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Speaker 1: These days, if you have a question about a medical issue,
Speaker 1: the internet is likely your first stop. After all, the
Speaker 1: next opening at your doctor's clinic is months away, and
Speaker 1: even if you managed to snag an earlier appointment, would
Speaker 1: you have enough time to ask all your questions and
Speaker 1: get them all answered? Probably not. Why wait when you
Speaker 1: can research at your leisure, scrolling through tiktoks, asking AI,
Speaker 1: or listening to a podcast where the overconfident hosts swear
Speaker 1: by peptide injections and smart rings, using medical language to
Speaker 1: disguise what they're really doing, which is inventing a problem
Speaker 1: and selling you the solution. Increasingly, people are turning towards
Speaker 1: the Internet to seek solutions for many of their health
Speaker 1: care and wellness needs. But even if you aren't actively
Speaker 1: searching for this type of content, it finds you anyway.
Speaker 1: The proliferation of wellness influencers and the commodification of health
Speaker 1: anxiety has had profound impacts on our relationship with medicine, expertise,
Speaker 1: and truth. In today's episode, I'm joined by doctor Deborah Cohen,
Speaker 1: medically trained, award winning journalist, broadcaster, and editor, to discuss
Speaker 1: these issues, which she explores in her recent book Bad Influence,
Speaker 1: How the Internet Hijacked Our Health. Extensively researched and compellingly written,
Speaker 1: Bad Influence uncovers the insidious manipulation by those seeking to
Speaker 1: make a profit and the way they prey on vulnerable
Speaker 1: individuals simply looking for help. As doctor Cohen demonstrates, the
Speaker 1: Internet is a double edged sword, rife with this type
Speaker 1: of exploitation, but also a source of empowerment and community.
Speaker 1: Navigating this virtual landscape has never been more challenging, with
Speaker 1: marketing masquerading as medicine and an endless supply of snake
Speaker 1: oil salesmen in their newest iteration, as podcast brows and
Speaker 1: one simple trick clickbaiters. Doctor Cohen pulls back the curtain
Speaker 1: on the underbelly of the wellness industry, and in so
Speaker 1: doing makes an urgent call for regulation to protect consumers
Speaker 1: until that happens, if it ever happens. She leaves readers
Speaker 1: with a crucial piece of advice, Ask yourself, why you're
Speaker 1: seeing what you're seeing in your feed, who's telling you
Speaker 1: this stuff? And why. Bad Influence is a timely and
Speaker 1: necessary guide to the wild West of Internet wellness and
Speaker 1: the nefarious health influencers spreading lives for profit. I'm very
Speaker 1: excited to bring this conversation to you all, so let's
Speaker 1: just take a quick break and get started. Doctor Cohen,
Speaker 1: thank you so much for joining me today.
Speaker 2: Thank you for having me, and thank you for being
Speaker 2: interested in the book.
Speaker 1: Oh of course. I mean I was so excited to
Speaker 1: come across your book and to read it because it
Speaker 1: explores so many of the things that I feel like
Speaker 1: on this podcast we're constantly confronting. It's this kind of
Speaker 1: one two punch between these active disinformation spreaders along with
Speaker 1: worsening access to medical professionals, and it's created this perfect
Speaker 1: storm of just where do you get good information and
Speaker 1: how do you recognize the good and the bad. Was
Speaker 1: there a moment in the construction of this book and
Speaker 1: the production of this book where you said, Okay, this
Speaker 1: needs to be a story that I want to tell.
Speaker 2: It was quite early on the reason I read it.
Speaker 2: There was a few things happening at the same time.
Speaker 2: So one of my cousin I'm from Liverpool in England,
Speaker 2: and I was at my auntie's birthday and one of
Speaker 2: my cousin's friends said to me she just bought an
Speaker 2: AMAH test and I was like, well have you done that?
Speaker 2: And she said, I want to know how fertile I am.
Speaker 2: I said, is it really going to is it really
Speaker 2: going to tell you that? And people in Liverpool if
Speaker 2: your audience don't know, we're very direct. There's no smooth talking.
Speaker 2: It's all very direct. So why have you done that?
Speaker 2: And I said, well, what are you going to do
Speaker 2: with the results? Say? If they're though, what you're going
Speaker 2: to do? And she went, well, I going to go
Speaker 2: and see my GP or primary care physician. And I said, well,
Speaker 2: what are you going to do if the normal And
Speaker 2: she looked at me and she said, I'm going to
Speaker 2: go and see my primary care physician. And I said,
Speaker 2: who isn't going to be able to use the results
Speaker 2: because it isn't telling you anything about your fertility. You've
Speaker 2: just wasted one hundred and sixty pounds, so two hundred
Speaker 2: dollars and that that was sort of the start. And
Speaker 2: I said, where did you get the information from? And
Speaker 2: she said our insta As if I was stupid, you know,
Speaker 2: why wouldn't you going to insta your health information book?
Speaker 2: Doctors couldn't give her the information she needed because she
Speaker 2: couldn't conceive. She was struggling to conceive. There was no
Speaker 2: real medical reason for it, and it was an obvious
Speaker 2: place to go. And there it was all sorts of
Speaker 2: clinics were offering that as a solution. The egg time
Speaker 2: of test and then other friends I noticed who the
Speaker 2: university educated smart and again going online for information about
Speaker 2: hormone replacement therapy or menopause hormone therapy, whichever turned me
Speaker 2: on to use testosterone, you know, full body screening ADHD information.
