Conclusion first: There’s a line you don’t have to cross when it comes to medical misinformation.
When it comes to determining if your healthcare organization should pull out all the stops to convert patients who are inextricably dug in, it’s tough to acknowledge the line beyond which caregiver resources cannot be effective. Especially for persistent providers dedicated to hope and healing. Yet it’s a more palatable one today as the consequences of misinformation get ever more personal and even violent. It’s a moment to recognize what’s possible and what’s a waste of caregivers’ precious energy. It’s a moment to ensure caregivers are empowered to speak on issues where they have trust and authority rather than expending themselves fighting a battle outside their domain.
This report focuses primarily on how providers should deal with the misinformation du jour around COVID-19 vaccines – whether unproven treatments or government conspiracy. The current moment is also useful for examining a problem that existed before and may well become an even greater concern in the future.
Today, 204 million adults have received at least one dose of a COVID-19 vaccine. Of the remaining 54 million, more than half are likely diehards. Convince the holdouts at all costs? Or draw that line to protect your exhausted staff? That’s the crux of it.
On the surface, it seems bizarre that people would go to such great lengths to push back against what most deem a straightforward issue: Get vaccinated to reduce your chance of dying from COVID-19. How did this evolve to threatening nurses and school boards? Why now? What’s the psychology of misinformation and why is it driving us apart?
In many cases the issue isn’t binary – good vs bad thinking – which is easy to forget but must be remembered. Sure, there are topics where there’s no middle ground: The Earth is not flat and Bill Gates is not controlling us through 5G activated nanobots. But often the pushback is reasonable and addressable, as with people in the “wait and see” camp concerned about possible vaccine side effects. Put another way, it’s not always straightforward, and those on one side of an argument may be too quick to label the other side’s position “bizarre.”
Once we make that distinction and consider the thinking of the deeply entrenched, we often find a virulent blend of moral codes and confirmation bias used to try and create an ordered worldview. It can all be topped off with a dollop of social pressure that keeps people from changing their mind (or at least admitting to doing so).
“It comes down to how strongly you’ve internalized and wrapped an idea in moralistic language,” said Jon Hughes, a Jarrard Inc. consultant and former practicing psychotherapist. “People have turned the idea of freedom into a moral code and created a zero-sum game where any threat is unacceptable.”
Misinformation and conspiracy theories are related but separate. Last year, a group of researchers from Belgium, Switzerland, the Netherlands and Canada surveyed almost 9,000 adults from around the world. The resulting study defined the terms and noted differences in the characteristics of people inclined towards believing misinformation compared to those who buy in to conspiracy theories. Their definitions:
The team found those embracing misinformation and/or conspiracy theories had greater levels of national political polarization, greater consumption of information through social media, lower engagement with traditional media and were younger. While the more educated were less likely to buy into conspiracy theories, belief in misinformation was similar among educational levels.
Many healthcare workers have experienced what should have been a pleasant visit with acquaintances that was torpedoed by someone bringing up vaccines/mandates/Ivermectin/etc., unprovoked and out of context. “In situations like these, the person in healthcare represents a moral threat,” said Hughes. “And that threat is bigger than the moment. Something existential. Something the other person has to fight.”
The next piece is confirmation bias inherent in all humans. We look for anything to reaffirm our stated positions, working backwards into evidence rather than forward into a conclusion. With some, there might be a powerful change of heart when they see the reality of the situation. But not all. Their conclusion is so strongly held that their own imminent death isn’t enough to sway them.
People also want order and explanation. According to The New York Times Science Reporter Benedict Carey, a lot of us dabble in the conspiratorial. “Estimates of how many Americans firmly believe at least one discredited conspiracy theory hover around 50 percent, but that may be low,” he wrote last September. Two aspects worth noting about what leads people towards conspiracy and misinformation:
People often adopt conspiracy beliefs as a balm for deep grievance. The theories afford some psychological ballast, a sense of control, an internal narrative to make sense of a world that seems senseless. The belief that drug companies invent illnesses to sell their products, for instance, can provide a way of processing a grave diagnosis that arrives out of nowhere.
