often hard to do because the same people want to be the answer for everything. And that doesn't work. I also think, and this is more personal. It requires time and effort to truly get to understand where the lesion is, where's the misinformation or misunderstanding come from? What's the concern? How do I address it? But my biggest gripe is that the answers are often complicated. When someone wants to say, "Do masks work?' I'm like, that's going to take 10 minutes for me to answer. I cannot put it in a sound bite. And most people unfortunately consume their news from cable news where it's, if you're lucky, you get to say three sentences and then someone else is going to say three contradictory sentences, and then they'll go, people disagree, when really it's a nuanced long answer required. Dr. Aaron Carroll: And there just isn't a lot of space for that in today's media with the exception being podcasts, which is why it's one of the few things I'll say yes to, because there's an actual chance to have the long form discussion where you might actually get into some of the nuances of the answer, as opposed to a quick hit on a panel where nothing gets lost. Rae Woods: Exactly. And that's one of the reasons why I think the physician to patient or clinician to patient relationship is so important because we see that generally speaking people still trust their doctor. And in ideal circumstances, of course which aren't always there, there is a moment for trust-building in the physician office or through tele-health or in a portal message where you can at least spend a little bit more time unpacking where that person came from, or the, "Evidence that they are trying to pit against yours." What is your advice for how clinicians can in the moment try to get these messages to stick? Dr. Aaron Carroll: Well, again I think it's important to try to figure out where the problem is. Some of it is just misinformation and there's no negative intent. Some people think it costs a lot of money still to get vaccinated. No, I mean it's free, but they just think it. And so just making sure they understand that for some people it's literally a logistical barrier. It takes activation, energy and time that they don't feel they have. If we can just figure a way to get the vaccine to them, they might get it. Some of it is mistrust in the healthcare system, which has to be combated with long-term building of trust. And some of it is they've just literally heard lies and they have to be carefully and thoughtfully countered in a respectful and compassionate manner. You're right though, that is something that physicians should be able to do because they should have that kind of relationship where they can probe and get the answers they want. Of course, office visits get shrunk and shrunk in terms of [inaudible 00:10:05] time. Rae Woods: That's exactly right. Dr. Aaron Carroll: That's the problem. Rae Woods: Yeah. That's a problem that I'm hearing. It's not that clinicians don't think that that's their role or that they don't want to do it. It's that they're saying, "Hold on, I'm this overworked, I'm this understaffed. You've pushed me to be transactional in all of these different ways through tele-health. How the heck am I going to take? I don't have time to build a trusted relationship, let alone spend time unpacking this information in the moment." What advice do you have for that pushback? Dr. Aaron Carroll: Make the time, I mean, I know that that's a flip answer, but we're the last line of defense here. I mean, I look, I'm a pediatrician. So for a long time, it's been difficult convincing some parents to vaccinate their children. This is not new, certainly for pediatricians who have dealt with myths and misinformation about fixed vaccines for decades. So this is part of what we're going to need to do for COVID as well. I don't think we've relied as much on the healthcare system to be very honest. And that's something that we might need to reconsider moving forward in that we've relied on broad public health messaging and the general public to try to get vaccines across. They're not often delivered in the doctor's office the way most vaccines are. And so- Rae Woods: That's right. Dr. Aaron Carroll: ... it's very different. And we've perhaps missed that opportunity where if we were making this part of the regular doctor visit, maybe we could get a few more people or at least a decent number of people vaccinated. Rae Woods: And maybe don't assume that you're going to change somebody's mind one time. Especially if you're thinking about a longitudinal patient relationship, if you're going to be seeing someone over and over again, if you're taking a couple minutes at the end of each visit, talking about the vaccine, I read this wonderful piece that was talking about a patient with HIV, who related very strongly to his physician who was a fellow black homosexual male. And he spent the better part of a year at the end of each visit when they were doing regular checkup to say, "What about vaccination? What about COVID-19?" And it took time. But the moment that the patient said, "Doc, I did it," made it all worth it for this physician. Dr. Aaron Carroll: I would agree. And I think that physician should be used. I mean, if you've ever tried to counsel someone on diet and exercise, like, it doesn't happen in the one visit. I mean, the way I've been talking, I've been assuming an established relationship that now, if you already have the level of trust you can build, but if you're seeing a new patient for the first time, of course, very little is going to be successful in