Combating online misinformation in clinical encounters

As of 2023, there were ~5 billion social media users worldwide. A systematic review on social media use in healthcare reported that it can help to provide more bilateral communication and harmonious relationships between doctors and patients but conversely can drive suboptimal interactions [1].

A particular concern is the substantial prevalence of misinformation about urological topics on social networks [2]. In this new information landscape, it is essential for urology trainees to have strategies to manage exposure of patients to misinformation and mitigate the downstream consequences on clinical care.

To this end, we examined the strategies used by urologists and other health professionals to manage encounters with patients exposed to online misinformation, how to prevent misinformation exposure, and the extent to which this was addressed during training. Following Institutional Review Board approval, we conducted in‐depth interviews with healthcare providers (n = 13) and community health workers (n = 10) in the prostate cancer field until thematic saturation was reached (n = 23). Interviews were recorded and transcripts were independently coded by experienced qualitative investigators using a constant comparative method. NVivo qualitative software was used for organisation and analysis. Key themes from our qualitative study were synthesised with the published literature to identify the most relevant and useful techniques for trainees to consider and opportunities for future education.

Table 1 shows strategies that were described by participants to manage encounters with patients discussing misinformation. Key themes included validation of the patient's beliefs, building trust, and respecting their autonomy. Specifically, actively listening to patients to truly understand their underlying concerns and beliefs is essential. ‘It's all the basic principles of being a doctor, you know, respecting your patient, taking them seriously, spending your time, answering all of their questions, helping them.’ (Interview 4). Conversely, acting dismissively may undermine trust and ‘fracture the physician patient relationship by just basically telling them they’re crazy.’ (Interview 15).

Table 1.

Key themes and representative quotes from healthcare providers and community health workers regarding strategies used to mitigate online misinformation in patient encounters and prevent misinformation exposure.

Key themes	Representative quotes
Validating patient beliefs and building trust	‘I generally first make sure to understand what the patient believes or understands about what they just said. I’ll ask clarifying questions: where did you hear that or learn that? And then try to rather than make them feel badly about this information or be interrogating, try to then focus our conversation on correcting that misperception or explaining why it may not be true or might not be applicable in their case.’ (Interview 21)
Listening to the patient without acting dismissive	‘Listen to the person. I don’t dismiss their claim offhand and I try not to do it in a condescending way. I try to recognise that they are trying to take an active role in their healthcare. That's a good thing I try to acknowledge. And then I say that you have to be careful about who you get your advice from and try to find out what their motivation is behind the scenes and how to find reputable sources.’ (Interview 1)
Recognising patient autonomy	‘I tell all my patients, it's their body, their choice. They can do whatever they want. Most of the patients I’ve just met for the first time. And I tell them, I don’t know you very well. So this is what's working for you and your family and your beliefs then go with it. I just don’t have enough knowledge about some of these supplements, or some of the things that you’re seeing online… but it's their body, their choice they can do whatever they want and I’m here to support them.’ (Interview 4)
Clear communications	‘Try to speak in a layman's manner and try to speak in a way that they can understand you, and give them trust about it, reassurance.’ (Interview 13)
Identifying trusted programmes to address patient concerns	‘I try to get at the root of why they’re seeking out these alternative sources if it's a general mistrust of Western medicine, then I talk to them about how the VA has programmes where clinicians have training in eastern medicine approaches and homeopathy and so I talk about the benefits of staying within our system but still getting that alternative or complimentary medicine advice.’ (Interview 22)
Highlighting published data and guidelines	‘I try to take them to published papers. I show them NCCN guidelines. Things that people accept, and I try to look at the source of what they’re coming up with to see if it's published and trying to explain to them the difference between stuff that's published and that's not. I’ll generally try to appeal to the evidence and consensus statements.’ (Interview 12)
Teaching digital literacy strategies	‘A lot of times people just don’t even really know how to evaluate a website and look at who is sponsoring the website and that type of thing. So, I usually do some education around medical information on the Internet, like literacy, and then try to provide some reputable websites for them for follow up information.’ (Interview 16)
Giving an information prescription	‘I don’t know what we can do in terms of social media platforms, there seems to be no regulation out there. So I would say it's trying to steer people to reputable Internet sources. I steer everybody to the Prostate Cancer Foundation and away from Proton Bob, and other popup sites.’ (Interview 12)
Using social media to promote awareness	‘What I try to do through my podcast is present the right information that's applicable and that people can implement. I present the information that I believe is good and will help people that are watching.’ (interview 14)

NCCN, National Comprehensive Cancer Network; VA, Veterans Affairs.