Even if people might be willing to reconsider their position, social pressure can prevent them from taking that step, or admitting it if they do so. That secrecy can give misinformation a longer life. Steve O’Neill is a faculty member in the Center for Bioethics at Harvard Medical School. He recently retired from his role as associate director of the Ethics Support Service at Beth Israel Deaconess Medical Center, where he also served as the social work manager for Psychiatry, Primary Care, and Infectious Disease. We spoke with him about the roots of skepticism and where providers should jump in. He said,
“It’s very difficult if you’re in a group where your peers are not getting vaccinated,” he said. “I hear this all the time from people who have gotten vaccinated but are afraid of telling their friends because it feels like they’re betraying their loyalty to them.”
All told, information that says what we want it to say and helps us feel more comfortable is a shockingly powerful drug.
Some of those who remain unvaccinated to this point - but are still considering it - are facing significant in-group pressures. Choosing to get the vaccine for them is uphill and takes courage.— Esther Choo MD MPH (@choo_ek) October 13, 2021
Never has it been so easy to feel the comfort or order and explanation we crave – even when the “comfort” is found in getting riled up. We have social media to thank for that.
We recently collected input from three dozen healthcare followers within our Jarrard Inc. network on the topic of misinformation. They overwhelmingly pointed to Facebook as the greatest source of misinformation. This was consistent with a widely discussed study last May about the “Disinformation Dozen” – 12 people who are responsible for nearly two-thirds of vaccine falsehoods on Facebook.
To be clear, our small sampling tells us more about those who engage with Jarrard Inc. content rather than providing dramatic new insight into the problem of misinformation. But the feedback is additive to the larger conversation.
The next questions looked at how our audience – healthcare administration, marketers, communicators and consultants – thinks about the effects of the ideas swirling around out there. The most influential piece of misinformation, according to respondents, was that the COVID-19 vaccines have not been researched. It’s an interesting point because it’s a relatively believable idea. And on paper, at least it’s easier to rebut than government conspiracies and microchips.
Coupling that high-level psychological context and dose of reader perspective, let’s look at some collective missteps that may have helped foment the confusion. Yes, that means looking at ways our industry has opened itself up to criticism and loosened the ground for misinformation to take root. Maybe then we can avoid doing so in the future.
To understand who’s buying into misinformation, you need to consider backgrounds. “We need to understand the genesis of misinformation,” O’Neill said. “It’s like doing a differential diagnosis.” There are significant differences in the source of concern between someone from a marginalized community (historical abuse), an immunocompromised person (vaccine side effects), and political persuasion (belief in a conspiracy or worry about being disloyal to their social circles).
Yet there’s a common thread among these patients, per O’Neill. It’s the feeling that providers aren’t acting in their best interest. In other words, the individuals suspect clinicians are doing things “to line their own pockets.”
O’Neill believes that giving patients access to their medical records and clinical notes will allay that fear and engender trust. People can see what their care team is saying about them. They can see that they are not being pumped for money or experimented on. O’Neill himself was active in pushing for passage of the CURES Act and its transparency requirements and also works with OpenNotes, an organization that promotes transparency in healthcare, in part through access to medical records including both physical and mental health notes.
One respondent to our survey wrote:
Despite Dr. Fauci’s credentials, his inconsistency has seriously undermined trust in the organizations that should be leading the communication effort. Any news outlet that continues to have him on is furthering the problem…NBC, CNBC, Fox, CNN, doesn’t matter. He needs to be removed from the discussion.
