Nuance can help health field regain public trust: AcademyHealth CEO

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Mark Masselli ( 00:04 ):
Our guest is a pediatrician and researcher who considers it his mission to take down health myths and
weak medical research. In his new role, he has a bigger platform than ever to share his message.
Dr. Aaron E. Carroll ( 00:17 ):
The way that we discuss nutrition and food is a great example of the way that we burn people's belief in
science in that it feels like people are told one or the other. Eggs are going to kill you because of
cholesterol. Oh, it actually doesn't matter. Eat as many eggs as you like. Red meat will kill you. Oh no,
red meat can be part of a diet. Drink no alcohol to you'll read other studies and hear like, "Oh, no, no.
Drinking red wine is perfectly healthy," when a lot of that is caused by the fact that we're not good at
discussing nuance about research especially in nutrition.
Margaret Flinter ( 00:51 ):
Dr. Aaron Carroll is the newly named president and CEO of AcademyHealth, which aims to improve
healthcare by advancing evidence to inform policy and practice.
Dr. Aaron E. Carroll ( 01:01 ):
Most people should know that going to extremes can add a tiny bit of risk here or there, but the
extremes that we are often sold one way or the other about what you should or should not eat are often
not really well-supported by science.
Margaret Flinter ( 01:19 ):
And this is Conversations on Health Care.
Mark Masselli ( 01:30 ):
Well, Dr. Carroll, welcome to Conversations on Health Care.
Dr. Aaron E. Carroll ( 01:33 ):
Thanks for having me.
Mark Masselli ( 01:35 ):
Yeah. We know you as a prolific writer, producer of media about healthcare policy and research. We
want to get into the specifics in a minute, but first, congratulations on your new role as president and
CEO of AcademyHealth. I think it is a perfect fit because AcademyHealth has really been working to
improve healthcare by using evidence to inform policy and practice. I'm wondering if you could tell our
audience a little more about the work that AcademyHealth undertakes.
Dr. Aaron E. Carroll ( 02:06 ):
Thanks for the opportunity. Yeah. I couldn't be more excited to be stepping into this role. I was at
Indiana University for 21 years before this and I used to joke that there were only one or two jobs that
could ever pull me away. This just happens to be one of them. I mean, AcademyHealth's mission is to
use data and evidence to prove health and healthcare for all. And I like to think that over the course of
my career as a researcher, it was about how do we take data and evidence and use it in clinical decision
support or medical decision making to help healthcare providers provide better care?

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Dr. Aaron E. Carroll ( 02:43 ):
In mentorship it was how do I take data and evidence and use it to improve research and how we train
researchers? When I got into science communication work, it was how do we take data and evidence
and bring it to the public so that they can make better decisions about health and health policy? And
even when I was chief health officer, it was how do we take data and evidence and apply it to public
health in a pandemic response or the improvement of mental health? And all of that was taking data
and evidence and using it to improve health and healthcare, which is really what AcademyHealth is all
about. The organization is ... I'm sorry. I was just-

Margaret Flinter ( 03:19 ):
Nope. Go ahead. Go ahead.

Dr. Aaron E. Carroll ( 03:20 ):
The organization is the professional home for health services researchers and health policy researchers.
We have about 3,000 members. About half of them probably come from universities or academic
environment, but others work for government or for think tanks or for nonprofit or for-profit
companies, but all of whom engage in creating the body of evidence that we can use to improve health
and healthcare. We put on a couple big national meetings focused on research or on data or on
dissemination implementation science and in addition, we do a decent amount of extramurally funded
work as well, working with partners to help improve the ways that we can gather and disseminate and
produce evidence.

Mark Masselli ( 04:10 ):
And what's the financing model for AcademyHealth? Is both working with some funders or is there
endowment?

Dr. Aaron E. Carroll ( 04:21 ):
I'd say about half our revenue comes from extramural sources, which include foundations like the
Robert Wood Johnson Foundation or the Commonwealth Fund or others. We also get some funding
from AHRQ and for PCORI and the NIH for either meetings or individual research projects, which we
work with various partners across the country. Some of it is obviously membership and some of it is
some of the big meetings we put on. Our biggest meeting is the annual research meeting, which is just
next week, which usually gets about 2,800 to 3,000 attendees. We also have Health Datapalooza, which
is on September 17th and the Dissemination Implementation Science meeting, which will be later this
year.

