Science Education Gets Better

Editor’s Note: We are indebted to Professor Lara K. Smetana of Loyola University, Chicago for spending time with us to tell us about the exciting developments that have occurred in science education in the last decade. Despite a number of challenges, there is now reason to believe that science education at the elementary, middle, and high school levels has been significantly improved.

Are you old enough to remember when science class in elementary, middle, and high school involved almost entirely the memorization of “facts?” Even through introductory classes in college, students were required to replicate the periodic table of the elements by heart, memorize the anatomy of frogs and other animals, and know the equations that govern the forces of nature, like gravity. It was generally quite tedious work, and many students were completely turned off to science as a result. Those classes created the misperception that everything about science is already known and that the only role of science learners is to memorize what scientists have already proven.

         At some point a few decades ago educators realized that this approach to science education was not creating a cohort of students eager to engage in scientific and engineering careers. Why be a scientist if everything is already known? So the concept of teaching science “by doing science” was introduced. Scientists work in laboratories doing experiments, it was reasoned, and therefore students should have the experience of conducting “experiments” in class to demonstrate to them how scientists actually developed all these “facts.”

         The problem with this approach, however, is that it more closely resembles what an amateur cook does in the kitchen than the work actual laboratory scientists pursue. Students were given “experiments” in which a carefully prescribed set of steps were to be performed leading to a “correct” outcome. Deviations in the protocol would yield the “wrong” answer and therefore students, like people following recipes in a cookbook, needed to carefully replicate every step of the exercise. While this might be a bit more fun than memorizing the periodic table of the elements, it once again hardly mirrors what scientists really do. The point of experiments is that you never know the outcome until you’ve finished the study. Sometimes, you get results that match predictions you made before you started; more often things happen that don’t match your initial hypothesis and you need to do another experiment and then another. Gradually over time something that looks like a fact might emerge.

Traditional Science Pedagogy Had Adverse Consequences

         The approach to teaching science as a set of already known facts and outcomes is consequential, as we have seen clearly during the pandemic. The face mask saga is a case in point. There is no question that recommendations on the benefits of face masks to reduce the likelihood of acquiring and transmitting the virus that causes COVID-19 changed substantially over the last two years. Part of the reason is there was a paucity of good data about face masks prior to the pandemic. Once the pandemic was underway, scientists scurried to study whether they are helpful or not, quickly finding that this is not an easy thing to research. Clinical trials in which people are randomized to either wear or not wear face masks are exceedingly difficult to pull off and subject to a myriad of complications that can make findings difficult to interpret. Other kinds of studies, called observational studies, finally did yield convincing data that face masks are effective for reducing the spread of COVID-19 and that has resulted in health officials recommending we wear them when in high-risk situations, like crowded indoor spaces.

         For many people, however, the uncertainty and changes in guidelines meant that the “scientists don’t know what they are talking about,” leading some to reject face mask recommendations. Many observers believe this attitude derives in large part from the way we have been teaching people about science. The notion that science is a constantly evolving process in which findings build upon each other and that every scientific concept is subject to revision when new data emerge is something left out of traditional science education. “Scientific progress as reflected in reports and public debate during the COVID-19 pandemic offers vivid examples of teachable aspects of the nature of science,” wrote Wei-Zhao Shi recently in Nature Human Behaviour. Unfortunately, as educators Sherry A. Southerland and John Settlage wrote earlier this year ”the culmination of so much of our recent global experiences suggests that the public does not share a robust understanding of how science proceeds, nor a recognition of the features of the knowledge it produces—and these factors work together to limit the utility of science’s use in problem solving at a time when our problems have become most fearsome.”

These problems with how science is taught extend to the college level. In their recent article “Redo college intro science” published in the journal Science, David Asai, Bruce Alberts, and Janet Coffey wrote “Far too often an introductory course asks students to merely repeat what they ‘know’ instead of to explain what they think. With so many facts and concepts to cover, faculty have little time to engage students in what should be the most important learning goal: to understand how the scientific process advances knowledge and arrives at evidence-based judgements on issues such as clean drinking water, climate change, and vaccination”

         The three scientists go on to call for a complete restructuring of college introductory science courses that “replace their standard ‘cookbook’ laboratories with course-based research experiences…” All of this, they say, is in the service of “preparing citizens to engage with evidence to make informed choices.”

New Science Curricula Emerge

         Teaching students at all levels how science really works is the focus of what seems to us a revolution in science education that began 10 years ago with the publication of “A Framework for K-12 Science Education: Practices, Cross Cutting Concepts, and Core Ideas” by the National Academies of Sciences, Engineering, and Medicine. The report, which led to publication of the now widely used Next Generation Science Standards in 2013,  begins with the dramatic statement that “The overarching goal of our framework for K-12 science education is to ensure that by the end of 12th grade, all students have some appreciation of the beautify and wonder of science; possess sufficient knowledge of science and engineering to engage in public discussion on related issues; are careful consumers of scientific and technological information related to their everyday lives; are able to continue to learn about science outside school; and have the skills to enter careers of their choice, including (but not limited to) careers in science, engineering, and technology.”  

         This Framework articulates an approach to science education that has been adopted by schools across the United States and is the subject of a great deal of research and scientific publication. It calls for helping students understand how science actually works. No longer is science to be represented as a set of immutable concepts or cookbook “experiments” but rather as a dynamic process in which questions about the natural world are investigated, data accumulated, and theories developed, only to be subjected to further testing and revision. Students are encouraged to wonder about things, to question how things work and are, and are guided through hands-on exercises they develop that do not have pre-set outcomes but rather can be used to develop ideas for further work. After all, as one tool for science teachers points out, “Uncertainty in scientific activity motivates scientists’ engagement in practices…Children can be supported to engage with scientific uncertainty from the earliest years of schooling.” As the face mask example illustrates, adults have difficulties dealing with the uncertainty that is the natural course of science, especially science that is forced to develop as rapidly as was the case during the pandemic. Instead of defaulting to an attitude that uncertainty means absolute lack of knowledge and rejecting evidence-based recommendations, even young students can be taught to not only tolerate uncertainty but to welcome and work with it.

         Now, elementary school students are working with their teachers to design experiments that interest them. In a typical scenario, the teacher might pose a question like “why does something seem louder the closer it is to us” and invite her students to speculate about possible reasons for this phenomenon and consider ways to explain it. Some of the resulting designs do not work out as planned, but according to one study, elementary teachers using a new curriculum to teach engineering are now “more comfortable preparing students for design failure experiences, and responding when design failure occurred.” Given that design failures happen with great regularity in real-life laboratories, this kind of experience helps students understand how science really works. “If an observer were to ask students ‘why are you working on this?’” explain scholars from Northwestern University, “at any point, students should respond in terms of what they are trying to figure out and why that matters to them—not in terms of accomplishing the demands of the teacher or textbook.”

Learning the Nature of Science

         In their book Teaching Science to Every Child: Using Culture As a Starting Point, John Settlage, Sherry A. Southerland, Lara K. Smetana, and Pamela S. Lottero-Perdue (Routledge, 2018) describe teaching children about “the nature of science,” which they define as “both actions of science and the characteristics of the knowledge produced through these activities” (p. 28). In addition to acknowledging that science is an empirical undertaking, they emphasize two additional aspects of the scientific enterprise: creativity and social relationships. With respect to creativity, they write “Far from being a mindless and mechanical gathering of evidence, the work of science benefits from personal creativity and the ability to shift from data to explanations” (p. 37). With respect to the social aspect of science they note that “A common caricature of a scientist is someone working in almost complete isolation…With this common stereotype, is it any wonder that many students fail to see any appeal in the prospects of becoming scientists?” (p. 40). In fact, modern science is done by teams of scientists across academic and industrial centers, who meet frequently at conferences to share data and ideas, and who interact with each other on a regular basis.  