Though we at Jarrard don’t agree with removing Fauci from the discussion, as communications experts, we acknowledge that he fell into a trap all-to-common for scientists and medical professionals. In an effort to be precisely accurate, he publicly presented a stream of evolving scientific data in real time. There was too much emphasis on that day’s data and not enough on what remained uncertain or how the information could change with new data. Think back to the initial days of the mask discussion, which is when Fauci first came into the spotlight and his and others’ credibility was first called into question. The goal was to get people to take precautions, yet how to do that changed rapidly in those early weeks as masking was studied. It felt like bait and switch, which was then pounced upon by his critics. Fauci wasn’t being inconsistent, he was simply following the data, which, as is always the case with research, evolved. But the messaging left people who don’t understand the quirky scientific process with whiplash.
More recently, the Biden Administration’s countering of public health experts’ recommendations on boosters has sown confusion via inconsistency. It’s been a back and forth that leaves us skeptical of everyone. “Why can’t they agree?” “Why is this different than what they said last week?” Those questions crack the door for insinuating nefarious motives and, voila, you’ve got yourself a full-blown conspiracy theory.
In both cases, instead of driving a desired action, you’re freezing people while they’re caught between different messages. This is where the healthcare and scientific communities must be better about explaining the limitations of what we do know. Or, as another respondent mused, “On one side of the spectrum it’s all misinformation. On the other side, it’s ‘Where is your narrative aligned?’”
Similarly, being too definitive can backfire because so much of what we’re dealing with today is evolving. Vaccines are the perfect example. Again, from a survey respondent:
Many physicians are implying or saying the vaccine is 100 percent safe. No one knows this. No one. You can't say that based on the limited time/data we have still on the vaccines.
Last winter the medical community was saying that the vaccines were “highly effective,” without enough discussion of what exactly that meant in technical terms. Almost a year later as Delta surged and caused breakthrough cases, one common refrain from vaccine skeptics was, “See, they don’t work. You said you couldn’t get sick.” In trying to be succinct, health experts turned the word “effective” into a sort of shorthand that simply didn’t allow for the nuance the moment required. And that stridency has led to skepticism, hardening people’s positions.
A couple more quotes from survey respondents that get at this idea:
The media and providers need to acknowledge that alternative treatments could have some merit; don't throw out all claims as misinformation without listening to anecdotal evidence and doing the research.
Some of the above are not false in the absolute. For example, that COVID vaccines were approved on less initial evidence than normal through the emergency use pathway. Not true now. The delicate balance is to provide data that refutes the misinformation (e.g., COVID vaccines are more protective than flu vaccines), but in bite-sized pieces that don’t lose the audience.
However, offering nuance and explaining what we don’t know isn’t license to put people to sleep with too much detail. Don’t swing the pendulum too far in the other direction. Simplicity, clarity and storytelling are key elements to presenting technical information and countering misinformation.
“If we’re going to be presenting facts to hopefully change opinions and ideas, it has to be presented in a way that people can capture in literally seconds,” said Jarrard Inc. Partner Kim Fox in a conversation about this report. She went on to applaud data visualizations many hospitals used to show how few vaccinated individuals are dying or suffering from severe COVID-19. Those graphics have been clear, accurate and tell a compelling story.
HHS estimated in August that about 13 percent of American adults could be classified as “unvaccinated but willing.” That number is probably lower now that more time has passed and, presumably, some of those people have received a dose. Of those, most were worried about side effects or simply wanted to wait and see.
Remember, too, that our survey results found that “lack of research” was considered the most significant misinformation factor. All told, those are ideas that can be combatted with time and clear messaging. Despite the heat and polarization, all is not lost.
The question is, how heavily should providers – individuals and organizations – be involved in pushing back? Our short answer is that organizations need to provide consistent air cover in the war against misinformation and support clinicians but not expect or demand they take on the responsibility for convincing the public. Clinicians are burned out and frustrated enough as it is.
We asked our audience where the line should be drawn. A vast majority said that healthcare leaders and clinicians should be involved – less than one in five said clinicians should simply treat patients. But to what extent and how aggressively? Half said that those working in healthcare should be engaged on social media and working to educate patients. That’s distinct from driving hard – being vocal, talking to the press, pushing patients. Put another way, the general sentiment is that healthcare workers should say what they have to say and let it go at that.
