Dr. Emily Oster (00:00):
We're just not in a place where most people want simple guidance and we've got to adapt our communication systems for that world.

Rae Woods (00:08):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. My name is Rachel Woods. You can call me Rae. In last week's episode, we talked about the growth we're seeing in patient distrust at the institutional level, at the healthcare ecosystem level, and even at the interpersonal provider level. And I'm actually pleased to report that that conversation ended on a relatively optimistic note. There are things that you can start doing today to build back trust, particularly in the patient-provider relationship. But here's the thing, no one doctor can solve the societal problem of misinformation and distrust, but when it comes to that discrete healthcare interaction, there are strategies that healthcare leaders can implement to support their providers and help them build stronger relationships with their patients, which can in turn build trust and make it easier to combat misinformation.

(01:06):
That might sound simple, but effective public health communication is actually extremely difficult. That's why I've invited Dr. Emily Oster to Radio Advisory. Emily is an economist and a professor at Brown University where she studies data-driven decision-making. I know her as the New York Times bestselling author and founder and CEO of ParentData, an evidence-based platform that translates research and data into practical guidance for pregnancy, parenting, and personal health. Honestly, she's the source that I go to for many of my parenting-related panic moments. Emily Oster, welcome to Radio Advisory.

Dr. Emily Oster (01:45):
Thank you so much for having me.

Rae Woods (01:48):
A former colleague once told me that there are two kinds of people in the world. There are two name people and there are one name people. And I am going to really struggle to separate you as anything other than a two-name person. You are Emily Oster in my head. Should I call you Emily? Should I call you Dr. Oster? What would you prefer?

Dr. Emily Oster (02:06):
You should call me Emily. I do not like being called Dr. Oster. It freaks me out.

Rae Woods (02:12):
Well, Emily, I want to admit that I am genuinely a huge fan of your work.

Dr. Emily Oster (02:16):
I love it.

Rae Woods (02:18):
But more importantly, I kept thinking in this moment, with so much misinformation, with disinformation, with rising distrust, health leaders needed to hear from you. They needed to look outside of the traditional healthcare delivery system when it comes to this challenge. And that's because it's not just a healthcare challenge. We are talking about a societal problem. You, Emily Oster, wear a lot of hats. You are an economist, a professor, a writer, a founder, a CEO, a parent, a runner. How many other things could I add to that list? Across every single one of those things, you are an effective communicator of science. Tell our listeners a little bit more about the kind of economics that you study, how led to multiple New York Times bestselling books and really why they should listen to you when it comes to this challenge.

Dr. Emily Oster (03:06):
Through all of those things that you have said that I do, the connecting thread is data. So I will start there. That is the kind of economist that I am. So I am an economist who studies empirical questions with data and also, actually, I study how we can learn about empirical questions from data. Some things in my research look a little bit more like statistics than what many people think of as economics. I came up studying healthcare economics and taking those data tools to that topic. And then I turned it to pregnancy and parenting when I got pregnant. And I've since then really specialized analyzing the data around these questions of pregnancy and parenting, but then also translating that for a broader audience and that's probably my superpower.

Rae Woods (03:57):
Which is exactly why I want the Radio Advisory listeners to hear from you. And one specific thing that I admire about your work is that you tend to take things that are big, that are complicated, maybe that are even scary, and you break down the science and the data behind them. You do this regularly on your newsletter. You do this regularly on your social platforms. In this moment, there are a lot of panic headlines about healthcare. My question for you is when it comes to rising misinformation and rising distrust with the healthcare system, where on the panic scale should health leaders be?