         To be sure, the road to implementing the new approaches to teaching science has challenges. One major obstacle will be the critical shortage of qualified science teachers in the U.S. According to Steven Yoder writing in Undark magazine, “Data show many of the 69,000 U.S. middle school science teachers have no scientific background. Almost a quarter have neither a science degree nor full certification to teach science…” Furthermore, Yoder writes, “few middle school science teachers report feeling confident about all the material they are responsible for teaching.” The impressive work to advance a new model of teaching science to children is thus threatened by the lack of qualified science teachers.

         There is also clearly a lag in realizing the benefits of the new science curriculum. It is now less than ten years since the Next Generation Science Standards were introduced, so that most current adults experienced the previous generations of science education approaches, approaches as we have pointed out that emphasized memorization of supposedly established facts and deemphasized creativity, wonder, social relationships, and uncertainty that are all part of real-life science. Hence, it is no wonder that we hear many complaints about the ways in which people still lack the ability to tolerate scientific uncertainty, misunderstand the ways in which scientific consensus is developed and adjusted, and default to ideas and behaviors that lack scientific evidence. Unlike today’s students, most adults were rigorously turned off to science during their school years. It would be interesting to consider to what extent some of the ideas in the Next Generation Science Standards could be applied to today’s adults via public health campaigns.

         We should also note that as wonderful as the new science curricula are, we lack empirical evidence that experiencing them during childhood and adolescence in fact leads to more scientifically informed health decisions by adults. That is, do new approaches to teaching science lead to adults who can recognize the difference between real and sham science, tolerate scientific uncertainty, and make informed health decisions? Those are important areas for researchers to undertake.

         Reading through the Framework and Next Generation Science Standards gives us great hope that phenomena like today’s anti-vaccination advocates will be displaced by future generations of people who learn to love and embrace science, understand its power and limitations, and represent informed science consumers. Thanks to the hard work of many science teachers and education scholars we now have reason to believe that is a likely outcome.   

Towards More Publicly Funded Media

Americans view freedom of the press, enshrined in the First Amendment to the U.S. Congress, as essential to the functioning of its democracy. For some people, the notion of government-funded media seems antithetical to that principle.

         Now, however, a study published last December in the International Journal of Press/Politics by two University of Pennsylvania professors calls that notion into question. Timothy Neff and Victor Pickard looked at the state of democracy and at various media funding mechanisms across 33 countries, including the U.S. They found that “high levels of secure funding for public media systems and strong structural protections for the political and economic independence of those systems are consistently and positively correlated with healthy democracies.”

         In other words, countries with independent and publicly well-funded national broadcasting systems had consistently stronger democracies according to the Neff and Pickens study. It turns out that the U.S. scores badly both in terms of the quality of its democracy and how much it spends on public media. According to The Economist’s Democracy Index, the U.S. is now considered a “flawed democracy.” At the same time, the U.S. spends .002 percent of Gross Domestic Product (GDP) on public media, according to a recent report from the Annenberg Center at the University of Pennsylvania, which translates to just $1.40 per capita. That compares unfavorably to countries like the U.K., Norway, and Sweden, which all spend around $100 per capita or more on public media and all have higher ratings than the U.S. on the Democracy Index.  The Annenberg Center report thus quotes Professor Pickard as stating that “there is a growing body of research that suggests substantial social benefits from strong public media systems, including well-informed political cultures, high levels of support for democratic processes, and increased levels of civic engagement.”

Journalism in Crisis

         What journalism we do have in the U.S. appears to be in crisis. As Timothy Karr notes in his article “The Future of Local News Is Noncommercial” that appeared in the March 18, 2022 edition of the Columbia Journalism Review, we have witnessed a precipitous decline in local news coverage in the U.S. during the 21st Century. “Between 2008 and 2020,” Kerr writes, “more than 1,000 newspapers ceased printing, and the number of newspaper-newsroom employees shrank by more than half.” Although this fall in journalism outlets is often attributed to the rise of digital media on the internet, Kerr makes a strong case that “conglomerate and hedge-fund media” companies are at least equally to blame. “We need,” he argues, “to reinvent the news economy from one that serves a few owners to one that serves the needs of democracy…”

Local newspapers are declining at a fast pace in the U.S., in part because of acquisition by business conglomerates that force mergers and closures (image: Shutterstock).

         The decline in print and broadcast media is especially acute for science journalism, where one study showed that between 1989 and 2021 the number of weekly science journalism sections fell from 95 to 19. As the number of full-time science journalists at newspapers and broadcast stations declines, more and more free-lance science journalists and general journalists are called upon to cover the ever-increasing complexity of modern science. High-quality science journalism written by reporters with expertise in scientific specialties is thus in ever-shorter supply, leaving us nowhere to turn except the internet for scientific information about health, climate change, and other vital topics.

Internet Science is Only Sometimes Reliable

Enough has been written at this point about the deluge of disinformation and misinformation in general and about science and health in particular that appears on internet platforms. Thus, if we are forced to look online for information about the latest medical advances, as is happening because of the decline in quality science journalism, we will find some things that are accurate and others that are not. Discovering which online sources are reliable is difficult and we know that many people wind up making unhealthy decisions in part based on inaccurate online information. We thus fully agree with Timothy Kerr that we need to reconsider public funding for high-quality, independent media in the U.S. to fill the severe losses in reliable local news and science journalism that we face.

         Of course, many will raise the objection that government funded media is a slippery slope to loss of a free press and government control of newspapers and airwaves. That is a legitimate concern. Critica Chief Medical Officer David Scales acknowledged this worry when he wrote “I completely agree that we need to be very careful about government funding of media” but he goes on to point out that we could adopt models like the U.K.’s BBC “where the government doesn’t directly fund it at all but puts in place a revenue stream for public broadcasting.” Scales went on to assert that “as the evidence for investing some sort of publicly-supported media in a robust democracy grows stronger, the ideological argument that this should remain an unregulated space to encourage free speech and allow the private sector to innovate grows increasingly hollow.”

         According to Timothy Karr, the non-profit organization Free Press now advocates for a “doubling of public funds for noncommercial news and information.” Still, having the U.S. federal government be the funder for such an effort may be impossible given the robust objections to anything that smacks of impinging on freedom of the press. Therefore, Critica believes that independent foundations should come together to create a steady stream of funds for high-quality media, focusing particularly on, but not limited to, health. The coronavirus pandemic has taught us how vital it is to get clear and trustworthy health information to the public, information that is not sensationalized but rather covers the background information that people need to make healthy and informed decisions. Research shows that publicly funded, high-quality, and independent journalism advances healthy democracies. We will continue to advocate for a plan to bring this concept home to the U.S.

Are Conspiracy Theorists Always Extremists?

Levels of conspiracy theorizing suggest an array of people believe in them.

On May 14, 2022, an 18-year-old man opened fire at a supermarket in Buffalo, New York, killing 10 people. The suspect, Payton S. Gendron, had apparently been planning the attack for several months. Subsequent investigation of his social media accounts suggested a racist motivation behind the attack, with Gendron having chosen this particular area because it has a high proportion of Black residents. The tragedy was soon labeled a hate crime by the U.S. Justice Department. Of the 13 people shot at the supermarket that day, 11 were Black. The shooting was another in a line of recent White supremacist hate crimes, including recent mass shootings in El Paso, Texas; Charleston, South Carolina; Norway; and New Zealand.

“The Great Replacement”

The gunman in the Buffalo shooting seems to have subscribed to a particular conspiracy theory called “the great replacement.” Between 2010 and 2020, a great deal of demographic change has happened, especially in Western European countries and the United States. During this time, the percentage of Americans who identify as “white only” dropped from 72 to 62 percent, and, at the same time, there were record influxes of migrants from Muslim nations, especially into Western Europe. The “great replacement” posits that this demographic shift has been orchestrated by elite power holders as a kind of “white genocide.” In the United States especially, believers in this theory posit that Jews are bringing in immigrants and promoting interracial marriage to suppress the white population. What’s especially frightening at this point in time is that this seemingly “fringe” theory has become much more mainstream, with one in three Americans now believing some version of this idea.

