Special Episode: Deborah Cohen & Bad Influence

Summary

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This Podcast Will Kill You

Special Episode: Deborah Cohen & Bad Influence

Release Date: August 11, 2026
Host: Erin Welsh
Guest: Dr. Deborah Cohen, author of Bad Influence: How the Internet Hijacked Our Health

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Episode Overview

In this Book Club installment, Erin Welsh sits down with medical journalist and broadcaster Dr. Deborah Cohen to discuss Bad Influence, Cohen's deeply reported investigation into the collision of Internet wellness culture, influencer marketing, and consumer health. They dissect how social media and online platforms have transformed the way we understand (and misunderstand) health, medicine, and trust — with crucial implications for patients, practitioners, and public health. The episode tackles themes like the commercialization of health anxiety, the role of algorithms in shaping beliefs, the double-edged sword of online health communities, and the urgent need for regulation in digital health spaces.

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Key Discussion Points & Insights

I. Origins & Motivation for Bad Influence

• Personal Story as Catalyst
  • Dr. Cohen shares a pivotal anecdote: her cousin’s friend buys a costly AMH test for fertility after seeing it promoted on Instagram – despite it having little clinical value.
  • “Where did you get the information from? And she said, oh, Insta. As if I was stupid, you know, why wouldn't you go to Insta for your health information?” (07:53, Cohen)
• Cohen notes a pattern among smart, educated friends relying on social media for advice on fertility, menopause, ADHD, and more, reflecting wider gaps in healthcare access and trust.

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II. Mapping the Landscape of “Bad Influence”

• Who is Influencing, Where, and Who’s Affected? (10:59)
  • The landscape is crowded:
    • Traditional commercial actors (tobacco, pharma, food)
    • New actors: big tech companies (Meta, TikTok), wellness influencers, telehealth services, wearables/app makers.
  • Algorithms play a decisive role, not simply surfacing information but prioritizing those with commercial incentives.
  • “What was really interesting to me was we’ve got this whole new set of commercial players now…I think of it as big tech meets all these other little industries, influencers, online pharmacies, telehealth, wearables, apps – it’s unfettered advertising.” (11:14, Cohen)
  • U.S. and U.K. healthcare differ, but both face the same pressures: declining access, growing privatization, and increasing consumer vulnerability.

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III. Nocebo, Placebo, and the Social Media Mind-Body Loop

• Exploring mind-body medicine and how expectations sculpt physical experience.
  • “If you believe something is going to help you, then that may help your symptoms…equally, there’s something called the nocebo effect and that is the evil twin…It literally means I will harm. So…that very graphic visual image of someone being sick…It can make you feel nausea. And that is your mind.” (19:19, Cohen)
• Social media intensifies this: seeing others’ symptoms or fears online can “spread” subjective ailments.

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IV. The Double-Edged Sword of Online Health Communities

• Social media provides community, validation, and resources — especially for the underserved or isolated.
• Yet, these communities can:
  • Become echo chambers
  • Intensify fears
  • Make people susceptible to predatory marketing.
• “Fear sells and stress and anxiety equally sells. Tell somebody that there might be something lurking beneath them and create that fear. But then you sell the solution.” (23:22, Cohen)
• The full-body MRI screening trend is dissected as an example of stoking anxiety for profit.

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V. Algorithms, Illusion of Truth, and Normalizing Misinformation

• Algorithms create hyper-personalized information flows; what you see is nothing like what your neighbor sees.
• Content that’s vivid, emotional, and sensational is algorithmically rewarded, not nuanced or evidence-based info.
• “Illusion of truth bias is the more you see something, the more true it feels.” (26:31, Cohen)
• Example: A girl’s TikTok feed fills with stories of young people with stage 4 cancer, distorting her sense of risk and reality. (27:00)

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VI. The Crisis of Nuance and Uncertainty

• Social media platforms don’t reward “grey area” or uncertainty — yet ambiguity is inherent to science.
• In responding to misinformation, healthcare pros risk driving away the underserved if they’re too strident.
• “If people are too robust with pointing out misinformation…that drives people away…turning to social media because they feel that the health profession doesn’t listen.” (32:24, Cohen)
• The rise of consumer-style medicine (private clinics, direct-to-consumer health products) in the UK echoes American trends, complicating the regulatory and consumer protection landscape.

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VII. Medicine's Own Shortcomings Fueling Distrust

• Acknowledgment of medicine’s history of being dismissive, underfunding women’s health, and being slow to include women in clinical trials.
• Gatekeeping and lack of empathy in medicine push people towards unvetted online sources.
• “Our expectations are very powerful shapers of how we experience our illnesses.” (22:56, Cohen)
• Generative AI and large language models may further complicate trust in the doctor-patient relationship.
  • “People rate them as being more empathic than doctors…That’s rough. Yeah, it really is.” (35:31, Cohen & Welsh)

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VIII. How Social Media Shapes (and Warps) Medical Diagnosis and Experience

• ADHD as a case study:
  • Social media helps underdiagnosed people find community and validation.
  • Simultaneously, diagnoses risk being broadened or shaped by viral, non-clinical definitions and catchphrases.
  • Terms like “rejection sensitivity dysphoria” and “object permanence” are discussed in new, popular ways that feed back into real-world diagnosis.
  • “People’s way of describing their ADHD has taken a social media element.” (41:42, Cohen)
• Health, even diagnostics, is culturally and socially contextual—and social media accelerates those shifts.

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IX. The Optimization Trap and Wearables

• The trend of pathologizing normalcy and targeting healthy people for profit.
  • Example: Continuous glucose monitors, once for diabetics, now widely marketed (with little evidence) to healthy people.
  • “If you think about it, it’s obvious: if you’re a company, where’s the bigger market? A sick person or a well person?” (45:46, Cohen)
• Single-focus metrics (“glucose spikes!") oversimplify health and can lead people to make unhealthy secondary choices.
• Welsh’s personal anecdote: smartwatch-driven misery from over-tracking.