that first contact. It's just the beginning. And we just have to take the long road on this. It's a marathon, not a sprint. Rae Woods: You brought up diet and exercise. I wonder if that means there's actually something that we can learn from old school, patient activation here. In PopHealth we assess patient activation because we want to know, should we intervene? And if so, when? Which of course means sometimes we don't. Do you think that there's some application here of choosing when, how, when to ignore medical misinformation, even when it shows up at our practice? Dr. Aaron Carroll: Well, I mean, I will gauge sometimes and granted not as much in clinical practice, but more when I'm doing more public health, I will gauge some times how entrenched someone is. There are some people I'm like, they're so angry or antagonistic about it, then if I truly try to go deep and argue with them, I'm just going to entrench them further. And so sometimes it's worth just backing off because if I'm not the right person and I'm not the trusted individual, then if I argue, I'm just convincing them. They're right and I'm wrong. Rae Woods: What's the red flag for you when you go, "Oh, I I'm actually might be doing more harm than good. I might be entrenching them." Dr. Aaron Carroll: When people leap from argument to argument, to argument, to argument, and then they start circling around again, where it's, if I have an answer to everything they say, and they just keep leaping into arguments, I'm like, okay, this is not going to work. But if people have a concern or a block, and I can address that and we can go in depth into that, then I feel like there's more progress that's likely going to be made. And especially if I feel like I can answer this in a way that maybe will stick and convince. I mean, you can sometimes tell when people are being thoughtful about it or whether they're just using an excuse. I know plenty of people who are like, "Well, I won't get it because it's not FDA authorized." And the day Pfizer got authorized and then it was, well now they authorized it too fast. Rae Woods: I know. Dr. Aaron Carroll: They didn't. Okay, that was an excuse. That was not a reason. And that's fine. Just if you'd said that we could have saved both of us some time. People have genuine concerns and I can explain why it feels fast for the vaccines have been developed, but that doesn't mean that safety got skipped. Then so many people can be convinced. And so sometimes it's also opening it up, asking them if they have questions, seeing what kind of questions or concerns they have answering the first few of them, and then getting a feel for, is this someone that we're going to be able to make progress with today? Or is this a, let's just establish some relationship and trust and move along the next time, part of that is being a clinician and establishing relationships with patients. Rae Woods: Yeah, absolutely. I think if we're going to address misinformation myths, disinformation, we have to understand how it spreads. And you mentioned one way that it spreads, which is through the cable news networks. But a lot of this comes from online information and online discourse. But what strikes me is that I'm also seeing more clinicians, more researchers, more scientists online. You've obviously been doing this for a very long time. My question though, to you is, do you believe that everyday clinician should be moving their guidance online and maybe even into social media platforms? Dr. Aaron Carroll: It depends how engaged and involved you're willing to be. I think that the problem is that with social media, especially with things like Twitter, is that people think there's a magic tweet, which will convince everyone that they were right, and everyone else was wrong and that never ever, ever happened. Most of the time you are preaching to the choir that your engagement is going to be mostly followers who already agree with you or- Rae Woods: In your bubble, yeah. Dr. Aaron Carroll: ... people who just retweet it. And then you just get like a mob people who violently disagree with you. I think very few people are ever convinced by anything on Twitter. So I've always seen Twitter as a tool. I use it to drive people to content that I think might make a difference. So columns, I've written videos, I've made other things other people have written, thoughtful articles by really good journalists or data that might sway someone's... But I always am amazed that if I have something that maybe went viral and people are like, "Oh," I'm like, this made no difference. You don't understand this, no one was convinced by this. It made me feel better for five minutes that, just that of angst. Rae Woods: Yeah. But are people convinced in the opposite way? I'm thinking there are a lot of videos that have been shared on new platforms like TikTok. And I see nurses, I even see physicians that are using their own medical background almost as armor to spread miss and disinformation. So if you feel like it's not enough to make a positive impact, is it though making a negative impact when clinicians are doing this? Dr. Aaron Carroll: I mean, granted there's people that absolutely believe that the answer is yes, this is where I'm taking the long view on this. Anti-vaccination sentiment has existed as long as there have been vaccines. I mean, we did an app one or two episodes on this. We did a series on vaccination at Healthcare Triage. It is not as if we needed social media to have a massive worldwide misinformation backlash against MMR, it did not need social media for that. And it was real