Margaret Flinter ( 05:07 ):
Well Dr. Carroll, AcademyHealth is very well known among people engaged in health services, research,
and other areas, but I'm really curious, as you looked at this opportunity and as you spoke with people
and maybe did a deeper dive, how do you think a clinician in the field and practice or an average patient
sees AcademyHealth's efforts in action? Can you point to a few areas where you think AcademyHealth
has really made a big difference for people in recent years in healthcare?

Dr. Aaron E. Carroll ( 05:37 ):

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So I mean, some of it is going to be below the radar because it's definitely in the promotion of the field
and bringing researchers along and helping to advance their careers, but some of our advocacy efforts
focus on our policy priorities, promoting research and science innovation. We're constantly talking to
the hill and to the NIH and to other federal funders to improve research and science innovation, to
improve the health system and how we might do research to tell us how to have the United States
healthcare system work better.

Dr. Aaron E. Carroll ( 06:10 ):
We focused in recent years on healthcare provider resilience, which has been a big issue since the
pandemic. We certainly focus on capacity in reducing health disparities and including racial and
socioeconomic factors. A lot of these, again, aren't going to be front page we cured a disease kind of
things, but it's the bread and butter of health services research, trying to improve the access, quality,
and cost to the healthcare system, which definitely benefits all of us.

Mark Masselli ( 06:41 ):
I want to try to balance two things. One was something you wrote about, a study that found American
support, the use of data for public health and research purposes, and then sort of the general
observation that it seems that the public is not really supporting science as much as they have in the
past, but you also talk about the drop in support by African-Americans, the decrease that they have in
terms of that data. How do you balance all of these out and what are the consequences if these views
really don't change?

Dr. Aaron E. Carroll ( 07:21 ):
Well, I mean, there's lots of really good reasons that a variety of different communities don't trust
research. We have not often been honest with them in both in their inclusion and research and how
their data is used. We need to do a much better job of that. We need to be inclusive and honest and
respectful in both the invitation and the conduct of research involving all different kinds of communities,
especially those from underrepresented groups that have traditionally been ignored. In addition, I think
science has taken a bit of a hit during the pandemic. We are not often very good about discussing
nuance. I think too often science has been portrayed as binary, positive or negative. When the truth is,
really a lot of it is gray and each individual study adds a little bit to our complete fund of knowledge.

Dr. Aaron E. Carroll ( 08:18 ):
But a lot of people aren't comfortable with that nuance or discussing that nuance and when you
describe things in absolute terms when the data and the evidence don't warrant it, it creates a climate
where people don't trust exactly what you're saying, especially when they see things change. I also don't
think we've been very good about that, discussing the fact that science changes. It is not an absolute
thing where we know this all to be true and then we're just adding to it. A lot of the work that we do is
completely adjusting some of what we found before and trying to figure out how do we add to it. I'd
also say that good science communication has to be built around trust and building trust takes a lot of
time and a lot of effort.

Dr. Aaron E. Carroll ( 09:02 ):
Too often we're searching for that sound bite, the perfect tweet or the perfect TikTok video which will
convince everyone what is correct or truth. That is rarely the case. It's often really sitting and talking and
listening and building up trust and answering the same questions over and over and over again, trying to

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get people to understand why we think things are the way they are, where the gaps are, and how they
might change in the future. We need to do better.

Mark Masselli ( 09:30 ):
You need those disclaimers on the bottom that with more data points we may change our minds or no? I
mean-

Dr. Aaron E. Carroll ( 09:37 ):
Yeah. I mean, I like to think that when you read a column that I've written or a video that I've produced,
what you see is not just an explanation of what I think is correct, but why? In a discussion of the entire
fund of knowledge, even if we're discussing a new study, how that is placed in context with what we
know before. What are the pros and cons of the research methodology that was used? How assured are
we of certainty? How much of a change should this make us enact? That, again, unfortunately takes
time. It is not how you can discuss things on cable news. It's not how you can discuss things in a very
short video. It requires a longer conversation and it's one of the reasons I think that people so often
aren't getting the full story and then when they hear something else, they worry that things just aren't
true.