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X. Can You Trust Any Online Health Influencer?

• The appearance of medical credentials and slick production often masks industry ties and conflicts of interest.
• “There’s a phrase...‘I only work with companies I believe in or use personally’…But what happens if evidence suggests that that company isn’t very good? Do you suddenly drop it? For me, it’s a nonsense term.” (49:38, Cohen)
• Paid advocacy can go undetected by listeners, and even physicians/influencers aren’t immune.
• U.K. example: physician influencer advertising AG1, potentially violating regulation boundaries.

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XI. Does Reliable Science Belong Online? What About Regulation?

• Science communicators and health institutions should meet people “where they are,” but also push for better critical thinking and skepticism.
• Content can be manipulated behind the scenes (e.g., being made chatbot or “LLM optimized”), further muddying trustworthiness.
• Regulations are nearly absent; both the U.S. and U.K. lag badly in protecting consumers from digital snake oil.
• “If someone’s only telling you the benefits of something, why aren’t they telling you about the harms?...If someone’s over certain, then they’re probably not right.” (54:10, Cohen)
• Cohen urges skepticism: ask who is providing information (and why), what their interests are, and look for both benefits and harms.
• Medical/health authorities must rethink how they communicate with more compelling, accessible, and transparent campaigns.

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Notable Quotes

“Where did you get the information from? And she said, oh, Insta. As if I was stupid, you know, why wouldn't you go to Insta for your health information?”
— Dr. Deborah Cohen (07:53)

“Big tech meets all these other industries… it’s unfettered advertising.”
— Dr. Deborah Cohen (11:14)

“If you believe something is going to help you, then that may help your symptoms. So placebo is an incredibly powerful effect. Equally, there’s something called the nocebo effect and that is the evil twin, if you like, of placebo.”
— Dr. Deborah Cohen (19:19)

“Fear sells and stress and anxiety equally sells. Tell somebody that there might be something lurking beneath them and create that fear. But then you sell the solution.”
— Dr. Deborah Cohen (23:22)

“Illusion of truth bias is the more you see something, the more true it feels.”
— Dr. Deborah Cohen (26:31)

“If people are too robust with pointing out misinformation and individuals, obviously there are bad actors. I worry that that drives people away.”
— Dr. Deborah Cohen (32:24)

“If you think about it, it’s obvious: if you’re a company, where’s the bigger market? A sick person or a well person?”
— Dr. Deborah Cohen (45:46)

“There’s a phrase…I only work with companies I believe in or use personally…For me, it’s a nonsense term.”
— Dr. Deborah Cohen (49:38)

“If someone's over certain, then they're probably not right.”
— Dr. Deborah Cohen (54:10)

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Crucial Timestamps

• 07:53 – Personal stories that prompted the book’s creation.
• 11:14 – Mapping the players in the current online health landscape.
• 19:19 – Placebo, nocebo, and the mind-body link on social media.
• 23:22 – The commodification of anxiety and the economics of health fear.
• 26:31 – Algorithms, illusion of truth bias, and normalization of misinformation.
• 32:24 – Nuance, uncertainty, and the challenge for science communication.
• 41:42 – ADHD and the recursive influence between social media and diagnosis.
• 45:46 – “Optimization trap”: wearables and the selling of wellness.
• 49:38 – Trust, conflicts of interest, and influencer sponsorship.
• 54:10 – Regulation, skepticism, and critical health literacy.

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Take-Home Messages

• Social media has democratized access to health information, but equally elbowed out nuance and made space for new, under-regulated forms of exploitation.
• Algorithms and profit incentives mean engaging, sensational content drowns out sober, evidence-based advice. The result is the normalization of misinformation (the “illusion of truth”).
• The medical profession must adapt: not only fighting fire with fire in communication, but also fixing systemic empathy and access issues that drive people online in the first place.
• Ordinary people should develop a routine skepticism: always ask who benefits, what interests are in play, and whether both sides — risks and benefits — are presented.
• Until regulation and better consumer protection catch up, critical thinking is the best defense.

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This wide-ranging, engaging conversation is a powerful wake-up call for anyone navigating health information in the digital age—be they patients, health professionals, or policy makers.

Transcript

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[Erin Welsh]

Hi, I'm Erin Welsh, and this is

this podcast Will Kill youl. Welcome to the latest episode of the TPWKY Book Club series, where I bring on authors of popular science and medicine books to chat about their latest work. These books span such a wide range of subjects, there's really something for everyone.

Maybe you'd like to learn more about

the evolution of language or what's going on with the diagnosis crisis around the world. The maybe you're curious about how refrigeration transformed the world, or how our understanding of cancer was shaped by tragedy. You can check out the full list of books featured on this series and upcoming books by heading over to our website thispodcastwillkillyou.com under the Extras tab, you'll find a link to our bookshop.org affiliate page, which has a bunch of TPWKY related lists, including one for this Book Club and and one for the Kids Book Club, which is hosted by Erin Updike. On our socials, make sure you're following us there if you aren't already. We always say it, but we always mean it. We love hearing from you, whether it's episode suggestions, book recommendations, firsthand accounts, or anything else that's on your mind. The best way to get in touch with us is through the Contact Us form or the Submit yout Firsthand Account form. You can find both on our website. Two last things before we get to this week's book, and that is to please, rate, review and subscribe.

[Ashley (Ben and Ashley Podcast)]

Subscribe.