Val Dunne Photography/Shutterstock
Source: Val Dunne Photography/Shutterstock

While some might think about conspiracy theorists as people in tinfoil hats who believe the moon landing never happened or that the Earth is flat, these ideas affect much more than what we think of the galaxy. Especially recently, the tie between conspiracy theories and extremist political and social beliefs is undeniable. QAnon, with its very clear white supremacist undertones, is a good example of this. The beliefs spouted by “Q” and his or her followers are particularly “moralist” in nature, suggesting that the “enemy” is unthinkably evil. This enemy is not only the opposite political party but also very often any group that might be maligned by Q’s followers, including Black people, immigrants, and Jews. After being marginalized from politics for so long, the alt-right, neo-Nazis, and neo-Fascists certainly saw the value of QAnon to help them shoulder their way back into the political mainstream, and they were often successful.

But what about the one in three Americans who believe versions of the great replacement theory? Is everyone who engages with a conspiracy theory an all-out extremist? It is difficult to fathom that this is in fact the case, considering the extremely high percentage of people who believe in at least one conspiracy theory. The vast majority of them will thankfully not act on their beliefs, as the Buffalo shooter did. So what makes the difference between someone who dabbles in these ideas and someone who acts on them?

Susceptibility to Conspiracy Theories

There is good research now to suggest that certain circumstances and personality traits make some people more susceptible to conspiracy theories than others. People who are socially isolated, have high levels of existential doubt and paranoia, and who feel socially and politically powerless and marginalized are especially at risk. More recent research also suggests that openness to new experiences as well as personal traits such as agreeableness are protective against conspiracy theories. “Disagreeable” people, who are more likely to believe in conspiracy theories, tend to have higher levels of Machiavellianism (manipulativeness and cynicism), narcissism, and sadism. These are all traits that are on a spectrum, with everyone displaying some degree of all of them.

Feeling socially and politically powerless and marginalized can especially motivate people to seek out in-groups that will make them feel included. Conspiracy theories offer an automatic, tightly knit group of people who share particularly strong beliefs. The strength of shared beliefs helps make the group relationship even tighter. The personality traits and feelings of overall uncertainty and existential dread can range from being somewhat muted to being quite powerful. Small amounts of these traits and circumstances can push someone to start engaging with conspiracy theories but may not cause them to be completely taken over by them. In instances such as the case of the Buffalo shooter, it is completely appropriate to ask questions about highly pathological traits that may be associated more with mental illness than just with variance from the mean. For example, the Buffalo shooter may have had pathological levels of paranoia, rather than simply a higher dose of it than the average conspiracy-theory adherent.

Understanding What Drives People to Act

Our job is to better understand what drives people such as the Buffalo shooter to do what he did and to make sure that there are more societal safeguards to ensure that a person like this does not carry out what he did. These safeguards might include things like better access to mental health care and less access to firearms. But it is also our job to understand how people with low levels of conspiracy theory beliefs can be redirected. We are gaining a better understanding nearly every day about some of the protective features that may help us here, including open-mindedness and, especially in cases related to science, scientific curiosity.

Public acceptance of extremist conspiracy theories creates the environment for people with pathological traits and beliefs to blossom and flourish. Part of the answer to these tragic events is to better address the fact that many Americans engage with conspiracy theories at a lower level, utilizing the protective factors we already know about and the ones that will continue to emerge as a result of continuing research on the topic. Only then can we disrupt the feedback that ultimately gives extremists the encouragement and motivation to act on their beliefs.

Using Data to Stem the Tide of Gun Violence in the U.S.

Gun violence and firearm-related deaths are surging in the U.S. since 2020. This paradoxically may lead some people to think that owning a gun is a good idea and indeed gun sales in the U.S. have also been surging since the coronavirus pandemic began. Most gun owners in the U.S. say they own their guns for protection and that they make them feel safer.

         The data on gun ownership actually show quite the opposite. Numerous studies have demonstrated that the presence of a gun in the home increases the risk that a household member will die by firearm-related suicide or homicide. A new study published in April in the Annals of Internal Medicine found that homicides were twice as high among people who lived in households with a gun owner as those who lived in households without guns. The concluding statement from the paper is important:

Homicides and suicides account for 97% of the nearly 40 000 firearm-related deaths in the United States each year. It is implausible that gun access decreases suicide risk, and every rigorous study that has examined this relationship has found a positive association. Nonetheless, if firearm ownership enhanced personal safety in other ways, as many gun owners reportedly believe, tolerating some elevated risk for suicide might be considered a worthwhile tradeoff. This study adds to mounting evidence that no such tradeoff exists, because a gun in the home is associated with higher—not lower—risk for fatal assault. People who do not own handguns but live with others who do bear some of that risk, and the amount they bear appears to be substantial.

More Policing Not Correlated with Violent Crime Reduction

         Believing that owning a gun offers protection is a form of science denial, because the evidence we currently have is clear that it does not. Apparently, owning a firearm does exactly the opposite of what most gun owners believe: it increases the risk that the gun will be used to harm owners themselves or their families. Another belief that many people have is that more policing is a potential solution to stemming the rising tide of gun violence. A recent Brookings Institute report helps us consider if there is evidence to support that claim.

         The report indicates that there is little correlation between increasing police funding and decreasing crime. Even if there were, the report notes that municipalities would still have “to weigh the negative effects that accompany adding more police officers, such as increasing arrests for low-level crimes which contribute to mass incarceration and disproportionately affect Black communities. Exposure to the criminal justice system itself can perpetuate underlying issues that contribute to violent crime and recidivism, such as low socioeconomic status and unemployment, homelessness, and poor mental health.”

         According to the Brookings report, “One of the most evident social factors correlated with violent crime is mental health.” High levels of poor mental health at the community level in aggregate, reflected by measures like overall community levels of depression and anxiety, are correlated with increased rates of violence. Efforts to improve community-level mental health may reduce violent crime. The report notes that “An estimated 20% of police calls are for mental health and substance use crises.” 

         This of course does not mean that most individuals with mental illness are prone to commit violent acts; we know that even though overall people with mental illness are somewhat more likely to to commit violent acts than people without mental illness, the great majority of people with mental illness are not violent. Rather, it suggests that poor overall community mental health and lack of access to mental health care increases the risk for violent crime, including gun-related violence. Furthermore, it begs the question of whether most police officers are properly trained and prepared to deal with the staggering number of calls that involve mental health disturbances.

Police Are Not Prepared for Mental Health Emergencies

         These data suggest that owning a gun is clearly not a solution to dealing with increasing gun-related violence in the U.S. Nor is simply spending more money on policing likely to address the problem. In addition to stricter gun control legislation and addressing the social factors that increase the risk for gun violence, the data indicate that improving access to mental health care facilities may have an impact. Also, we need to develop and evaluate alternatives to standard police responses to mental health emergencies. We have heard people scoff at the idea of “having a social worker respond to a police call,” but in fact there is little evidence to suggest that having police officers respond to calls that involve a person in the midst of a mental health crisis is an effective intervention. Whether police officers can be better trained to respond to mental health emergencies or in fact we should be deploying behavioral health professionals for these calls is an empirical question that critically needs exploring.        

Scientific data alone cannot be the basis for all public policy decisions; these require careful consideration of social needs, politics, and economic realities. But we believe that public policymakers should always ask if there are data relevant to their decisions or if more studies could be useful. Available data tell us that liberalizing gun ownership laws and spending more money on policing are unlikely to lead to meaningful and acceptable reductions in gun violence in the U.S. Rather, we need to consider factors that are known to increase the likelihood for gun violence and design interventions to address them. One of those factors seems clearly to be poor community mental health. Thus, any attempt to reduce gun violence in the U.S. should consider the evidence and include an approach that addresses our police and overall community responses to mental health needs.

