Good afternoon. I hope everyone has been enjoying this fabulous conference. Before we get started today, I would like to take a moment to recognize and congratulate Rutgers Occupational Medicine Program on its 40th anniversary. On this day in 1983, Dr. Michael Gottschfeld became the founding residency director for the program, serving in that capacity until 2013. Dr. Gottschfeld continues to serve as a senior advisor and mentor, as well as associate director. He has participated in the training of more than 70 occupational and environmental medicine residents. Many of his graduates have assumed top leadership roles in government, NGOs, industry, hospitals, and clinics. Dr. Gottschfeld received his MD from Albert Einstein College of Medicine and his PhD in environmental toxicology from the City University of New York, with a postdoc at the Rockefeller University. He trained in pediatrics and served as a provincial public health officer in the Vietnam War. He has been in the field of occupational and environmental medicine since 1969 and has been on the Rutgers faculty since 1980. He served as division director for occupational medicine from 1983 to 1995. Among other positions, Dr. Gottschfeld has been past chair of the directors of occupational medicine residencies group, past president of the New Jersey chapter of ACOM, and past chair of the academic section of ACOM. He has approximately 400 scientific publications, including a two-part history of occupational medicine published in JOEM in 2005. His research has focused on the health effects of heavy metal exposures and the environmental consequences of energy options, and his efforts laid the groundwork for the environmental justice movement. Mike Gottschfeld is truly a pioneer and a giant in occupational and environmental medicine. Dr. Gottschfeld, congratulations on the success and longevity of your program. Please stand to be recognized by your peers. Now we will hear a few words from our UK counterpart, the Society of Occupational Medicine, better known as SOM. I have the pleasure of introducing SOM president, Dr. Sriddhi Patani. Dr. Patani is the clinical director in occupational health for England's National Health Service. She is the chair of NHS Health at Work Network, which represents NHS occupational health services across England. Please help me welcome Dr. Patani. Thank you, Doug, very much, and good afternoon to all of you. It's a real pleasure to be here, and I would like to thank Doug and the executive committee for inviting the Society of Occupational Medicine to join you for the conference, which has been fabulous, and, of course, very grateful for all your hospitality as well. Truly a privilege. For those of you who don't know about the Society of Occupational Medicine and our work with ACOM, I'd just like to give you a little bit of background. The society was founded in 1935 as a membership organisation, and then just over 10 years ago we welcomed and opened our arms to a multidisciplinary membership, and we serve our membership with special interest groups to ensure that education that's relevant and guidance that's relevant to our members is actually created. Our main purpose, as I've said, is education, learning, and networking, and actually supporting our younger members by mentoring and developing them into the area of occupational medicine and well-being. We have a journal, which, of course, all colleagues and our colleagues here as well are welcome to submit to. We also lobby on behalf of our membership at a national level, and recent mentions of occupational health and funding in the UK budget statement just a few weeks ago was really rewarding to hear, and we hope that occupational medicine and well-being will continue to grow and develop in the UK. Our association with ACOM was sealed 10 years ago when together we worked to create IOMSC, which celebrated its 10th anniversary this year, and the founders and all who work to have created this should be very proud that there are now 44 countries who are members and 50 societies. We had a very successful meeting last Friday, and many more ideas and developments are to come, in particular support for countries with resources less than ourselves. On that note, again, I would like to thank you very much for having myself and many of our colleagues over from the UK. You really have had a fabulous time. It's been great to meet colleagues. Again, thank you very much for your hospitality, and we continue, look forward to continuing our work together with ACOM. Thank you again. Thank you, Dr. Patani and the SOM. Before we introduce our Patterson Memorial Lecturer, I am privileged to present the recipients of the 2023 Occupational and Environmental Medicine Media Excellence Awards, also known as the OEMEs. This is the third annual OEME awards ceremony. Established by the 2020-2021 Presidential Task Force on OEM Visibility, and continued by ACOM's Council on External Relations and Communications, the OEMEs are a series of awards which aim to recognize and honor the efforts of journalists who promote understanding of occupational and environmental medicine, increase public awareness of workplace health, and focus coverage on worker well-being. The OEME awards were developed to encourage and promote visibility of OEM and ACOM to the public and establish relationships with external media. This year, awards were given in four categories, written journalism, OEM trade-specific journalism, multimedia journalism, and student journalism. ACOM received a record number of submissions, and this year awarded five written journalism awards, two OEM trade-specific journalism awards, one multimedia journalism award, and one student journalism award. Awards were mailed to recipients who are not in attendance at AOHC. The first recipient of an OEME for written journalism is Katie Camaro from BuzzFeed News for her article entitled, Health Risks Linked to Working in the Cannabis Industry, are largely unknown, but a 27-year-old's death reveals the potential dangers. Katie is here in Philadelphia to receive her award. Please join me in congratulating her. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. 