Vaccines, cancer, and science communication: Oh my!

Tara Haelle, writing for NPR recently, tells how a university press release, inaccurately entitled "Study explains how early childhood vaccination reduces leukemia risk", was covered widely in the press last month. The release attempted to explain newly published research carried out, in part, at UCSF. She describes how conversations with the senior author of the study failed to temper some questionable passages in the press release, and how follow-up with other researchers expert in vaccines helped to provide clarity. It's a good article and I recommend reading it. The bottom line, she suggests, is to always be skeptical of press releases.

That's certainly sage advice. I don't want to go into the details of this particular case; Haelle does that very competently, as do others, and it's easy enough to check the face validity of the claims of the release and author interview yourself via the SEER Website and FDA vaccine license time lines. Rather, I want to step back from the details and think about the episode more broadly.

This is a case of a group of scientists carrying out research that passed peer review and was published in a prestigious journal. When such a study is published, universities understandably want to make the presumed important information available to a broader audience. The titles and topics of many research articles probably won't draw the attention of casual readers, so universities have media relations teams that work with researchers to write press releases and help investigators interact with the press. One danger of this, and again it is understandable, is the potential for over simplifying and overselling research in order to make it accessible and relevant to the public.

It can also lead to a misunderstanding of the process of discovery. Medical science is a fluid, dynamic endeavor in which knowledge emerges iteratively, often triggered from conflicting results. Rarely does one study show anything definitively. In fact, many findings described in peer-reviewed studies are refuted later by the findings of other peer-reviewed studies. It has been argued that most published research findings are false, and recent evidence suggests that an alarming number of published results aren't reproducible. It reminds one of a quote attributed to physicist Wolfgang Pauli,

I don't mind your thinking slowly; I mind your publishing faster than you think.

Regardless of publication rates (and the pressures leading to those rates), knowledge emerges as conflicts are resolved, which can take years or even decades. It's unclear whether this is widely understood by those consuming medical and scientific information via the popular press. We need to think about how to communicate both new scientific findings and the process of science to the public more effectively. 

(image source: SEER)

The calculus of online credibility

It's been estimated that roughly one quarter of the global population will soon be using smartphones. Recently, Nathaniel Barr et al have studied how the instant and ubiquitous access to information from smartphone use is impacting our propensity for critical thinking. The paper's abstract captures the issue:

With the advent of Smartphone technology, access to the Internet and its associated knowledge base is at one’s fingertips. What consequences does this have for human cognition? We frame Smartphone use as an instantiation of the extended mind—the notion that our cognition goes beyond our brains—and in so doing, characterize a modern form of cognitive miserliness. Specifically, that people typically forego effortful analytic thinking in lieu of fast and easy intuition suggests that individuals may allow their Smartphones to do their thinking for them. Our account predicts that individuals who are relatively less willing and/or able to engage effortful reasoning processes may compensate by relying on the Internet through their Smartphones. . . . These findings demonstrate that people may offload thinking to technology, which in turn demands that psychological science understand the meshing of mind and media to adequately characterize human experience and cognition in the modern era.

Tania Lombrozo, writing for NPR, put it more succinctly:

We all know a little knowledge can be a dangerous thing. Research increasingly supports a related proposition — that easy knowledge can be a dangerous thing.

I don't want to go into the strengths and weaknesses of the study, or it's ability to assess causality. Researchers will no doubt address these important issues in time, and Lombrozo discusses them nicely in her essay. However, it's important to contemplate some of the implications of the study.

One implication is that, as the Internet and mobile technology have changed the way we acquire information, they have also changed the way in which we assess its credibility. We've all seen people read claims and discussions from different online media and rapidly accept them as true. Sometimes the information they glean is true -- online communities of people possessing similar interests and expertise are often rich sources of specialized information -- whereas other times online discourse is not so authoritative. Regardless, acceptance of what surfers read is often rapid. If people increasingly rely on digital information and forgo complex, analytic thinking -- the "cognitive miserliness" that Barr et al describe -- perhaps it's because they trust what they're reading.

If true, what are the implications for public health? Insofar as health behavior is influenced through online information gathering, we must understand how people determine trust and credibility of online information. Professional achievement in terms of academic degrees, certifications, or job titles of those publishing information online may be important, but also important are a source's online profile in terms of site appearance and ease of navigation, number of followers, and number of page views. In fact, the latter may be more important than the former.

If it's true that we are increasingly putting our brains in our pockets and avoiding critical thinking, as Barr et al suggest, then it's important to understand the calculus of credibility in cyberspace. If people find Facebook, Reddit threads, and Fox News more credible than the CDC or their own doctor -- rightly or wrongly -- we had better understand why and engage it as a tool.

(image source: David Hartley)

Ebola, EHRs, and the difficulty of communication

A quick update to a point discussed in the last post. On Thursday night, the Dallas hospital treating the patient suffering from Ebola virus disease explained the mix-up over his travel history. A news release on the hospital's website reads:

10/02/2014
 . . . Protocols were followed by both the physician and the nurses. However, we have identified a flaw in the way the physician and nursing portions of our electronic health records (EHR) interacted in this specific case. In our electronic health records, there are separate physician and nursing workflows.

The release then explained that the flaw had been remedied, by relocating the "travel history documentation to a portion of the EHR that is part of both workflows" and to "specifically reference Ebola-endemic regions in Africa".

The promptness of the communication was reassuring and helpful, and suggested that an analysis of the situation had been undertaken promptly, a cause of the error identified, and action taken to fix it. But 24 hours after the news release, a perplexing clarification was posted:

10/03/2014
We would like to clarify a point made in the statement released earlier in the week. As a standard part of the nursing process, the patient's travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow.

There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.

It's difficult to interpret the dissonance of these two releases, and I think they highlight a hugely important in hospital care: the challenges of effective communication between all members of the healthcare team.

Joyce Frieden wrote a very nice essay on the Dallas episode (published before the hospital's "clarification"), which I recommend reading. One passage describes some of the challenges to effective communication in the clinic:

Although the EHR could have been configured to import the nursing notes -- or at least their key items -- into doctor's notes automatically, "I'm sure some doctors would say it would be a bad idea because it would fill their notes with stuff they're not interested in," he [Dr Dean Sittig] continued. "So that's the culture of the two professions not respecting what each profession does. Whereas before docs had to flip through the nurse's notes to get to where they wanted, now they're on a separate tab. The flaw was that they weren't pushed into the doctor's face."

The importance of effective communication, from the perspective of the Magnet® process, has been discussed by Swanson and Tidwell, who note that 

One characteristic of exemplary professional practice is meticulous attention to communication processes. . . . This use of SBAR has created a standardized approach to information sharing. It has created a shared mental model for effective information transfer by providing a standardized structure for concise, factual communication among clinicians, whether it is nurse-to-nurse, doctor-to–doctor, or nurse-to-doctor communication. It is now used to ensure that patient information is consistently and accurately communicated, especially during critical events, shift handoffs, and patient transfers between levels of care. [Emphasis added.]

Apparently this critical nurse-doctor communication and information transfer didn't occur during the patient's hospital visit on September 26th.

Effective communication is a human process. Software should be used to improve that process, not replace it.

(image source: David Hartley)