The Importance of Bringing Science and Medicine to Lay Audiences
As a faculty member in the Alan Alda Center for Communicating Science at Stony Brook University, I have spent the past 6 years working to help scientists and medical professionals learn to communicate more effectively about their work. I can cite many reasons why this is important, and later in this article I will. But the one that comes first to mind is a personal one. I see myself, 25 years younger, standing on the street outside a medical center, sobbing into a pay phone as I wait for my mother’s cardiologist to come on the line. A surgeon had just performed an aortic value replacement on my mother. Then, with eyes fixed on the floor, he had delivered a cryptic 15-second update that left me believing she had had a stroke of unknown magnitude. I knew her cardiologist was a good listener and patient talker and I was hoping that, for better or worse, he could explain things to me.
Just as I felt on that street corner, lay people are yearning for information they can understand. They need explanations in plain language that fit their level of knowledge and anxiety, the chance to air options and risks with someone they can trust. They want someone to hear the uncertainty in their voice and respond to it, to anticipate the areas of likely confusion and deal with misconceptions and fears that may never be voiced. This is true whether the people are patients, relatives of patients, or just 21st Century humans trying to make sense of successive waves of diet trends, child-rearing advice, and as-seen-on-TV prescription drugs. Not to mention the difficult issues of advanced directives and end-of-life care.
Ironically, it has never been easier for lay people to find information about health and science. All they have to do is wade into the Web’s ocean of facts, rumor, opinion, and advertising. About 60% of US adults get health information online, and 35% say they have gone online specifically to identify a medical condition they or someone else might have.1 In this age of Dr Google, it can take only 0.28 seconds, roughly speaking, to get 1 760 000 hits on a phrase like aortic stenosis.
Nor has there ever been more pressure for clinicians to communicate well. The issue has taken on new financial urgency for hospitals, now that the Centers for Medicare and Medicaid Services has decided to link up to 2% of reimbursements to hospitals’ scores on a survey of patient satisfaction, the Hospital Consumer Assessment of Healthcare Providers and Systems survey. The 25 questions in the Hospital Consumer Assessment of Healthcare Providers and Systems survey include 8 that deal with communication, including direct queries, such as: “During this hospital stay, how often did doctors explain things in a way you could understand?” and “During this hospital stay, how often did doctors listen carefully to you?” With funding at stake, hospitals increasingly are seeking ways to improve doctors’ and nurses’ communication skills.2,3
But effective communication involves far more than stating facts, even if the facts are true. Communication is a 2 -way process that requires understanding, context, and judgment. It is always a conversation, even when only 1 person is speaking. In this duet, the harder role is the experts’, because they must try to get into the mind of the other. They must make an imaginative leap, setting aside the language and assumptions they have worked so hard to acquire, and remembering what it was like not to know.
At the Alan Alda Center for Communicating Science, part of the School of Journalism at Stony Brook University, we teach courses and workshops for graduate students in scientific disciplines; for medical, nursing and dental students, and for science and medical faculty members, at Stony Brook, NY, and in workshops around the country. We try to help experts make that leap.
The Alda Center Method
Our approach focuses on connecting with and responding to other people, on knowing your audience and knowing your goal, on empathy and clarity. We use, among other techniques, exercises based on improvisational theater games. The goal is not to turn scientists into actors or comedians. The goal is to help them learn to pay intense and dynamic attention to the other person, reading and responding to verbal and nonverbal cues, rather than following a script. We have found that becoming a better communicator is more like learning to play a musical instrument than like acquiring a set of facts. It requires not only instruction and examples, but practice, feedback, reinforcement, and more practice.
Alan Alda, the actor, writer, and science advocate, helped found our Center and continues to work with us as a Visiting Professor in the School of Journalism at Stony Brook, part of the State University of New York. It was he who first suggested we experiment with improvisation (improv) exercises. He said improv was the only acting training he had ever had, and he felt it transformed him as an actor and as a person.
How does improv work? Here are 2 examples.
