COVID-19 Conspiracies and Beyond: How Physicians Can Deal With Patients’ Misinformation | Public Health | JAMA | JAMA Network
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Medical News & Perspectives
December 30, 2020

COVID-19 Conspiracies and Beyond: How Physicians Can Deal With Patients’ Misinformation

JAMA. 2021;325(3):208-210. doi:10.1001/jama.2020.22018

Early in 2020, communication science expert Brian Southwell, PhD, launched a training workshop at the Duke University School of Medicine to address a major clinical problem: What physicians should do when patients are misinformed about their health. It’s one of only a few such programs in the nation. This year, Southwell, a scholar with the medical school’s Social Science Research Institute, and his collaborator Jamie Wood, PhD, plan to make it available as a live virtual offering for clinician practices and health care systems.

Peyton Williams/RTI International

“There’s a lot that we can learn from the past in terms of how people have engaged with misinformation historically,” Southwell said in a recent interview with JAMA. “That’s going to be helpful, but we also need to think about some of the challenges of the moment.” Misinformation is a longstanding issue, he acknowledged, but one that social media has facilitated and exacerbated—sometimes with dangerous consequences. The coronavirus disease 2019 (COVID-19) pandemic brought it all to a head.

In the edited conversation that follows, Southwell, who is also a senior director at the independent, nonprofit research institute RTI International, discussed the viral spread of false health information and malicious disinformation campaigns, why we’re vulnerable to falling for them, and how time-pressed physicians can deal with all the noise.

JAMA:How has health misinformation evolved with the internet and the era of social media?

Dr Southwell:Misinformation has been with us for a very long time. In the current moment though, there’s a dizzying array of information that’s available to you very quickly. It’s also the case that when you see something that you’re perhaps excited about or interested in, you can share it so much more quickly than has ever been the case. We worry about not only people’s exposure to information but also the diffusion of that information and misinformation in all sorts of ways.

One of the interesting aspects of social media is a flattening of the landscape in which it’s difficult to tell and to trace the lineage or authorship of information. You might have legitimate information alongside information that might be much more problematic. That’s something that we might worry about—the sense in which there’s an equalized platform that may well give people the impression that all information is equivalent in terms of how useful or credible it is.

Now it’s also the case that you’ve got some people and organizations actively seeding the internet with misinformation. “Misinformation” might cover the whole range of noise that we might think about, but some of what people are encountering has a really problematic or nefarious authorship.

JAMA:It sounds like you’re referring to the difference between misinformation and what some people call disinformation.

Dr Southwell:That’s a really important distinction, I think, from an ethical standpoint. But from the standpoint of patients, from the standpoint of those that we’re trying to serve, it may not necessarily matter as much in terms of the authorship. Because we know that the processing systems that people carry around with them tend to not necessarily differentiate based on who originally crafted a message unless they’re aware of that source.

JAMA:What type of health misinformation tends to be common on social media?

Dr Southwell:I think it’s important to realize that people use social media not just in search of the truth per se, but also to connect with one another and to bond with one another. If we think about information and potentially misinformation in terms of its currency, it’s not going to surprise you that some of what travels on social media is that which is sensational or that which seems to be directly linked to everyday life. Relevance really matters here quite a bit.

We know that the misinformation that seems to be related to one’s own personal well-being or the well-being of their loved ones not only gains attention but is also more likely to be shared. Similarly, we might think about more abstract scientific information perhaps as being viewed as more distant from people’s everyday life and perhaps less likely to be shared.

If you think about an almost inherent advantage that many folks who are putting together misinformation might have, it’s easier to craft something that’s sensational or relevant if you have the ability to just put together whatever you’d like without necessarily worrying about it being true. Whereas, folks who are operating from the standpoint of science and medicine often are thinking about the rules of peer-reviewed journals.

JAMA:Why are we vulnerable to believing health misinformation—and what do these beliefs say about us?

Dr Southwell:There’s a long-standing debate in psychology. The nutshell argument has to do with what happens when people encounter false information. The philosopher Descartes essentially thought that people could know it when they saw it and screen out false information. Spinoza had a subtly different argument and suggested that we take in all information and then we make sense of it a little bit later. That slight hesitancy, that sequence between taking in information and accepting it, and then later tagging it as being false or true, makes all the difference, because that’s enough time to potentially share something on social media.

That’s perhaps enough time to forget to bother to critically engage or to not necessarily have the capacity to critically engage information further. On some level we’re all vulnerable to sensational or other types of misinformation when we encounter it, at least for a moment. The question is what can we do to encourage people to take that extra moment to critically evaluate what they’re seeing.