Dr. Aaron E. Carroll ( 10:36 ):
It's nuanced and while I don't think we need to say a disclaimer of, "This can change at any time,"
because some things we are more assured of. The overwhelming amount of data for instance that we
have that vaccines don't cause Autism means that even if a new study comes along, a new cohort study
or case control study that might appear to differ, that has to be placed in the context of an
overwhelming amount of data from randomized controlled trials and large studies. It's worth always
discussing that broader context and as we develop more and more data and we get more and more
assured, then newer studies shouldn't move us as much, but when it's new, hot information, then
clearly things are not yet set and they can move.

Margaret Flinter ( 11:23 ):
Well Dr. Carroll, one of your AcademyHealth, I should say, big initiatives is research on how to build trust
between communities and clinicians. Now you can look at that a lot of different ways.

Dr. Aaron E. Carroll ( 11:34 ):
Yep.

Margaret Flinter ( 11:34 ):
How do I feel about my primary care provider, but it's also how do I feel about my hospital, my health
system? How do I as a member of a certain community feel about these institutions? Tell us more about
this. We certainly know all the data for 20 or 30 years that nurses are the most trusted people, but
people's primary care provider, what they often refer to as their personal physician, I think is probably a
close second. So what are you studying and what are you learning?

Dr. Aaron E. Carroll ( 12:01 ):
Well part of what I think we're studying is how to measure and know if there is trust or mistrust because
too often we just rely on anecdote or what we might see in social media when really, even in this high,

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everybody's concerned about distrust or that no one trusts science, again, I think if you look at the data
on year to year, still physicians, nurses, very highly held in terms of trust, even as we are worried that
we're losing everyone to disinformation and misinformation on social media. So we need to be able to
measure these things, but I also think we need to figure out what are the critical factors in building
trust?

Dr. Aaron E. Carroll ( 12:45 ):
It can't just be your famous and get to be on cable news. We know that we need trusted voices in the
communities that are listening because often it requires a trusted voice in the community to actually get
people to listen and to perhaps change their views. But we're also working on what are the key
components of building trust, keeping trust, and combating misinformation and disinformation because
of course, just throwing things out there, rebutting often doesn't work as well as, for instance, pre-
budding. Trying to build those relationships and get people to understand how science works and what
questions they should ask when they hear new information is much more powerful than trying to
change their minds after they've heard things that are just not true.

Mark Masselli ( 13:39 ):
I want to pull the thread on building trust and keeping trust and thinking about your new position and
what changes might you bring or focus that you might bring to your role at AcademyHealth that talks
about those relationships that need to be built beyond the scientific community to the larger public?

Dr. Aaron E. Carroll ( 14:00 ):
Well I think we need to really, really focus on science communication. I think we also need to change the
ways that researchers and scientists talk about science. Too often people are only comfortable
discussing the research that they did with their own two hands. If you go to a traditional scientific talk,
it's often, "Let me tell you about a study that we did and why that's important." With very few
exceptions. Individual research studies rarely change the landscape of what we're talking about. They're
all adding a small amount to what we already know, either reinforcing or perhaps changing direction a
little bit.

Dr. Aaron E. Carroll ( 14:40 ):
But too few scientists are willing to have that general, broad discussion about a whole area, which
leaves people not understanding the whole context, but also feeling like things are whipping up and
back and up and back. I also think we have to get better at talking about that research is not research,
that there are different types of research that some will much more easily be changed into actual
practice, some are more foundational, some might be hypothesis generating, while others might
actually change the things that we think we ought to do in the practice of health or healthcare.

Dr. Aaron E. Carroll ( 15:20 ):
I also think we need to have a more honest conversation about all the incentives, which can sometimes
unfortunately push us away from good reproducible science and recognize that we probably need to
reform a lot of the ways that we conduct, fund, report, analyze, and even discuss research in order to
make people understand its limitations as well as its benefits and how we might place it in context to
understand the world in a better way.