Dr. Emily Oster (04:33):
I think pretty high, honestly. And in part because I have had this increasing sense that people are getting panicked even when they know they shouldn't. For example, something came out about if you get COVID in pregnancy, your kid's at risk for neurodevelopmental issues, which was a classic panic headline and the research behind it really wasn't especially good. But many people came to my Instagram. At first they came saying, "Tell me if this is real, tell me if this is real." And then I recorded some stuff and then they came back and they said, "Thank you so much. Even though I knew that's what you were going to say, I still was freaked out. I've been watching you for two years. I knew where to look in the paper." I had taught them how to understand that this is probably not something to worry about, and yet still the way that we're delivering information to people is really getting under their skin in a way that, I think, is the most concerning, even relative to the production of misinformation, which, of course, is the underlying problem.

Rae Woods (05:36):
And of course, I'm happy that you're out there addressing the panic headlines, giving the information to the end user, but what probably gives heartburn to our listeners is that you are not part of the healthcare system.

Dr. Emily Oster (05:47):
Right.

Rae Woods (05:48):
And yet this is an example of real people that have real questions in many cases about their health, about their child's health, about their family member's health. And it is good that they are eager to get information and that they have questions, but I think your example speaks to the fact that the traditional delivery system is not meeting patients and consumers where they are. Now, we've spent a little bit of time on Radio Advisory talking about this rise in scientific skepticism. There's no single root cause here. But I'm curious, from your perspective, why do you think scientific skepticism and distrust and disinformation are at the peak that they seem to be at right now?

Dr. Emily Oster (06:29):
It feels to me like there's a bunch of stuff going on. I think we have to start at the pandemic. I think the pandemic eroded a lot of trust for people. There was a lot of feeling like people were being told something that they needed to do, which was very costly for them. I don't mean in terms of money, but which made their lives worse in some way and they weren't really being told why. And as the pandemic went on, that became increasingly true and I think we lost a lot of people.

(07:01):
We're now trying to get them back and I still think the issue of not helping people explain why you're telling them what you're telling them is there. And actually, if anything, because of this experience during the pandemic, I think people now expect to be told why. They've generated this skepticism, a little bit more of a feeling of I want to do my own research. And even if, in 2017, I would've been happy to just have you tell me, "This is what the scientific consensus says," they're not happy with that anymore.

Rae Woods (07:29):
That's right.

Dr. Emily Oster (07:29):
We need to adapt the messaging such that they hear, "This is what I recommend and this is why." And maybe even here is the reason why you might hear someone else say something different. And that kind of messaging is not how we often have trained medical providers or certainly broader medical systems.

Rae Woods (07:47):
But there's something else that's on the rise that I think might have you, in your role, a little bit more worried. And that's that you're seeing more bad science, more bad studies. How does imperfect science, imperfect data contribute to this challenge?

Dr. Emily Oster (08:06):
I think we are seeing more bad studies. Just to be clear.,There have always been bad studies, but there are more of them. There are more opportunities, I think, for people to "publish," and I put that in loose quotes, research in outlets that seem real but are not. A very hard thing for the broad audience of people in the world to understand is what's the difference between the International Journal of Cardiology and the International Journal of Cardiology and ... which is actually just a blog.

Rae Woods (08:39):
And you're not even, by the way, talking about the blogs, talking about what you would see in social media.

Dr. Emily Oster (08:45):
Right. So these are research journals which look real, which have some claim to authenticity, but actually are not vetting in the way that we would ideally like research to be vetted. And that then gets out there in the world and then is often covered by the media. And then patients come in saying, "I saw this in the media." And doctors and health systems don't always have a lot of time to explain, "Well, this is why that isn't very good research," and then we're down this rabbit hole of confusing misinformation.

Rae Woods (09:13):
And the cycle just repeats itself and repeats itself.

Dr. Emily Oster (09:15):
Exactly.

Rae Woods (09:16):
So there's more misinformation, there's less trust, there's more bad studies. That's a lot of challenges. Here's my issue. Health leaders aren't necessarily taught or prepared to manage any one of those challenges that we just named. And I have a lot of sympathy for the tough position that, in particular, clinicians are in, the doctors and nurses themselves. Maybe they can't actually manage these challenges. They don't have time in their day, it's not built into their workflow, it's not part of the process or the structure of delivering care.