Great Science, Terrible Science Communication

The Paxlovid Story

It usually takes, on average, 11 years to develop a new drug. That is one reason why the introduction of an antiviral drug for Covid-19 treatment with the brand name Paxlovid is so remarkable: it was developed in just 20 months. The science that permitted this, as detailed in a STAT news article by Mathew Herper, was impressive indeed. The article quotes Eric Topol, the director of the Scripps Research Translational Institute, as calling the development of Paxlovid “the fastest development of a small molecule drug, with clinical validation and high efficacy, in history—no less in the midst of a pandemic.” In a study of unvaccinated people, Paxlovid reduced the risk of hospitalization for Covid-19 by 89%, leading the FDA to issue an Emergency Use Authorization (EUA) for the drug last December. It is now recommended for people with mild to moderate symptoms of Covid-19 who are at risk for developing more serious illness.

         That impressive science makes the fact that the drug is, by all accounts, substantially underutilized, both perplexing and disturbing. The situation is highly reminiscent of what happened when the vaccines were first rolled out for Covid-19 under FDA EUA rules: brilliant science leading to a safe and effective vaccine in record time and then profound difficulties getting it into the arms of people in the U.S. and around the world. The roll-out of Paxlovid in the U.S. appears to be another story of dysfunctional healthcare and science communication systems.

         Vaccines are highly effective at reducing the risk for serious illness, hospitalization, and death from Covid-19, but especially since the emergence of the Omicron variant it is clear that highly infectious mutants can readily infect even vaccinated people. More vulnerable people, especially the elderly, the immunocompromised, and those with underlying medical conditions like diabetes, are then more likely to develop significant symptoms. Developing drugs that can treat infected people and reduce the risk for this slide into serious illness has been a priority for scientists and pharmaceutical companies. One strategy is to administer antibodies specific to the virus that causes Covid-19, called monoclonal antibodies, as soon as someone is infected, but those require intravenous administration and therefore are not ideal.

         Two oral medications have been granted EUA for preventing serious illness in people who have been infected with Covid-19, Paxlovid and molnupiravir, but the latter does not appear to work as well as Paxlovid. (We are breaking our usual policy and referring to Paxlovid by its brand name because it is not available as a generic drug and its generic name—nirmatrelvir with ritonavir—is a tongue-twister that almost no one seems to be using yet). Paxlovid is a combination of a drug invented by the Pfizer company (nirmatrelvir) and an older drug used to treat HIV infection (ritonavir). They are both in the category of medications called protease inhibitors, drugs that block a virus’ ability to assemble itself inside a human cell and then replicate.

Paxlovid is an orally administered antiviral drug that has proven highly effective in preventing serious illness in people infected with the virus that causes Covid-19 (image: Shutterstock).

         If Paxlovid is so effective at preventing serious Covid-19 illness, then why isn’t it being widely used at a time when ever more infectious variants seem to be spreading? There are multiple reasons for this failure that fall into three main categories: 1. Lack of drug distribution, 2. Lack of awareness by the public, and 3. Lack of awareness and unwillingness to prescribe it by physicians.

Initial Distribution of Paxlovid was Problematic

         In her New York Times article “Covid drugs save lives, but Americans can’t get them,” Zeynep Tufecki detailed on April 22 the travails people have gone through to find a pharmacy stocked with Paxlovid. Some pharmacies had no Paxlovid while others had stocks of unused doses. “Social media is also replete with stories of despondent patients unable to locate doses or managing to do so after much effort and paying extra when they ended up out of their insurance networks,” she wrote.

         At the end of April, the Biden administration announced it would take a series of steps to increase the availability and use of Paxlovid, but that was four months after the EUA had been issued. It is still unclear why it has taken so long for Paxlovid to become widely available in hospitals, clinics, and pharmacies. The problem could rest with how much was initial manufactured and distributed by Pfizer or with the supply chain that links pharmaceutical companies to pharmacies. It is also unclear why it took federal and state governments so long to make a concerted effort to get Paxlovid to pharmacies. This all needs to be investigated because it seems absurd that a drug this effective should languish for four months off so many drug store shelves.

Public Poorly Informed about Paxlovid

         But even as Paxlovid does become more available, people may not know enough about it to ask for it or know how to access it.  Paxlovid must be prescribed by a physician, nurse practitioner, or physician’s assistant, and it needs to be taken within five days of first exhibiting symptoms. Not all Americans have such relationships with prescribers or even if they do are able to get through to them fast enough to make taking Paxlovid possible. Furthermore, because Paxlovid is not an FDA-approved drug yet but rather only available under the EUA program, Pfizer is not allowed to advertise it, either to the public or to prescribers. That leaves it up to local, state, and national public health authorities to ensure that people know that a pill is available that they can take to prevent serious illness if they develop symptoms and test positive for Covid-19. In some places, like New York City, frequent television ads about drugs to treat Covid-19 are appearing, but this is not the case throughout the U.S., and we are unaware of any systematic CDC or FDA programs to inform the public about it. Thus, the disjointed American healthcare system has not been able to provide sufficient public information about Paxlovid or to come up with a viable plan for getting it to people who need it.

Prescribers are Reluctant to Prescribe Paxlovid

         The prohibition against drug company advertising about Paxlovid extends to prescribers. As Tufekci notes “In the United States, such doctor outreach is often, sadly, left to pharmaceutical companies, which spend tens of billions of dollars each year marketing their drugs to physicians. This has led to heavily promoted drugs getting prescribed even when cheaper, effective alternatives exist.” Once again, there has been a lackluster attempt on the part of public health agencies to educate physicians and other prescribers about Paxlovid. Our healthcare system appears content to default to drug companies to provide physicians with information they need about newly available medications.

         This lack of prescriber education about Paxlovid may explain one of the main reasons physicians appear to be reluctant to offer patients the medication: what are called drug-drug interactions. Most medications we take are broken down (that is, metabolized) by the liver, thus controlling how high the blood levels of the drug can go. The liver has a set of enzymes called the cytochrome P450 system that is responsible for metabolizing drugs. The activity of these enzymes is controlled by our genes, so that activity varies from one person to the next depending on the individual’s genetic make-up. Some people are faster metabolizers of specific drugs than others.

         Some drugs we take can inhibit the activity of these metabolic enzymes, and Paxlovid is one of them. Its ritonavir component inhibits an enzyme called 3A4 in the cytochrome P450 system, making metabolism of a host of other medications less efficient. That means that there are many drug interactions with Paxlovid that can lead to significant increases in blood levels of certain medications. Since elderly people are considered among the important candidates to take Paxlovid and they are most likely to be taking multiple other medications, prescribing Paxlovid can be tricky.

         A doctor or other prescriber about to give someone a prescription for Paxlovid may see the long list of potential drug-drug interactions and become wary. Some of the medications that interact with Paxlovid might be stopped for the five days a person takes Paxlovid, but others, like drugs to control heart rhythm disturbances such as atrial fibrillation, cannot be stopped so easily. There are probably ways to handle these situations (such as temporarily lowering the dose of a drug with which Paxlovid interacts), but prescribers have not been given sufficient information about what to do in such instances and we hear anecdotally that this is discouraging some physicians from prescribing it. How widespread a reason this is for the lack of Paxlovid uptake is unknown at present, but again speaks to the failure of public health agencies like CDC and FDA to conduct timely and meaningful prescriber education campaigns.

         On three levels then—supply, public information, and prescriber education—our healthcare system has failed to get Paxlovid into the hands of people who should take it. This is another example of the shortcomings of the American healthcare system, a system that is based on some of the world’s most outstanding biomedical research but nevertheless routinely fails to make the progress of modern science available to its constituents. In the case of Paxlovid, we see a disjointed drug distribution system and a failure of vital health science communication to both the public and healthcare providers. We also see the results of years of default to pharmaceutical companies for critical public health education to both groups.

         The Paxlovid story is a case in point, then, of some of the things that are wrong with the American system. What should have happened was three-fold. First, the moment Paxlovid was first presented to FDA for an EUA, federal authorities should have planned for the drug’s rapid distribution to pharmacies and hospitals around the country. Second, federal, state, and local public health agencies should have developed a comprehensive plan to provide the public with information about Paxlovid, including who should take it and where to get it. Third, the same public health authorities, along with medical and nursing associations, should have developed an education campaign aimed at prescribers, informing them about the benefits of prescribing the drug and providing them with algorithms for what to do in complex situations such as those that arise because of drug-drug interactions. Once again, we have witnessed the benefits of great science vitiated by poor public science communication.