Margaret Flinter ( 15:52 ):

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Well Dr. Carroll, there's so many interesting things underway at AcademyHealth, but one area that we're
intrigued with and would like to know more about is the interdisciplinary research group on nursing
practice, nursing workforce, the delivery of care. How has this initiative come about? What are some of
the key areas that it's involved in and what do you see on the horizon for that work?

Dr. Aaron E. Carroll ( 16:17 ):
Well one of the most important things I think we've learned in the last few decades is that we can't just
focus on one aspect of healthcare. So little is truly fixed, for instance, just in a doctor-patient office visit.
There is so much more that occurs, both in the public, both in the use of nurses, both in other
practitioners of healthcare, and we have to get better at working with each other as part of teams in
order to provide better healthcare and to really affect health and not just healthcare. A lot of the work
that we've done focuses I think on workforce and burnout in recent years because of course during the
pandemic, while everybody really rallied behind healthcare workers, including nurses at the beginning,
over time, people just became disgruntled with the response and how we were all responding to COVID,
how it was making people feel and having to act.

Dr. Aaron E. Carroll ( 17:19 ):
And people also got a lot of misinformation and disinformation, which led people to develop, again,
we've discussed some of this mistrust. It's also led a lot of people to consider leaving the field or to
experience burnout and we have to stop that. We had already areas of the country that had a huge lack
of medical services, a lot of which are provided by nurses, a lot of which are provided by other types of
practitioners, and we need to focus on resilience and keeping people feeling valued and trained and able
to continue to love the work that they do because we need a lot of healthcare providers in order to
maintain the healthcare system that we have and we all know it could be a lot better.

Margaret Flinter ( 18:05 ):
Well I think if I could just sort of continue on that for a second, and I think you were right on about what
happened during COVID, that tended to focus a lot of attention and well-deserved on the acute care
setting, but we're at a place in the country where maybe 50% of primary care providers in this country
today are nurse practitioners and yet, the conversation is rarely about that and it's about the shortage of
primary care physicians. Is this research group on nursing issues addressing how we maybe change the
public understanding or mindset about this?

Dr. Aaron E. Carroll ( 18:40 ):
Absolutely. I mean, I think we have to get used to, I should say, full disclosure, my wife's a nurse
practitioner. So take the biases where you will, but there's lots of studies that show that nurse
practitioners provide some primary care services better than physicians. And unfortunately there's still a
bias, both within the healthcare system and without, that often they provide substandard care. What I
think we have to get better about in general is understanding that this should be viewed as a team.
There's lots of things that nurse practitioners are going to excel at, there's lots of things which PAs are
going to excel at, there's lots of things that MAs are going to excel at, and there's lots of things that
physicians are going to excel at, there's lots of things that different types of physicians are going to excel
at, and we're all part of a team working together, especially in primary care, to provide the best care
that we can to get to the best health that we can for individuals.

Dr. Aaron E. Carroll ( 19:39 ):

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I think I wrote a column years ago, which was there's a big debate about do we have a physician
shortage and a lot of health services researchers and health policy researchers will argue we don't have
a physician shortage. We have a physician or medical services shortage in that we are not properly using
all of the people that we have in the healthcare system to the best of their ability in a way to provide
optimal care. But everyone, and especially I think a lot of the work that we do, focuses on the fact that
we need to get everyone working with each other in teams in order to do the best care that we can.

Mark Masselli ( 20:17 ):
But I think we have to prepare the public as well that there's a transformation going on in primary care.
The number of nurse practitioners that are in primary care is dramatically increasing. The number of
physicians who are retiring who simply want to go into specialty care is also increasing, right? So the
world is going to be different for the population. We need to prepare it. And nurse practitioners, we
would say with residency training are fully equipped to manage that transition and it's just facts.

Dr. Aaron E. Carroll ( 20:51 ):
Yes.

Mark Masselli ( 20:51 ):
That this is accurate.

Dr. Aaron E. Carroll ( 20:51 ):
I mean, we had more pediatric, I'm a pediatrician, we had more pediatric slots go unfilled in this year's
match than we've seen in decades.

Margaret Flinter ( 21:01 ):
Wow.