[Erin Welsh]

We'd love to make this podcast as long as we can, and this really does help us out. And finally, you can find full video versions of most of our newest regular episodes on YouTube. Make sure you're subscribed to Exactly Right Media's YouTube channel so you never miss a new episode Drop these days if you have a question about a medical issue, the Internet is likely your first stop. After all, the next opening at your doctor's clinic is months away and even if you manage to snag an earlier appointment, would you have enough time to ask all your questions and get them all answered? Probably not. Why wait when you can research at your leisure, scrolling through TikToks, asking AI or listening to a podcast where the overconfident hosts swear by peptide injections and smart rings using medical language to disguise what they're really doing, which is inventing a problem and selling you the solution. Increasingly, people are turning towards the Internet to seek solutions for many of their health care and wellness needs. But even if you aren't actively searching for this type type of content, it finds you anyway. The proliferation of wellness influencers and the commodification of health anxiety has had profound impacts on our relationship with medicine, expertise and truth. In today's episode, I'm joined by Dr. Deborah Cohen, medically trained, award winning journalist, broadcaster and editor, to discuss these issues which she explores in her recent book Bad Influence how the Internet Hijacked Our Health. Extensively researched and compellingly written, Bad Influence uncovers the insidious manipulation by those seeking to make a profit and the way they prey on vulnerable individuals simply looking for help. As Dr. Cohen demonstrates, the Internet is a double edged sword, rife with this type of exploitation, but also a source of empowerment and community. Navigating this virtual landscape has never been more challenging, with marketing masquerading as medicine and an endless supply of snake oil sales in their newest iteration as podcast bros. And one simple trick, clickbaiters. Dr. Cohen pulls back the curtain on the underbelly of the wellness industry and in so doing, makes an urgent call for regulation to protect consumers. Until that happens, if it ever happens, she leaves readers with a crucial piece of advice. Ask yourself why you're seeing what you are seeing in your feedback. Who's telling you this stuff? And why. Bad Influence is a timely and necessary guide to the wild west of Internet wellness and the nefarious health influencers spreading lies for profit. I'm very excited to bring this conversation to you all, so let's just take a quick break and get started.

Doctor Cohen, thank you so much for joining me today.

[Dr. Deborah Cohen]

Thank you for having me. And thank you for being interested in the book.

[Erin Welsh]

Oh, of course.

I mean, I. I was so excited to come across your book and to read it because it explores so many of the things that I feel like on this podcast we're constantly confronting. It's this kind of one, two punch, these active disinformation spreaders, along with worsening access to medical professionals. And it's created this perfect storm of just where do you get good information and how do you recognize the good and the bad? Was there a moment in the construction of this book and the production of this book where you said, okay, this needs to be a story that I want to tell?

[Dr. Deborah Cohen]

It was quite early on, the reason I wrote it, there was a few things happening at the same time. So one of my cousin, I'm from Liverpool in England, and I was at my auntie's birthday party and one of my cousin's friends said to me, she just bought an AMH test. And I was like, why have you done that? And she said, I want to know how fertile I am. And I said, is it really gonna. Is it really gonna tell you that? And people in Liverpool, if your audience don't know, were very direct. There's no smooth talking. It's all very direct. I was like, why have you done that? And I said, well, what are you going to do with the results? Say if they're low, what are you going to do? And she went, well, I'm going to go and see my GP or primary care physician. And I said, well, what are you going to do if they're normal? And she looked at me and she said, I'm going to go and see my primary care physician. And I said, who isn't going to be able to use the results because it isn't telling you anything about your fertility. You've just wasted £160, so $200. And that was sort of the start. And I said, where did you get the information from? And she said, oh, Insta. As if I was stupid, you know, why wouldn't you go to Insta for your health information? But the doctors couldn't give her the information she needed because she couldn't conceive. She was struggling to conceive. There was no real medical reason for it and it was an obvious place to go. And there it was. All sorts of clinics were offering that as a solution, the Ectimer test. And then other friends I noticed who university educated, smart, and again going online for information about hormone replacement therapy or menopause hormone therapy, whichever term you want to use. Testosterone, full body screening, ADHD information. And there are problems with the access to healthcare, whichever part of the world you're in. And it differs according to what part of the world you're in. We've got a National Health Service in the UK and there's massive waiting lists. But equally a lot of the book, I speak to a lot of US based physicians and patients and influencers and different challenges, but even still, challenges getting access to healthcare and traditional healthcare services can't provide an answer. There's always someone online who will. And there was a noticing an increasing growth of that and then people were sort of having to. In my day job as a journalist, I'll sort of go, well, why are you coming to me with that information? What's your agenda? What's your. Why are you telling me that I look for the benefits, I'm looking for the harms, I'm looking for the evidence. And they were having to be almost their own mini journalists online, but without the, the background that I had or that training that I had to critically appraise information and perhaps that's some of that automatic skepticism. If I get a press release, I'm thinking, yeah, why do you want me to cover that story? So as a journalist, I'm naturally skeptical and that's what was supposed to be. But people were being bombarded with stuff and didn't really know what to make of it.

[Erin Welsh]

I want to dive into the influence in your title. Who is doing the influencing, the bad influencing, where are they influencing and who is being influenced? Can you sketch out the major areas where this is happening?

[Dr. Deborah Cohen]