and impactful and we're still feeling the lingering effects. There was actual crime and violence about vaccines long before we had any of this. Now, does it make it faster and easier? I imagine it does. But I don't know how much of it is actually to blame versus it's easy to point and say, well, this must be what it is. I don't know. Was anyone expecting the vaccination in the United States to go much more smoother- Rae Woods: Too easy? Dr. Aaron Carroll: ... than that? I mean we don't ever get more than it's number in flu shots. What is it? I think I saw in the CDC that right now, something fewer than 20% of young adults are vaccinated against HPV right now. Rae Woods: Oh, wow. Dr. Aaron Carroll: Well, we don't mandate vaccines. People don't take vaccines. That's how it goes. Now, all the vaccines with very high levels of vaccination are mandated and organizations and the schools that have mandated the COVID vaccine achieve very high levels of vaccination. When we don't mandate them, it doesn't happen blaming it on social media may feel convenient, but I don't know that that's really the cause. Rae Woods: I agree. And I think there's a lot of debate, not just about mandates, but how strongly should we push? What kinds of, I'll say maybe draconian measures should we use? So that brings me back to misinformation. Do you believe that health care organizations, medical boards, professional boards, are they doing enough to enforce standards on physicians, on nurses who are spreading harmful messages? Dr. Aaron Carroll: Well, they're just starting to threaten to do something. And so they really haven't done much. Rae Woods: That's right. Dr. Aaron Carroll: Having said that, shit is hard to police this stuff. It is very easy for physicians to couch themselves in specific patient information or uncertainty or levels of evidence to, because again, we deal with uncertainty so often, I see all the time where patients are like, "I know this is what we're supposed to do in this situation," but my patient is different. And there's a lot of acceptance from both patients and physicians for that kind of attitude. Rae Woods: In a lot of different ways. My patient is different from a safety perspective. Oh yeah. Always [inaudible 00:20:39]. Dr. Aaron Carroll: Hate guideline, hate protocols, hate anything, because my patient is different and I know better. And that has also existed long before COVID. So it's just, policing this is, I don't want to say a slippery slope because I hate the word. But if they're going to start with this, there's lots of other areas where we also could say, well, this isn't right either and that's not right and that's not right and that's not right. We just don't do that. Unless things get really egregious. And maybe right now, we're at really egregious, but I'm sure it's hard for the organizations and licensing boards to want to wade into that. Rae Woods: We're talking about combating misinformation between the patient and the physician. Or the physician and the lay person maybe is what I'll say, whether it's in the office, whether it's online. But one interesting trend that we've been tracking is there's just a lot more online communication between clinicians. Clinicians are using open online platforms to actually debate with each other. My question for you is, does that online communication, does it quicken the pace of translating new research, new ideas into clinical practice? Or is there a downside here? Dr. Aaron Carroll: I think it's both. I think it probably does, but again, it's like, this is where I think it's important to understand that it's still a minority of probably clinicians are engaging in this space. And so while it seems like it's huge and pervasive, it's still mostly a smallish number of massively exposed people. And that goes across the board. So look, I think in general more transparency is better. I think the public understanding that there is uncertainty in a lot of what we do and that being able to ask open and honest questions of their clinicians and get good... I think that's massively important. So I think that's great. And I don't think it's bad for doctors or any other clinicians to be on social media or to have a presence or to answer questions. I think that's great, but I do worry that not everything that's said is true and people often hang their hat on credentials as if that's the metric by which we should trust. And that that's a problem. Rae Woods: Or, let's be honest people, even experts can see different things in data can come to slightly different conclusions. And that again could have a downstream impact to real people who are going, "Oh, they don't know what they're talking about." Dr. Aaron Carroll: The most angry people professionals have gotten to me was I want to say it was, oh God, I can't remember. Now at this point, I might have been two years ago, there was a series of randomized controlled trials in annals of internal medicine that looked at what's the real danger of meat? And that the evidence is not great. And so I wrote an editorial on it and I would argue this isn't a prestigious peer review journal. I was taking a reasonable take of like, let's assess the evidence and clinicians lost their minds because whatever side you fall on the meat wars, it's going to kill you. Or people have really over- Rae Woods: Over hyped this. Dr. Aaron Carroll: ... and anger and vitriol. And I would be like, this is the issue. We don't know, but both sides are convinced they absolutely do know. And the other sides lying. And I could see how for the general public, that could be