Speaker 2: And there are problems with the access to healthcare whichever
Speaker 2: part of the world you're in, and it differs according
Speaker 2: to what part of the world you're in. We've got
Speaker 2: a national health service in the UK and there's massive
Speaker 2: waiting lists. But equally a lot of the book, I
Speaker 2: speak to a lot of us BACE physicians and patients
Speaker 2: and influencers and different challenges, but even still challenges getting
Speaker 2: access to healthcare and traditional healthcare services can't provide an answer,
Speaker 2: there's always someone online who will. And there was a
Speaker 2: noticing an increasing growth of that, and then people were
Speaker 2: sort of having to In my day job as a journalist,
Speaker 2: I'll sort of go, well, why are you coming to
Speaker 2: me with that information? What's your agendas? Why are you
Speaker 2: telling me that I look for the benefits, I'm looking
Speaker 2: for the harms. I'm looking for the evidence. And they
Speaker 2: were having to be almost their own mini journalists online,
Speaker 2: but without the background that I had, or that training
Speaker 2: that I had to critically appraise information. And perhaps that's
Speaker 2: some of that automatic skepticism. If I get a press release,
Speaker 2: I'm thinking, yeah, why do you want me to that story?
Speaker 2: So as a journalist, I'm naturally skeptical, and that's what
Speaker 2: we're supposed to be. But people were being bombarded with
Speaker 2: stuff and didn't really know what to make of it.
Speaker 1: I want to dive into the influence In your title,
Speaker 1: who is doing the influencing, the bad influencing, Where are
Speaker 1: they influencing, and who is being influenced? Can you sketch
Speaker 1: out the major areas where this is happening.
Speaker 2: So I think we've talked about for many years on
Speaker 2: medical journals, or in academia, or in healthcare. Generally, there's
Speaker 2: always been commercial actors that influence our health. We know
Speaker 2: the tobacco industry sat on the arms of smoking for
Speaker 2: decades even though they knew it was causing lung cancer.
Speaker 2: We know the drug industry ask certain questions to get
Speaker 2: certain answers. You know you can be clever in how
Speaker 2: you do your randomized control trials. We know the alcohol industry,
Speaker 2: big food, fossil fuel companies. They influence healthcare. They lobby politicians,
Speaker 2: they lobby decision makers to create policies that are favorable
Speaker 2: in their interests. And we know that they influence the
Speaker 2: evidence space. And what was really interesting to me was
Speaker 2: We've got this whole new set of commercial players now.
Speaker 2: So I was less interested in the classic conspiracy theorists.
Speaker 2: I was much more interested in these industries that perhaps
Speaker 2: are shaping scientific industry. Should I say that are shaping
Speaker 2: our healthcare. So the obvious one is big tech, and
Speaker 2: they host the platforms, they operate the algorithms that influence
Speaker 2: what we see. They decide what's going to be first
Speaker 2: in our feed. If it's an advert, you are an
Speaker 2: obvious advert from a company, you're going to drop further
Speaker 2: down the feed. But they will surface the influencers that
Speaker 2: have financial relationships with other companies. So that's the obvious one.
Speaker 2: So in my mind, I think of it as big
Speaker 2: tech meets all these little other industries, all these other
Speaker 2: little companies if you like influencers, online pharmacies, telehealth a
Speaker 2: big one, your wearables, your apps. It's unfettered advertising, and
Speaker 2: so you've got all these different commercial incentives that are
Speaker 2: at play that are being surfaced by the big tech companies,
Speaker 2: whether that's Meta or TikTok or dance vital or Google YouTube,
Speaker 2: and they're controlling in many ways what we see in
Speaker 2: our feed. And I was interested to think about, well,
Speaker 2: how are these actors shaping our health And I think
Speaker 2: there's a big open questions still because there's an absence
Speaker 2: of evidence as so I didn't want to be too
Speaker 2: certain because what I didn't want to do is deep
Speaker 2: and bad science by doing bad science myself. You say,
Speaker 2: that's overstated claimer, and I've made over stated claims. But
Speaker 2: there's clear that there's something going on. And we know
Speaker 2: health and our understanding of medicine is shaped by culture,
Speaker 2: is shaped by society, and is massively shaped by commercial interests.
Speaker 2: So they were the questions really for me, and in
Speaker 2: what direction are we going? And there's some interesting anecdotes
Speaker 2: from US physicians. Actually. On one obgyn University said to me,
Speaker 2: and she deals with contraception, and she said to me,
Speaker 2: I know when my young patients come to see me,
Speaker 2: they spent four hours a day on TikTok getting their information.
Speaker 2: I've got like twenty minutes with them. And men's health
Speaker 2: specialists that are half a deffiliated hospital. He said to me,
Speaker 2: he feels he's tilting at windmills where he's got all
Speaker 2: these men's health providers that are offering testosterone at a
Speaker 2: drop of a hat, and he wants to counsel patients
Speaker 2: properly about health interventions that might actually change change their
Speaker 2: health and actually help their testosterone levels losing weight, but
Speaker 2: it's like they want to quick fix. So that was
Speaker 2: a very long winded way of saying, there's all these
Speaker 2: different actors that are on our platforms that are trying
Speaker 2: to grab our health, that are trying to shape our health,
Speaker 2: and influencers as well. With certain symptoms, they will change
Speaker 2: their symptom profile according to what's going viral. So if
Speaker 2: you take the example of ADHD and you are changing
Speaker 2: what your symptoms are because you know it's resonating with
Speaker 2: an audience, what's that going to do to our understanding
Speaker 2: of ADHD if you look at it through a social
Speaker 2: media prism.
Speaker 1: Let's take a quick break and when we get back,
Speaker 1: there's still so much to discuss. Welcome back everyone. I've
Speaker 1: been chatting with doctor Deborah Cohen about her book Bad Influence,
Speaker 1: how the Internet hijacked our health. Let's get back into things.
Speaker 1: It's so interesting what you mentioned about somebody spending four
Speaker 1: hours a day on social media and TikTok scrolling, and
Speaker 1: that's where they're getting the vast majority of their information
Speaker 1: versus this twenty minute time with their doctor. And there's
Speaker 1: also what they're seeing and you dive into this when
Speaker 1: you discuss the nocebo effect.
Speaker 2: Yeah, it's fascinating. I don't think we talk enough about
Speaker 2: mind body medicine in healthcare. I think we can often
Speaker 2: follow the biomedical model too much, and some of the
Speaker 2: more Eastern philosophies perhaps use the mind body model more.