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Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Congratulations. Con you to make us aware of the issues that are affecting your patients in subtle ways. And along those lines, I invite you to reach out to me personally, or certainly journalists more broadly, anytime you feel like there's a position for awareness to be raised about a certain affected population in a way that may be preventable. In the meantime, I just wanna thank you again for this award and wish you all the best in the work that you do. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. At the time of his death, at only 59 years old, Dr. Patterson was a member of the AECOM Board of Directors, Chair of the Committee on Ethical Practice in OEM, and was Assistant Vice President at Concentra Health Services, responsible for clinical operations in New England and New York. In recognition of Dr. Patterson's life and service, AECOM hosts a lecture at the AOHC in the spirit of Dr. Patterson's work to support ethics-oriented leadership development for OEM residents and young physicians. The 2023 Patterson Lecturer is Dr. Sarah Gorman. Dr. Gorman is a public health and behavioral science expert who has written extensively about science denial, misinformation, science communication, and psychology, among other topics. Dr. Gorman's first book, Denying to the Grave, Why We Ignore the Facts That Will Save Us, explores the psychology behind irrational health beliefs and decisions. The book also provides advice for how the general public can discriminate between valid and invalid science, and considers how public health professionals and doctors can communicate with patients who have a fundamental mistrust of science and medical research. She is currently working on a second book for Oxford University Press on medical mistrust, conspiracy theories, and the U.S. healthcare system. Dr. Gorman's work has appeared or been reviewed in Time, The New Yorker, Science, Psychology Today, The Atlantic, BBC, and NPR, among others. Sarah is also co-founder of Critica, a community committed to making rational decisions about health. Please join me in welcoming Dr. Gorman. (*audience applauds*) Okay, thank you so much for having me today. I'm really thrilled to get a chance to talk about this topic. In case you haven't guessed already, I really like to choose very easy topics to study, you know, no complications or anything that's hard to solve in the kinds of topics that I choose. So, as was said, I'm Sarah Gorman. I'm the CEO of a research nonprofit called Critica that focuses on counteracting medical and health-based and scientific misinformation and improving science communication. And I'll get a little bit more into the particular methods that we use to do that in the course of this talk. What I hope to do in the next 45 minutes or so is to lay out for you the reasons why I think that we're approaching misinformation, conspiracy theories, mistrust in medicine and the medical field in actually a little bit of the wrong way. And I'm gonna present sort of a new framework for thinking about this and try and convince you all that you are key players in working against some of these issues that we're facing today. And we all know this concept is everywhere. I see it in the headlines, I see it in the published literature, new studies on misinformation almost every day. So I think I'm in good company probably in seeing what the need for rethinking this might be. But what's harder is really coming up with those solutions to the problem. And I hope that I can give you a few ideas of that. Before I get started on all of that, I just wanted to acknowledge a few people. Obviously, no one works alone. We have some great collaborators. We have a great team at Critica of scientists, sociologists, medical professionals, and then our infodemiologists who I'll talk a little bit about later and explain what that is. And we've been very lucky to have extensive collaboration with Kathleen Hall-Jameson at the University of Pennsylvania, and Tyrell Starks, who's an expert on motivational interviewing, which I will also go into a little bit more detail. And I have no conflicts of interest to declare. The support for a lot of the work that's done at Critica comes from the Robert Wood Johnson Foundation, and the ideas that are expressed here are not necessarily the views of the foundation. Okay, so before I sort of talk about what we do at Critica, I should probably tell you what we are and who we are. So as was said in the intro by Dr. Martin, Denying to the Grave was my first book that came out in 2016. And really looking at the science of this, the psychology of science denial. So what are some of the key factors in risk perception, confirmation bias, group psychology that lead to issues with accepting scientific fact? And when this book came out, it was right before the 2016 presidential election, and I was approached by many, many people who wanted to talk to me about what I was gonna do about the problem that I laid out in the book. And I quickly realized that if I wasn't gonna do anything, then many other people weren't gonna do anything either, so I may as well try to start doing some work in this area, aside from just diagnosing and writing about it. So Critica was founded shortly after the book came out, and there's also a second edition of the book that came out in 2021 and talks in more detail about the coronavirus pandemic and all of the science denial that came with that as well. Our mission is to simply improve public understanding of scientific consensus, which isn't always agreed upon in the general public, counteract misinformation about science and health, and increase the use of scientific evidence in public policymaking. And so a lot of what we do, and a lot of our funding traditionally from the Robert Wood Johnson Foundation has been around creating and testing interventions to counteract misinformation, mostly on social media. And I'll be talking about this in much more detail later, but that is sort of the backbone of what a lot of our work and a lot of our publications and a lot of our research is about. And we also do trainings and technical assistance for public health institutions. So we have departments of health that come to us and I want to have their employees be trained