So I think we've talked about for many years on medical journals or in academia or in healthcare generally, there's always been commercial actors that influence our health. We know the tobacco industry sat on the harms of smoking for decades, even though they knew it was causing lung cancer. We know the drug industry asks certain questions to get certain answers. You know, you can be clever in how you do your randomised control trials. We know the alcohol industry, big food, fossil fuel companies, they influence our health care, they lobby politicians, they lobby decision makers to create policies that are favorable in their interests. And we know that they influence the evidence base. And what was really interesting to me was we've got this whole new set of commercial players now. So I was less interested in the kind of classic conspiracy theorists. I was much more interested in these industries that perhaps are shaping scientific industries, should I say, that are shaping our healthcare. So the obvious one is big tech, and they host the platforms, they operate the algorithms that influence what we see. They decide what's going to be first in our feed. If it's an advert, you are an obvious advert from a company, you're going to drop further down the feed, but they will surface the influencers that have financial relationships with other companies. So that's the obvious one. So in my mind, I think of it as big tech meets all these little other industries, all these other little companies, if you like influencers, online pharmacies, telehealth, a big one, your wearables, your apps, it's unfettered advertising. And so you've got all these different commercial incentives that are at play that are being surfaced by, by the big tech companies, whether That's Meta or TikTok, Dance Byte or Google, YouTube, and they're controlling in many ways what we see in our feed. And I was interested to think about, well, how are these actors shaping our health? And I think there's a big open question still, because there's an absence of evidence. So I didn't want to be too certain because what I didn't want to do is debunk bad science by doing bad science myself. You say that's overstated claim and I've made overstated claims, but there's clear that there's something going on. And we know healthcare and our understanding of medicine is shaped by culture, is shaped by society and is massively shaped by commercial interests. So they were the questions really for me and in what direction are we going? And there's some interesting anecdotes from us physicians, actually. And one obgyn at Duke University said to me, and she deals with contraception, and she said to me, I know when my young patients come to see me, see me, they spent four hours a day on TikTok getting their information. I've got like 20 minutes with them. And a men's health specialist at a Harvard affiliated hospital, he said to me he feels he's tilting at windmills where he's got all these men's health providers that are offering testosterone at a drop of a hat and he wants to counsel patients properly about health interventions that might actually change their health and actually help their testosterone levels. So losing weight, but he's like, they want a quick fix. So that was a very long winded way of saying there's all these different actors that are on our platforms that are trying to grab our health, that are trying to shape our health and influencers as well with certain symptoms. They will change their symptom profile according to what's going viral. So if you take the example of ADHD and you are changing what your symptoms are because you know it's resonating with an audience, what's that going to do to our understanding of ADHD if you look at it through a social media prism?

[Erin Welsh]

Let's take a quick break and when we get back, there's still so much to discuss.

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[Cal Penn]

Hey, everyone, it's Cal Penn. I'm the host of Irsay, The Audible and iHeart Audiobook Club. This week on the podcast, I am sitting down with Ray Porter, the narrator of Andy Weir's audiobook project, Hail Mary, Massive sci fi adventure about survival and science and what happens when you wake up alone, very far from Earth.

[Ray Porter]

I really had to make a decision because I caught myself getting that frog in my throat and starting to get teary as I'm narrating some of these sections and it's like, okay, yo yo yo, is this indulgent? And I really thought about it. I was like, no. At this point it would kind of be betraying the trust the author and the listener have in telling this story if I don't go through it. But there's places in this book that that deeply, emotionally affected me and I left it on the mic. That's great because it served the story. People will say like, oh my God, I cried at the end. It's like, yeah dude, me too.

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Listen to Irsay the Audible and iHeart audiobook club on the iHeartradio app or wherever you get your podcasts as summer

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[Erin Welsh]

Welcome back everyone. I've been chatting with Dr. Deborah Cohen about her book Bad Influence how the Internet Hijacked Our Health. Let's get back into things.

It's so interesting what you mentioned about somebody spending four hours a day on social media on TikTok scrolling and that's where they're getting the vast majority of their information versus this 20 minute time with their doctor. And there's also what they're seeing and you dive into this when you discuss the Nocebo effect.

[Dr. Deborah Cohen]

Yeah, it's fascinating. I don't think we talk enough about mind body medicine in healthcare. I think we can often follow the biomedical model too much and some of the more eastern philosophies perhaps use the mind body model more. But we know that our expectations shape so many different things and symptoms are included if how we experience stuff comes from, comes from our head. And it's not to say it's all in the mind. Symptoms are very real physical manifestations. But if we have anxiety, say for example, we're more likely to experience pain. We know how we experience stuff. Our views are going to shape how we experience symptoms. And that is for good and for bad. So placebo is. If you believe something is going to help you, then that may help your symptoms. So placebo effect is an incredibly powerful effect. So you take testosterone, which we know is being promoted heavily to men and to women, perimenopausal and menopausal women. We know testosterone has quite a strong placebo effect. So if you feel tired or low energy, you have some testosterone, suddenly you feel better quite a lot. That is placebo, and that's a very powerful effect. Equally, there's something called the nocebo effect and that is the evil twin, if you like, of placebo. It literally means I will harm. So you will know if you see someone throwing up, you feel sick yourself. It does not mean that you have that viral infection or bacterial infection, but that very graphic visual image of someone being sick. It can make you feel nausea. And that is your mind. Those symptoms of nausea are real, but that is your mind mimicking if you like what you are seeing. If you think about little bugs crawling up your neck, you can feel a little bit twitchy, you know, you can literally feel it. And what we know is visually seeing something is more powerful than reading about an effect. And when you read the side effects of a drug, it increases your chances of having those side effects. And we're talking things like headache and nausea and fatigue and those kinds of symptoms. And that is something that researchers are starting to look at, which I think is fascinating about how social media shapes how we think about our symptoms or how we feel about our symptoms. And this is where I think some illness forums are a double edged sword where they can provide people with support and feeling heard and seen and a sense of camaraderie, cut through loneliness equally. If people are constantly talking about their symptoms, what does that do to your expectations of whether you're going to have those particular symptoms connected with a certain condition? And we're sort of in the foothills of really exploring that and the contribution of social media to, to that nocebo effect. The last thing you should do if people are having very real symptoms from a nocebo effect is dismiss their experience because those symptoms are real. Just the causation of it might not be physical or it might not be pathological. There might be another reason for it. And they're very powerful. Our expectations are very powerful shapers of how we experience our illnesses.

[Erin Welsh]

You mentioned social media being this double edged sword where you have these supportive communities that can be formed and someone can finally no longer feel alone in their experiences. And so it's, it's on the one hand very empowering, but on the other hand it can lead to these formation of echo chambers potentially or leave people vulnerable to exploitation. Can you share more about what this means in terms of social media and the commodification of stress and anxiety?