Speaker 2: But we know that our expectations shape so many different things,
Speaker 2: and symptoms are included. How we experience stuff comes from
Speaker 2: all comes from our head, and it's not to say
Speaker 2: it's all in the mind. Symptoms are very real physical manifestations.
Speaker 2: But if we have anxiety, say for example, we were
Speaker 2: more likely to experience pain. We know how we experience
Speaker 2: stuff of us are going to shape how we experience symptoms,
Speaker 2: and that is for good and for bad. So placebo
Speaker 2: is if you believe something is going to help you,
Speaker 2: then that may help your symptoms. So placebo effect is
Speaker 2: an incredibly powerful effect. Testosterone, which we know is being
Speaker 2: promoted heavily to men and to women perimenopausal and menopausal women,
Speaker 2: we know testosterone has quite a strong placebo effect. So
Speaker 2: if you feel tired or low energy, you have some testosterone,
Speaker 2: suddenly feel better quite a lot. That is placebo, and
Speaker 2: that's a very powerful effect. Equally, there's something called the
Speaker 2: Mecibo effect, and that is the evil twin. If you
Speaker 2: like of placebo. It literally means I will harm, So
Speaker 2: you will know if you see someone throwing up feel
Speaker 2: sick yourself. It does not mean that you have that
Speaker 2: viral infection or bacterial infection, but that very graphic visual
Speaker 2: invict of someone being sick. It can make you feel nausea,
Speaker 2: and that is your mind. Those symptoms of nausea are real,
Speaker 2: but that is your mind mimicking if you like what
Speaker 2: you're seeing, if you think about little bugs crawling up
Speaker 2: your neck, you can feel a little bit twitchy. You know,
Speaker 2: you can literally feel it. And what we know is
Speaker 2: visually seeing something is more powerful than reading about an effect.
Speaker 2: And when you read the side effects of a drug,
Speaker 2: it increases your chances of having those side effects. Or
Speaker 2: we're talking things like headache and nausea and fatigue and
Speaker 2: those those kinds of symptoms. And that is something that
Speaker 2: researchers are starting to look at, which I think is
Speaker 2: fascinating about how social media shapes how we think about
Speaker 2: our symptoms or how we feel about our symptoms. And
Speaker 2: this is where I think some illness forums are a
Speaker 2: double edged sword where they can provide people with support
Speaker 2: and feeling heard and seen and a sense of camaraderie
Speaker 2: cut through loneliness. Equally, if people are constantly talking about
Speaker 2: their symptoms, what does that do to your expectations of
Speaker 2: whether you're going to have those particular symptoms connected with
Speaker 2: a certain condition. And we're sort of in the foothills
Speaker 2: of really exploring that and the contribution of social media
Speaker 2: to that no Sebo effect. The last thing you should
Speaker 2: do if people are having very real symptoms from an
Speaker 2: Acibo effect is dismiss their experience because those symptoms are real.
Speaker 2: Just the causation of it might not be physical, or
Speaker 2: it might not be pathological, there might be another reason
Speaker 2: for it, and they're very powerful. Our expectations are very
Speaker 2: powerful shapers how we experience our illnesses.
Speaker 1: You mentioned social media being this double edged sword where
Speaker 1: you have these supportive communities that can be formed and
Speaker 1: someone can finally no longer feel alone in their experiences,
Speaker 1: and so it's on the one hand very empowering, but
Speaker 1: on the other hand, it can lead to these formation
Speaker 1: of echo chambers potentially or leave people vulnerable to exploitation.
Speaker 1: Can you share more about what this means in terms
Speaker 1: of social media and the commodification of stress and anxiety, fear.
Speaker 2: Cells We know that from newspapers you know you, or
Speaker 2: headlines sensationous headlines, fear cells and stress and anxiety equally sells.
Speaker 2: Tell somebody that there might be something lurking beneath them
Speaker 2: and create that fear, but then you sell the solution. So,
Speaker 2: for example, full body MRI is I have a chapter
Speaker 2: on that, and influencers have really jumped on that because
Speaker 2: it sort of makes sense there might be something inside you.
Speaker 2: You might feel perfectly fine, symptom free, but there might
Speaker 2: be something inside you that is lurking. We have the
Speaker 2: machine that will spot that. When you give somebody a
Speaker 2: medical test when they are otherwise healthy, that is called
Speaker 2: a screening test, and there are all sorts of problems
Speaker 2: with that. There are very few screening tests that a
Speaker 2: recommend it at a population level, even by the American
Speaker 2: authorities that prevented His Services Task Force, say, for example,
Speaker 2: or even the American College of Radiology. Likewise, in the UK,
Speaker 2: we have very similar bodies and their guidelines between them
Speaker 2: are very very similar as it happens, but there are
Speaker 2: very few because of the risk of what we call
Speaker 2: false positives, and if you see something on a scan
Speaker 2: you sort of have to follow it up, you want
Speaker 2: to follow it up, and that can then lead to
Speaker 2: a cascade of care of further investigations that might expose
Speaker 2: you to all sorts of different harms or risks, plus
Speaker 2: financial But that idea of there might be something within
Speaker 2: and Andrew Houberman is guilty of doing this. Him and
Speaker 2: Peter are here guilty of quite a few of these,
Speaker 2: and a lot of the podcasters are. And you know,
Speaker 2: he talks about you might be walking around with all
Speaker 2: these spots on your brain. Don't you want to see it? Well?
Speaker 2: Do you? Do? You?
Speaker 1: And I it was also, I think was that the
Speaker 1: chapter where somebody you know went and purchased this full
Speaker 1: body MRI and then in order to like unlock the results,
Speaker 1: you had to pay again even further. And it's just
Speaker 1: sort of like this endless, just parasitic sucking people dry
Speaker 1: of money, more and more and more money grabs that
Speaker 1: just prey on this anxiety. Once you hook someone, then
Speaker 1: you've got them.
Speaker 2: You've got them.
