Earn trust, counter misinformation
Physicians are on the front lines of addressing medical misinformation, increasingly figuring out what to address and how.
Eric Last, DO, FACP, has become more adept at addressing medical misinformation, but some encounters continue to rankle, such as an exchange early in the pandemic with a long-time patient.
COVID-19 vaccines had just become available, providing the first protection against the life-threatening virus, said Dr. Last, an internal medicine physician at Northwell Health in Wantagh, N.Y. But misinformation also was circulating in some quarters that physicians and others in health care were making money off the shots, a concern raised by his patient.
“I remember saying [that] I had no intention of having the conversation further because I had been his physician for over 20 years,” Dr. Last recalled. “And if he thought that my motivation was financial, then he really needed to rethink who his doctor was.”
Dr. Last is still the patient's physician, and he's since learned to set aside his anger. He reminds himself that patients want to make good choices for their own health, even if they're being misled by inaccurate information. Still, he added, “I'm saddened and disappointed when those conversations happen, and they happen literally every day.”
In recent years, and particularly since the pandemic, physicians have found themselves on the front lines of addressing misinformation, as new strains are disseminated through social media and other outlets. Increasingly, physicians must figure out which inaccuracies to address and how, both during time-pressed office visits and more broadly in their communities and on social media.
Numerous medical groups have highlighted the key role that physicians can play in addressing misinformation, along with their professional obligation not to spread it. In 2021, the Federation of State Medical Boards issued a statement that physicians “who generate and spread COVID-19 vaccine misinformation or disinformation” are risking state medical board disciplinary action, a stance that was endorsed by medical groups, including the American Board of Internal Medicine (ABIM). At ACP, leaders have taken steps to promote accurate information, including through YouTube videos that address patient questions, and have provided online resources that physicians can use to debunk medical misinformation. The College also recently joined the Coalition for Trust in Health & Science, a nonprofit organization focused on countering misinformation.
Physicians can be influential with their patients if they lead with questions and adopt an open-minded approach, said Darilyn V. Moyer, MD, MACP, ACP's Executive Vice President and Chief Executive Officer. “You have to understand where they're coming from and not be defensive. Hear them out. Be curious.”
Whenever feasible, physicians can adopt a “pre-bunking” approach, to ideally inoculate patients against believing false information by providing the facts and pointing them to credible sources, said Dr. Moyer, who also treats patients at the Lewis Katz School of Medicine at Temple University in Philadelphia. Use plain language and keep in mind patients' literacy levels and lived experience when laying out fact versus fiction, so they're better prepared to be skeptical when they encounter inaccurate information moving forward, she said.
After an exchange and before patients walk out, physicians can use the teach-back method to gain a sense of what they have absorbed, Dr. Moyer said. This helps determine what patients took away from the visit and allows physicians to reinforce important points and answer any other questions that come up, she noted.
Countering misinformation
Both misinformation and disinformation refer to false or misleading content, but disinformation is shared with the intent to deceive or cause harm, according to the Coalition for Trust in Health & Science. A relatively small number of voices can exert an outsized role. A 2021 analysis found that two-thirds of the antivaccine content shared on Facebook and Twitter could be traced to 12 individuals and their organizations, dubbed the Disinformation Dozen, according to findings from the Center for Countering Digital Hate.
A recent pilot study involving an online survey of 2,183 North Carolina physicians and physician assistants found that nearly all, 94.2%, had encountered misinformation from patients. Yet training on how to engage patients in conversations about misinformation is limited, with just 18% of respondents reporting any formal training, according to the findings, published in 2021 in INQUIRY: The Journal of Health Care Organization, Provision, and Financing.
When addressing misinformation, social scientist Brian Southwell, PhD, an author on the North Carolina study, echoed Dr. Last's point: It's important for physicians to remember that most people want to make healthy choices for themselves and their families, even if they don't have access to the best information.
Dr. Southwell co-directs the Duke Program on Medical Misinformation, which was launched in 2019 and provides workshops and other training to physicians, nurses, and health professionals. “You can view a lot of decision making, even during the pandemic, as having been incorrect, but still coming from a place of people trying to keep themselves safe,” he said.
During these conversations, physicians should strive early on to gain a sense of where the patient learned the misinformation, whether it was from surfing social media or from someone they know, said Dr. Southwell, who is also a senior scientist at RTI International, a nonprofit research institute. “Because when you're dismissing some piece of misinformation that a patient is raising, you might be dismissing that person's spouse or their loved one or somebody else that has shared it with them,” he said.
Try to avoid responding with a litany of facts, said Dr. Southwell, which not only consumes time but may be difficult for patients to quickly absorb. Plus, he added, “People don't like to be just blatantly wrong, and so there's some degree of defensiveness that I think comes up.”
Instead, physicians can focus on gaining insights into a patient's underlying values or concerns, Dr. Southwell said. For instance, a patient may refuse to get colon cancer screening, saying that it's unnecessary because they consume a healthy diet and use herbal remedies.