In a classic, basic improv exercise, Mirror, 2 people stand facing each other. One is the leader, the other is the reflection. The leader moves, lifting arms, bending, smiling, turning, whatever, and the other person must mirror each gesture. The goal is to move so closely together that an observer cannot tell who is leading. At first, there is usually a lot of nervous laughter. Just looking into another person’s eyes can be uncomfortable. Leaders often start by making clever, unexpected gestures. But with help from the instructor, they start to understand that the leader succeeds only when the follower can keep up. The leader must pay close attention to the follower, adjusting to him or her, and making moves clearer. Typically, the room becomes silent, and people move more slowly and purposefully. The instructor shifts the roles, so that each person leads and each person follows, back and forth. When the partners are in tune, even a close observer will have trouble telling who is leading. Eventually, the instructor tells them to keep going, with both of them leading and both following. Amazingly, thrillingly, this works for most, and the 2 partners move on together.
The analogy to communication is obvious. The leader, the speaker, must take responsibility for making sure the listener can follow. To do this, the leader must focus attention on what the other person needs and how he or she is reacting. During the conversation, these roles may shift. But in either role, you do not succeed by showing off how clever or creative you are. You succeed by paying very close attention to the other person. It sounds simple, and it provides fresh language and images for people to refer to when they think about communication. But with Mirror, as with other improv exercises, actually practicing the game has a very different impact than just hearing about it. Participants experience a transformation over time that surprises them and often makes them aware of capabilities they did not know they had.
Or take the Two-Minute Rant. Again, participants work in pairs. Each person rants to their partner for 2 minutes about something that bothers them, whether serious or trivial. They are encouraged to let it all hang out, to yell and stamp if they feel like it. Then each partner introduces the other to the group as a friend, and reframes the other person’s rant in a way that tries to find an underlying positive motivation. Say John and Mary are partners. John has ranted about the stupid, incompetent drivers he sees each day as he drives his son to school. “These idiots don’t signal, and they drive between lanes. Then they cut you off and immediately slow down. Do these people even have licenses? Where did they learn to drive? Are they drunk? I don’t care what they are – they should all go to jail for attempted murder. But not likely because there are never cops when you need them. The police are too busy giving tickets to parked cars. What do we even pay taxes for?” And so on. Mary might then introduce John to the group this way: “This is my friend, John. John is a very concerned father. He worries about the safety of his son when he drives him to school each day and wishes all drivers were as responsible as he is. As hard as he tries, he knows he cannot fully protect his son from reckless drivers, and that preys on his mind.”
This exercise reinforces a deeper kind of listening, which doctors tell us they find helpful, especially when they, or their colleagues, are the target of the rant. As listeners, the participants practice excavating the emotion behind the words and expressing it clearly. As ranters, they gain insight from the reframing and feel the warmth of being introduced as a friend. Most experience what it is like to be heard and understood by a stranger, or at least to be given the benefit of the doubt. And within a few minutes, the members of the group get to know each other in a way that usually would take far longer.
Improv games are not the only methods we use. Our other foundational approach, called Distilling Your Message, focuses on choosing words, providing context, using metaphors or props, and telling stories. Stories are the magic bullet of communication, and because they are so memorable and convincing, they can kill or cure. Sometimes a brother-in-law’s third-hand story about a bad side effect can outweigh a briefcase full of studies. But stories can serve the truth, and medical professionals, who typically have many dramatic stories from personal experience, forego a powerful tool if they choose not to tell them (within Health Insurance Portability and Accountability Act limits, of course). We also use role-playing, videotaped interviews, and many other techniques. But all these tools work in the same direction: to focus attention on your goal in communicating and on how getting into the head of the listener can help you meet that goal.
An anesthesiologist told our Medical Program Director, Evonne Kaplan-Liss, MD, MPH, how she had applied this approach:
Previously, I would ask the patient if they “did okay with anesthesia” and would immediately proceed into what they could expect. I felt like I was doing well because of the detail I was providing; who else spent the time doing that? (Aren’t I wonderful...)
Now I start the speech with, “I’m your anesthesia doctor and I’m here to keep you safe and comfortable.” I swear to God, the patients visibly relax when I tell them this - and only then do I discuss the specifics. I believe I am serving my patients so much better and I am very grateful to you for this (private communication, November 13, 2013, to E. Kaplan-Liss) .
Why Communication Counts
Why is it so important for clinicians and researchers to communicate effectively about science and medicine with people?