Speaker 1: You mentioned earlier the algorithm and social media. This this
Speaker 1: really struck me to social media has become so individualized,
Speaker 1: or it is so individualized rather than social. You know,
Speaker 1: what I see on my feet is going to be
Speaker 1: profoundly different from what you see on your feed is
Speaker 1: going to be different than what you know, just like
Speaker 1: every single person's feed has been directed by these tiny
Speaker 1: decisions how long you look at a video, whether you
Speaker 1: like or you share something. It's on my mind all
Speaker 1: the time now where I'm like, if I just set
Speaker 1: my phone down with it's still open, does it think
Speaker 1: that I want to look at that video the whole time?
Speaker 1: But as you write this, this engagement, this algorithm, it
Speaker 1: can normalize misinformation, this illusion of truth bias. What is
Speaker 1: this bias? And how does the rewarding of certain engagement
Speaker 1: what sort of content is it promoting?
Speaker 2: So a little of truth biases. The more you see something,
Speaker 2: the more true it feels. Now, not everybody is susceptible
Speaker 2: to all sorts of all biases. And again, what's still
Speaker 2: trying to understand how this information affects behavior? And as
Speaker 2: you said, then it's very hard to study from an
Speaker 2: academic perspective because everybody's fee are different and you need
Speaker 2: to follow it up longitudeinly, and you don't always know
Speaker 2: what is that little bit of information that you have
Speaker 2: that tips over a certain behavior change. Because we're bombarded
Speaker 2: with information all the time, but people are spending on
Speaker 2: a lot of time on their phones. And the thing
Speaker 2: with the phone and social media is it's so personal.
Speaker 2: It's in your pocket, it's in your phone. It's the
Speaker 2: place where you might speak to your grandmother on FaceTime,
Speaker 2: or your or your family, or you connect with people,
Speaker 2: and you've got these influences in your phone. You're looking
Speaker 2: at them bills like eye to eye. But then one
Speaker 2: of the issues is it's the more sensationless stuff that
Speaker 2: gets surfaced. It's the stuff that grabs attention. I think
Speaker 2: of the book in the sense this is what happens
Speaker 2: when you put health on platforms that are geared for
Speaker 2: entertainment and for commerce. It's not the dry statistics or
Speaker 2: evidence based information that's going to be surfaced in your feet.
Speaker 2: It is the grabby the sensation list the stories, and
Speaker 2: we are we're geared to listen to stories. We're humans,
Speaker 2: and it's all those that will surface in your feed.
Speaker 2: And there's one anecdote that I have in there. It's
Speaker 2: from some Harvard academics who talk about a young girl
Speaker 2: who was terrified that young people her age were getting
Speaker 2: stage four cancer because she'd lingered on the video. Her
Speaker 2: feed filled with more and more videos of young people
Speaker 2: with stage full cancer. Even though it was incredibly rare
Speaker 2: for people her age, she felt that everybody was being
Speaker 2: diagnosed with stage full cancer.
Speaker 1: Let's take a quick break here, We'll be back before
Speaker 1: you know it. Welcome back, everyone, I'm here chatting with
Speaker 1: the wonderful doctor Deborah Cohen about her book Bad Influence.
Speaker 1: Let's get into some more questions. These algorithms reward these
Speaker 1: extreme stories, these personal anecdotes, these things that are shocking
Speaker 1: or more shareable. But the two things that the algorithm
Speaker 1: does not reward are nuance and uncertainty, both of which
Speaker 1: are foundational to science and medicine. How does this play
Speaker 1: out in the media representation of scientific research and is
Speaker 1: there anything that we can do to make uncertainty a nuance,
Speaker 1: more clickable, more and more engaging.
Speaker 2: It's a really good question, and I si slightly I'd
Speaker 2: love to know the answer to that. In many ways,
Speaker 2: I think there's I think we have to get better
Speaker 2: at communicating, and there are people online that do it
Speaker 2: very very well. For me, one of the risks if
Speaker 2: people are too robust with pointing out this information and individuals.
Speaker 2: Obviously there are bad actors. I worry that that drives
Speaker 2: people away. So one example, young women side effects of
Speaker 2: them or hormonal contraceptive pill believe they are having particular
Speaker 2: side effects from the pill, like weight gain that isn't
Speaker 2: necessarily backed by randomized control trial evidence. It might be
Speaker 2: because the time they're going on the pill, they're going out.
Speaker 2: You know, they've got new partner, they might be going
Speaker 2: off for dinners more, they might have just gone to college.
Speaker 2: It might be all sorts of reasons why they're gaining
Speaker 2: weights at that particular time. But they're people as well
Speaker 2: that they are turning to social media because they feel
Speaker 2: that the health profession doesn't listen to them. But by
Speaker 2: pointing out and saying you're spreading misinformation doesn't make them think, oh,
Speaker 2: I'm going to come back to the health system if
Speaker 2: they're already feeling alienated. So I think we have to
Speaker 2: do that carefully. There are some very good physicians online,
Speaker 2: but then there are some that are nefarious as well.
Speaker 2: As you're engaging in nefarious activity selling products, selling dumpty
Speaker 2: services and everything else, it's it's a real minefield for people.
Speaker 2: My view is someone that trained to be adoptor is
Speaker 2: that health profession needs together, get their act together as well,
Speaker 2: get their own house in order. But I do think
Speaker 2: we need better health literacy and coming from the UK,
Speaker 2: what's really interesting for me is how we are adopting
Speaker 2: US style health system by the back door, because our
Speaker 2: national health service is really struggling. We've got this massive
Speaker 2: rise of private clinics of consumer health that is only
Speaker 2: really in the last sort of five years that is
Speaker 2: really taking hold, where people have private general practitioners or
Speaker 2: private primary physicians on the part of the hand, that's
Speaker 2: all relatively new. So we're we in Europe and the
Speaker 2: rest of Europe as well, because what we've got from
Speaker 2: the US is director consumer advertising and prescription drugs that
Speaker 2: is banned across Europe, but it's bordered US. A story
Speaker 2: I'm doing for the BMJ at the moment, actually it
Speaker 2: should come out the next couple of weeks is how
Speaker 2: we've adopted director consumer advertising. What's the impact of that
Speaker 2: because the systems are bordered US and we're not used
Speaker 2: to navigating it in the UK and Europe, so it's
Speaker 2: all a bit of a it's sort of a bit
Speaker 2: of a shock to the system.