in how to do this infodemiology method that I'll explain in more detail in a little bit, and how to really talk to people who don't accept scientific fact or how to make their communications a little bit more wary of the way that people may not agree with what they're trying to say. And so the major areas that we focused on to date have been the COVID-19 vaccines and all of the misinformation that still surrounds those, as well as now a very interesting project focusing on reproductive health and misinformation surrounding that. And we also do public education and training. So in a variety of different audiences, different professions, because everybody does have a role to play in counteracting misinformation. And so we view some of our work as sort of making publicly available some of the trainings that we do more intensively with our employees. So why does this matter for occupational, environmental occupational medicine? I know that in talking to some people in advance of this conference, what I really got a feel for was that this is a very diverse group of people that works on a whole range of topics and in different environments, work environments. But I think that all of the environments that you work in are very relevant here, because I'm gonna argue that we need to get behind a view of misinformation and how it spreads as really an environment, almost an environmental hazard, that people live in certain information environments, and they're being exposed to toxic misinformation, and they're being targeted by disinformation peddlers, and they don't have good access to high quality or high integrity information. And so this perfect storm kind of is created around certain communities where people are just not able to get, they may see the right information, but they're not really part of their information hygiene to really know what sources to go to and who to trust. And there may also be a lot of trust issues in some of these settings as well. And so I'm gonna talk about a few familiar public health models, epidemiological, social ecological, and sort of this environmental health model that I just laid out a little bit, and really argue that we need to think about this problem differently. And I think that all of you have a really good perspective to take on how to reconceptualize it. So before I do that, I did just wanna touch on some of the literature on this topic, because there is a lot, and there continues to be more and more. And there's still, of course, a lot that we don't know. And so that's part of the problem. So we do know certain things, like there's consistent evidence that shows that there's a high prevalence of misinformation, either belief or spreading of misinformation, that distinction is not always so clear in the literature, but there's consistent evidence that there's a high prevalence of misinformation circulating in populations over the age of 65, especially in social media environments. There's very little evidence, on the contrary, about patterns in younger adults and adolescents. So if anyone's looking for a new research area, this is kind of a prime area that we still don't know quite enough about the information hygiene and practices of younger populations, how they differ from older adults, and what sorts of things influence them the most. Social and psychological vulnerability factors are important here as well. So my first book really looked at the psychology of science denial and focused on some of the key characteristics that make people more prone to believing in misinformation. And my second book is very focused on the structural level of what has happened in the healthcare system that has led to such low trust, and how does that interact with the spread of misinformation. But I never like to leave behind the psychology aspect of this, because it's very important to recognize that there are certain individual factors that make some people more prone to misinformation than others. And there's been a lot of literature published about this, including the idea that the more narcissistic traits somebody has, the more they may be prone to conspiracy theories, as one example. Or people who score very high on certain depression scales may also be prone to believing in misinformation and conspiracy theories. But we don't always know some of the basic demographics, like men or women, is there any proclivity by gender, ethnicity, location, political views, there's a lot of back and forth in the literature, and I'd say that that science is far from settled. Sorry, I thought I skipped a slide, but I didn't. So what comes out of the literature at the moment about what we should do about misinformation? I just got finished telling you that there's so much we don't know. And so what kind of suggestions are people making? And I would say, in general, they fall into one of these four categories. So one being inoculate, so try to get to people before they see misinformation, and actually present them with a version of that misinformation that's just a little bit diluted and not as interesting and appealing, and give them time to build up their counter arguments so that when they do, in the wild, later get and see these misinformed statements, they have a little bit of a runway to get around these ideas and to think about them a little bit differently, and it supposedly works the way a vaccine works. Now your mind knows what to do with the misinformation, and you don't get pulled, sucked into it because you've had this advanced warning. And that actually is a pretty, that's a pretty efficacious method. The problem with it is that we don't always know, and we certainly don't have enough systems in this country to sort of look at what misinformation is rising and what populations at different times to be able to say, okay, here's what's going to be a big misinformation topic. Let's train people to get out there and inoculate people against these ideas before they encounter them on social media. So that turns out to be very difficult from just from a logistical perspective, but very effective. The main thing that most people do now is to debunk. And again, this is effective to a degree, but it assumes that people are believing in misinformation because they don't have