Are Popular Personality Tests Accurate?

Here’s what we do and don’t know about Myers-Briggs.

It’s common in many workplaces these days to encounter some kind of personality or “work style” assessment. Many employers ask employees to take these assessments to get a better sense of optimal work settings and workflows for individual employees. For example, naturally introverted employees might do better doing primarily internally-focused research and desk work while someone who is naturally more extraverted might have an easier time working in sales, marketing, or any kind of external-facing work that involves contact with a variety of partners.

The Myers-Briggs Type Indicator is a personality inventory that categorizes people across four domains: introverted versus extraverted; sensing or intuition; thinking or feeling; judging or perceiving. People’s preferences and personality profiles can thus be summed up along these four domains; for example, an INTJ would be someone whose proclivities line up most with being introverted, intuitive, thinking, and judging. While the Myers-Briggs inventory is by no means the only kind of personality or work style inventory that is used in the corporate world (many new assessments have cropped up over the years), it is a very commonly used instrument when people are trying to figure out their general preferences.

Yeexin Richelle/Shutterstock
Source: Yeexin Richelle/Shutterstock

But is Myers-Briggs reliable from a scientific perspective?

The test might be popular and pervasive (many readers will have heard of it, and some have probably taken it more than once), but there is some pretty lively debate about whether it is a reliable and accurate instrument. From a purely anecdotal perspective, it is easy to see where there might be considerable flaws in the test. For one thing, we know people who have taken the test once and then taken it again a few weeks later and scored very differently on certain items.

In addition, it is hard to know how to interpret a score that is on the border between two types. For example, it is possible to score right in the middle between being extraverted and introverted. What exactly does this mean, then? It is not clear how to use this kind of information.

2018 article in Scientific American offered a relatively harsh view of Myers-Briggs and other personality tests. Among the problems already noted about the test, experts also argue that the questions are confusingly worded, thus making it difficult to know whether people are interpreting the questions in the ways they were intended. In addition, most personality tests were invented in the first half of the 20th century on the basis of researchers’ subjective feelings about the most important components of personality. The result is a wide variety of tests that are not based on solid academic theory about what comprises the most important aspects of a person’s preferences and personality.

In a more recent article in Psychology Today, Dr. Aqualus Gordon argues that claiming the Myers-Briggs has been “debunked” is going a step too far. He argues that calling it pseudoscience is unfair since rigorous academic studies of its efficacy have not been performed. He also points out that people often expect the assessment to predict things that it is not set up to predict, such as job performance. The assessment has a lot more to do with preferences and job satisfaction than with actual performance. Predicting job performance is undoubtedly outside the purview of the Myers-Briggs, but expectations that the assessment can serve this function might lead to more skepticism of the instrument. Furthermore, it is unclear whether the test even does what is within its purview, such as accurately predicting job satisfaction.

Key takeaways

Until we more rigorously study the Myers-Briggs, we cannot make claims about its efficacy or accuracy. Psychometric scales need to be subjected to rigorous validation tests, which it is clear this test has not. Most other personality tests have not been subjected to this kind of validation either. If we want the scientific community to take these tests seriously and advocate for their use, they do need to be properly validated. In the meantime, it probably does no harm to take some of these tests for fun just to get a better sense of how one scores. But putting great stock in their results and making major career decisions based on them may not be warranted without more thorough engagement with the science of psychometric validation.

Primary Care in the U.S. Falls Short

About three-quarters of Americans have a primary care physician. Having a primary care doctor is associated with better health outcomes. As we have previously noted, Americans tend to trust their primary care physicians more than most other sources of healthcare information.  

         All of this should mean that it might be a wise move to extend primary care to more people and to ensure that primary care doctors have enough time to spend with their patients to take advantage of that trust and help them navigate the many pathways to optimal health outcomes.

In fact, however, according to a recent report from the Commonwealth Fund, the U.S. is failing at providing high-quality primary care compared to other high-income countries. The report is based on surveys the Fund conducted in 2019 and 2020 with primary care physicians in the U.S. and 10 other high-income countries. Among the findings are:

·  U.S. adults have nearly the lowest likelihood of having a regular doctor or place to go for care (Sweden was slightly lower).

·  U.S. adults are the least likely to have a long-standing relationship with a primary care provider (43% versus 71% of adults in the Netherlands or 57% in Canada).

·  U.S. adults are least likely to be able to see a primary care provider after regular office hours

·  Primary care physicians generally do not screen their patients for social needs, but here U.S. doctors are the most likely to do so (30%). The authors of the report speculate, however, that this may be because the U.S. has the poorest social services networks for its citizens, creating a greater need for such inquiries. Only Canadian primary care providers are more likely to have social workers in their practices (42% versus 37% in the U.S.).

·  Only one-third of U.S. primary care physicians have mental health providers in their practices. This is about midway among the countries in the survey, with nearly all practices in Sweden and the Netherlands having mental health providers in their practices, but almost none in Germany, Switzerland, or Norway.

·  Only half of U.S. primary care providers report adequate levels of coordination with specialists and hospitals about changes in their patients’ care plan, putting the U.S. near the bottom in this category. Similarly, only half of U.S. primary care providers are notified when their patients are seen in an emergency department, compared to 85% and 84% in New Zealand and the Netherlands, respectively.

Overall, then, the report makes clear that the U.S. is doing a poor job at primary healthcare. Importantly, the report notes that these shortcomings in U.S. primary health care are not distributed evenly but “affect predominantly Black and Latinx communities and rural areas, exacerbating disparities that have widened during the COV ID-19 pandemic.”

What Do People See Primary Care Providers For?

         An average visit with a primary care physician lasts 18 minutes. According to a Mayo Clinic study, these are the top ten reasons for those visits:

  • Skin disorders;
  • Osteoarthritis and joint disorders;
  • Back problems;
  • Cholesterol problems;
  • Upper respiratory conditions, excluding asthma;
  • Anxiety, depression, and bipolar disorder;
  • Chronic neurologic disorders;
  • High blood pressure;
  • Headaches and migraines; and
  • Diabetes.

Now let’s look at the top causes of preventable premature death in the U.S. This list is topped by tobacco smoking and includes obesity, alcohol use, hypertension, some infectious diseases for which vaccinations are available, firearm injuries, and suicide. In the 18 minutes that a primary care doctor has with a patient, how much time is spent dealing with these preventable causes of premature death? Take cigarette smoking, for instance. We know that relatively brief primary care interventions can have a significant effect on increasing the chances that a smoker will quit. The same is true for harmful alcohol consumption. Primary care physicians may themselves be surprised to learn that their paying attention to their patients’ weights can influence obese patients to attempt weight loss, a practice that may be helpful for many people with high blood pressure or diabetes. We can also wonder about the potential impact on mental health and suicides if more primary care practices had mental health practitioners within them.

Primary care is at the heart of all healthcare systems, but it is inadequate in the U.S., with primary care doctors having inadequate time and resources to deal with the things that affect their patients’ health (image: Shutterstock).

Do primary care physicians have time to talk to patients about their lifestyle and behavioral issues? Do they keep careful track of their adult patients’ vaccination status? When a patient circles “yes” on the pre-visit form about cigarette smoking, does the doctor recognize that even a few minutes spent talking about options for quitting can save more lives than almost anything else the doctor can do?

U.S. Primary Healthcare Needs an Overhaul

It is clear we need to fix the primary healthcare system in the U.S. Right now, it is a disorganized system that disadvantages people of color. It is also unprepared to deal with the factors that are clearly responsible for most people’s adverse health outcomes. Treating rashes, upper respiratory infections, and backaches is important, but primary care clinicians could have far more impact on the public’s health if they also dealt with tobacco and alcohol use, obesity and lack of exercise, and vaccine hesitancy. Furthermore, their practices would become far more impactful if they included mental health providers to deal with common psychiatric conditions like anxiety disorders and depression and social workers to help with the social determinants of health like food and housing insecurity.

