Dr. Google Is a Liar

Dr. Pickard:
Dr. Google is a Liar.  That’s the title of a recent New York Times article about a medical consultant to millions.  But, can it be trusted? 

I’m your host, Dr. Maurice Pickard, and you’re listening to Book Club on ReachMD, and with me today is the author of that article, Dr. Haider Warraich.  Dr. Warraich is a cardiologist at Duke University Medical Center and also is the author of 2 well-received recent books, Modern Death and the State of the Heart.  Thank you very much for joining me today. 

Dr. Warraich:
Thank you for having me on the show, and thank you for your interest in this piece. 

Dr. Pickard:
To begin with, are we really experiencing a modern epidemic of fake medical news? 

Dr. Warraich:
I certainly think so, just like there has been so much attention on fake news in general in sort of the media and in our culture.  I think along with that there’s really been an epidemic of fake medical news.  Now, I don’t want to say that this is a new phenomenon in any way.  If you look, medical misinformation has really been something that’s been prevalent ever since we started to sort of think about human health in any sort of structured way, but the Internet and where things are as far as social media is concerned, I think they have really made this a problem of epidemic proportion, so I agree that this is definitely a modern pandemic.  And as clinicians, we are seeing the effects on a daily basis. 

Dr. Pickard:
So, is there a real harm in people getting information?  I mean, are they then turning around and wasting their time pursuing symptoms that they may or may not have?  Are they spending money where they shouldn’t be spending prompted by the kinds of things that they are hearing on social media? 

Dr. Warraich:
Absolutely.  I focused the article on 3 key things in which I think we can definitely show that there is harm.  Vaccines are something that we have seen a backlash to for many years, and we’re seeing that there are ongoing epidemics in areas in the United States and some very affluent areas because parents have prevented their kids from getting vaccines based on stuff that they read on the Internet which we know to be false.  As a cardiologist, I see a lot of fake news harm in the space of cholesterol medications called statins, which are some of the best studied medications in human history.  There have been more randomized clinical trials and studies in statins than I would say pretty much any other medication known to man.  And no medication is safe.  Every medication comes with side effects, but we know that there is a lot of dribble on the Internet that exaggerates the harm of statins immensely.  In fact, there’s a lot of material that even questions the cholesterol hypothesis at its core that, in fact, lowering cholesterol is actually a good thing.  There are many people who say that it’s a bad thing.  And there are many people who are making a lot of money off of this, a lot of people selling alternative therapies, a lot of people who are driving traffic to their web sites, etc.  And we know that there have been studies that show that patients, especially patients at high risk for heart disease, when they don’t take statins, they expose themselves to real harm of either repeat heart attacks and whatnot, stroke, etc.  So I think the harm is there, and that’s really one of the reasons why a lot of clinicians reacted to this piece positively, because they have been seeing the effects of fake medical news on a daily basis and then finally now seeing that it’s being covered in sort of the national press. 

Dr. Pickard:
You know, you, in your article, talked about the placebo effect, and all of us have experienced it.  I personally sometimes have noticed that I can take an aspirin for a headache and feel better like in 10 seconds.  Now, obviously, I know that my salicylate levels are not going to be very high in 10 seconds.  But you also talk about something else.  You talk about the proliferation of side effects associated with medications and that people will, because they read about the side effects, will actually have the side effects, which can be a negative phenomenon. 

Dr. Warraich:
Yes, and that’s the nocebo effect.  I call it the evil cousin of the placebo effect.  And if you think about why human beings experience a nocebo effect, it’s really a form of self defense.  If we anticipate some type of negative stimulation or an ill feeling, then we will prepare ourselves by really sort of reenacting that in our bodies.  One physician shared this really interesting story.  He had a patient who he started on statins, and as soon as the patient took the drug, they started having all the signs and side effects that they had heard about, things like mental fogginess and body aches, etc., and that patient immediately called the physician but realized as they were making the call that they actually had never taken the medication to begin with and it was still sitting in the pill box. We’ve even seen the nocebo effect for statins in clinical trials.  There was one trial in which it was blinded so patients didn’t know what they were taking, whether they were taking placebo or a statin, and as long as the trial was blinded, the number of patients having muscle aches in both the placebo and the statin arm were the same, but as soon as patients found out what they were taking, the number of patients who were on statins, then the rate of myalgia shot up in that arm, showing that now that they knew that they were taking a statin they were much more likely to have the side effects.  So I think that it’s a very real effect, and I think that the more negative press there is, I think more likely patients are likely to experience this. 