(09:48):
Maybe they won't address it, they don't believe it's their problem to solve or maybe they just don't know how. And this is where I think you come in. Let's take this one bite of the apple at a time. You already said there's just a lot more research coming out every day. No person can keep up with this, even if you're a scientist, even if you're a doctor. What techniques do you recommend for identifying what makes good research versus what makes imperfect research?

Dr. Emily Oster (10:16):
Many of the techniques for looking for good research are really about looking at methods. So a lot of the poor research that we see out in the world is research that confuses correlation and causation or one step even worse than that, which is both correlation and causation confusion and selection of the sample in a very odd way that makes it impossible to learn anything about the general impacts. I think the first thing I would always tell people is look to see is this a randomized trial? Is there a claim to causality? Does the paper, somewhere in their limitations, say this is just an association? There are actually a tremendous number of papers where the authors themselves would say, "Well, we don't really learn anything from this. It's just an association." I feel like if you're saying that, why am I reading this?

Rae Woods (11:03):
Yeah. Why are you publishing that?

Dr. Emily Oster (11:03):
Why are you publishing it if you're not learning anything from it? And so I think we really could hold things to a much higher bar there.

Rae Woods (11:10):
To the extent that we're not learning new things, that's almost a reason for providers to feel a little bit of relief. I said that there's so much information coming out, there's so much data coming out, but it sounds like you're saying that there's still not meaningful change in the way science or medicine works, so doctors can still rest on what they know and what they can tell patients.

Dr. Emily Oster (11:30):
Yeah, exactly. So I think that's a really good technique for individual clinicians. Your patient comes in with this new study and except in very rare cases, that new study is not actually new information. It's 47 study with the same non-causal association and it's trumped by one really good study that exists of this. So often tell, there's a way to answer a question on television. When the anchor says, "Well, what about this new study," to say, "I'm not familiar with that exact study, but let me tell you what this broader literature says about this," and I almost think we need that communication because it's what's true. We know something, in many of these cases, about what the best data says, and we're not going to be in a position to respond to every new piece of garbage data and garbage study that comes across, but we can anchor back to the best evidence says the following, and that's often a very effective messaging strategy.

Rae Woods (12:26):
Yes. So we can better spot the imperfect research that comes out, but more importantly, we can rest on the best data that we have. That hopefully provides a little bit of relief. The next challenge on the how is a lot more complicated, which is that the healthcare system, the traditional form, doesn't necessarily do a good job explaining these findings to patients, to the public, to politicians and that gets into just being a good public health communicator. How do you want clinicians to approach public health communication with evidence, but also in many cases knowing that there is a genuine desire to change behavior?

Dr. Emily Oster (13:09):
I think this is extremely hard, partly because time is very limited. We would like people to be able to communicate this, but we only give them 10 minutes.

Rae Woods (13:17):
Yes.

Dr. Emily Oster (13:17):
There's one way into this, which is to try to help clinicians with that problem, which is to give them some tools about even how to manage the visit. So when the person first comes in, rather than starting with what you are planning to start with, I think there's often a case for saying, "What are the two things you want to get out of this visit? What are the two things you want to learn here that are important to you?" At least that's what they want to cover. You don't get to that in the last minute of the visit. In some ways, anticipation of this new regime is the first step to better communication.

Rae Woods (13:51):
And to say, "Well, we might not get to all six complicated things, but we can get to at least one. Maybe we can get to two." And you're grounding, then, in what the patient desire is. I think it's important that you're not just having complicated conversations about evidence or about trying to change behavior, but they're also doing this with empathy.

(15:28):
I want to meet the doctors and nurses and healthcare workers where they're at. We spent a lot of time, when we talk about challenges in healthcare, talking about how exasperated the public is, how exasperated politicians are, and we see that with One Big Beautiful Bill Act and this big step back from responsibility in healthcare, but the interior of the delivery system is pretty fed up too, and it can be really hard to have these complex conversations with a workforce that is burned out, at best, that is facing this moral injury. I mean, your life's work is really about communicating data and evidence to help people make decisions. How has that influenced how you think about an empathetic approach to people when they have these questions or when they come even with true disinformation?