massively confusing. Rae Woods: Especially if it plays out online, right? Dr. Aaron Carroll: Yeah. Rae Woods: And it comes back to your comment about policing. We talked about medical boards policing in a very specific, strong way, but is there a role where you do want clinicians online to be policing each other and saying, "Hey, maybe we shouldn't do this publicly or you are wrong, or you are spreading misinformation?" Dr. Aaron Carroll: It less than it was public than how angry it got. I think it was good to have, I think, honestly, a discussion that I ran in my camp, a discussion and actually of how questionable the evidence is in some of these cases is a good thing. And Lord knows I've written enough column. I was saying the evidence here is weak. People should know that, but I don't do it attacking, I don't make it about you're trying to kill people, you're evil. And when it gets to that level, then there's, I think a level of trust. I think people understanding that there is some gray in healthcare and we're all doing our best to understand it better. If people understood that and saw that play out, that might increase trust. I think people viewing us screaming and yelling at each other like children, will only decrease trust. And so it's the way we do it sometimes. Not just that we do. Rae Woods: I think you are spot on. If the thing that we know that works is the trusted relationships that patients have with their clinical team. We need to figure out how do we use the media? How do we use the internet? How do we use the existing relationships we have to keep building that trust, which might mean being transparent about what we don't know, saying that this is a gray area, explaining the process behind why we don't have black and white information. And then that can actually be building trust, not detracting it. Dr. Aaron Carroll: Yeah, I say, I don't know all the time. I don't understand why people are so afraid of that. And sometimes I don't know I got to go look that up and sometimes I don't know because we don't know. Even when we talk about things like masks, people talk about masks with a really fairly large amount of surety and it's like, and I'm like, okay, there are situations. And we have a knowledge base about when masks might be useful. But then there's times where it's like, yeah, the absolute value or the benefit is probably getting small. I mean, if you're talking about, should I wear a mask if I'm sitting outside with someone 20 feet away. But there are other people are like, "No masks are always going." It's like, okay, now we got to be able to talk about the nuance here. Rae Woods: Yeah. The nuance, the gray area, the trade-offs yeah, absolutely. Dr. Aaron Carroll: And be able to do so carefully and to be able to do so honestly, and this passionately and not assume the worst in each other, but too especially on social media, too many of these discussions become just yelling at each other and that the problem. Rae Woods: And this is where good digital citizenship becomes really, really important. And right you use all sorts of platforms to communicate with your peers, with the public. What advice do you have? Let's say for other clinicians that might be thinking about getting a little bit deeper into their online presence, how should they be practicing good digital citizenship? Dr. Aaron Carroll: I mean, I tried, I mean, for me, it always was at the beginning was I tried to ground almost everything I said with evidence that even when we started the blog, which is the first thing I did in 2009, 2010, it was not that I wanted to come and tell you my opinion. It was that I wanted to explain. Here's the reason I believe this. And here's all the evidence and the... And if you disagree, there's a comment section and let's talk about it, but it wasn't trust me. It was let me explain why. And I like to think that that's what my columns are too, that they're full of links to research and I'm explaining why this study matters and why this is so and what evidence and what caveats exist and how I get to this opinion, this how I get here. Not, I just believe it because then we can debate the rationale behind it, as opposed to just having a yelling match as to what we each believe. Rae Woods: I love that. Let me explain instead of, and that also is an element of trust. I know it's not just trust me explicitly, everything that comes out of my mouth should be chapter and verse for you. Instead it's let me explain. I love that. Dr. Aaron Carroll: And it is building trust. I agree with you. It's like, don't expect if I show up with one blog post that people are going to believe me and in the beginning, no one came to the blog, but that feel like, after- Rae Woods: I read the Incidental Economist, I've got it. Dr. Aaron Carroll: I know, but it's like, but in the beginning I took all the time. Our leadership was in the tense and I'm sure people have got that right. But over time, people like, "Okay, these guys are rational and they're explaining it and they get it." And journalists started to pay attention and it built an audience. Healthcare Triage is the same way. It takes time to build that level of trust and you don't ever squander it. So I try to be very careful, but what it does and it takes the other thing, as I said before, it takes time. I think people often want to show up in social media and think, let me get viral as quickly as I can. Rae Woods: Which is dangerous. Dr. Aaron Carroll: You can do that. It can be done, but that's never been my goal. It's more, I want to build a level of trust. And then that is one of the