all the correct information or there's a knowledge deficit problem. And that turns out to sometimes be the case, but in many, many cases, that isn't the problem. And so just debunking usually doesn't do harm, but it doesn't really upend the kind of thought patterns that lead people to believe in misinformation. Meaningful conversations I'll come back to because that's a little bit of the sort of literature on motivational interviewing that can be used for changing people's minds. And then reducing community vulnerabilities, that's going to be a big theme in a few minutes because really looking at environments, information environments versus individuals in those environments to understand what is this whole community facing as a threat to real information that they need. And so what does the literature so far say about other methods that we might take on a more regulatory or policy level? So there are things like, there's always a suggestion that in the regulatory environment that there should be a redoing of section 230, which is the thing that allows social media companies to not take responsibility for things that are posted on their sites. And this always comes up for a huge amount of debate and people, there's never agreement politically about whether this can actually be done. And so this is a very difficult thing to do in reality. And you could argue that we don't really know how effective that would actually be. But there are some other smaller steps toward that, making social media companies be more transparent about what they're doing to address misinformation and make their data more available to researchers. Structural interventions involve things like we've heard, many of us have heard what was going on in California earlier this year about taking doctor's medical license away for spreading mis- and disinformation. That is something that's hard to pass in many settings, but it is something that effectively or officially, the AMA says should be happening on a much wider stage. So what do we still not know? I touched on a few of these things earlier, but it's kind of surprising to me to see that there's so much literature coming out each and every day about these topics, but we still don't really know what the impact of most misinformation interventions is. We don't actually understand the true relationship between misinformation and behavior. So there is an argument to be made that you might read about or a little bit flirt with a misinformed idea, but that might not affect your health behavior or ever affect health outcomes. And so that is something that is kind of up for grabs that we still need to understand better. We don't really know much about how stable people's beliefs in misinformation is over time. And we don't know whether some of the sharing behavior, spreading misinformation online, is akin to really believing it. So there's a lot of measurement problems and a lot of difficulty linking these issues with health outcomes still in the field. So what I want to go through with you mostly in the remaining time is to talk about what I think needs to be a paradigm shift in our approach to misinformation. So I gave a little preview of this earlier, but information environments should really be thought of as a social determinant of health. And an environmental health model can help us understand what are the predispositions? What access to mitigators do people have? And what are their own predispositions and the types of exposure that they're having to make them form a toxic belief in misinformation? And it's not always so straightforward. So you have to understand what are the various things that are acting on, usually at a community level, not on an individual level, that will make somebody actually more susceptible to misinformation? And it is a social determinant of health because we know that there are many things in those factors that I just mentioned, including access to mitigators, what kind of access people have to good information on a sort of community level, and the ways in which people are sometimes targeted by disinformation peddlers to, and these are people who come from certain socioeconomic and racial and ethnic backgrounds are regularly targeted by disinformation peddlers. So there's a real social element of this that needs to be better understood. And we need to think more carefully about what information environments are as opposed to individual people or individual pieces of misinformation. We don't wanna focus so much on did somebody get exposed to one piece of misinformation, but what is the entire environment around them that would make them potentially fall into these beliefs? And we really like to think about an environmental health approach here with three interrelated concepts, as I said, predisposition, exposure, and access to mitigators. So if you think about somebody's risk of developing asthma or having bad outcomes as a result of having asthma, there are all these interplaying factors that are really important to understand as a whole. What is their genetic predisposition? What are some of the social determinants that might affect whether they are more predisposed to having a bad outcome? What are their exposure to toxins and pollutants, literally, in the environment? And then do they have access to healthcare? Do they have access to parks, trees? What is their actual physical environment look like? And those things together help you understand what is this person's level of risk? And we should be doing the same thing when it comes to misinformation and also conspiracy theory beliefs, et cetera. Because we really want to know, not just is somebody exposed, everyone's probably exposed to some misinformation, but some people and some communities are much more harmed by this than others. And so we need to understand what is the media diet in these communities? What are their news choices? What are their social media use like? Not just whether they use social media, but how important is social media in their everyday life? Do they depend on it for their identity? Or is it just something they kind of do when they're bored? Those kinds of questions will really help to look at whether this community is going to be exposed to a toxic kind of