Rather than getting sidetracked into a discussion about why these things don't negate the need for screening, Dr. Southwell suggested, physicians can briefly outline the importance of colon screening before soliciting any questions or concerns. The patient may have rationalized that a healthy diet is sufficient protection, but really, they're fretting about the invasiveness of a colonoscopy or the ick factor involved with stool testing, he said.
Primary care physicians should take it as a compliment if a patient asks them about medical information they have learned elsewhere, said Yul Ejnes, MD, MACP, a Rhode Island internal medicine physician and chair of the ABIM's board of directors. Also, they're better situated to respond than emergency physicians or other specialists who only have brief interactions with patients, he said. “Having a long-term role with the patient gives me a little more liberty on what I can say to them.”
Dr. Ejnes has turned to analogies, often not involving medical care, to illuminate inaccurate or misleading information. When a patient says that they got the COVID-19 vaccine but still caught the virus, he may pivot to seat belts. Wearing a seat belt, he reminds them, reduces their chance of injury and death, but it doesn't provide iron-clad protection.
When another patient questions whether to trust infection control guidance, given that it's shifted during the pandemic, Dr. Ejnes may discuss the initial uncertainties surrounding hurricane tracking and where a storm will land. As more scientific data come in, that landfall prediction is refined. Nobody accuses weather forecasters “of lying if they forecast that the storm is going to hit New Orleans and instead it hits Biloxi,” Dr. Ejnes said.
Even so, sometimes repeated efforts over a series of visits to convince a patient to, for instance, get the COVID-19 vaccine or to counter another type of medical misinformation can become circular and nonproductive, and it's best to move on, Dr. Ejnes said.
“You don't want it to become an area of conflict that then intrudes on other things you're trying to do with the patient,” he said. “We're not just trying to keep people from getting COVID. We're also treating their diabetes, their hypertension, other issues that require their buy-in.”
Achieving small wins
More research is needed to better understand and develop effective ways to counteract misinformation, said Dhruv Khullar, MD, MPP, a hospitalist and assistant professor of health policy and economics at Weill Cornell Medicine in New York City. In a JAMA viewpoint piece published Oct. 11, 2022, Dr. Khullar cited Duke's training efforts as a good start. He also credited Massachusetts General Hospital for hosting virtual town halls to answer COVID-19-related questions from the public. But addressing misinformation on social media forums, such as Twitter, may carry some potential pitfalls for physicians, Dr. Khullar said.
“You could envision a world in which doctors being very active on social media, pushing back against some of these things, is helpful,” he said, “because people have a more evidence-based point of view that they're able to take in. But you could also imagine that trust in doctors declines because they're engaged in these online fights with people, patients, media figures, etc.” (For more on physicians and social media, see the related story in this issue.)
Yet Meredithe McNamara, MD, MS, who describes herself as an early-career physician, believes that physicians should play a more prominent role in debunking erroneous information that's promoted by politicians. “I am staring at a potentially long and dark road ahead where false information can decide the standard of health care in health policy debates that don't include experts, unless something changes,” said Dr. McNamara, an assistant professor of pediatrics at Yale School of Medicine in New Haven, Conn.
She points to gender-affirming care for youth as “ground zero for scientific disinformation.” In a perspective piece, published Nov. 24, 2022, in the New England Journal of Medicine, she called for scientists, including medical groups, to collaborate with lawyers to defeat medical bans on gender-affirming care as they make their way through the courts.
“We really have to win here to continue to provide evidence-based medical care in every domain of medicine,” said Dr. McNamara, who specializes in adolescent medicine. “If you're a nephrologist in Kentucky, this is your problem. And it's a slippery slope, in which scientific evidence that we work tirelessly and ethically to maintain doesn't matter.”
For instance, some of the medications prescribed to treat gender dysphoria are used off-label, which some politicians have incorrectly criticized as experimental treatment, Dr. McNamara said. Off-label prescribing is a common practice in pediatrics, she noted, because many medications are not studied in the same way in pediatric populations as they are in adults.
In her own practice, Dr. McNamara is encouraged when parents trust her enough to raise misinformation. She thanks them for sharing what they've heard and asks if she can point out other information.
Along the way, Dr. McNamara counts any small win, for instance, if the conversation wrapped up on a good note or the parent didn't leave angry. Above all, she keeps her eye on the long game.
“Really solid disinformation debunking is something that unfolds over time,” she said. “So, I'm going to plant some seeds and build some trust and leave my door open, and be here for them next time around.”
Similarly, Dr. Last reminds patients that his job is to educate and what they do with the information is up to them. In some cases, he's found he can successfully leverage his long-term clinical relationship with the patient.
“I say to them very sincerely, ‘Listen, I want to talk to you about this, and I want to talk to you about this because we have a relationship for 10 years, 15 years, 25 years. And I am telling it to you because I am concerned about you and concerned about your health.’”