things I will say I like about social media is that I can follow journalists that I trust as opposed to just reading outlets. And so even during the pandemic, your Ed Young's, other people The Atlantic, Amanda Mull, or Olga Cazan, or it's Stat like Helen Branswell, or Matt Harper, or I grant that I've colleagues in the New York Times that I really follow, but I follow individuals and journalists that I've- Rae Woods: Me too. Dr. Aaron Carroll: ... learned to trust, as opposed to, I just read the New York Times. Rae Woods: Yeah. How do you handle the trolls? Dr. Aaron Carroll: Mostly two different ways. Dr. Aaron Carroll: If they're horrible people I ignore. But if there's even a chance of... and on Twitter, I will mostly just ignore or mute. But if somebody sends me an email and they took the time to write, if they had all seem reasonable, I will sometimes answer them and surprise them. And nine times out of 10, you'd be surprised. People respond by like, "Oh, now I feel terrible. It didn't occur to me that like, you're a human being and you might actually read this and respond." Rae Woods: Because to see it as an opportunity to build trust. Dr. Aaron Carroll: Yeah. And so sometimes you will break through, but I mean, clearly if somebody is just being terrible, I just ignore it because what else- Rae Woods: Yeah. Well, this has been unbelievably helpful for me also as somebody with her own kind of social media presence. And I know that our listeners and the clinicians who are listening to this podcast will find it valuable as well. At the end of my episodes, I always want to give our guests the platform and the chance to just speak directly to our audience. So when it comes to the world of medical misinformation and disinformation, is there one thing that you want healthcare leaders of all kinds to focus on or act on right now? Dr. Aaron Carroll: Just like this thing, the biggest thing is that don't miss an opportunity to connect with patients that I know everybody is busy, and I know that it's really hard, and this has been an incredibly stressful year and a half it's ongoing, but it is amazing to me that in poll, after poll, doctors remain the most trusted source of information above anyone you see on TV- Rae Woods: That's right. Dr. Aaron Carroll: ... above any politician, above any expert, I know people can't see my air quotes, but expert people trust their doctors. And we should make use of that. And take it out of duty if you can. Connect with patients, you'll probably do more to convince someone to get vaccinated or do the right thing and all the other messaging [inaudible 00:33:42]. Rae Woods: Yeah. And if you're an administrator, make sure that your clinicians have the protected time to do that because I agree this is an untapped resource that we need to use going forward. Dr. Aaron Carroll: Yeah, absolutely. Rae Woods: Well, Aaron, thank you so much for coming on Radio Advisory. Dr. Aaron Carroll: My pleasure, thank you, Rae. Rae Woods: Welcome Solomon and Pam, were you as excited as I was to talk to Aaron Carroll? Or is this just me? Solomon Banjo: I was incredibly excited, but I don't know if anyone can be as excited as you were, but I was very, very excited. Pam Divack: I have to echo that. Rae Woods: Well, what was your favorite moment from the conversation? Was there a piece of advice or something that you latched on to that you went, that's it, that is the thing that we want to make sure people know when it comes to addressing medical misinformation? Pam Divack: One of the things that he said that really resonated with me is that it seems like right now, we're at a time where people in the general public are exposed to just how much uncertainty there really is in medicine. And I think we're seeing this come to life right now with the ongoing debate over boosters. First, we thought the evidence said the boosters should be for everyone. Then some experts said high-risk. And even within the medical community, there's a debate there. And I think that debate is really exemplifying. Just how much uncertainty we're dealing with on a day to day. Rae Woods: And how hard it is to communicate it because right Pam, you were on the very last podcast we did talking about that debate, which was changing literally day by day. And I think has already changed again. So not only is it difficult for people to understand the dynamics, it can make it really hard for people like us to just communicate that to the public. Solomon Banjo: I think this is also what's complex when you think about misinformation and you insert clinicians into this equation, because absolutely what Pam said. But the other thing I took away is just how much trust the public has in clinicians. And yet they don't understand, we don't understand or appreciate just that level of uncertainty. And so when these conversations play out in public, is this really hard as a lay person to wrap your mind around, "Oh, well, who should I trust here?" And I think I really liked the point too, about pointing people back to the evidence Pam was referencing as his girlfriend gauging online. And I think it's something we should all be keeping in mind. Rae Woods: You're both bringing up the role of physicians, but you actually don't work with physicians. You work with the rest of the healthcare industry. The pharmaceutical companies, the drug makers, the device makers, the part of the industry that I don't think it's talked about enough, especially in this debate. So to do some translation for me beyond the physicians, the providers, the clinicians themselves, what's the role of