Dr. Emily Oster (16:15):
I try very hard, and it is sometimes very hard, to think about what lends someone to this point where they're asking this question. I mean, I get a lot of people who ask me about vaccines and they say, increasingly I get people who say, "I'm really skeptical about vaccines. I'm really worried about them. This doesn't really seem like the right thing to do." And I really believe strongly in vaccines, and I think that they're great and they prevent people from getting diseases. And so my instinct sometimes coming into that is like, "What do you mean? Come on."

Rae Woods (16:46):
Or what do you mean you've done your own research? That's my trigger, I'll admit.

Dr. Emily Oster (16:50):
But people are coming to me with genuine, real questions that they have.

Rae Woods (16:56):
Or maybe it's not even questions. There's fear, right? They're scared about making the wrong choice.

Dr. Emily Oster (17:01):
Yes, they're afraid. They're coming in afraid and they care, especially with their kids. There is nothing in the world that they care more about than doing the right thing for their kids. And I guess that's the thing I remind myself almost every day. Everyone who is coming to me has come because they want to do the right thing for their kids, which is the thing they care the most in the world about. And that's underlying motivation and a lot of them are afraid, and how do we meet them and try to help them be less afraid and make different choices? But I also feel like I sometimes have to understand. I can tell you, everyone a billion times how great vaccines are, and some of the people following me are not going to vaccinate their kids and I got to just let that go.

Rae Woods (17:40):
And again, I understand the frustration that clinicians are feeling, but it also sounds to me like you're saying, "Hey, let's take a different approach. Let's have a little mindset shift here and remember that there's nothing inherently bad about a patient that is coming to you with questions or wanting answers." That feels like something that we need doctors to almost embrace, seeing questions and concerns almost as an opportunity to engage patients in their health journey.

Dr. Emily Oster (18:08):
I think that would be great if people could do that. I also really understand it's very hard that it does not come across to doctors as I'm interested in having a fun, intellectual conversation about this. It comes across as I don't trust you and your expertise.

Rae Woods (18:24):
Yes.

Dr. Emily Oster (18:24):
That is a really triggering feeling to have someone say, "I don't trust you and your expertise," even if that isn't what they're saying.

Rae Woods (18:31):
So let's lean into that moment. The tricky, complicated, maybe even chaotic moment when a clinician is faced with the incredibly daunting task of actively pushing back in the moment against misinformation. I want to empower clinicians to deploy the expertise that they already have as medical professionals, as scientists to deploy their expertise as effectively as possible. How do they do that in an era where there's just so much misinformation?

Dr. Emily Oster (19:02):
I think it is with questions. So I actually would give doctors the same advice I give patients. So patients will often come to me and they say, "My doctor recommended something which I know is not based on evidence." So, "My doctor recommended that I be on bed rest," something like that, which I know, hearing them, is not based on evidence. And they want to know what's a good way into this conversation that isn't confrontational.

Rae Woods (19:23):
Because you're also not trying to say, "Don't listen to your doctor. Listen to me."

Dr. Emily Oster (19:27):
Absolutely not. There are times when maybe there's something else that's going on, and so rather than coming into the conversation with, "I know the evidence shows blah, blah, blah doesn't work." I tell them, "Hey, why don't you open with, 'I've seen this evidence that suggests this doesn't work. Can you tell me why you're recommending something different for me?'"

(19:45):
And that is an open, because then the doctor can say, "Well, actually the evidence is weak, but we generally, I like to be cautious." They can answer like that, but it opens for the possibility that there is a reason, which of course you would want to know, but it also just emotionally opens up the possibility. So what's the flip of that for the doctor? I think it's to say, "It seems like you're reading some data that's different from what I usually recommend. Can you tell me a little bit more about that and about why you think it might be relevant for you?"