misinformation. And what is one's predisposition to finding misinformation credible? This has a lot to do with some of the psychological and social factors that I talked about at the beginning, things like whether people are part of a group that believes in certain types of misinformation, how important that group is to their identity. Those are some of the things that will tell us, are there elements here that would make this person or this community more predisposed to finding that misinformation credible versus other communities who may be much more resilient to that misinformation. And then access to mitigators really has to do with what is the ability to access high quality or high integrity information. And a lot of this has to do with the concept of trust. Whether the community trusts medical professionals, they have community leaders that they trust. Who are the trusted members or leaders of their societies? And do these people have, are they armed with good information about science and health? So when we now look at this model, the environmental model of misinformation or addressing the information environment versus single solitary pieces of incorrect information that may pop up on social media, then the range of different interventions that we might want to use becomes a little bit different. So one thing that some of my colleagues and I have published about is a suggestion that maybe we should do screenings for patients, employees, members of the general community about these factors. What are their predispositions? What are their exposures looking like? Do they have access to good information? And you can actually do sort of a risk assessment of very hot areas where there's a lot of potential for people to fall into misinformed belief. But the other thing that's really important is creating a culture that values good information. And there's no easy recipe to do that, but for those of you who work in work environments and obviously in occupational health, the culture can be created where there is rewards for people who utilize good information and there is not penalties, but some kind of consequence for spreading misinformation in the workplace, for example. But the idea is that you have trusted community leaders who are speaking to the communities about what good information hygiene looks like. And so we're addressing this more at this kind of structural level and the environmental level versus at the individual level. Now, it wouldn't be, we wouldn't be, this wouldn't be a great talk if I just gave you one model. I have to give you multiple models to confuse you. So we also, in addition to thinking about this environmental model, there are a couple of other ideas that we want to think about and overlay on this. So one is the social ecological model of misinformation. This comes from, you know, very squarely from public health where, again, the individual is there, but there are all these other influences outside of the individual. And misinformation is not an individual level problem. It's really existing at a community or population level, and so the solutions need to be targeted accordingly. So we really need to think about the community level and the policy level and understand that the information environment is what we're trying to target, not the individual people within each community, which would be very hard to actually do comprehensively. And then finally, there's the epidemiological model of misinformation. So you probably heard me say in the beginning, infodemiologists, that was not a portmanteau or a typo in my notes. The idea comes from taking an epidemiological model and applying it to the problem of misinformation. And so I'll tell you a little bit more about how we train our infodemiologists and who they are and how I think that that model can be scaled up. But this is basically what we do in epidemiology. We have surveillance, diagnosis, risk assessment, and response. That's a very simplified version of what the epidemiological model looks like, but when we're dealing with misinformation, we have to take these steps as well. And so that's why we have to have a cadre of people who are able to look at the information environments and understand and do the surveillance and understand where are the hotspots where there are communities that are falling prey to some of these misinformed ideas. And they have to diagnose that and realize what is the risk of this community? Is this a community that already had very low trust in healthcare professionals? Are they primed to sort of believe things that eat away at that trust even more? And then you have to have a response. So that's the infodemiologist. So what is an infodemiologist? Epidemiologists respond to epidemics. Infodemiologists respond to infodemics. So we all saw this word during the pandemic propping up many, many times, and there's an infodemiology, infodemic management system at the World Health Organization now, some of which we at Critica have helped to train some of those infodemic managers that work all across the world. But what we do at Critica is we hire and train people to be infodemiologists, usually who have a background in psychology and science communication or some version of those things. They're not usually necessarily have medical or public health backgrounds, but they have constant access to people who do have subject matter expertise in whatever the topic is. So if it's COVID-19 vaccines, they have people who study COVID-19 and COVID-19 vaccines. And if it's reproductive health, they have OBGYN consultants that they can ask actual questions to when their actual knowledge of the area is not sufficient. But what they do is they, in collaboration with the University of Pennsylvania, we are able to see the sort of range of things on the internet, on social media that are being spread as misinformation, the most popular prevalent claims and how consequential or harmful they might be. And we sort of target those, our infodemiologists target those threads and they perform sort of a motivational interviewing kind of intervention. And sometimes the person that's going back and forth with them, whether it's in a comments in a social media thread or some other format on social media, it's not always the