Now, what people’s acceptance of misinformation also says about them, which is the other part of your question, is that we are human beings that have particular needs, and those are almost universal in a lot of ways. The need that we have to be social and to connect with other people. The need that we have for hope for the future. The need that we have for basic safety and security and health and well-being.

What’s interesting when you look at patterns of misinformation acceptance is that people are finding information that offers those things. Sometimes it turns out to be false or inaccurate. Nonetheless, if a piece of misinformation is framed in a way that offers you hope for the future, well, it makes sense that that would be something that you’d attend to. If misinformation is framed in a way that got one of your colleagues or a friend or family member excited, and they shared it with you, again, it’s sometimes important to connect with people and that sometimes overrides our other critical judgment.

In a lot of ways, you might view people’s acceptance of misinformation as partly a symptom of people trying to make sense of this crazy chaotic world. Even in the case of conspiracy theories, I think there is at root a hope that somehow there is some explanation for the situation that otherwise is really viewed as problematic. That somehow there is some rationality to what otherwise seems like an open, uncertain future.

JAMA:Can you contextualize that for COVID-19? Does this explain why some people would rather believe that the pandemic is a hoax or is something that doesn’t need to be taken that seriously?

Dr Southwell:We’ve been thinking about misinformation for a while but so much of this has come to a head during this pandemic that we’re all struggling through. I do think that there is something about the types of misinformation that people are holding onto that offers them some encouragement. It’s easier perhaps to believe that we aren’t actually facing this global pandemic, so at least initially I think that may have explained part of the reason why people would turn to those types of conspiracy theories.

Similarly, people are looking for a relatively convenient and easy way to address what is a really threatening problem. There has been some more dramatic misinformation that’s been spread, but some of it’s been relatively mundane. There are recommendations to drink a lot of water to protect yourself or [clear] the virus, which we know don’t seem to hold up. I think that’s been important to note, not just because that information is false or inaccurate but because it somehow was offering an explanation or a concrete action that somebody might take.

That turns out to be really important for people in what’s frankly a scary time. I think that even people who are holding on to information that seems to deny the larger contours of the pandemic probably, underneath that on some level, are feeling some uncertainty or fear that they’re trying to ameliorate with the false information.

JAMA:What inspired the clinician training you developed at Duke?

Dr Southwell:I’ve had the good fortune to connect with a number of colleagues in the medical school who have been worried about misinformation for a number of years. A few years ago, I had opportunities to connect with Robert Califf, MD, the former US Food and Drug Administration commissioner, when he was at Duke. Rob has worried about medical misinformation and its potential effects on society for a long time. In that context, the question then becomes, what can we do about all of this?

Many clinicians have had the frustrating experience of their patients wanting to point to misinformation that they found online or that they’ve heard from somebody else.

You’ve got this pressing concern and yet most people don’t know exactly what to do about that. The question was, could we come up with some ideas, some guidelines?

JAMA:What are the basic principles of the training?

Dr Southwell:We developed a workshop that emphasizes a few different themes. The first is this perhaps nonobvious realization that we need to think about patient psychology a little bit differently. That we maybe should not focus right away on just how wrong somebody is when they bring in a piece of misinformation. First, realize that we’re all in this boat together and that we all are vulnerable to misinformation. I think that leads to greater empathy and compassion than sometimes is the case.

These conversations frankly are just awkward and difficult. Part of the guidance that we offer has to do with how to manage those challenging conversations. In a very time-limited clinical encounter, we advise you to not spend time discrediting sources and to not necessarily go into a heavily technical explanation as to why something is wrong.

It’s important not to shame the patient for being wrong. That can be done in terms of your own body language—not having arms folded, trying not to scowl at what somebody’s saying. Also, think about the questions that you’re asking. Instead of grilling them on the technical points of what they’ve raised, at least have a short conversation about why what they raised is important to them, which might actually offer you some insight as to what values they’re expressing. Then that offers a path to potentially point them toward credible information.

I also want to point out, though, that this isn’t the job of any one clinician to do alone. It also is an opportunity for our health care organizations to think about different roles that they could develop and different opportunities that they might have. One of those is to think about ways that they might be able to use tools to better monitor the information environments that their patients encounter.

Some of this can happen online in terms of actually scraping and monitoring what’s out there in places that many health care professionals wouldn’t normally look. It also might be very simple in terms of really having a robust and constantly updated frequently asked questions section on your website. It may well be an organization-level response as well as an individual clinician response.

JAMA:It sounds like the goal should not be to convince the patient that what they believe is wrong.

Dr Southwell:Yes. Because there’s probably not time in a quick exchange. Instead, if you can see the patient, if you can acknowledge them in some way, that might help. If you can also celebrate that conversation as a victory in and of itself, I think that’s also crucial. There’s an opportunity for you to potentially redirect them to more credible information.