Speaker 1: Social media in influencers can of course be very predatory nefarious.
Speaker 1: We have these bad actors, but science and medicine also
Speaker 1: of course have roles to play. There's this long history
Speaker 1: of medicine being dismissive or paternalistic towards patients. There are
Speaker 1: these horrifically unethical scientific or medical experiments, and there's kind
Speaker 1: of a general gatekeeping of like, how dare you question
Speaker 1: me or trust me, I'm the expert here attitude, And
Speaker 1: it seems like these are also contributing to people seeking
Speaker 1: answers elsewhere. Can you tell me more about that?
Speaker 2: Yeah? And I think certainly. Again, and this comes up
Speaker 2: a lot in women's health, where women's health has been
Speaker 2: largely underfunded. I think it was nineteen ninety three that
Speaker 2: the NIH sort of said that women could be part
Speaker 2: of clinical trials that they founded in nineteen ninety three.
Speaker 2: That's what Interactic Park came out. You know, we had
Speaker 2: all this great sub computerized films. Only then where we
Speaker 2: go in clinical trance and so there's been there's a
Speaker 2: sense of not feeling seen, not feeling heard, and it
Speaker 2: becomes really again, it becomes a double edged soul because
Speaker 2: the doctors that i've spoken to, and you know I
Speaker 2: speak to a lot day to day. Is they're battling
Speaker 2: with information that comes up in people's feed when they
Speaker 2: come into the consultation, and then they're left with even
Speaker 2: less time to deal with the kind of the issues
Speaker 2: at hand. And what I'm really interested in going forward,
Speaker 2: and this is what I'm hoping to actually formally study,
Speaker 2: is how social media and large language models are shaping
Speaker 2: doctor patient relationships and our relationship with the healthcare, particularly
Speaker 2: when we know the lllms people rate them has been
Speaker 2: more empathic than doctors. It's wasn't saying I think it's
Speaker 2: about the medical profession. I have to say it really is.
Speaker 2: We need to get our own house and order again
Speaker 2: and say that sense of feeling heard, but then that's exploited.
Speaker 2: And that's the challenge again with social media is with influencers.
Speaker 2: I hear you, I see you, Now buy my support,
Speaker 2: you buy my DONT test or come to see me
Speaker 2: my private clinic, and I'll give you that un necessary scam.
Speaker 2: So it's fascinating, really, I mean it does feel quite dystopian.
Speaker 2: But I do wonder going forward, what our expectations will
Speaker 2: be of healthcare and what the role of the doctor
Speaker 2: obviously not just doctors, but you know, health professionals generally
Speaker 2: will be in that sort of dynamic in the new
Speaker 2: information ecosystem. I'm going to put Panned in the jar
Speaker 2: a dollar in the jarst. I hate the term ecosystem,
Speaker 2: but I've just used it. Bit's awful. I feel like
Speaker 2: a chat box saying it a little yeah, dead box.
Speaker 1: And these doctors, these physicians are also on social media,
Speaker 1: and they're also being exposed to They have their own
Speaker 1: algorithm which might or might not be filled with bad influencers, right,
Speaker 1: these various actors, but even still, there are many of
Speaker 1: them that I'm sure are not exposed to the information
Speaker 1: that their patients are exposed to, and so that creates
Speaker 1: more of this gap in saying, okay, well, what is
Speaker 1: the information I know? What is the information that you know?
Speaker 1: And how do we communicate and get on the same
Speaker 1: level in this twenty minute appointment.
Speaker 2: It's really hard. And one conversation I had recently with
Speaker 2: the PETERA Tricia here he says when his patients come
Speaker 2: in the first thing he does is say, come on,
Speaker 2: let's chat about what you've looked at tap GPT today
Speaker 2: or co Pilots or Claude or whatever. Let's have a conversation.
Speaker 2: Let's just get that out on the table so we
Speaker 2: can talk about it. And one ADHD physician in the
Speaker 2: UK she uses what her patients see about ADHD on
Speaker 2: social media as a way to talk to them. So,
Speaker 2: how do you feel about seeing that? What have you
Speaker 2: seen on social media today? How shall we talk about that?
Speaker 2: So get them to open up, because it's almost got
Speaker 2: to be part of the conversation. And in one paper
Speaker 2: that I read, and it was in one of the
Speaker 2: pediatric journals, a sort of throwaway line at the end
Speaker 2: was doctors now and they just start asking their patients
Speaker 2: about what they're seeing on social media, And it was
Speaker 2: sort of a throwaway line, and I thought, Wow.
Speaker 1: You mentioned the commercial and digital determinants of health, which
Speaker 1: I feel like that's going to be a big thing
Speaker 1: moving forward. How would we even begin to measure or
Speaker 1: incorporate that into understanding people's health and how it is
Speaker 1: influenced by their social media experiences.
Speaker 2: It's really going to be a really hard area to study.
Speaker 2: First of all, there's no transparency from the tech company
Speaker 2: so getting data and I know there are ways of
Speaker 2: potentially sharing data. But as it stands as an example
Speaker 2: in the book, one academic I spoke to said, if
Speaker 2: he wants to do study, let's say on TikTok, they
Speaker 2: will want to see the protocol. They will want to
Speaker 2: see everything before they release any data, and then on
Speaker 2: top of that, they will want to see the final
Speaker 2: publication before it goes anywhere. Now we've learned over years,
Speaker 2: let's say with the drug industry, that if they subsidize
Speaker 2: research or fund research, then you have to have sort
Speaker 2: of walls in place and protocols in place so that
Speaker 2: research isn't there for influence before it goes to publication.
Speaker 2: There has to be an element of that. And I
Speaker 2: feel that again we're very much there's a bit of
Speaker 2: tech exceptionalism at times that we can race ahead and
Speaker 2: do things. And again, if you think about what science is,
Speaker 2: we have the null hypothesis. We assume something doesn't work
Speaker 2: unless shown otherwise. Tech feels to me like, let's just
Speaker 2: get it out. We'll assume it works until it doesn't.