Rae Woods (20:14):
I love that because I was going to say that just providing more data, and I realize I'm saying this to somebody whose entire business is based around providing data, sometimes doesn't help. That sometimes isn't the actual thing that changes the behavior, especially when folks cherry pick data, they pick bad data, things like that. But I love that you're just saying just pause and before you, I'm not going to say push back, like argue?

Dr. Emily Oster (20:39):
Yeah.

Rae Woods (20:40):
To ask a question.

Dr. Emily Oster (20:41):
It's coming back and trying to start into a conversation where you have your data, I have my data. That's not likely to lead to where you want, even if you are the person with the best data. Because most of the time when people come into that conversation, they're actually not looking to fight about data. They're looking to be reassured in some way or to understand something that they're hearing. And so if you come in a let's fight about whose data is the best quality, rather than opening to what somebody might call an understanding conversation, like let me understand why you're saying that so then we can try to move forward. That's going to tell you a little more about what kind of evidence you want to provide them, but also just lower the temperature of the conflict, which is really what you're often looking to do in those moments.

Rae Woods (21:24):
And I think this is not just a way to push back on misinformation. This might actually be a way to build back trust because the reason why or a reason why we're seeing this declining trust is because the delivery system isn't stopping to have these conversations, therefore the general public is going elsewhere. Maybe they're going to good sources, like Emily Oster, like ParentData, like any of your books, or maybe they're going somewhere that they shouldn't be and falling into this cycle of worse and worse misinformation.

(21:55):
I want to talk about this opportunity for building trust in the context of shared decision-making because at the end of the day, the doctor and the patient together need to make a decision on what happens next in their care, and ideally, that is a decision that is made together. How should we evolve our approach to shared decision-making in an era of distrust and misinformation?

Dr. Emily Oster (22:20):
I think we need an overall reshape of what we mean by shared decision-making because I think very often shared decision-making sounds to people like we're going to do the whole thing together. And that's a really weird way to frame a decision where one person is a medical expert and one person is the person to whom the thing will be done because in fact, both of those people do bring information to the table that should be important to the decision, but it's not the same information. It's not we come together and we each bring half of the information and it all matches. The patient is the expert in the preferences that they have and the things that they care about and the doctor's the expert in medicine.

(22:57):
Ideally, those two things would both contribute to questions like do I want to have a repeat C-section? That's actually a question that has a lot of really important medical input, like what kind of C-section did I have last time? Why did I have it? How big is my baby? There's a bunch of stuff that goes in there, and then there's a personal part which is how much do I care about having a VBAC, a vaginal birth after cesarean? How many more kids do I want to have? Those are all pieces of information, they're coming from these different sides. They should come together to the decision-making, but that's what we mean by shared decision-making. Not the patient is an expert in how C-sections work or the doctor is an expert in the patient's preferences, neither of which are reasonable things to expect.

Rae Woods (23:38):
This is another example of a subtle mindset shift, of not thinking about the intellectual debate or the intellectual weight that each party brings to the table and instead seeing the specific value that the patient and their caregiver and their family bring to the table, which is just different than the value that the expert brings to the table.

Dr. Emily Oster (23:56):
Absolutely. It all comes together, but it's not all the same.

Rae Woods (24:00):
At the end of the day, doctors' first responsibility is do no harm. And so it makes sense why they would push back on misinformation when it shows up, why they would want different ways to engage in shared decision-making. They don't want to deviate from the choice that is "right." And as a result, there is a change that I'm seeing at the organizational level, not just the provider level. Organizations are drawing more lines, blanket policies that they follow as an institution. Maybe it is the individual doctor drawing lines themselves and it makes sense. They want to help, but they don't want to open themselves up to risk or liability.