Dr. Pickard:
So, what is social media going to do about this?  How are they going to vet the material that they put on their platform, or even can they?  Are we going to begin to hear that this is an invasion of our rights because of vetting material?  And who’s responsibility is it going to be? 

Dr. Warraich:
So, I think social media and Silicon Valley in general need to be part of the solution.  I don’t think that my answer would be that, “Oh, patients should not Google things or patients should stay off the Internet.”  I don’t think that that’s realistic.  I don’t think that that’s useful.  I think that this has to be taken in the context of the fact there are a lot of advantages of the Internet for our patients.  I mean, they can get a lot of—there’s a lot of good information out there as well that they can access for free.  It’s usually written in a language that patients can understand.  But I do think that Silicon Valley and social media companies in general need to take note of the fact that patients are experiencing harm from material that is being widely shared using their platforms, and I do think that they need to have some type of ownership of this material that they are really giving a very, very wide platform for. Certainly, we have seen increased accountability as far as fake news in politics is concerned, but I think that this is equally important.  The answer isn’t to shut anything down but to really think about how can we provide accessible, simple, but also accurate information to patients, and whether that’s through some type of policing of people who put out negative stories or who put out false stories, such as we’ve done with people putting out false stories in politics—like we’ve done that with Alex Jones, for example, of InfoWars.  I mean, why can’t we do something similar for people who are serially producing false information that affects patients’ health in a negative way? 

Dr. Pickard:
So I pointed towards social media, but if you follow what’s happening in the Senate right now, dealing with social platforms and about what they are doing, you kind of wonder about throwing up your hands.  Let me turn this question around.  How can we train doctors to respond to their patients when they come in with these various ideas?  And part of that is, why have they turned to the Internet rather than to their doctors to get their information?  So, if I can rephrase that, how can we prepare doctors to deal with this phenomena? 

Dr. Warraich:
So, first of all, I think that as physicians we need to win back the trust of the public starting with the individual patient sitting in front of us.  I think it’s very important to realize, as you said, why are patients going and accessing information on the Internet?  What is it about that information that makes it attractive for them?  And I think that is extremely, extremely important as we try to build an environment in which patients are more trusting of their physicians and the information that they are getting, and what that means… And one of the ways that I’ve sort of used an example is that of myself.  When I had a patient who was suspicious of statins, I told her something that is very true and very personal.  I told her about my own dad who had a heart attack and that I was actually pushing for his physicians to actually keep him on the highest dose of statin possible to show that, just like them, I’m also a human being and that I would want the best thing for my own parents or my own self, and that if I’m willing to do that, then I think that they are more willing to trust me as someone who is more than just someone who’s giving them information that’s unattached to reality but something that is deeply emotional and personal, and I think that that’s one way to start that—but also taking it to the next level, talking about this on public forums.  I think a lot of people still look to doctors for information and have a lot of faith in the medical profession. 

And the last thing I think that we need to get rid of in medicine is really, we really need to be much more strict with regards to financial conflict of interest.  There’s a growing sense in the public that medicine and physicians have sold out to Big Pharma, and to some extent that is correct, and we need to police ourselves much more vigorously so that we can earn people’s trust back.  I think part of what’s happened is even the opioid epidemic.  I think a lot of people look to the medical profession as not having taken ownership of this, even to this day, and I think that we need to really think about our profession in general, think about our role in society and think about how we can win people’s trust back so that they don’t look to other places for information. 

Dr. Pickard:
If you are just tuning in, you’re listening to Book Club on ReachMD, and I am your host, Dr. Maurice Pickard.  And joining me today is Dr. Haider Warraich, and we’re discussing the misinformation that has actually almost become an epidemic on our social media. 

You did talk about trust, and that really is an important phenomenon.  There was a recent survey that showed that only 36% of Americans have confidence in the medical system.  And like you say, the news of medical research being funded by drug companies has done a tremendous amount of damage to this.  This whole concept of, “Are patients listening to us, and are patients turning to us?”—I sometimes wonder whether the medical record,  the electronic medical record, has sometimes interfered with the communication skills that we used to have.  If I’m talking to the back of the doctor, how interested can he be?  And maybe the Internet will respond a lot faster and quicker than my doctor whose back is turned to me or whom I had to wait for a long time or who I called in to some large system and had to wait a long time before I could actually connect with him.  Research shows that falsehoods travel faster than truths.  There is something sexier about a falsehood, which I don’t particularly understand; but does this play into our patients’ search for truth? 