Speaker 2: It flips scientific thinking on its head. But we sort
Speaker 2: of have just come to accept that is what happens.
Speaker 2: But is that good science? I would can to probably.
Speaker 1: Not We've touched on a few times ADHD throughout this
Speaker 1: conversation so far, and this is a condition that has
Speaker 1: received a lot of attention on social media and that's
Speaker 1: been very positive for some people who have found community
Speaker 1: and a greater understanding of their own experiences. People who
Speaker 1: are getting diagnosed or going to their physician and saying
Speaker 1: is this is this what I've been experiencing? How can
Speaker 1: I manage this? But it is more complicated than that.
Speaker 1: Of course, their diagnoses are increasing, but there might does
Speaker 1: that also mean that it might be overdiagnosed in situations
Speaker 1: like how do we know where to draw the line
Speaker 1: between help and harm in this context?
Speaker 2: It's really difficult, And I think you can have two
Speaker 2: things together at the same time. So you can have
Speaker 2: people being missed, so you can have them to diagnosis.
Speaker 2: And we know they're largely in certain ethnic groups, so
Speaker 2: African Americans, Spanic people. There's a massive social gradient there
Speaker 2: as well, and that's mirrored in the UK. So if
Speaker 2: people have lower socioeconomic groups are less likely to get
Speaker 2: the diagnosis that they need to access treatment and help. Meanwhile,
Speaker 2: you have people that perhaps have more access health care
Speaker 2: well wealth that are getting diagnoses that may not be robust,
Speaker 2: so there we might have misdiagnosis. But also we've got
Speaker 2: this idea of perhaps over diagnosis. So the expanding definition
Speaker 2: of what cancers ADHD, and that is always subject to
Speaker 2: debate in healthcare. And I don't come down either way,
Speaker 2: but what I do think is that, and I hear
Speaker 2: it amongst my friendship groups that people's way of describing
Speaker 2: their ADHD has taken on a social media element. People
Speaker 2: talk about rejection sensitivity dysphoria like it is a certain symptom,
Speaker 2: a well described symptom of ADHD. As it stands, experts
Speaker 2: are still debating it. Is it part of ADHD or
Speaker 2: isn't it? We don't know because there isn't the evidence there.
Speaker 2: But that has come down into clinical notes, and that's
Speaker 2: sort of been born out of conversations on social media.
Speaker 2: Other medical or psychological terms have been co opted by influence.
Speaker 2: They object permanence, which is a Jean Pierge stage of
Speaker 2: development where a child realizes that if a parent isn't
Speaker 2: in the room or something isn't the room, they still
Speaker 2: exist just because they can't see it, that person still exists,
Speaker 2: And that's been co opted by influences to me, I
Speaker 2: don't miss things, and those terms go viral and again
Speaker 2: people talk about it like it is a definite part
Speaker 2: of ADHD and so and I hear that in conversations
Speaker 2: just day to day. I've got rejection sensitivity, dysform it,
Speaker 2: or I've got object in permanence because I don't miss people.
Speaker 2: And if you think about how we do field studies
Speaker 2: or we validate our questionnaires when it comes to ADHD diagnoses,
Speaker 2: if people are kept saying, well, this isn't how I
Speaker 2: see ADHD. We haven't got all these different conditions that
Speaker 2: I'm seeing. What does that then do further down the
Speaker 2: line to how we see ADHD? And I don't know.
Speaker 2: It's an open question.
Speaker 1: Yeah, how does social media shape diagnoses in a medical context?
Speaker 1: I mean it's not a one way relationship. This is
Speaker 1: all kind of intersecting and feeding into each other.
Speaker 2: Absolutely, And health is defined socially and culturally. There's a
Speaker 2: lot of healthcare that is defined. And I think what
Speaker 2: often surprises people, even diagnoses changed what the threshold, the
Speaker 2: cutoff threshold is. Sometimes it's so many standard deviations away
Speaker 2: from the mean is what you consider abnormal. That's often
Speaker 2: a surprise to people. It is not fixed in stone
Speaker 2: and over the years we've seen the idea of pre
Speaker 2: diabetes come about as we move the goalposts of what
Speaker 2: needs who needs treatment. Healthcare is constantly iterating, and it's
Speaker 2: not all pure hard science. It's real where arts and
Speaker 2: culture and society meets hard science. It's that strange interface.
Speaker 1: And health optimization, I feel like, is a key part
Speaker 1: of this too. It's doing whatever you are told is
Speaker 1: the best thing to do to optimize your health. And
Speaker 1: there's a huge market for this. I got sucked into
Speaker 1: it with a smart watch, and then I realized that
Speaker 1: I hated it. It made me miserable, so I stopped
Speaker 1: using it. Can you discuss the optimization trap, which is
Speaker 1: what you call it in your book, and how this
Speaker 1: market both over promises and underdelivers.
Speaker 2: So if you think about it, it's obvious if you
Speaker 2: if you've got a market, if you're a company, where's
Speaker 2: the bigger market a sick person or a well person.
Speaker 2: So if you take if you take continuous glucose monitors,
Speaker 2: and there's been a big trend for them. They were designed.
Speaker 2: So advert is one of the big companies that makes
Speaker 2: it a US company that makes them. They were designed
Speaker 2: principally to help people type one and type two diabetes
Speaker 2: who use insulin to monitor their blood sugar levels, so
Speaker 2: they could adapt their insulin to get optimal dosing, because
Speaker 2: we know in the short term, if you've got the
Speaker 2: right level of insulin, you're less likely to have hypos
Speaker 2: and hyperglycemic attacks, and in the longer term it reduces
Speaker 2: the risk of long term health complications. But there was
Speaker 2: a pivot. That's only a small market. There's a much
Speaker 2: bigger market in well people and if you can encourage
Speaker 2: them that they need to constantly monitor their glucose in
Speaker 2: the absence of evidence, and the NIH have done some
Speaker 2: brilliant studies and there's some brilliant clinical trials in this
Speaker 2: Kevin Hall, who is no longer at the NIH, but
Speaker 2: he's in some fascinating trials showing that you get different readings.