case that that person changes their mind. But we have been able to study the effects on bystanders to these interventions. And it turns out that there are many bystanders who are on the fence and they're not sure and they're watching this unfold and we're able to change their attitudes and behavioral intentions. So if they were hesitant about the COVID-19 vaccine, being a bystander to these interventions helps them really see and unpack what some of the concerns are and what their real goals are, what they really want to achieve by either not getting the vaccine or getting the vaccine. And so helping to align people's goals for their health and their family's health with the really correct scientific information, which is that getting the vaccine will advance that goal. But we also use other evidence-based strategies. So part of the beauty of this model is that it doesn't depend on just one type of intervention, but we train our infodemiologists in using inoculation techniques when that's appropriate, evidence-based rebuttals, building self-efficacy, which is a hugely important part of training people and getting people to feel that they are able to find the correct information themselves. And a simple sounding one, but is often left out of the discussion is just repetition. The misinformed claims get so much more repetition on social media than the correct information. So just being voices that are there to reinforce what the correct information is, but the real balance, the real thing that they're mostly focused on is these kind of motivational interviewing interactions, and we train them extensively in that. So I'll give you, I think I have two examples I'll give you just so you get a better sense of what we actually do. So what are some of the evidence-based methods for addressing misinformation? Respectfully demonstrating an understanding of the values, fears, and beliefs of the person who is espousing the misinformation or asking questions about it. And that's really the motivational interviewing spirit. That's at the base of what motivational interviewing does. It acknowledges that people are dealing with conflicting emotions and they're having trouble sort of aligning in some cases their values with the behaviors that they are saying they're going to undertake. Being mindful of knowledge deficits. So knowing when there is a place to actually give somebody the correct information, but not rushing to do that. Because sometimes that takes up too much space in the conversation, was not the problem the person was having. The problem may have been having, they may have been having, may have had to do with their identity, that they form some kind of thought pattern around vaccines that they saw as aligning with their identity, whatever that identity might be. And so they're having trouble changing their view about that. And so in those cases, you want to be careful because giving people more information can sometimes backfire. So we train them on how to look for those different situations and where they should be using just facts and where they should be helping people really think about what they want to accomplish with their health behaviors. Be aware how corrections from peers are more likely to change opinions. So leading other people to be able to question what somebody's saying in these social media forums versus just telling them that they're wrong. So that is why we have our infodemiologists identify communities that they think are at risk for believing a lot of misinformation. And they work within those communities. Address common difficulties with probability and contradictory evidence. So we also train them in risk communication, which is a whole scientific field I'm sure you know very, very much about. And the difficulties people have with understanding not just risk, but even just basic sort of statistics and probability and how to phrase things in a way that will be more easily understood when that's the issue. Anticipate misinformation and counter it immediately and respectfully. So this gets into a little bit of trying to use the inoculation technique, get to it before it may be fully expressed. Or when you feel that things are leading up to that, someone dropping a lot of misinformation into the conversation, you can say, I know you might say this, but just listen to what I have to say about it first. And then we insist that they be transparent about any conflicts of interest. They always have to disclose that they're working for Critica and we're funded by Robert Wood Johnson Foundation. And so sometimes people do come after us and say that Robert Wood Johnson Foundation is a pharmaceutical company, which it's not, but that still does happen. But we don't shy away from that because that can obviously backfire if you don't address that up front. And we do actually train them to give a little bit of information about what they're trying to do so that it doesn't feel like it's a trick or something or just a research experiment. So here's an example. We've all seen a lot of claims about vaccine adverse events, especially in response to COVID. And the rationale in the misinformation, there's often cherry picked evidence or experiences. There's an overestimation of the incidents and severity of vaccine adverse events. So that will be playing on people's availability bias. When they hear about a really gruesome event that happened, they keep that in their minds much more easily than just the base rate of most people get vaccinated and nothing happens. And so that situation suddenly seems higher risk to them. And so we try to have our infodemiologists understand what the typology of the different misinformation claims are, because there's always kind of a pattern that different claims fall into. And it's helpful for them to actually categorize these and know what are the actual techniques that whoever's spreading the misinformation is using to make this more sticky for people who are gonna eventually believe it. So, this is just an example of Nicki Minaj, my cousin in Trinidad won't get the vaccine because his friend got it and became impotent. Okay, so that is, these kinds of stories that people have, and that is cherry picked experiences. So the infodemiologist will say, okay, this