other parts of the healthcare industry in addressing myths and misinformation? Solomon Banjo: I think one piece is just accepting or at least acknowledging that historically part of what our members life science, pharma and device members have worked to do is to generate the evidence, to prove in front of regulators, in front of the medical community, whether their treatment works, what are the trade offs associated with it? And that has largely been done for the consumption of regulators, for the consumption of clinicians who do have the training to engage with that. But I think as we start to see evidence consumed, debated by clinicians and with patients and happening in this open forum, what then is the role, or what are the implications for these evidence generating individuals, organizations to try and proactively combat misinformation. Because this is a thing that is not going anywhere. And so how do we actually adapt to try and mitigate it? Rae Woods: And that is so interesting to me because one of my aha moments from Aaron is you don't just directly vomit back the information. You say, let me explain it to you. But to your point, Solomon, these upstream actors have never had to do the, let me explain it to you before they write it in a way so that other scientists, other physicians, other regulators can understand. And I wonder if there's this moment of translation of, let me explain it to you. That becomes part of their social responsibility, which has hasn't happened before. Pam Divack: I've seen it play out in a few pharmaceutical companies where they are starting to make more patient focused videos or podcasts or taking steps to explain it. And I think it's a really good step, but hopefully that doesn't stop when the pandemic ends. That's something we should be doing always with all types of evidence. Rae Woods: I have to admit, there's a specific reason why I wanted the two of you to debrief with me. And that's not just because you work with another part of the health care industry. I know that you two are working on some thought pieces around the world of misinformation, but you're focused more explicitly on what happens within medical communities. So for you, what have you learned about the role of good digital citizenship within online spaces? Pam Divack: One of the biggest things that I learned is that there are so many places where physicians go online to have these debates, but it's important to keep in mind who your audience is and what you're discussing. So on the one hand, we know there are so many physicians on platforms like Twitter, Clubhouse, where these conversations are out for the whole public to see, but we also know clinicians go to online forums like Doximity or Sermo, which are these physician only communities. And thinking about when and where to have these debates is one core element of good digital citizenship. Solomon Banjo: And I also think we're trying to really figure out what it means to be a good digital citizen as a clinician. Pam and I have quipped as we were writing this about tweak no harm, what does that principle actually mean? So it is being grounded in the evidence. It is like what Aaron said about providing the context. So we can debate that and not the blurbs and just talking points and keeping in mind that the conversation online is not the end goal. And so how do we drive to the things that are actually going to impact heavily address misinformation, change behaviors? So we are all a healthier as individuals, as communities, as a country. Rae Woods: Well, given the conversation with Aaron and all of the things that you have learned about misinformation, online presence, the right way to think about digital citizenship. What's the one thing you want to make sure that our listeners take away or act on? Pam I'll start with you. Pam Divack: So for me, obviously, misinformation has really been in the spotlight over the last year and a half, two years, but where the conversation has focused is what are the role of big tech companies, the Facebooks, the Twitters, and controlling this? But I do think we need to narrow the focus a little bit to think about this online clinician communities and the role that they are having and the spill over effect on the public. Rae Woods: Solomon, what about you? Solomon Banjo: My piece of advice would be more of a call to action. Right now we're talking a lot about these concepts through the lens of COVID, but this was happening beforehand. There is no vaccine we can take against digital misinformation. And so really grappling wherever you sit in the health [inaudible 00:41:29] system of like, what's my role here? How do I help mitigate this support clinicians, ultimately support patients to get the information they need to make the right decisions for themselves, their families, et cetera. Rae Woods: Well, Pam, Solomon, thanks for coming on Radio Advisory. Pam Divack: Thanks, Rae. Solomon Banjo: Always a pleasure. Rae Woods: I know that in this conversation, we focused a little bit heavily on the clinician's role because a clinician's role is at the end of the day to protect patients from harm. And that includes harm that they might be feeling or facing online through medical misinformation. But Solomon is right, every single one of us plays a role here, whether you are upstream or downstream, whether you have decided to adopt an online presence yourself, whether you're an administrator, it doesn't matter what corner of the healthcare ecosystem you come from. You have a role in combating this misinformation. And remember as always, we're here to help.