Dr. Warraich:
I mean, one of the things that a lot of people who are spreading misinformation—they have an advantage.  They don’t have to...  They are not accountable to anyone.  They’re not accountable to the truth, to the facts or to their patients, and they can say things with absolute certainty, while as a physician, I understand that there is no such thing as certainty.  There are no guarantees in life, and there are no guarantees with regards to any of the treatments that we prescribe, and so everything we say, especially when—and I see other physicians do this regularly—is that we don’t have the same type of certainty, rightfully, about many of our recommendations that someone who has no relationship with the truth needs to have, so I think that makes it much more likely that there can be a lot more assertiveness in the lie than there can be in the truth, which is inherently uncertain, especially when it comes to human health.  And I think that’s one of the things that we need to make people comfortable with.  I think we need to make people comfortable with the fact that there is uncertainty in life, there is uncertainty in science, that there are uncertain—that science is not something that’s absolute but is iterative and that develops and grows but that there are some things that we know with a lot of certainty.  Part of what I think we need to do is not just educate people about different medications or drugs or lifestyle changes but also educate people about how to read a clinical trial, how to understand a simple research study so that they can understand what the limitations of that might be, and I think that that is something that extends to really a lot of things even outside of medicine even that could apply even to things like climate science and etc.  I mean, I think that we need to really tackle this with a very broad mandate. 

Dr. Pickard:
Yes, you are really talking about what I was then just going to get to, which was how to teach health literacy to patients.  We’re concerned about that, I mean, even from the standpoint of them being able to read their prescriptions.  I’m always amazed that my patients will not run out of their medication that they are taking 3 times a day when they haven’t been able to read the label that says 3 times a day.  They are taking it once a day, or they’ll confuse their blood pressure medicine with their cholesterol medicine, and this is a real risk to the patients.  And we’re talking about something so much more sophisticated.  Patients are not quick to admit the deficiencies they may be having in, say, reading their prescriptions or reading an article.  Especially as patients become elderly and they are beginning to have some cognitive impairment, they are very, very hesitant to tell you about these deficiencies, and now you’re talking about, well, we should teach them about double-blind studies.  Who’s going to teach them all of that?  How are we going to work in this environment of certainly our older patients? 

Dr. Warraich:
I mean, I think that’s a very important point, and I think that’s part of really—it goes to the heart of this.  And really, I think recognizing the problem is an important thing.  I asked one of my patients who was being discharged today—can he read the discharge materials you give him, and he said yes, but I think unless we start asking and rather than just assuming, I think that’s the first step.  The next step is really, I think, really broadly changing norms around seeking health and being interested in one’s own health, but also, these are really, really sort of massive public health problems, but they all end up starting at the bedside.  They all start with the patient sitting across from the clinician or from the physician or from the nurse or from the social worker or pharmacist.  All of us have an opportunity every day to educate our patients, to build a bond with them, a relationship with them that we can then use to help them heal rather than just kind of go through the system, and I think making the most of all of these encounters is going to be what’s going to be at the heart of undoing some of the damage we’ve done by losing our patients’ trust. 

Dr. Pickard:
Well, I can’t think of a better place to stop, because like so often, we come back to that patient-doctor relationship, which is so key to our patients taking our advice.  I’m always reminded, if I can just digress, I often would write instructions on a prescription pad in my own handwriting, and we’d give it to the patient.  I was amazed that years later, even after I retired, I would run into a patient who would reach into his wallet and pull out this now yellow prescription pad or piece of paper from the prescription pad with my instructions on it and how he looked at it frequently from time to time to remind him.  So, going back to where does the patient really get his information, there’s nothing like talking to your doctor.  I really want to thank you so much for joining us today. 

Dr. Warraich:
Thank you so much for having me and for giving me time to talk about this important issue. 

Dr. Pickard:
In closing, this is Dr. Maurice Pickard, and if you missed any of this discussion, please visit ReachMD.com/BookClub to download this podcast and many others in this series.  Thank you for listening.