The U.S. clearly has a long way to realize any of these goals. As Kevin Grumbach and co-authors wrote in their September 2021 New England Journal of Medicine article “Revitalizing the U.S. Primary Care Infrastructure”:

More than half of office visits in the United States are to primary care clinicians, yet primary care physicians make up only 30% of the physician workforce and are supported by only 5.4% of national health expenditures, and research on primary care garners just 1% of federal agency research awards.2 One in five Americans live in a federally designated primary care Health Professional Shortage Area. Primary care physicians earn 30% less than other physicians, on average, and they have among the highest rates of physician burnout.3

         In its sweeping 2021 report on rebuilding the U.S. primary health care system, The National Academies of Sciences, Engineering and Medicine noted that “The value of primary care is beyond dispute” but at the same time “this foundation remains weak and under-resourced.” Clearly, the first order of business in repairing our crumbling primary healthcare system is to fund it adequately. This is perhaps easier to do in countries that have rational, single-payer healthcare systems (as is the case in all high-income and many middle- and low-income countries, but not the U.S.). What we need, and what the National Academies endorse, is a major rethinking of how we finance medicine.

Instead of spending time discussing their patients’ health and risk factors for disease, primary care doctors face increasing bureaucratic demands that are uncompensated and contribute to high burnout rates (image: Shutterstock).

         Right now, the highest paid medical specialties are mostly surgical. Primary care physicians are way down on the list. If someone does choose a career in primary care medicine, they will be faced with having to see large numbers of patients for short periods of time, day in and day out. There will be endless hours logging all these patient encounters into the electronic health record (EHR), most of which gets done after hours and without compensation. No wonder we have a shortage of primary care physicians and those that do enter the field suffer high rates of burnout. The first order of business, then, in repairing the primary care system is to compensate primary care providers better and make primary care a desirable medical specialty.

         Next, we must compensate those primary care practices to be able to spend enough time with patients to accomplish a public health mission: the prevention of disease. That means not only asking patients to fill out questionnaires about their health and habits (many of which seem never to actually get read by any health professionals) but having the time to actually deal with the responses. If someone smokes, is drinking alcohol excessively, is eating a high sugar diet, or is hesitant to have a flu vaccine, the doctor or another health professional in the office needs to address that problem using evidence-based approaches. The healthcare system must be prepared to pay people to do that.

         All of this will require training primary care physicians, nurses, social workers, and other healthcare providers in a new paradigm of care, one in which attending to the real causes of diseases and the impediments to successfully overcoming them is of paramount importance. For example, primary care physicians must be trained in techniques like motivational interviewing and other evidence-based approaches to helping patients with substance use issues. A mental health clinician trained in cognitive behavioral psychotherapy for depression and anxiety should be part of every primary care practice. Patients who need to lose weight or exercise more should be given help, encouragement, and follow-up support by people they trust, that is, by their primary care doctor. Primary care offices should have social workers who can assist patients in getting assistance with housing, food, and health insurance. We know that doing these things works to prevent disease, but we are stubbornly unwilling to implement them. That needs to change.        

Our primary healthcare system is broken and because of it, Americans are missing out on the chance to benefit from a great deal of science telling us how to prevent many diseases and premature deaths. Fortunately, there is now widespread agreement that funds must be directed toward a bold revamping of how we deliver primary care.

Mental Health Emerges As A Major Issue During the Pandemic

From nearly the beginning of the Covid-19 pandemic, experts in psychology and psychiatry worried that there would be major increases in the number of people with mental health issues and diagnoses. Evidence now supports that those worries were well-founded, and the situation has been called a pandemic mental health crisis. Studies find clear increases in anxiety and depression in both adults and children and last December the U.S. Surgeon General, Vivek Murthy, issued an advisory on the youth mental health crisis that he noted has been exposed by the pandemic. Unsurprisingly, given the disproportionate impact of the pandemic, communities of color have been especially affected by the mental health consequences of Covid-19. Although suicide rates appear not to have increased in the American population overall during the pandemic, they are rising among Black, Latinx, and Asian American people. Suicidal ideation and attempts have increased in some groups, including adolescent girls

         Equally disturbing as the rise in mental health problems during the pandemic is the failure to provide increased access to mental health services. Although telehealth applications may be improving access to mental healthcare for some people, there is still a shortage of mental healthcare providers in many parts of the world, including the U.S., and many people have restricted access to care due to lack of affordability and insurance coverage.

Is There a Broader Solution To the Increase in Mental Health Problems?

         Researchers have tried to figure out ways to improve access to care  for people with mental health conditions and our attention was recently drawn to one such study. Published in the Journal of the American Medical Association, investigators from several Kaiser Permanente health facilities randomized nearly 19,000 patients who had endorsed having suicidal thoughts to one of three conditions: a care management condition in which care managers sent messages to patients encouraging them to have outpatient care; an online version of an evidence-based intervention called dialectical behavior therapy (DBT); or usual care. All the participants were free to also receive care in the usual way from the Kaiser Permanente system, but only those in the first two groups were offered additional care as well. The hope was that making proactive outreach attempts to people with a mental health issue, rather than relying on them to take the initiative to get help, might improve outcomes and reduce suicides and suicide attempts. The study was funded by the National Institute of Mental Health.

         The results of this large and rigorously conducted study were disappointing. Neither additional intervention decreased the number of serious suicide attempts or deaths by suicide compared to continued usual care. In fact, the patients randomized to the shortened version of DBT had more suicidal events than the usual care only group, a finding we believe was probably a fluke.

         Why would offering additional care to people suffering with suicidal thoughts not be helpful? There are several possibilities, many acknowledged by the authors of the study. One is that attrition from both outreach interventions was very high, with only 30% to 40% of people invited to actively engage with the interventions actually participating. Furthermore, it could have been that usual care provided to all the study participants was maximally effective, creating a ceiling effect whereby any additional care would not be able to make a difference

         Another important limitation of the study was described by the study authors as follows: “The care management intervention tested in this trial was a low-intensity program delivered by online messaging with rare telephone contacts and no in-person visits.” Similarly, the DBT intervention was done online and involved only a portion of the elements usually incorporated into a DBT intervention for people with suicidal ideation. The authors point out that there is evidence from previous studies that these interventions might work, but one wonders if it would have been possible to do a much smaller study first to see if they worked with this particular design. With almost 19,000 people randomized, the study must have required a substantial amount of federal funds to run.  While there is never any guarantee that a research study will yield positive results and the journal is to be commended for publishing a study with negative results, it still might have been prudent to do some exploratory work before launching into such a major undertaking.

         This is particularly true because one might have anticipated that offering watered-down versions of mental healthcare would not be effective. Dialectical behavior therapy (DBT), for instance, has been shown in multiple studies to be an effective treatment for several conditions, but it is unclear that the online version used in the study would work as well.  Shouldn’t that have been tested first? While it is understandable to want to provide help for as many people as possible at a time when mental health access is so difficult, it may be inadvisable to rush into offering diluted versions of evidence-based interventions to achieve that goal.

No Shortcuts to a Solution

         The solution to the mental healthcare access problem—and thereby to the increase in mental health issues so many experts say we are facing—is to figure out how we can deliver the evidence-based interventions we already have to more people. For people with anxiety disorders, depression, and posttraumatic stress disorder (PTSD), there are both evidence-based psychotherapies, like cognitive behavioral therapy (CBT), and antidepressant medications that have proven effective. We doubt that anyone would contemplate reduced dose studies on such a large scale of proven medications for the treatment of other medical conditions like diabetes, heart disease, or cancer without some at least preliminary evidence that this might be effective. Why then do we assume that this is a good strategy for mental health disorders? 