But there’s also something there to celebrate, which is that that patient has brought something to your attention. They trusted you enough to talk to you about it, which means that they aren’t off on their own, unbeknownst to you, searching on the internet and not connected with the health care system at all.

JAMA:Can you talk more about how to reframe thinking about these encounters so that physicians can avoid coming off as scornful or dismissive?

Dr Southwell:We’re all human, right? It’s difficult sometimes to hide our reaction to misinformation that we might hear. The real key is trying to listen and to not necessarily jump in right away with ideas. That turns out to be important. Humility also turns out to be important in terms of not overstating one’s own certainty. That can be difficult sometimes if you only have a limited time for an exchange.

I think one important principle to keep in mind is that the patient hasn’t come in to try to offend you or to insult your intelligence. They’re attempting to consult with you as an expert. They might be excited about or have found a lot of information.

It doesn’t do anybody any good to win the momentary argument if people walk out feeling like they aren’t going to necessarily trust or feel comfortable raising something else in the future. It really is a matter of trying to have some patience and compassion in ways that we have so much evidence of clinicians doing in so many other aspects of their everyday care for patients.

JAMA:Let’s offer a scenario. An older patient with type 2 diabetes has read online that cinnamon is good for diabetes, so he tells his physician that he’s going to start taking cinnamon pills and stop taking his diabetes medications. How you would you advise a physician to respond?

Dr Southwell:A really important caveat is that I’m not trained as a medical professional. But I would offer advice along the following lines. The physician could say, “I’m curious to know, what is it about the cinnamon pills that’s attractive to you? Is it a matter of cost or convenience?” That might give a chance of actually understanding if we are talking about somebody who’s desperate for something that is differently priced, potentially more efficacious, or is not going to have the same side effects.

At the end of the day, we’ve got human beings interacting with one another. It’s important that we continue to see each other in those ways. We’re hopeful that people are going to be able to take a breath, be more compassionate to one another, and realize that part of the way through this is to not have all the answers, even when what your patient’s raising seems pretty outlandish. To realize that listening to them for a moment might save you a step or two down the line might be better for all of us together.

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    3 Comments for this article
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    Civil Discourse
    Robert Burney, MD | Retired
    Outside medicine there are scholars and programs devoted to civil discourse ("how to talk to people who disagree with you"); see eg University of Arizona's National Institute for Civil Discourse and the Karsh Center for Law and Democracy at the University of Virginia. A general approach is to challenge the patient for more details on their point of view. "Where did you hear that? Is that a reliable source? What would be the consequences/costs of implementing that view?" Try not to let them know your opinion. They need to discover for themselves they may be wrong. Don't argue. Don't tell them they are wrong. And don't expect instant results.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Medical misinformation
    Ernest M Kraus, BS Pharmacy | None
    I encounter this numerous times with my wife who asks me a question based on what her girl friends and beautician tell her about their medical conditions and how they have decided to treat themselves. I try the same approach and get " so and so said" and I say I wonder what their physician really said as opposed to what they think they heard. It becomes frustrating when I eventually lay out the science facts vs the anecdotal comments. Eventually I give up and remember the comment from the House of God; "The patient has the disease."

    Ernest
    M Kraus, RPh
    CONFLICT OF INTEREST: None Reported
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    The Art of Not Knowing
    David Stumpf, MD, PhD | Professor Emeritus, Northwestern University
    Physicians face challenges when treating patients with conditions we do not initially understand, or which have a limited repertoire of evidence. We encounter this almost every day. COVID-19 illuminates the issue. It also illuminates us and reminds us that the art of medicine is often the "art of not knowing." There is no time for a clinical trial with a patient at death's door. Books and experts do not have the answers. This uncertainty requires humility, an open mind, exploration, and actions without full understanding. The most important action is listening to and observing the patient. Dr. Southwell is careful in not labeling perceptions as misinformation and cautions against trying to win an argument. The art of not knowing involves exploring the beliefs and desires of the patient and helping them formulate intentions. A pandemic expands the relevant venue from a patient room to a population and everyday life, decisions under conditions of uncertainty become more consequential. How carefully are we listing to and observing the population, their beliefs, desires and intentions? Are we trying too hard to win an argument or impose a policy? It's not just about medicine, but also work, education, family life and more. We will do better in communicating about this pandemic if we seek to understand and address what we do not know about these beliefs and desires of our fellow citizens, many of whom are scared by what they have been told, angry about policies, and worried about their fate. "Not knowing" involves addressing both the imagined and real terrifying outcomes.

    Additional disclosure: Executive and paid consultant, Woodstock Health Information & Technology
    CONFLICT OF INTEREST: I'm writing a book on The Art of Not Knowing
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