is an example of cherry picked experiences. And they'll have a certain way of combating that particular type of category of misinformation versus necessarily engaging so directly in every single word that was said in that comment. So, and then what we also train them to do is the spirit of motivational interviewing. So motivational interviewing was developed as something that was done usually between two people, a therapist and a patient, and then it expanded into couples therapy and group therapy. So it can be done in a group setting, and it can work for things outside of substance use, which is where it was initially developed. But using it on social media is sort of a new kind of experiment. So, what we do is we train our infodemiologists in what is the spirit of motivational interviewing, which is something that's talked about a lot in the literature about motivational interviewing and the evidence base for it. And then we train them to not so rigidly, they can't so rigidly stick to exactly the way it might unfold in a one-on-one session with a person who's struggling with something, but we want them to get the basic principles. And then that is how that they can really dislodge some of the misinformation that people believe. And that's really what we found to be the most effective thing. So, some of what they might do in a case like that with the vaccine adverse events would be to acknowledge right off the bat that they know that any new medical intervention can be frightening. They should empathize with the fear of the adverse effects, saying, you know, I understand that it's very scary. Asking open-ended questions is a big part of this and is one of the easiest thing to sort of hang your hat on if you're having one of these conversations on social media, whether it's not, even if it's not professionally oriented, if you're just having these conversations with people that you know in your social network and these kinds of pieces of misinformation come up, try asking more open-ended questions. That's one thing that you can try immediately that can, you know, can elicit a little bit more from the person about, okay, like, why do I really believe this? And maybe I should think about it a little bit more deeply. And then we teach them to reframe the narrative. So, the obvious one is to tell stories about people harmed by the disease, the vaccine prevents, and about people who have been successfully vaccinated, of which there are many, many examples. And then we always want to provide high-quality resources for further inquiry, giving people the option to sort of think about what are information sources that they trust. So, you have to meet them where they are. If they don't trust the government, you shouldn't give them CDC resources because that's not going to go over well. But there are other community-based, respectable and reliable sources of information that they may be more responsive to. And so, we kind of try to keep a repository of these things in each field that we work in and offer those to people, especially when they are really suspicious of the government. So, this is a little bit more about what I was saying about how we categorize and typologize the different misinformation or concerns that come up in the COVID-19 vaccines. There were a lot of comments about how the vaccines are not natural. We don't have information on long-term side effects. And then there were these personal accounts of, I know someone who nearly died from the vaccine. And so, your response to each of these might be a little bit different, but what we're doing is forming this database, basically, of the different types of misinformation so that you can have that ready at hand and understand when someone comes on with some variant of one of these that, oh, they're in this category now. They're talking about the long-term effects. Okay, I'm gonna counter that with, however I usually counter that particular kind of argument. And then reframe. And so, you acknowledge and reframe is sort of one of the other elements that's very central to the spirit of motivational interviewing, so that people feel recognized for what they said and that you're not just dismissing it out of hand, but that you're really offering a new way of thinking about it. So, I spent a lot of time talking to you today about misinformation, and there always is this elephant in the room when we talk about this topic, which is the trust issue. And I've just spent the past six to nine, no, more like a year, working on a book that really focuses on this topic and what has happened to trust in healthcare, specifically, in many cases, as a result of the COVID-19 pandemic. And so, just before I say what I found, I've done a lot of original research to actually talk to people who have recently felt like they've lost trust in the medical and healthcare system. But before I present some of that, I just wanted to point out that there is actually a viewpoint in the American population that I think people assume that, in some ways, they will be taken care of. And this comes from, this can go as far back as Cicero or John Adams, who's calling on Cicero to say, the public good, the salus populi, the health of the people, is the end of all government. So, part of the difficulty we face when we're dealing with low trust in the healthcare system is that people are also really disillusioned about even larger questions about, what is the government even doing for me? Are they completely useless? Maybe I shouldn't trust them at all. All those issues get very bound up in one another, and you end up with people who are really questioning, in some cases, the backbone of our democracy. So, not to scare you, but that is one aspect here. The other thing that I think is really interesting that happened as a result of the pandemic, in many ways, is that medical mistrust, including in the prevailing literature, is traditionally defined as trust in one's physicians or other healthcare professionals. And it's really an interpersonal level of trust, not an institutional kind of trust. But the pandemic has actually turned that on its head a little bit, because I've found, and others have found, time and time again, in doing research on this topic, since the pandemic