Dr. Aaron E. Carroll ( 21:01 ):
And I mean, if we're being perfectly frank, the way that we reimburse primary care services makes it less
attractive than it used to be compared to going into other physician specialties. Lots of medical students
and residents are graduating with hundreds of thousands of dollars of debt. Financial incentives matter.
And while I'm not arguing that physicians are going to go hungry, if you can make a lot more money over
here and you already know that you are deep in the hole, more and more people are going to choose
that. A lot of the incentives are aligned unfortunately to drive a lot of people away from primary care,
but there's lots of people who still want to work in the field and provide that care. They just might not
all be physicians and a lot of other practitioners, including nurse practitioners, can provide incredibly
high quality care.

Mark Masselli ( 21:53 ):
I do want to shift, as you said the word incentive, and think about what's happening in the private equity
space for hospitals, the undermining it seems to be having of the system. It's also eroding primary care
as these private equity hospital-based health systems are buying up practices, splitting them up, selling
them for their parts. Talk a little bit about the role private equity is having and what your observations
are.

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Dr. Aaron E. Carroll ( 22:24 ):
Well, I mean, we'd be ignoring reality if we didn't recognize that 18% of GDP, which means that almost
one-fifth of our economy, is based in healthcare. There's clearly a lot of money to be made in healthcare
in the United States. It is therefore not unexpected that private equity would get into that. But simple
economics will tell us that even in private, especially in private equity, they'll be drawn to the parts of
the healthcare system that make money. That is not primary care unfortunately.

Dr. Aaron E. Carroll ( 22:57 ):
And so as more and more of the system focuses on which parts of the system can make money, the
parts that don't can be ignored. Yet primary care still does a massive amount of good and necessary
work. It just doesn't make a lot of money the way that we have our healthcare system set up. That
leaves the system with more and more private equity and more and more profit-driven focused really
being put into the healthcare system, means that primary care is going to suffer. At some point we have
to recognize that some things are just a good and that we're going to need to find ways to fund them
and support them even if they don't make huge amounts of money.

Margaret Flinter ( 23:43 ):
Well Dr. Carroll, I'm going to pivot to a book that you wrote, which I thought had a great and
provocative title, The Bad Food Bible: How and Why to Eat Sinfully, and you've explained that you can
eat red beets several times a week, have a drink or two a day, have a gluten-loaded bagel from time to
time, which sometimes feels like it goes against the advice that we're regularly given, but take us
through that advice. What prompted you, in particular, what prompted you to write that book with that
message?

Dr. Aaron E. Carroll ( 24:14 ):
I mean, it was written well before the pandemic, but I think it really came out of my frustration as I
wrote more and more columns that the way that we discuss nutrition and food is a great example of the
way that we burn people's belief in science in that it feels like people are told one or the other. Eggs are
going to kill you because of cholesterol. Oh, it actually doesn't matter. Eat as many eggs as you like. Red
meat will kill you. Oh, no. Red meat can be part of a diet. Drink no alcohol to you'll read other studies
and you're like, oh, no, no. Drinking red wine is perfectly healthy. When a lot of that is caused by the fact
that we're not good at discussing nuance about research, especially in nutrition. A lot of the work is
cohort or case control studies, which point to a potential risk, but we again, are binary in our thinking.

Dr. Aaron E. Carroll ( 25:01 ):
It's risk or no risk as opposed to really tiny risk as long as you're doing things in moderation. And so the
book really tries to look at foods we've been told are terrible and discuss that really it's a much more
nuanced conversation. For some people, there's a risk. If you have celiac disease, of course you should
not be consuming gluten. If you have incredibly high blood pressure and consume an enormous amount
of salt, of course you should reduce your salt intake. But for tons and tons of the vast majority of people
who don't have those issues, then a lot of the changes you make won't make much of a difference at all
and sometimes even randomized controlled trials, when we go from hypothesis generating to, "Let's
actually see if changing this makes things better," don't bear out the results that we think that they
should.

Dr. Aaron E. Carroll ( 25:51 ):

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And therefore, most people should know that going to extremes can add a tiny bit of risk here or there,
but the extremes that we are often sold, one way or the other about what you should or should not eat,
are often not really well-supported by science. And we should be honest about that and we should be
able to have a nuanced conversation again.