It’s important to make that cutoff because the battle against misinformation and conspiracy is contributing to the burnout our healthcare community. As one of our survey respondents said, “It’s too much to ask them to wade into external dialogues. That’s contributing to burnout. They’re a couple of years into being the heart of the dialogue and that’s not what they’re used to doing. It’s bled into the front line. Clinicians are being asked to be part of this never ending, exhausting conversation AND providing care.”
Tim Stewart, a Jarrard Inc. vice president shared what he’s hearing: “Part of the burnout here is, ‘I’m sick of trying to care for people who won’t care for themselves. I’m sick of being attacked for trying to do my job and being told that I’m part of a deep state conspiracy. As someone who is in a healing vocation, that really tries my patience and tries my empathy.’”
Leadership should avoid putting the onus on clinicians; instead, encouraging them to tailor their conversations to patients’ needs using their own level of comfort. O’Neill suggested that, after their differential diagnosis on the roots of skepticism, clinicians can ask, “Can I point you to resources with good information?” It’s a gentle way to push people in the right direction without starting a fight.
Telemed shift yesterday: several unvaxxed patients. How I start the convo: “Tell me what’s keeping you from getting vaccinated?” The responses: fertility concerns, unsure what is in the vaccine, & delta breakthroughs. We tackled them one by one. #MedTwitter #VaccinesSaveLives 1/— Andrea Austin MD (@EMSimGal) October 13, 2021
Marcom can step in here and help relieve the burden on clinicians by building materials that are clear and avoid the traps noted above:
Another good approach is to layer information. Use multiple channels to blanket your community with the right message. Tailor the messages to different groups within your community. But, at the same time, be willing to push hard if a specific mechanism works exceptionally well. One of the survey respondents wrote in with this perspective:
There is fatigue around these messages, but they must continue if we are to combat misinformation. One thought is to try new avenues of communication or make existing communications platforms the focus. For example, if speaking to community groups has been one of many strategies and it’s been well-received, take a bigger step in that direction with a more concerted, concentrated approach – doing more of them with more and different types of organizations, more diverse audiences, etc. Max out the potential of that platform.
And that, really, might be the best piece of advice for this entire discussion. Back to our opening conclusion. Put your resources into areas where they can make a difference and be willing to step away from the others. Ask whether a particular idea you see taking hold is borne out of confusion and, perhaps even unclear messaging from your organization. Or, whether it’s coming from a place of division and conspiracy. The vaccines haven’t been researched. That’s something we can discuss. The government is working with Bill Gates to track our every move. Not worth it. Set the limits and encourage your teams to do the same.
Then, stick with it. Be okay knowing that you can’t solve every problem. Once you do that, individually and as an organization, you can refocus some of that energy inward. Support your staff. Retain your talent. Show people that whatever the issue, you have their back – even including permission to back away from trying to convince the inconvincible.
By knowing when to cut your losses with a vocal minority, you’ll be better positioned to deliver the quality care your entire community needs.
Providers can only do so much. What about the industry designed to present stories to the public? Our survey respondents had something to say about the media, too:
“The media needs to be “media trained” on how to properly report information. Often, rushed sound bites are lifted as misinformation. For example, the vaccines were never promised to completely prevent infection by COVID-19. The media ran with the story talking about vaccine effectiveness percentages but failed to explain to the public what that actually means. The anti-vaxxers and doubters used the ‘lazy’ messaging to illustrate inconsistency.”
“Media is a time, energy & financial sink for healthcare leaders who must remain strategic and maintain credibility in media engagement. Healthcare leaders who engage with media in a surgical manner to share accurate information contribute to optimal outcomes for both clinicians and patients. Here’s how: A ‘first, do no harm’ philosophy must guide all media engagements; ensure media engagement is timely; choose consistently appropriate and efficient media engagement tools; and continuously monitor and, as necessary, adapt.”