For clinicians, the benefits of communicating effectively with patients and with their colleagues are clear, urgent and practical. There is evidence that good communication by physicians can reduce malpractice claims 4,5 and medical errors 6 and can improve treatment compliance,7,8 improve health outcomes 9 and improve patient satisfaction.10–,12 And, as mentioned earlier, the Centers for Medicare and Medicaid Services has put a financial premium on patient satisfaction, with good communication an important element.
But effective communication of science and medicine matters far beyond the clinical setting. We live in a world based on science, and many of the most important decisions we face, as a society and as individuals, need to be informed by scientific modes of thought if we are going to reach good decisions. To deal wisely with issues like climate change, sustainable food production, reproductive and genetic technologies, emerging infectious diseases, vaccination, energy production and cybersecurity, we need scientific literacy. People who are not scientists need to understand and appreciate the processes of science: the importance of gathering, testing, and weighing evidence, of revising conclusions as new information emerges, of assessing risk, of confronting possible sources of bias. Daniel Patrick Moynihan used to say, “Everyone is entitled to his own opinion, but not to his own facts.” It is science that stubbornly insists on this distinction, and if it could prevail on this point, how much safer and saner our world would be.
The public and its policy makers also need to understand, in this age of translational research, why society still needs to invest in curiosity-driven research, basic research whose possible applications are beyond our abilities to predict. It was this kind of research, “the work of thousands of basic scientists whose primary goal was understanding the fundamental working of living things, ” that led to the spectacular flowering of biomedical advances and the biotech industry in the past 50 years.13 It was the arcane and paradoxical world of quantum physics that led researchers to the transistor and the laser, which in turn made possible personal computers and mobile phones, the hallmarks of our era.14 Scientists have a responsibility to share the meaning and importance of their work with the people who are funding it.
Every so often, the Alda Center’s Improvisation Program Director, Valeri Lantz-Gefroh, takes a video camera out on our campus and nearby towns and asks people on the street questions like “what is metastatic cancer?” Answers to that question were about evenly divided between “cancer that has not spread,” “cancer that has spread, ” and “don’t know.” One Stony Brook employee, a technical manager, tried to decode the word; static means “unchanged,” he reasoned, so “metastatic” probably meant it had not spread. Another employee said she used to know, but could not remember. Respondents were similarly divided on the question, “If you were tested for cancer and were told the results were positive, would that be good news or bad news?”
These video exercises are by no means scientific surveys, but seeing them is illuminating for the scientists and medical professionals we teach. The people in these videos are educated, responsible, working adults who know a lot about a lot of things. But they do not speak the language of science or medicine or have the context that gives that language meaning.
Overcoming the Curse of Knowledge
If nonscientists like me are going to appreciate scientific ideas, the way nonmusicians can appreciate Beethoven or revel in Ravel, scientists need to be out in public adding their voices more fully to the public conversation. From using social media, like Twitter or Reddit, to speaking at high schools and libraries, to testifying before Congress or writing books, the modern landscape provides many routes to join the conversation. One benefit to outreach is that it tends to be self-reinforcing. We hear time and again from scientists that it is fun and invigorating and that they learn a lot from people who are not experts in their field.
Nicholas Spitzer, Distinguished Professor of Neurobiology at the University of California San Diego and director of the Kavli Institute of Brain and Mind at University of California San Diego, put it this way:
...when I talk publicly, I appreciate the need to step back and present the big picture, and in so doing put details into a larger context that is much more accessible – and much more memorable – for an audience. This has stimulated me to think about larger questions over the years and has influenced the directions of my research. This happens simply by virtue of stepping back from the immediacy of the details of a particular experimental paradigm, or a focused, tightly drawn question, then restating it in a context that the public finds understandable and interesting.15
The good news is that the so-called Sagan effect, the belief that a scientist who spends time in outreach or public communication is not a real scientist, seems to be fading, especially among younger scientists. When the Alda Center began offering Communicating Science courses to science graduate students in 2011, many faculty members were skeptical. The courses were offered in short modules in the evening, to make them easy to sneak into students’ crowded schedules, and did not count toward any degree. Now > 600 students have taken them, 4 graduate programs require them, and several graduate programs cite them in recruiting students.