Many reasons for the current rise in mental health conditions have been advanced. Worry, loss of sleep, and economic strains from job losses are all posited factors. The pandemic has highlighted the huge disconnect between the scope of mental health problems and the availability of mental health interventions in this and many other countries. We need to join with the Surgeon-General’s call to work much harder to bridge that gap. It will probably require providing sufficient funding to allow people to engage with psychiatrists, psychologists, and other behavioral health professionals, both via telehealth and in person, using the tools we already know are effective. Attempts to find broader solutions to the treatment gap should be careful not to assume that diluted versions of those tools are going to be effective because shortcuts to solve the mental health crisis may well not work. We need to educate primary healthcare providers about how to recognize and treat mental health illnesses; train and deploy an adequate number of psychiatrists, psychologists, and therapists; provide appropriate insurance coverage for mental health needs, including better enforcement of already on the books mental health parity laws; and initiate better public health campaigns to educate people about the signs of mental health problems and their proven solutions. Doing this will be money well spent.

Building Trust Amid Uncertainty

Sometimes It Is Best To Say, “We Don’t Know”

In what was without a doubt a scientific triumph, scientists sequenced the genome of the new virus causing a rapidly spreading pandemic and then harnessed a new technology involving messenger RNA (mRNA) to bring us vaccines that dramatically reduce the risks of our getting severely ill or dying from it.

         The above statement is the accurate way of looking at what happened in the first year of the coronavirus pandemic. How is it possible, then, that a Pew Research Center report issued on February 28 tells us that “fewer U.S. adults are confident that scientists are acting in the public’s best interest than before the pandemic began.” The report showed that between April 2020 and December 2021 the percentage of Americans who have a great deal of confidence that medical scientists act in the best interests of the public declined from 43% to 29%.

         There is clearly a huge disconnect here between what scientists have accomplished during the pandemic and how people view their work. That means there is major work ahead of us to understand what caused that lack of trust and to repair it. Fortunately, many scholars and policymakers are examining the problem and recommending steps for us to take to improve the situation.

Uncertainty Drives Mistrust

         A driving force behind the growing lack of trust in medical scientists seems to stem from the discomfort some of us have with uncertainty.  James Dillard, a communication scientist at the Pennsylvania State University who studies warning messaging, recently explained that “Pro-vaccine messaging is taking place in a highly competitive message environment—one that involves active efforts to undermine public health advocacy…The fact that scientific knowledge evolves and always possesses a degree of uncertainty explains why health agencies change—and continue to change—their messaging. Regrettably, this inconsistency also undercuts the impact of health messaging in a public that wants simple, consistent answers.”

It turns out that we vary in how much uncertainty we can stand and that many factors determine that variability. “As intolerance of uncertainty has begun to be studied as a separate trait from a tendency to worry, “writes Francine Russo in Scientific American, “psychologists have identified typical behaviors—often unconstructive ones—that people use to tamp down their distress at not knowing…Some collect every bit of information they can find online and offline.” If scientists appear uncertain, in part because they change their recommendations based on evolving information, then people with high uncertainty avoidance will seek certainty elsewhere, putting their trust in sources that seem confident even if we know them to be misleading or incorrect. 

Russo describes a study conducted at the University of Illinois, Chicago two years before the coronavirus pandemic in which neural activity during an uncertainty test was measured using functional magnetic resonance imaging. Two years later, participants in the Chicago study  who manifested high activity in a brain region called the anterior insula during the uncertainty test reported increased anxiety, depression, or emotional distress during the pandemic. The anterior insula is associated with unpleasant emotions and fear and this finding suggests that there is a biological trait linked to discomfort with uncertainty.

Lack of trust in health authorities may also have deep roots. A recent study from the U.K. showed that a history of childhood trauma predicted COVID-19 vaccine hesitancy and was independently associated with low levels of trust in National Health Service information about COVID-19. Any attempt to improve our trust in medical science must therefore take into consideration these traits, some of which are inherent in our makeup, some of which are cultural, and others acquired by the often traumatic experiences we have through our lives.

Acknowledging Uncertainty

Borrowing from their research in child development, scientists Tamar Kushnir, David Sobel, and Mark Sabbagh recently wrote that “Research suggests that people are more likely to follow advice delivered with confidence and to reject advice delivered with hesitancy or uncertainty.” When, however, that advice changes, as it has frequently and inevitably during the pandemic, the uncertainty created in peoples’ minds leads to decreased trust in the advice-givers. Their work suggests a solution. “Our research suggests that, in many cases people trust those who are willing to say ‘I don’t know.’”  They go on to assert that:

“The good news is that, based on our research, we believe the human mind doesn’t balk at hearing communicated uncertainty – quite the opposite. Our minds and brains are made to handle the occasional ‘I think so,’ ‘I’m not sure’ or ‘I don’t know.’ In fact, our ability to do this emerges early in child development and is a cornerstone of our ability to learn from others.”

It may not be uncertainty alone, then, that is so discomfiting to us but rather the illusion of certainty that is breached by overly confident health officials that most unnerves our trust in them. What follows from this is that we need a massive campaign to train scientists and health authorities about how to communicate uncertain science without undermining confidence in science. Just as important, we need to educate people how to live with that uncertainty. It will be crucial to ensure that this work is culturally sensitive as well, as the ability to tolerate uncertainty differs not only among individuals but among cultural groups as well. Scientists need to be able to say “this is what appears to be the case from the work we have done so far and therefore we are making recommendations based on what we know now. More research will be done, and these recommendations may change as new information emerges. We’ll be sure to let you know right away when there is a new development.”

The effort to improve trust in scientists will take time. A Yale University research group led by Tauhid Zaman has developed a method of moving people away from online inflammatory ideas that “begins with an attempt to build trust over time,” a tactic he calls “pacing and leading” that is played out over months. “I come close to you,” Zaman explains about his work with people expressing uncivil attitudes about things like immigration on Twitter, “and then I take a step. I start to pace you and lead you somewhere else.” He has expressed the belief that his slow and steady approach to building trust with people online will also work in the public health arena. About COVID-19 vaccines, for example, he says:

“I think public officials’ approach to persuasion about the vaccine has been totally misguided. There are people who don’t want to get the vaccine, and the response has been to tell them it’s good and jam that message down their throats. That’s just going to create more antagonism, more skepticism, more denialism. Persuasion takes time; it’s not instantaneous.”

         A similar approach to regaining trust is followed by astronomer Katie Mack of North Carolina State University. “What I try to do is share the real information, and I try to share it in a nonjudgmental way. When people ask me a question, and they have a misunderstanding, I try to correct that misunderstanding in a way that doesn’t imply that they’re dumb to believe it in the first place. I try to start from the point of, ‘it’s great you’re interested in learning more about this. Here’s how you can learn more about it.’”

         Last February New York Times columnist Ezra Klein put the issue bluntly. “Public health is rooted in the soil of trust. That soil has thinned in America.” Klein cited a recent paper in the journal Lancet that examined the relationship between trust in government and fellow citizens and COVID-19 infection rates in 177 countries. “This yields the paper’s most striking finding,” Klein wrote. “Moving every country up to the 75th percentile in trust in government…would have prevented 13 percent of global infections. Moving every country up to the 75th percentile of trust in their fellow citizens…would have prevented 40 percent of global infections.”

         Mistrust in government, public health authorities, and medical scientists has a real effect on our individual and collective health. It stems in large part from an inability to accept the uncertainty inherent in science and is worsened by communications from health authorities that are overly confident and that do not prepare us for the inevitable changes in guidance that result from newly emerging research. We need to think of trust as a public good, something that governments are in large part responsible for maintaining and, when necessary, repairing. It will take an understanding of the many factors that impinge on the tendency to uncertainty intolerance and of the ways we form and maintain trust in institutions and authorities. It will also take time, patience, and an empathic stance. Ignoring the growing issue of mistrust in public health institutions and medical science would be to put the public’s health in ever graver peril.

What Are the Odds?

How We Know What A Diagnostic Test Means

Mary, a healthy 30-year-old woman, wakes up one morning with a stuffy nose and a scratchy throat. She has been very careful about wearing her high-quality, N95 mask in public places and has had three shots of an mRNA vaccine against the virus that causes Covid-19. Still, she knows that even vaccinated people can become infected, so she does a home Covid-19 test on herself and it is negative.