Speaker 2: The same device can give different readings, or different devices
Speaker 2: give different readings, and your blood sugar level will change
Speaker 2: according to what else you've eaten, what else you've done
Speaker 2: at the same time, and so they're not really reliable
Speaker 2: because our bodies and healthy people have homeostatic mechanisms, Our
Speaker 2: blood sugar goes out, We release insulin and it comes
Speaker 2: back down again. It goes too low. We release glucagne
Speaker 2: and the blood sugar goes back up again. We're in
Speaker 2: this constant state of homeostasis. We don't know what abnormal
Speaker 2: looks like in a normal person, because you know does
Speaker 2: if you're out of range, your blood sugar goes up
Speaker 2: and people say, oh, I've got a spike. Got spike.
Speaker 2: You're like, yeah, just eaten banana. Of course you've got
Speaker 2: a spike. If it comes back down, that's what you're
Speaker 2: interested in. And guess what it comes back down, and
Speaker 2: then what happens is that then potentially creates more harm.
Speaker 2: So we don't know spikes have any issue in the
Speaker 2: certainly in the short term and certainly not in the
Speaker 2: long term. But then people change the diet accordingly. So right,
Speaker 2: I'm not going to eat banana, but I'm going to
Speaker 2: eat a burger because burger doesn't spike my glucose levels.
Speaker 2: So people then become wedded to this metric. And the
Speaker 2: thing when you look at one metric is you're not
Speaker 2: looking at all the other things that you might be ingesting.
Speaker 2: So if you have a burger, you might be eating
Speaker 2: words of cholesterol or fat or salt and all those
Speaker 2: other things, but you're so sort of wedded to this
Speaker 2: one metric in this case is glucose. You might be
Speaker 2: watching one very well monitored tree and missing the wood
Speaker 2: around it. And that's the problem is if you can
Speaker 2: measure it, you fixate on it. And in some way
Speaker 2: we saw this in the pandemic a little bit without
Speaker 2: getting too sort of controversial, is we really certainly in
Speaker 2: the UK, we focus very much on COVID desk because
Speaker 2: we can measure them. We could see it, but everything
Speaker 2: else around it was far more complicated to measure, you know,
Speaker 2: the impact on education, the impact on psychology and all
Speaker 2: those other things. They're just harder. So it's it's very
Speaker 2: easy to focus on that more metric if you can
Speaker 2: see it and it's easy to measure. And this a
Speaker 2: tendency I think in medicine to think the more parameters
Speaker 2: we measure, the better our health, and that just isn't true.
Speaker 1: There are so many science and medical or wellness influencers
Speaker 1: out there, like the health podcast Grows that you mentioned
Speaker 1: throughout your book, and they come with not only these
Speaker 1: impressive credentials but also these substantial ties to health industries
Speaker 1: or supplement industries or the wellness industry. How can a
Speaker 1: consumer know when to trust a source or can they
Speaker 1: Can educational entertainment be trustworthy or be something that is viable.
Speaker 2: It's really hard balancing at because we know people don't
Speaker 2: want to pay for stuff. People don't want to pay
Speaker 2: for their media content, and it needs to be funded.
Speaker 2: And who's going to have the biggest interest in funding
Speaker 2: a health podcast is the people that are going to
Speaker 2: benefit from it. There's a phrase I heard a lot
Speaker 2: is I only work with the companies that I believe
Speaker 2: in or I use personally. Well, what happens if there's
Speaker 2: evidence that suggests that that company, that product isn't very good,
Speaker 2: but you've become financially dependent on it, do you suddenly
Speaker 2: drop it? So for me, it's a nonsense term. It's
Speaker 2: a nonsense expression. And we have seen certain podcast pros pivot.
Speaker 2: You know, I don't like glucose monitors. Oh look, I've
Speaker 2: just spoken to somebody that works for one and they're
Speaker 2: sponsoring my podcast, and now I recommend them. Oh I
Speaker 2: don't like this Ora ring go Look then I'm going
Speaker 2: to I'm going to stop backing it. And putting it
Speaker 2: on my podcast, and guess what, I'm going to be
Speaker 2: a paid advocate, and I'm going to try and get
Speaker 2: it into medical journals and I'm going to advocate for
Speaker 2: it in academic studies. It's that that was blown open
Speaker 2: in a court case between Aura and Peter Attia is
Speaker 2: his relationship with the company, and it sheds the light
Speaker 2: on these commercial relationships that podcasters have with companies. And
Speaker 2: I think it comes more problematic in many ways when
Speaker 2: it's a medical professional that does it, because it sort
Speaker 2: of gives it more of an endorsement. And there's one
Speaker 2: UK podcaster, doctor angan Chaategy and I took him out
Speaker 2: the book and I'm kicking yourself for taking him out
Speaker 2: the book, but he's sponsored by ag One and our
Speaker 2: regulator Offcom they don't regulate podcasts, but they did highlight
Speaker 2: this as an example is when it's a health professional
Speaker 2: that is working with a company, even if they say
Speaker 2: they declare it, it looks like an endorsement. And in
Speaker 2: many ways, I think health professionals have to have an
Speaker 2: even well, they should do have a higher standard. You know,
Speaker 2: we're a regulated profession you know you've got your state
Speaker 2: licensing boards we have the General Medical Council in the
Speaker 2: UK and it's really difficult balancing how do you get
Speaker 2: the funding and remain independent at the same time. It's tricky.
Speaker 1: Does accurate scientific inform me have a place on social
Speaker 1: media and what does that place look like?
Speaker 2: I think it has to because that's where people are going.
Speaker 2: I think we need to be more skeptical. I think
Speaker 2: we need to be have better health literacy. But even then,
Speaker 2: is somebody going to be able to interpret a systematic
Speaker 2: reviewer a better analysis or around vice control trap. That's
Speaker 2: a difficult task. I think health professionals have to do
Speaker 2: better or have to sort of meet people where they're at,
Speaker 2: and there are some people that do it very well.