(24:33):
So I'll give an example from my personal life. Our pediatrician says that they follow the CDC guidelines for vaccination schedules, and if you don't want to follow those guidelines, you need to see another doctor. I think they've actually changed that and now it's not CDC guidelines. I had a tough conversation with my pediatrician who said, "We're going to follow something. We just need to say that we can follow a guideline." And that's an example of these bright lines that would actually push vaccine-skeptical, in this case, patients outside of this high quality provider. What is the right way to think about drawing these bright lines around guidelines?

Dr. Emily Oster (25:11):
I would think about it in terms of externalities. So an externality in economics is the idea that the behavior that I undertake affects potentially other people. So when I choose to drive too fast, that's potentially damaging to me, but it's also negative for other people. It has a negative externality on other people because I might smash into them and that they might get hurt. So there feels to me like a very strong argument for guidelines when the behavior of a patient might negatively impact somebody else.

(25:40):
So for example, in the case of vaccines in a pediatric office, if there was a kid with measles and they come into the pediatrician's office and they touch the toys in the waiting room and some other kid comes in 10 hours later and they touch the toys in the waiting room, they might get measles. That tells me as a provider, I don't want patients without measles vaccination in my office because it's negative for my other patients. That is somewhat different from some other kinds of choices parents might make. Like you could say, "We're going to have a bright line. We're only going to allow patients who are willing to sleep train their kids." That's a choice you could make, but it's much less defensible in the sense that whether you sleep train your kid or not is really not important to the other people in the practice. It's not having a negative impact.

Rae Woods (26:22):
It's much more defensible, but it also puts you on the defensive, which we've argued is not good in a world where there is so much distrust. We need to embrace and try to figure out how a way to build that trust back and coming from a defensive posture isn't going to do that.

Dr. Emily Oster (26:35):
Yeah. I think in general, there's always value to prioritization, and I think there are many good choices in parenting and in fact, I think pediatricians are really quite good at which are the things that are important, which are the things that are not important and figuring out where are the hills that I need to die on? But we should always be thinking about when I have a patient who is skeptical about things or wants to do things differently, which of the things that I really want to push and which do I not? Because you cannot win every battle, and some of this is also about personal values. Some people feel very strongly about one particular choice or others, and it may be very hard for them to repeatedly interact with someone who disagrees.

Rae Woods (27:15):
Emily, I usually end these episodes by giving our guests, in this case, you, an opportunity to tell our listeners what they should be doing next. I might actually suggest a slightly different approach. You can certainly give an action step, but I'm actually curious, when it comes to being better interrogators of data, better communicators of public health and better partners to patients and caregivers, is there something that you want our listeners to stop doing?

Dr. Emily Oster (27:41):
I wish people in this position would stop thinking that people prefer bright line rules all the time. I think there has, for many decades, maybe hundreds of years in the space of medicine, been the sense that what patients want is to be told what to do by the expert, the doctor. That isn't really what most patients want. It's not that no patients want that, but I think it's increasingly true that's not what patients want and that we have to move away from that. I actually think it comes often from a very good place of I want to make it simple for people. People want simple guidance, but we're just not in a place where most people want simple guidance and we've got to adapt our communication systems for that world.

Rae Woods (28:26):
Couldn't have said it better myself. Emily Oster, thank you so much for coming on Radio Advisory.

Dr. Emily Oster (28:30):
Thank you for having me.

Rae Woods (28:36):
On Radio Advisory, we typically talk to healthcare business leaders about business strategy and finance, and today we shifted gears and instead spoke directly to clinicians. I want to say that we hear you and we know that the healthcare system is going to be asking a lot of you as we collectively battle misinformation and distrust, especially when it shows up in your exam rooms. I hope some of the guidance Emily gave today speaks to some of the pressures that you've been feeling. And remember, as always, we are here to help.

(29:27):
New episodes drop every Tuesday. If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Abby Burns, Chloe Bakst, and Atticus Raasch. The episode was edited by Katy Anderson with technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Leanne Elston and Erin Collins. We'll see you next week.