[Dr. Deborah Cohen]

Fear sells. We know that from newspapers, you know, you or headlines, sensationalist headlines. Fear sells and stress and anxiety equally sells. Tell somebody that there might be something lurking beneath them and create that fear. But then you sell the solution. So for example, full body mri, I have a chapter on that and influencers have really jumped on that because it sort of makes sense. There might be something inside you. You might feel perfectly fine, symptom free, but there might be something inside you that is lurking. We have the machine that will spot that. When you give somebody a medical test when they are otherwise healthy, that is called a screening test. And there are all sorts of problems with that. There are very few screening tests that are recommended at a population level, even by, by the American authorities, the Preventative Services Task Force, say, for example, even the American College of Radiology. Likewise in the uk we have very similar bodies and their guidelines between them are very, very similar, as it happens. But there are very few because of the risk of what we call false positives. And if you see something on a scan, you sort of have to follow it up. You want to follow it up. And that can then lead to a cascade of care of further investigations that expose you to all sorts of different harms or risks, plus financial harm. But that idea of there might be something within and Andrew Huberman is guilty of doing this, him and Peter at here are guilty of quite a few of these. And, and a lot of the podcasters are. And you know, he talks about you might be walking around with all these spots on your brain. Don't you want to see it? Well, do you?

[Erin Welsh]

Do you?

And I, it was also, I think was that the chapter where somebody you know went and purch full body mri and then in order to like unlock the results, you had to pay again even further. And it's just sort of like this endless, just parasitic, sucking people dry of money more and more and more money grabs that just prey on this anxiety. Once you hook someone, then you've got them.

[Dr. Deborah Cohen]

You've got them.

[Erin Welsh]

You mentioned earlier the algorithm and social media. This, this really struck me too. Social media has become so individualized or it is so individualized rather than social. You know, what I see on my feed is going to be profoundly different from what you see on your feed is going to be different than what? Just like every single person's feed has been directed by these tiny decisions. How long you look at a video, whether you like or you share something. It's on my mind all the time now where I'm like, if I just set my phone down with it still open, does it think that I want to look at that video the whole time? But as you write this engagement, this algorithm, it can normalize misinformation. This illusion of truth bias. What is this bias and how does the rewarding of certain engagement, what, what sort of content is it promoting?

[Dr. Deborah Cohen]

So illusion of truth bias is the more you see something, the more true it feels. Now, not everybody is susceptible to all sorts of all biases. And, and again, we're still trying to understand how this information affects behaviour. And as you said then, it's very hard to study from an academic perspective because everybody's feeds are different and you need to follow it up longitudinally and you don't always know what is that little bit of information that you have that tips over a certain behavior change. Because we're bombarded with information all the time, but people are spending a lot of time on their phones. And the thing with the phone and social media is it's so personal. It's in your pocket, it's in your phone, it's, it's the place where you might speak to your grandmother on a FaceTime or your, or your family or you connect with people and you've got these influences in your phone, you're looking at them feels like eye to eye. But then one of the issues is it's, it's the more sensationalist stuff that gets surfaced, it's the stuff that grabs attention. I think of the book in the sense of this is what happens when you put health on platforms that are geared for entertainment and for commerce. It's not the dry statistics or evidence based information that's going to be surfaced in your feed. It is the grabby, the sensationalist, the stories. And we're geared to listen to stories. We're humans and it's all those that will surface in your feed. And there's one anecdote that I have in there, and it's from some Harvard academics who talk about a young girl who was terrified that that young people her age were getting stage four cancer because she'd lingered on a video. Her feed filled with more and more videos of young people with stage four cancer. Even though it was incredibly rare for people her age, she felt that everybody was being diagnosed with stage four cancer.

[Erin Welsh]

Let's take a quick break here. We'll be back before you know it.

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[Cal Penn]

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[Erin Welsh]

Welcome back, everyone. I'm here chatting with the wonderful Dr. Deborah Cohen about her book Bad Influence. Let's get into some more questions.

These algorithms reward these extreme stories, these personal anecdotes, these things that are shocking or more shareable. But the two things that the algorithm does not reward are nuance and uncertainty, both of which are foundational to science and medicine. How does this play out in the media representation of scientific research? And is there anything that we can do to make uncertainty and nuance more clickable, more engaging?

[Dr. Deborah Cohen]

It's a really good question and I sort of slightly, I'd love to know the answer to that. In many ways, I think there's, there's, I think we have to get better at communicating and there are people online that do it very, very well. For me, one of the risks, if people are too robust with pointing out misinformation and individuals, obviously there are bad actors. I worry that that drives people away. So one example young women side effects of the oral hormonal contraceptive pill believe they are having particular side effects pill like weight gain that isn't necessarily backed by randomized control trial evidence. It might be because the time they're going on the pill, they're going out, you know, they've got a new partner, they might be going out for dinners more, they might have just gone to college, there might be all sorts of reasons why they're gaining weight at that particular time. But there are people as well that are turning to social media because they feel that the health profession doesn't listen to them. But by pointing out and saying you're spreading misinformation, doesn't make them think, oh, I'm going to come back to the health system if they're already feeling alienated. So I think we have to do that carefully. There are some very good physicians online, but then there are some that are nefarious as well. They're engaging in nefarious activity, selling products, selling dodgy services and everything else. It's a real minefield for people. My view, as someone that trained to be a doctor, is the health profession needs to get their act together as well, get their own house in order to. But I do think we need better health literacy. And coming from the uk, what's really interesting for me is how we are adopting US style health system by the back door because our National Health Service is really struggling. We've got this massive rise of private clinics of consumer health that is only really in the last sort of five years that is really taking, taking hold, where people have private general practitioners or private primary physicians on the palm of the hand. That's all relatively new. So we're in, we in Europe and the rest of Europe as well, because what we've got from the US is direct to consumer advertising and prescription drugs that is banned across Europe. But it's borderless. A story I'm doing for the BMJ at the moment, actually, it should come out the next couple of weeks, is how we've adopted direct to consumer advertising. What's the impact of that? Because the systems are borderless and we're not used to navigating it in the UK and Europe. So it's all a bit of a. It's sort of a bit of a shock to the system.