Another strategy is to explore their underlying concerns and identify legitimate healthcare settings to address them. For example, many patients seek online information about complementary and alternative medicine, with substantial risk of misinformation exposure. However, many health centres have trained practitioners specialising in these areas who patients can consult with (e.g., integrative medicine). In addition, some institutions have health educators or navigators who can help patients, and their families, find trustworthy sources of health information.

Participants also discussed preventive strategies including the importance of promoting health literacy with patients. They described ‘teaching people how to critically read something and know sources.’ (Interview 18). Tools exist to help lay audiences evaluate the quality of online health information, such as the National Library of Medicine's MedlinePlus checklist [3]. It includes questions about who is sharing the information, the source of funding, evaluating quality and ensuring privacy.

In addition, a key strategy that participating healthcare providers and community health workers used during encounters with misinformation was reviewing published data and guidelines directly with patients. Notably, some organisations such as the National Comprehensive Cancer Network offer Guidelines for Patients, which present expert recommendations in plain language with visual aids.

Participants emphasised the importance of confirming with patients that they understand the information. ‘Sometimes the patient might not know what you’re saying, and they’ll just go along with it, but making sure you ask them “are you sure you’re understanding and if not let me know.”’ (Interview 2) Use of videos, pamphlets and anatomical models were discussed as helpful aids in clinical practice. ‘What we do here is booklets, we have models where we talk about it and we go over it. Like, how is the progression, what steps need to be done? I think that helps more for the patients when you break it down for them.’ (Interview 6).

Even so, there are significant time constraints with the clinical encounters, and it is natural that patients and their families frequently seek additional information. Thus, healthcare providers should provide an ‘information prescription’ with trusted sources of information that they recommend, so that patients and their families are not left to explore the ‘wild west’ online environment without guidance. ‘They can trust the website that I point them to.’ (Interview 4). Fortunately, there are many reputable sources of online health information that can be shared with urology patients, which were previously summarised [4].

Finally, providers described the importance of playing an active role in social networks to share evidence‐based information with the public. ‘As urologists, they’re beating us. Companies that are interested in collecting money are beating the urological associations. They were ahead of us in social media, which is now probably 80% of the information patients get, and we should actually invade those medias with real evidence‐based medicine information…. Right now they’re looking at other things because we’re occupying only probably less than 5% of the media in health.’ (Interview 13). Multiple best practice statements exist regarding social media use in urology, which should be reviewed prior to active use [5].

Unfortunately, none of the physician participants in our study received any formal training on handling misinformation during medical training or continuing education, representing an important gap given the scope and prevalence of this problem. Participants recommended that future courses on patient–physician communications should include how to engage patients with medical mistrust, motivational interviewing techniques, and managing encounters with misinformation.

In addition, training on public‐facing health communications would be helpful, particularly for ‘presenting information in a more non‐medical way’ (Interview 20) and methods to promote greater engagement with trustworthy information. ‘There's likely a way to share information that is good information, that is science‐based information and in a way that it can inspire people or at least influence people in a positive way.’ (Interview 14). Validated instruments such as the Patient Education Materials Assessment Tool showcase key elements for effective public‐facing health communications, including understandability (e.g., avoiding jargon) and actionability (e.g., providing steps for viewers to act on the information) [6].

In summary, despite the concerning prevalence of online misinformation, there are many strategies that can be used by healthcare providers during patient encounters to build trust and promote health literacy. In the future, urology training should include greater emphasis on lay health communications, enabling urologists to play a greater role in public dissemination of evidence‐based information.

Funding

This study was supported by the National Cancer Institute at the National Institutes of Health (R01 CA278997). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Disclosure of Interests

Stacy Loeb reports a research grant from Endo, and consulting with Astellas, Blue Earth, Endo, Doceree, and Savour Health, unrelated to the present manuscript. The remaining authors have no disclosures.