Similar changes in attitudes have occurred nationwide, as more scientists come to regard communication as an essential skill. One reason for the change, I believe, has been the gradually accumulating impact of the National Science Foundation’s broader impacts criterion, which evaluates grant proposals in part based on their broader impacts to society. This criterion, adopted in 1997 and clarified in 2007, has encouraged researchers to include dissemination and include public engagement elements in their grants.16
Unfortunately, however, science communication and outreach still is rarely rewarded in academic careers. For researchers, especially young ones, heavy pressure to bring grants in and push research papers out can keep scientists blinkered in their academic lanes. Not everyone wants to communicate more broadly, and not everyone should. But if communication and outreach truly counted toward promotion and tenure decisions in universities and medical schools, we would begin to see greater engagement among researchers, clinicians, and lay people, all listening to and learning from each other.
In workshops at the Alda Center, we often refer to “the curse of knowledge,” a concept popularized in the book, Made to Stick, by Chip Heath and Dan Heath.17 The idea is that when you know something very deeply, it becomes difficult to remember what it was like not to know it. You become so used to the language of your specialty that you no longer realize that terms like impedance plethysmography or epigenetics are not part of most people’s vocabulary. Perhaps more importantly, you may become so habituated to your work that you no longer recognize what is surprising, fascinating, inspiring, frightening, disgusting, beautiful, frustrating, funny, or thrilling about it. When you make the effort to share your science with lay people in a clear and vivid way, you get a chance to reconnect with your own passion and see your science anew.
How can you begin to practice this approach? Normally we avoid giving tips, in favor of experiential learning, but here are some ideas to keep in mind.
Know your goal: What is the one thing you most want people to learn, remember, think or do? Plan your communication to serve that goal.
Remember the curse of knowledge. If you are speaking to someone who lacks the context you have, give them the big picture first before you give them the details.
Answer the “so what” question even if it is not asked. Why does this matter?
Avoid using any words or acronyms that an 11-year-old would not know. If you want to use a technical term explain it before, not after, you use it. (“The procedure I just described is called …”)
Tell stories whenever you can. Use analogies, metaphors, pictures, or other props if you can.
Consider being more personal, sharing more of your own authentic self, within appropriate limits. This can help you connect with other people, building trust.
Listen deeply. Be open to letting what you hear change what you say and do.
Let me tell you what happened in my story at the start of this article, the story about my mother’s aortic value replacement. As I waited on the street corner, her cardiologist came to the phone and told me in blunt language that the surgeon, a very fine surgeon, was a bad communicator who kept scaring patients and their families. Nothing had happened during my mother’s surgery to make him suspect she had had a stroke. In a confusing way, the surgeon was just mentioning the background risk of stroke, which we already knew about. “I keep telling him not to do this right after surgery –everyone gets the wrong idea,” the cardiologist said. His tone of honest exasperation was convincing. My mother recovered, and lived a dozen more years, long enough to become a grandmother. When she died, I wrote the cardiologist a letter. I will always be grateful for his kindness.
The author would like to acknowledge Valeri Lantz-Gefroh, the Alda Center’s Improvisation Program Director, and Evonne Kaplan-Liss, the Alda Center’s Medical Program Director, for their essential creative contributions to the work described in this article; Howard Schneider, Dean of Stony Brook University’s School of Journalism, for his leadership in establishing this work as a university priority, and Alan Alda, Visiting Professor in the School of Journalism, for inspiring this effort and continuing to guide it with his insights and passion.
About the Author
Elizabeth Bass, MPH, is the director emerita of the Alan Alda Center for Communicating Science at Stony Brook University. A longtime journalist, she was science and health editor of Newsday, Long Island’s daily newspaper, where she supervised reporting that won the Pulitzer Prize for explanatory journalism, and other top science journalism awards, as well . She has taught science and health reporting and news literacy at Stony Brook University, where she developed and initially led the School of Journalism’s master’s program, which focuses on coverage of health, science, the environment, and technology. She also has taught journalism at Hofstra University and at Columbia University’s Graduate School of Journalism. She is coauthor of 2 books, Bioterrorism: A Guide for Hospital Preparedness and Kids Health Guide for Parents and has edited or contributed to several other books about science and health for general readers.
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