[Erin Welsh]

Social media and influencers can of course, be very predatory, nefarious. We have these bad actors. But science and medicine also, of course,

have roles to play.

There's this long history of medicine being dismissive or paternalistic towards patients. There are these horrifically unethical scientific or medical experiments and there's kind of a general gatekeeping of like, how dare you question me or trust me, I'm the expert here, attitude. And it seems like these are also contributing to people seeking answers elsewhere. Can you tell me more about that?

[Dr. Deborah Cohen]

Yeah. And I think, certainly, again, and this comes up a lot in women's health, where women's health has been largely underfunded. I think it was 1993 that the NIH sort of said that women could be part of clinical trials that they funded in 1993. That's when Jurassic park came out. You know, we had all this, this great sort of computerized films. Only then can women go in clinical trials. And so there's been, there's a sense of not feeling seen, not feeling heard and it becomes really, again it becomes a double edged sword because the doctors that I've spoken to and I speak to a lot day to day is they're battling with information that comes up in people's feed when they come into the consultation and then they're left with even less time to deal with the kind of the issues at hand. And what I'm really interested in going forward, and this is what I'm hoping to actually formally study, is how social media and large language models are shaping doctor patient relationships and our relationship with the healthcare, particularly when we know the LLMs people rate them as being more empathic than doctors. Which doesn't say. I think it's about what the medical profession. I have to say that's rough. Yeah, it really is. We need to get our own house in order again and say that that sense of feeling heard, but then that's exploited. And that's the challenge again with social media is with influencers. I hear you. I see you now. Buy my supplement or buy my Dottie test or come to see me in my private clinic and I'll give you that unnecessary scan. So it's fascinating really. I mean it does feel quite dystopian. But I do wonder going forward what our expectations will be of healthcare and what the role of the doctor. Obviously not just doctors, but you know, health professionals generally will be in that sort of dynamic in the new information ecosystem. I'm going to put pound in the jar or a dollar in the jar because I hate the term eco ecosystem, but I've just used it. It's awful. I feel like a chat bot saying it.

[Erin Welsh]

Yeah, just put a little dashboard.

[Dr. Deborah Cohen]

Yeah, yeah, exactly. Deadbot.

[Erin Welsh]

And, and these, these doctors, these physicians are also on social media and they're also being exposed to, they have their own algorithm which might or might not be filled with bad influencers.

[Cal Penn]

Right.

[Erin Welsh]

These nefarious actors. But even still, there are many of them that I'm sure are not exposed to the information that their patients are exposed to. And so that creates more of this gap in saying, okay, well what is the information? I know what is the information that you know and how do we communicate and get on the same level in this 20 minute appointment?

[Dr. Deborah Cohen]

It's really hard. And one conversation I had recently with a paediatrician, he says when his patients come in, the first thing he does is say, come on, let's chat about what you've looked up on ChatGPT today or co pilot or Claude or whatever. Let's have a conversation, let's just get that on the table so we can talk about it. And one ADHD physician in the uk, she uses what her patients see about ADHD on social media as a way to talk to them. So how do you feel about seeing that? What have you seen on social media today? How, how should we talk about that? So get them to open up because it's almost got to be part of the conversation. And in one paper that I read, and it was in one of the paediatric journals, a sort of throwaway line at the end was, doctors now need to start asking their patients about what they're seeing on social media. And it was sort of a throwaway line.

[Erin Welsh]

And I thought, wow, you mentioned the

commercial and digital determinants of health, which

I feel like that's going to be a big thing moving forward. How would we even begin to measure or incorporate that into understanding people's health and how it is influenced by their social media experiences?

[Dr. Deborah Cohen]

It's really going to be a really hard area to study. First of all, there's no transparency from the tech companies, so getting data, and I know there are ways of potentially sharing data, but as it stands as an example in the book, one academic I spoke to said if he wants to do a study, let's say on TikTok, they will want to see the protocol, they will want to see everything before they release any data and then on top of that, they will want to see the final publication before it goes anywhere. Now, we've learned over years, let's say with the drug industry, that if they subsidise research or fund research, then you have to have sort of walls in place and protocols in place so that research isn't therefore influenced before it goes to publication. There has to be an element of that. And I feel that again, we're very much, there's a bit of tech exceptionalism at times that we can race ahead and do things. And again, if you think about what science is, we have the null hypothesis. We assume something doesn't work unless shown otherwise. Tech feels to me like, let's just get it out, we'll assume it works until it doesn't and it flips scientific thinking on its head. But we sort of have just come to accept that is what happens. But is that good science? I would counter probably not.

[Erin Welsh]

We've touched on a few times ADHD throughout this conversation so far and this is a condition that has received a lot of attention on social media and that's been very positive for some people who have found community and a greater understanding of their own experiences. People who are getting diagnosed or going to their physician and saying, is this what I've been experiencing? How can I manage this? But it is more complicated than that. Of course their diagnoses are increasing. But there might. Does that also mean that it might be over diagnosed in situations like how do we know where to draw the line between help and harm in this context?

[Dr. Deborah Cohen]

It's really difficult and I think you can have two things together at the same time. So you can have people being missed, so you can have under diagnosis. And we know they're largely in certain ethnic groups, so African Americans, Hispanic people, there's a massive social gradient there as well and that's mirrored in the uk. So if people of lower socioeconomic groups are less likely to get the diagnosis that they need to access treatment and help, meanwhile you have people that perhaps have more access to healthcare, more wealth, that are getting diagnoses that may not be robust. So there we might have misdiagnosis, but also we've got this idea of perhaps over diagnosis. So the expanding definition of what counts as ADHD and that is always subject to debate in healthcare and I don't come down either way. But what I do think is that, and I hear it amongst my friendship groups, that people's way of describing their ADHD has taken a social media element. People talk about reception, rejection, sensitivity, dysphoria, like it is a certain symptom, a well described symptom of ADHD as it stands. Experts are still debating it. Is it part of ADHD or isn't it? We don't know because there isn't the evidence there. But that has come down into clinical notes and that has sort of been born out of conversations on social media other than medical or psychological terms have been co opted by influence like object permanence, which is a Jean Piaget stage of development where a child realizes that if a parent isn't in the room or something isn't in the room, they still exist just because they can't see it, that person still exists. And that's been co opted by influencers to me, I don't miss things. And those terms go viral. And again people talk about it like it is a definite part of adhd. And so, and I hear that in conversations just day to day. I've got rejection sensitivity, dysphoria or I've got object impermanence because I don't miss people. And then if you think about how we do field studies or we validate our questionnaires when it comes to ADHD diagnoses, if people are saying well this isn't how I see adhd, we haven't got all these different conditions I'm seeing what does that then do further down the line to how we see adhd? And I don't know, it's an open question.