started, people start to question their physicians and their healthcare providers in the context of not trusting the government much more, and the system much more. So, they're not just thinking about, do I trust this person? But they see this person as a symbol of the system. And part of it is because there was probably a lot more exposure to elements of the system, like the CDC and all the state and local health departments that people didn't interact with as much before the pandemic. And so, that's why it's really important to understand institutional trust, and not just interpersonal trust in these cases. And I will say that trust of medical professionals in the healthcare system is important and also understudied. So, what has happened to medical trust in recent years? So, in this order, people trust the healthcare system as a whole, government agencies, pharmaceutical companies, and insurance companies the least. And members of the general public trust hospitals at a higher rate than physicians do. So, some of you might not be surprised to see that. I heard many, many stories of disillusionment in the immediate healthcare system that people were in. So, hospital systems. There were many people who felt kind of disillusioned by whether it was real or perceived vaccine mandates. People would sometimes say, there wasn't really a vaccine mandate, but it felt like there was, and if I didn't get the vaccine, maybe I would get fired. So, there was a huge decline in this time period in that area of trust. Then there's a little bit of a disconnect between what physicians think, the general public or their patients, how much they trust them. The 98 percent of physicians say their patients trust them, and 83 percent of people say that they trust their personal physician. So, there's a little bit of a disconnect in terms of who sees this problem of trust as an actual problem. I had a few quotes here because I think it just adds color to what I'm describing. A lot of what people were talking about when I interviewed them, and these were people who in some ways, they may be a little bit of a biased sample because they were people who came forward as recognizing that they had low levels of trust in the health care system. But it was still very telling, a lot of the testimony I got from dozens and dozens of interviews. A lot of people who worked in health care companies or were health care providers of some sort, became distrustful of the system during the pandemic. A lot of what they saw was the inefficiencies were things that really diminished their trust. So, one person said, I vowed to never work in a health care company, clinic or center because sometimes it can feel helpless, and you can't help the person. It's been three years since I worked in health care and it still makes me feel sad. And the other thing that is related to this that people talked a lot about was just members of the general public who felt they had low trust in health care because their access to health care was not good. So, usually I think we think maybe it goes the other way around. People distrust the system first, and then they don't seek health care. But actually, in a lot of cases, people are lacking access to care, and then they're making up sort of ideas that they might have about, well, I don't trust them anyway, and they seek out other forms of health care, and their trust just diminishes from that experience. So, that is a really important aspect of this problem. These are just some more quotes that I'm happy to share in more detail later. But there were very harrowing stories of people who, in some cases, actually died because they wouldn't seek health care. And one of the most interesting cases I heard about was a woman who grew up in rural Montana, and then she moved to Norway. And when she was in Norway, she said she trusted the health care system very much because it was easy to access. And then when she came back to Montana, she said, I don't trust the health care system anymore. So, that's one example, but it was just illustrative of some of what I was seeing throughout these interviews about people reacting to their lack of access to health care and not having an effect on their ability to trust the system. So, I didn't wanna just leave you with a lot of the problems and not say what I think some of the solutions might be. So, I alluded to some of this throughout, but I think there are some distinct things you could start doing today or tomorrow or whenever you're back in your workplace after this conference, that could make a difference in how we actually both think about trust in the health care system, what we do about it, and how we conceptualize and respond to misinformation. Then, then, then, then, then, then, then, then, then, then, then, then, then, then, then, then, then, then, then, information that people are in. And when they're in a workplace, what do those communities look like? How is information shared? Who leads the pack in terms of what's decided on what is the correct or trustworthy information? And if there's a problem with the way that that is happening, can you utilize and train people in this motivational interviewing technique? Anyone can do it. And you can even try it later on social media if you want, on your friends. But it is something that can be utilized to some degree at scale if more people are trained to actually just drill in to what's behind some of the hesitancy around some of these issues. And then working with community leaders. So I said before sort of who leads the pack in terms of deciding what information is credible and what information is not allowed to be passed around or they try to downplay. You have to realize that those are the leaders of the information environment. So those people are very important to reach. And then these people are. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. So. 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Dr. Michael Gottschfeld

Rutgers Occupational Medicine Program

founding residency director

Dr. Sridhi Patani

Society of Occupational Medicine (SOM)

education

networking

2023 Occupational and Environmental Medicine Media Excellence Awards (OEMEs)

journalists

Dr. Sarah Gorman

Critica

medical misinformation