Mark Masselli ( 26:15 ):
Well there should be no nuanced conversation about my love for kimchi and shouldn't write anything
bad about it.

Dr. Aaron E. Carroll ( 26:21 ):
Sure.

Mark Masselli ( 26:22 ):
But besides that, I really want to talk about your formulation for good communication because it seems
to me that this is at the core of what science needs to do and you've been remarkable in terms of your
ability to make complex healthcare policy understandable. You do this through your blog, The Incidental
Economist in the Healthcare Triage YouTube series. Tell our listeners what your keys to success in
making difficult issues relatable.

Dr. Aaron E. Carroll ( 26:52 ):
I think it, first of all, I would say a lot of it is practice. I think too many people think that you fall from the
sky or are born a phenomenal writer.

Mark Masselli ( 27:00 ):
How did you get to Carnegie Hall?

Dr. Aaron E. Carroll ( 27:02 ):
Exactly. Practice. And one of the reasons I actually started a blog was because I wanted to get better at
writing and I said, "I'm going to write 800 words a day for a couple of years until I'm better at writing 800
words," and it actually worked. But I think a lot of it is talking to the public. I wasn't writing the blog. I
don't write the column for hardcore researchers or even for academics. It's for regular people. And that
forced me over time to get better at talking and writing about things in ways that people can
understand. But I think if there were certain messages that work, it's being willing to question your
hardcore beliefs. It's always looking for all of the studies, not just some. It's being willing to discuss
nuance, and especially being willing to talk about absolute risk versus relative risk. Relative risk is the
way that we scare people.

Dr. Aaron E. Carroll ( 28:02 ):
We say, "Your risk goes up by 52% if you do X or Y," when really it's going up from 0.0001 to 0.00015.
And there's a big difference between those two things and we don't often discuss the absolute risk. I
also think sometimes we cherry-pick. We discuss pros without cons or cons without pros. And one of the
things that builds trust is being willing to discuss the benefits and harms of everything and being able to
weigh those and also understand that different people will rationally come to different conclusions
about what they want to do based on whether or not they really care about those harms and those

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benefits and that we can make different decisions, different rational decisions, about the same
questions based upon our different priorities.

Mark Masselli ( 28:57 ):
And sometimes you need to have, when you're speaking truth to power, having a thick skin. You face
this issue on your writing about artificial sweeteners. Anything you want to share with our listeners?

Dr. Aaron E. Carroll ( 29:08 ):
Yeah. I mean, no. I mean, the gist of that column was that a lot of the data and evidence that say
artificial sweeteners are damaging is massively flawed and really over read and that given that added
sugars, it's very hard to defend that and the evidence is overwhelmingly negative, I said, "I would drink
diet soda any day of the week before a regular soda." This led people to actually argue that my children
should be taken away from me and that my license should be revoked, which I was sort of shocked.
People are more passionate about artificial sweeteners than almost any other topic I've ever written
about. But I maintain that what I said was true. I mean, I'm not advocating you should drink a case of
Diet Coke a day, but the occasional diet soda is so much less harmful for you than sugar soda and likely
has minimal to no harm.

Margaret Flinter ( 30:04 ):
Well Dr. Carroll, I think it's easy to see why the search committee turned to you as their candidate to
lead AcademyHealth with your love of research and getting to the facts, the building trust, and also
speaking in an open way with people, whether they're healthcare professionals or our friends and
neighbors. So thank you for this really enlightening conversation and we want to thank our audience for
being here and be sure to subscribe to our videos on YouTube, find us on Facebook and X with the
account name CHC Radio, and as always, please go to chcradio.com to sign up for email updates and
also share your thoughts and comments about this program. Dr. Carroll, thank you so much for joining
us today on Conversations on Healthcare and we look forward to more conversations in the future.

Dr. Aaron E. Carroll ( 30:49 ):
You're very kind. Thank you very much.

Margaret Flinter ( 30:55 ):
This copyrighted program is produced by Conversations on Healthcare and cannot be reproduced or
retransmitted in whole or in part without the express written consent from Community Health Center
Inc. The views expressed by guests are their own and they do not necessarily reflect the opinion of
Conversations on Healthcare or its affiliated entities.

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