[Erin Welsh]

Yeah. How does social media shape diagnoses in a medical context? I mean it's not a one way relationship. This is all kind of intersecting and feeding into each other.

[Dr. Deborah Cohen]

Absolutely. And health is defined socially and culturally. There's a lot of health care that is defined. And I think, I think what often surprises people, even diagnoses change, what the threshold, the cutoff threshold is sometimes it's so many standard deviations away from the mean is what you consider abnormal. That's often a surprise to people. It is not fixed in stone. And over the years we've seen the idea of pre diabetes come about as we move the goalposts of who needs treatment. Healthcare is constantly iterating and it's not all pure hard science. It's real where arts and culture and society meets hard science. It's that strange interface.

[Erin Welsh]

And health optimization I feel like is a key part of this too. It's doing whatever you are told is the best thing to do to optimize your health. And there's a huge market for this. I got sucked into it with a smartwatch and then I realized that I hated it. It made me miserable so I stopped using it. Can you discuss the optimization trap, which is what you call it in your book and how the this market both over promises and under delivers?

[Dr. Deborah Cohen]

So if you think about it, it's obvious if you've got a market, if you're a company, where's the bigger market? A sick person or a well person? So if you take, if you take continuous glucose monitors and there's been a big trend for them, they were designed so Abbott is one of the big companies that makes it us company that makes them. They were designed principally to help people with type 1 and type 2 diabetes who use insulin to monitor their blood sugar levels. So they could adapt their insulin to get optimal dosing. Because we know in the short term, if you've got the right level of insulin, you're less likely to have hypos and hyperglycemic attacks. And in the longer term it reduces the risk of long term health complications. But there was a pivot. That's only a small market. There's a much bigger market in, well, people. And if you can encourage them that they need to constantly monitor their glucose in the absence of evidence. And the NIH have done some brilliant studies and there's some brilliant clinical trials in this. Kevin hall, who is no longer at the nih, but he's done some fascinating trials showing that you get different readings, the same device can give different readings, or different devices give different readings and your blood sugar level will change according to what else you've eaten, what else you've done at the same time. And so they're not really reliable because our bodies and healthy people have homeostatic mechanisms. Our blood sugar goes out, we release insulin and it comes back down again. It goes too low, we release glucagon and the blood sugar goes back up again. We're in this constant state of homeostasis. We don't know what abnormal looks like in a normal person because if you're out of range, your blood sugar goes up and people say, oh, I've got a spike, I've got a spike. You're like, like, yeah, just eating banana, of course you've got a spike. If it comes back down, that's what you're interested in. And guess what? It comes back down. And then what, what happens is that then potentially creates more harm. So we don't know spikes have any issue in the long, certainly in the short term, and certainly not in the long term, but then people change the diet accordingly. So, right, I'm not going to eat banana, but I'm going to eat a burger. Because burgers are, it doesn't spike my glucose levels. So people then become wedded to this metric. And the thing when you look at one metric is you're not looking at all the other things that you might be ingesting. So if you have a burger, you might be eating loads of cholesterol or fat or salt and all those other things, but you're so sort of wedded to this one metric in this case is glucose. You might be watching one very well monitored tree and missing the wood around it. And that's the problem is if you can measure it, you fixate on it and in some way we saw this in the pandemic a little bit, without getting too sort of controversial, is we really. Certainly in the uk, we focus very much on COVID deaths because we can measure them. We could see it. But everything else around it was far more complicated to measure. You know, the impact on education, the impact on psychology and all those other things, they're just harder. So it's very easy to focus on that one metric, if you can see it. And it's easy to measure. And there's a tendency, I think, in medicine to think the more parameters we measure, the better our health. And that just isn't true.

[Erin Welsh]

There are so many science and medical or wellness influencers out there, like the health podcast bros that you mention throughout your book. And they come with not only these impressive credentials, but also these substantial ties to health industries or supplement industries or the wellness industry. How can a consumer know when to trust a source? Or can they. Can educational entertainment be trustworthy or be something that is viable?

[Dr. Deborah Cohen]

It's really hard balancing out because we know people don't want to pay for stuff. People don't want to pay for their media content and it needs to be funded. And who's going to have the biggest interest in funding a health podcast is the people that are going to benefit from it. There's a phrase that I heard a lot is I only work with the companies that I believe in or I use personally. Well, what happens if there's evidence that suggests that that company, that product isn't very good, but you've become financially dependent on it? Do you suddenly drop it? So for me, it's a nonsense term. It's a nonsense expression. And we have seen certain podcast pros pivot. You know, I don't like glucose monitors. Oh, look, I've seen. Just spoken to somebody that works for one and they're sponsoring my podcast and now I recommend them. Oh, I don't like this. Or ravine. Go look. Then I'm going to. I'm going to start backing it and putting it on my podcast. And guess what? I'm going to be a paid advocate and I'm going to try and get it into medical journals and I'm going to advocate for it in academic studies. It's that that was blown open in a. In a court case between Aura and Peter Attia is his relationship with the company. And it sheds a light on these commercial relationships that podcasters have have with companies. And I think it becomes more problematic in many ways when it's a medical professional that does it, because it sort of gives it more of a endorsement. And there's one UK podcaster, Dr. Angan Chatterjee, and I took him out the book and I'm kicking myself for taking him out the book. But he's sponsored by AG1 and our regulator Ofcom. They don't regulate podcasts, but they did highlight this as an example is when it's a health professional that is working with a company, even if they say they declare it, it looks like an endorsement. And in many ways I think health professionals have to have an even. Well, they should do have a higher standard. We're a regulated profession. You've got your state licensing boards, we have the General Medical Council in the UK and it's really difficult balancing how do you get the funding and remain independent at the same time? It's tricky.

