Leveraging learner‐centered educational frameworks to combat health mis/disinformation

INTRODUCTION

Amidst the coronavirus pandemic, the impact of fake news has never been more consequential. ¹ , ² With the spread COVID‐19, physicians have been fighting twin pandemics ³ —that of the virus and the infodemic of fake news. Consequently, evidence‐based scientific and public health guidance are often crowded out by the sheer quantity of mis/disinformation. ⁴

According to UNESCO, the wastebasket term of “fake news” can be broken down based on intentionality. Misinformation is false information not created for purposes of inflicting harm, while disinformation is false information created to deliberately cause harm to a person, social group, organization, or nation. ⁵ , ⁶

Despite proven safety and efficacy of multiple COVID‐19 vaccines, ⁷ , ⁸ anti‐science groups and politicians continue to sow fear and doubt by spreading misinformation. ⁹ , ¹⁰ The Surgeon General of the United States has warned that “misinformation is the greatest threat to COVID‐19 vaccination efforts.” ¹¹ As we race to vaccinate as many as we can against emerging COVID‐19 variants, ¹² in the face of waning vaccine enthusiasm and demand, ¹³ , ¹⁴ , ¹⁵ the stakes are higher than ever.

All physicians must take a stand against health mis/disinformation. While many have done so with varying levels of success, little guidance exists to help frontline physicians respond to individual patients’ false beliefs or misconceptions. The fight against health mis/disinformation has mostly been led by public health experts, content experts, and researchers. However, all physicians have a responsibility to leverage their expertise and personal and professional relationships to push back against fake news. Clinician‐educators are well‐poised to lead the effort. The process of consuming sound scientific knowledge and rejecting false information is akin to learning and unlearning. Naturally, our approach should be grounded in sound educational pedagogy.

We aim to empower more clinician‐educators to lead the fight against medical mis/disinformation and to arm all physicians with practical knowledge and skills supported by learner‐centered educational frameworks to address misconceptions with our patients (Table S1). We intentionally focused on one‐on‐one or small group interactions between physicians and their patients, as opposed to pushing back publicly, through traditional or social media. This is because pertinent educational frameworks require a learner‐centered approach, which is difficult to maintain in large groups or online where audiences are often large, diverse, and unfamiliar. Moreover, recommendations already exist for physicians, public health experts, and researchers to improve science ¹⁶ and social media communications in the age of mis/disinformation. ¹⁷

CREATE A SAFE “LEARNING” ENVIRONMENT

Concerning scientific communication, it is necessary but insufficient to be evidence‐based, honest, clear, and transparent. ¹⁸ “Messaging” alone is not enough. Physicians must listen and try to understand before we attempt to persuade. ¹⁹ We must cultivate a strong educational alliance ²⁰ and establish an effective learning climate, where patients feel safe and comfortable voicing concerns, expressing their views, identifying, and stretching limits of knowledge without humiliation or ridicule. Individuals must feel heard. According to Maslow's hierarchy of needs, people have an inherent need for safety, belonging, and self‐esteem. ²¹ , ²² Patients must find interactions with physicians to be nonthreatening, stimulating, and pleasant. Keys to this are support, active listening, and constructive rather than destructive criticism. ¹⁸ While it is understandable for experts to feel anger or frustration in the face of science denialism, physicians must resist the urge to stigmatize at the outset. ¹⁹ Belittling others whose beliefs fall outside scientific consensus can further alienate those who are already disaffected by mis/disinformation. ²³

PROMOTE INTERNAL MOTIVATION

Individuals must be self‐motivated to actively seek information that may not align with their views and be open to challenging existing beliefs. ²⁴ , ²⁵ Promoting intrinsic motivation (informed by an innate desire to fulfill three needs: a sense of relatedness, autonomy, and competence) is more effective than targeting extrinsic motivation when seeking change.

With self‐determination theory in mind, physicians, as well‐respected community members armed with knowledge, expertise, and trusting relationships with patients and families, are well‐equipped to enable others to accept personal responsibility for self‐directed learning. ²⁶ We should appeal to patients’ sense of self‐concept (general opinion of self) and self‐efficacy (task‐specific comparison of self with a “master”) and encourage gap filling by cultivating their skills in asking questions, critically appraising new information, identifying own knowledge gaps, and reflecting on their learning process and outcomes. ²⁶ , ²⁷ Akin to fostering lifelong learning in medical trainees as master learners, ²⁶ physicians should nurture patient interest to become more health, news, and media literate.