         Mary has heard, however, that the rate of false negatives for the home tests, which detect the presence of a protein (also called an antigen) on the surface of the virus, is very high. She worries that despite the negative test she may actually be infected with SARS-CoV-2, the virus that causes Covid-19, so she seeks out a PCR test. The PCR, or polymerase chain reaction, test for the virus, she has heard, is more accurate but can take several days to get a result. She goes to a local pharmacy, gets the nasal swab test, and goes home to wait for the result. Her symptoms continue to worsen.

         Three days later Mary gets a text telling her that her PCR test is negative. She is pretty sure this means that she does not have Covid-19, but she now has a bad cough, some chest pain, and a very sore throat. She decides to visit her primary care physician. Her doctor agrees that it is unlikely she is suffering from Covid-19, asks questions about her symptoms and her medical history, and performs a physical examination. Her lungs sound clear, and the doctor finds no abnormalities on the examination. Blood tests, a throat culture, and a chest X-ray to rule out pneumonia are ordered.

         The next day, Mary gets a call from the doctor that her X-ray was normal but one of the blood tests of liver function the doctor ordered has yielded a slightly elevated level.  Mary is perplexed by this—she has no symptoms other than what now appears to be an upper respiratory viral infection. She does not drink excessive amounts of alcohol and has had only one sexual partner for many years. Why should she have an abnormal liver function test? Could it be a false positive? Should she see a liver specialist and have more tests?

How to Interpret Laboratory Tests

         This not uncommon situation raises the issue of how we interpret the myriad of laboratory and imaging tests doctors now have at their disposal to help make diagnoses. We would like to believe that the results of these tests have easy, cut-and-dry interpretations, either positive or negative for a disease. In fact, no laboratory test is perfect, false negatives and false positives occur with all of them, and even the decision about whether to order a test in the first place depends on many factors.

Diagnostic test results may give “positive” or “negative” results, or said to be “normal” or abnormal,” but their meaning is usually not so black and white. Several considerations are important in deciding whether to order laboratory tests in the first place and, if they are ordered, in understanding what the results mean (image: Shutterstock).

         An article in The New York Times last January highlighted an extreme version of the difficulty sometimes encountered interpreting diagnostic tests. Titled “When they warn of rare disorders, these prenatal tests are usually wrong,” the article details the perils of tests performed on blood samples from pregnant women that are intended to reveal whether a fetus will be born with a genetic disorder. The analysis of these tests by The New York Times investigative reporters showed that “the positive results on those tests are incorrect about 85 percent of the time.” The article tells the harrowing story of people who were told on the basis of these blood tests that their unborn child would suffer from severe genetic abnormalities and is rightly critical of the industry that performs and promotes these tests. “The Times reviewed 17 patient and doctor brochures from eight of the testing companies,” the reporters wrote. “Ten of the brochures never mention that a false positive can happen. Only one mentioned how often each test gets positive results wrong.”

         While it is obviously unacceptable to withhold information from prospective parents shelling out hundreds or thousands of dollars for these tests, which give false positive results most of the time, what The New York Times article did not explain is that none of this is at all a surprise to people who understand how diagnostic testing works. The accuracy of any diagnostic test depends not only on the accuracy of the test itself, on multiple other factors including how common the illness is in any population (that is, its prevalence) and something called “pre-test probability.”

Specificity and Sensitivity

         The accuracy of any diagnostic test can be measured in several different ways, most basically with metrics called specificity and sensitivitySpecificity refers to the ability of a test to detect someone who does not have the disease in question. A highly specific diagnostic test will yield very few false positive results. The specificity of the PCR test for Covid-19 is very high, around 95%, so that if you have a positive test you are very likely to really be infected. The sensitivity of a test refers to its ability to detect some who does have the disease. A highly sensitive diagnostic test will yield very few false negatives. The sensitivity of the PCR test for Covid-19 is also very high, around 90%, so that if your test is negative you most likely aren’t infected. Home Covid-19 tests are also quite specific, but not as sensitive so that Mary was correct that her negative test could have been a false negative and she did the right thing to seek a PCR test to be sure.

         When testing for very rare diseases, however, as is the case with the prenatal tests discussed in The New York Times story, even very specific tests can yield many false positives. An article in ProPublica noted by Critica Chief Medical Officer Dr. David Scales gives a good explanation of why this is the case. It gives the example of a disease that is present in 4% of the population. If 1000 people are screened and the test is 100% sensitive (note that almost no real tests are this sensitive), it will accurately detect all 40 people who truly have the disease. Let’s say that the test is 95% specific. That means that 5% of the remaining 960 people who don’t actually have the disease—48 people—will nevertheless test positive. The number of false positives thus exceeds the number of true positives in this example, even with a test with very high specificity and sensitivity. The genetic syndromes The New York Times article was concerned about are much less common than even 4%–occurring in some cases at rates of around 0.05% of the population or even less. It is obvious, then, that no matter how accurate the diagnostic test is, there will be more false positives than true positives with a screening test for diseases this rare. A negative result on one of these prenatal tests may be reassuring, but a positive test is hard to interpret and obviously will cause a huge amount of anxiety in the prospective parents, who will have to wrestle with decisions such as whether to continue the pregnancy, undergo more invasive diagnostic tests, or even just ignore the blood test result. Testing companies should be much more upfront informing people about the real-life accuracy of these prenatal tests, but no one should be surprised that positive results will usually be false.

Pre-test Probability

         One thing that can help sharpen diagnostic decision making is to consider the pre-test probability that a person has an illness. Before ordering any test, it is important to consider two things: how likely is it that the person has the illness in question and will the test result make any difference in the patient’s life. The first of these considerations is the pre-test probability. In Mary’s case, there was a reasonable pre-test probability that she had Covid-19 because she had typical symptoms of the illness: nasal congestion, cough, and sore throat. This makes her negative result on the home Covid-19 test more reassuring, because false negatives are more common in asymptomatic people.

On the other hand, Mary’s history and physical examination results make it very unlikely that she has liver disease. Were it not for the fact that she came to the doctor because of nasal stuffiness and cough, no blood tests would ever have been ordered. She has no risk factors for liver disease and on examination her liver was not enlarged. Many physicians would not have ordered liver function tests in this case in the first place.

         Now faced with an abnormal laboratory result, Mary and her doctor can apply an algorithm that takes into account the pre-test probability of liver disease and the accuracy of the laboratory test. We won’t go through the mathematics of that here but suffice it to say that applying the algorithm yields a very low percentage likelihood that Mary actually has any problem with her liver. The post-test odds of disease, then, are very low and Mary and her doctor conclude the test result is most likely a false positive (the magnitude of the abnormality of the liver test, which was small, is also a factor here that we haven’t discussed). They decide to ignore it and repeat the test in a few months just to be sure. Other patients and doctors may choose a different course of action, but the important thing is that once again there is no black and white about the blood test result. A “positive” test result in this case does not mean that Mary has liver disease.

         It was not that long ago that doctors had few diagnostic tests at their disposal and had to make diagnoses based mainly on history, physical examination, and intuition. There is no question that more sophisticated laboratory methods and new diagnostic tests have improved the accuracy of diagnoses and patient outcomes. But there is also recognition that many tests are ordered unnecessarily.  Before a test is ordered, some considerations are:

1. How accurate is the test—what is its sensitivity and specificity? How likely is a false negative or false positive result?

2. What is the pre-test probability that an illness is actually present? What effect would a positive test result have on the post-test odds that an illness is present?

3. What difference will the test result make? Will it alter management of an illness, provide reassurance, change plans?

Before you ask your doctor to order a blood test or an MRI scan, then, ask them to discuss those three considerations with you. It might be that you and the doctor will decide that the test is unnecessary. At the very least, you’ll be in a better position to understand what the test results mean if you do go ahead with it. Had Mary known all of this, she might have asked her doctor what all the blood tests they ordered were, what they were for, and why they were being ordered. Perhaps, with that information, the liver test would never have been done at all.