[Erin Welsh]

Does accurate scientific information have a place on social media and what does that place look like?

[Dr. Deborah Cohen]

I think it has to because that's where people are going. I think we need to be more skeptical. I think we need to be have better health literacy. But even then is somebody going to be able to interpret a systematic review or a meta analysis or understand control trial? That's a difficult task. I think health professionals have to do better or have to sort of meet people where they're at and there are some people that do it very well. It's not all bad. And I'm obviously doom and gloom. The book title Doom and Gloom for me is about let's think critically about where our information is coming from and what is shaping our health care and what incentives and what are the interests shaping our healthcare and our health information system system. And then the next challenge obviously is going to be the large language models and how the information on them are being shaped. And we know companies are already trying to make their information prioritized by the LLMs. You know, it used to be search engine optimized, now it's geoengine optimized or some. I can't remember the exact term, but there is. There's a whole cadre of people that are working on information to make sure the bots pick up on their content. And that is going to be the people with the deep pockets that are able to shape their content accordingly and who knows what deals going on behind the background. I wouldn't want to say and that would be pure speculation on my behalf. But already we know that if you do a Google search, it's the sponsored content that comes up to the top of your feed, but it's going to be less transparent.

[Erin Welsh]

So that's another question that I had, is that if we can make educational content reliable, accessible, interesting to people, there's still the issue of this flood of misinformation or information that is in the gray area or that isn't backed by these robust studies and people who have financial ties. How can we incorporate regulations or adjustments, health literacy training, to get people to recognize when what they're seeing is being promoted by these bad influencers?

[Dr. Deborah Cohen]

There just has to be a lot more skepticism. So one of the things I would say to people is don't dismiss someone's story, but ask why they're telling you it. Ask why they're stepping onto a platform in the first place to tell you about their condition or to tell you about this product or treatment. That's the first thing you should ask. Ask why is this person telling me this? Why should I believe you? And equally, why should people listen to me or believe me? I got asked that the other day at the Edinburgh Science Festival. The first question I was asked by a pediatric radiologist, why should I believe you? And I said, well, I sort of have to be accountable. But equally, you can dismiss me. You know, if I'm on the BBC, I'm regulated by Ofcom, you know, regulator, or if I write something in the bmj, I have responses, or you can literally come down on my door and hammer down the door. But there's no accountability here, or very little accountability, if any at all. And if someone's only telling you the benefits of something, why aren't they telling you about the harms? Because every treatment has benefit and every treatment has a harm. We don't necessarily know whether you're going to be the person that benefits or gets the harm. Medicine, again, is quite slow moving and that precision. If I give you a statin and to prevent a heart attack, as a doctor, I cannot tell you whether you will be that person that benefits from that statin. It's all statistics. And that's the problem. If someone's over certain, then they're probably not right. So it's just those little cues. If you're thinking about a treatment, what's the benefits of doing? What's the risk? Risks? What the alternatives? And what if I do nothing? They're the decisions that go into stuff and who's behind this information, really? So it's just being a bit skeptical. And in terms of provision of information, whether you're, you know, the Preventative Service Task Force in the United States or the NHS in the United Kingdom or the Institute of Medicine, or whoever you are, perhaps you need to think about presenting your information in different ways. It's really tricky because again, you're held to a different standard of accountability. If you are those institutions and let's say you mess up rightfully, you're going to be held to account. And I think it's very difficult for people to. I feel in the UK that we've got something called the Royal Colleges, so they're Royal College of Surgeons, Royal College of Physicians, Royal College of Obstetrics and Gynaecology. I feel that they need to do some kind of campaign about consumerization of health and all these tests and treatments that you see, be careful before you buy because it's a pretty unregulated market in the uk, I think the United States, possibly even more so than the United Kingdom. But equally, we're going that way. What should change here? If people are being offered egg freezing that isn't indicated or statistics that are wrong, where's the regulation going on here is who's protecting consumers? What we're talking about, I think in this particular instance is who's protecting consumers? And there isn't a huge amount of consumer protection going on. It's the new snake oil. That's what it is. It's the new snake oil.

[Erin Welsh]

Absolutely. Dr. Cohen, I really appreciate you chatting with me today. This has been such an eye opening conversation and your book has so much food for thought. It was fantastic. Thank you.

[Dr. Deborah Cohen]

You thank you so much for inviting me on.

[Erin Welsh]

A big thank you again to Dr. Deborah Cohen for taking the time to chat with me. If you enjoyed today's episode and would like to learn more, check out our website. This podcast will kill you.com where I'll post a link to where you can find bad influence, how the Internet Hijacked our Health, as well as a link to Dr. Cohen's website where you can find her other work. And don't forget, you can check out our website for all sorts of other cool things including but not limited to transcripts, quarantini, recipes, show notes and references for all of our episodes. Links to merch, our bookshop.org affiliate page, our Goodreads list, a first hand account form and music by Bloodmobile. Speaking of which, thank you to Bloodmobile for providing the music for this episode and all of our episodes. Thank you to Liana Squillacci and Tom Breyfogel for our audio mixing and thanks to you listeners for listening. I hope you liked this episode and are loving being part of the TPWKY Book Club. A special. Thank you as always to our fantastic patrons. We appreciate your support so very much. Well, until next time. Keep washing those hands.

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