Speaker 2: It's not all bad, and I'm obviously doom and glue
Speaker 2: the book titles them and glue for me is but
Speaker 2: let's think critically about where our information is coming from
Speaker 2: and what is shaping our healthcare, and what incentives and
Speaker 2: what are the interest shaping our health care and our
Speaker 2: health information system. And then the next challenge obviously is
Speaker 2: going to be the large language models and how the
Speaker 2: information on them are being shared. And we know companies
Speaker 2: are already trying to make their information prioritized by the lms.
Speaker 2: You know, it used to be search engine optimized. Now
Speaker 2: it's geo engine optimized or some I can't remember the
Speaker 2: exact term, but there is there's a whole cadre of
Speaker 2: people that are working on information to make sure the
Speaker 2: bots pick up on their content. And that is going
Speaker 2: to be the people with the deep pockets that are
Speaker 2: able to shape their content accordingly. And who knows what
Speaker 2: deals going on behind the background. I wouldn't want to say,
Speaker 2: and that would be pure speculation on my behalf. But
Speaker 2: already we know that if you do a Google search,
Speaker 2: it's the sponsored content that comes up to the top
Speaker 2: of your feed, but it's going to be less transparent.
Speaker 1: So that's another question that I had, is that if
Speaker 1: we can make educational content reliable, accessible interesting to people,
Speaker 1: there's still the issue of this flood of misinformation or
Speaker 1: information that is in the gray area or that isn't
Speaker 1: backed by these robust studies and people who have financial eyes.
Speaker 1: How can we incorporate regulations or just health literacy training
Speaker 1: to get people to recognize when what they're seeing is
Speaker 1: being promoted by these bad influencers.
Speaker 2: There just has to be a lot more skepticism. So
Speaker 2: one of the things I would say to people is,
Speaker 2: don't dismiss someone's story, but ask why they're telling you.
Speaker 2: Ask why they're stepping onto a platform in the first
Speaker 2: place to tell you about their condition or to tell
Speaker 2: you about this product or treatment. That's the first thing
Speaker 2: you should ask, why is this person telling me this?
Speaker 2: Why should I believe you? And equally, why should people
Speaker 2: listen to me or believe me? I got asked that
Speaker 2: the other day at the Edinburgh Science Festival. The first
Speaker 2: question I was asked by a pediatric radiologist why should
Speaker 2: I believe you? And I said, well, I sort of
Speaker 2: have to be accountable, but equally you can dismiss me.
Speaker 2: You know, if I'm on the BBC, I'm regulated by offcom,
Speaker 2: you know, regulator. Or if I write something in the BMJ,
Speaker 2: I have responses that, oh, you can literally come down
Speaker 2: on my door and hammer down the door. But there's
Speaker 2: no accountability here, or very little accountability, if any at all.
Speaker 2: And if someone's only telling you the benefits are something,
Speaker 2: why aren't they telling you about the harms? Because because
Speaker 2: every treatment has benefit and every treatment has a heart,
Speaker 2: we don't necessarily know whether you're going to be the
Speaker 2: person that benefits or gets the harm. You know, we're
Speaker 2: medicine again is quite slow moving and that precision. If
Speaker 2: I give you a statin and to prevent a heart attack,
Speaker 2: as a doctor, I cannot tell you whether you will
Speaker 2: be that person that benefits from that statin. It's all
Speaker 2: statistics and that's that's the problem. If someone's over certain,
Speaker 2: then they're you know, they're probably not right. So it's
Speaker 2: just those little cues. You know, if you're thinking about
Speaker 2: a treatment, what's the benefits are doing, what's the risks,
Speaker 2: what the alternatives? And what if I do nothing? They're
Speaker 2: the decisions that go in the stuff and who's behind
Speaker 2: this information really, so it's just being a bit skeptical
Speaker 2: and in terms of provision of information, whether you're the
Speaker 2: Preventative Terms Task Force in the United States or the
Speaker 2: NHS in the United Kingdom, or the Institute of Medicine
Speaker 2: or whoever you are, perhaps you need to think about
Speaker 2: presenting your information in different ways. It's really tricky because
Speaker 2: again you're held to a different standard of accountability if
Speaker 2: you are those institutions, and let's say you mess up rightfully,
Speaker 2: you're going to be held to account, and I think
Speaker 2: it's very difficult for people to I feel in the
Speaker 2: UK that we've got something called the Royal Colleges, so
Speaker 2: they're Royal College of Surgeons or color Physicians or College
Speaker 2: of Obstetrics and Gynecology. I feel that they need to
Speaker 2: do some kind of campaign about, you know, consumerization of
Speaker 2: health and all these tests and treatments that you see.
Speaker 2: Be careful before you buy because it's a pretty unregulated
Speaker 2: market in the UK. I think the United States possibly
Speaker 2: more so than the United Kingdom, but equally we're going
Speaker 2: that way. What should change here? If people are being
Speaker 2: offered egg freezing that it is an indicated or statistics
Speaker 2: that are wrong, where's the regulation going on here? It's
Speaker 2: who's protecting consumers? Really? What we're talking about in I
Speaker 2: think in this particular instance, is who's protecting consumers and
Speaker 2: there isn't a huge amount of consumer protection going on.
Speaker 2: It's the new snake oil, That's what it is. It's
Speaker 2: the new.
Speaker 1: Snakel Absolutely, doctor Cohen. I really appreciate you chatting with
Speaker 1: me today. This has been such an eye opening conversation
Speaker 1: and your book has so much food for a thought.
Speaker 1: It was fantastic thank you.
Speaker 2: Thank you so much for fighting me on.
Speaker 1: A big thank you again to doctor Deborah Cohen for
Speaker 1: taking the time to chat with me. If you enjoyed
Speaker 1: today's episode and would like to learn more, check out
Speaker 1: our website this podcast will kill You dot com. We're
Speaker 1: I'll post a link to where you can find bad
Speaker 1: Influence How the Internet Hijacked our health, as well as
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