LEVERAGE SCAFFOLDING

Constructivist principles and Knowles’ adult learning theory and highlighted the role of prior knowledge/experience in learning. ²⁸ , ²⁹ , ³⁰ The process of pushing learners to their zone of proximal development by building upon existing knowledge/experience is called scaffolding. ³¹ , ³² Scientific content should be presented in ways that connect old ideas to new ones. ²⁸ But first, we must perform a “learner analysis” of our patients regarding their background and prior experiences, along with their concerns and reservations. This establishes a safe learning environment, builds rapport, facilitates scaffolding, and promotes learner‐centered goals. The next step is aligning explanations with their level of education and goals. If successful, patients may be better equipped to take charge of their information‐seeking behaviors. ²⁸

PRIORITIZE FRAMING

Constructivism suggests that individuals construct their own reality. ²⁹ We all engage in biased information processing, informed by our cultures, norms, and values. People favor information congruent with their beliefs over contradictory evidence when forming attitudes. ³³ , ³⁴ When individuals seek affirmation as opposed to information, they are practicing goal‐directed information processing to protect pre‐existing ideologies, values, and beliefs. ³⁵ As a result, the same scientific information may be interpreted differently than intended, depending on the audience.

Optimal framing can maximize congruence between what we hope patients will come to understand and how our message is received. Framing focuses on the presentation of information, how it can influence human perception, and whether the message resonates, as opposed to content alone. ³³ , ³⁶ Framing effects are more pronounced when information is controversial, ambiguous, or rapidly evolving. Terminology or imagery used to frame scientific messaging, such as infographics, can be a powerful ally. ³⁷ , ³⁸ Framing is less about persuasion and more a matter of presenting information in an accessible manner to nonexperts. ³³ By effectively framing an issue, we can encourage patients to question their assumptions and look at the situation from multiple perspectives. ³⁹

MAKE IT SOCIALLY ACCEPTABLE

Social pressures exert enormous influence on individuals’ interpretation of scientific information. Sociocultural theorists like Vygotsky stressed that learning cannot exist without social interaction. ³¹ Situated learning perceives learning as context bound and occurring during social activities. ⁴⁰

Conversely, social factors may also hinder accurate observation of the world. Fake news does not spread in a vacuum. Misperceptions emerge as part of social networks. The very features that define social media (e.g., the ability to choose our own network in which to receive and disseminate information) are also responsible for spread of mis/disinformation. Given the strength of people's convictions within homogenous groups, social media bubbles are ripe targets for mis/disinformation by normalizing fake news and selectively excluding contradictory evidence. ³⁵ Longing for a sense of belonging, fear of being left out, and need to develop/improve social connections are negatively correlated with health, media, and news literacy. ¹⁸ We should encourage more heterogeneity in people's social networks, both in person and online, and allow group‐based cues to facilitate exposure to more diverse and reliable content. ³⁵ Specifically, physicians can make it more socially acceptable to follow evidence‐based recommendations by leveraging patients’ trusted friends, family, and local community leaders and encourage open discussions that challenge misconceptions.

FOCUS ON SALIENT, TAKE‐AWAY POINTS

Effective educators are deliberate in preventing information overload. According to cognitive load theory, working memory load is influenced by inherent task complexity/difficulty (intrinsic load) and by the way information is presented (extraneous load). ³⁶ The intrinsic load of learning complex medical concepts can be overwhelming. Therefore, efforts must be made to reduce the amount of content and focus on salient take‐away points. We must also reduce extraneous loads by avoiding unnecessary complexity. Physicians should initiate discussions around simple concepts to establish the educational alliance, then scaffold up to debunk more complex notions to manage intrinsic load. ³⁶ We can also apply split attention and redundancy principles by replacing multiple sources of information (e.g., primary research literature) with one integrated resource (e.g., Centers for Disease Control and Prevention guidelines). ³⁶

CONCLUSION

In the age of social media, patients have an overwhelming amount of health information at their fingertips, not all of which are valid. Although the pandemic is not over, the lessons thus far are clear. Fake news presents a clear and present threat to public health and is here to stay. Physicians must shift from a teacher‐centered fixation on “messaging” to a more learner‐centered focus on how the message is received. Existing educational frameworks can be leveraged to guide physicians in discussions with patients surrounding medical issues muddled by false information. Akin to enabling effective feedback, physicians must create a safe learning environment, promote internal motivation, and facilitate scaffolding. Physicians can make it more socially acceptable to follow evidence‐based recommendations. Lastly, keeping our discussions centered around salient take‐away points will make the message more digestible. With our practical recommendations in mind, we hope that physicians will be empowered to actively engage patients with misconceptions to combat mis/disinformation in a more effective manner.

Supporting information

Table S1

Sheng, AY, Gottlieb, M, Welsh, L. Leveraging learner‐centered educational frameworks to combat health mis/disinformation. AEM Educ Train. 2021;5:e10711. doi: 10.1002/aet2.10711