Monday, August 17, 2015

Escaping the echo chamber

Humans have a tendency to seek confirmation of our own beliefs, choosing to surround ourselves with like-minded people and information sources—a phenomenon that social scientists call the “echo chamber” effect.

For instance, if I asked my neighbors in my upscale Washington DC community about their views on a range of issues, they almost uniformly would tilt liberal: support for Obamacare (although some would have a preference for single payer), pro-gun control, belief in global warming and support for policies to mitigate it, and pro-gay marriage. If my neighbors only get their news and opinions from sources like the New York Times and MSNBC’s Rachel Maddow, they likely would conclude that their liberal views are held by most Americans, except for a “misguided” minority of people who have been “duped” into holding unscientific, illogical and contrary conservative views.

On the other hand, if people who live in “red state” communities were to ask their neighbors about their views on a range of issues, they almost uniformly would tilt conservative: opposition to Obamacare, anti-gun control, disbelief in global warming and opposition to policies to mitigate it, concern about gay marriage. If they only get their news and opinions from sources like the Wall Street Journal and Fox News’ Sean Hannity, they likely would conclude that their conservative views are held by most Americans, except for a misguided minority of people who have been “duped” into holding unreligious, illogical and contrary liberal views.

This is nothing new:  long before Fox News and MSNBC, Americans turned to highly partisan sources for news that reinforced their own views.  The University of Wisconsin’s Center for Journalism Ethics observes that in the 19th century, “‘The power of the press,’ one journalist candidly explained, ‘consists not in its logic or eloquence, but in its ability to manufacture facts, or to give coloring to facts that have occurred.’ Party newspapers gave one-sided versions of the news.  Papers in opposition to Andrew Jackson in 1828 attacked him for marrying a woman before her divorce had been finalized.  He was the violator of marital virtue, a seducer.  Jackson, one paper declared, ‘tore from a husband the wife of his bosom.’  Pro-Jackson newspapers insisted on the general’s innocence, and accused his critics of violating his privacy.  There was no objective, middle ground.”  (Donald Trump might have felt right at home!). Yet the extent of the echo chamber effect has ebbed and flowed.   By the early 20th century “most newspapers ceased to be party organs.”

Today, we seem to be in an era where the echo chamber effect is back in full force.   The Pew Research Center reports that “Republicans and Democrats are more divided along ideological lines – and partisan antipathy is deeper and more extensive – than at any point in the last two decades. These trends manifest themselves in myriad ways, both in politics and in everyday life. And a new survey of 10,000 adults nationwide finds that these divisions are greatest among those who are the most engaged and active in the political process.”  “’Ideological silos’” are now common on both the left and right” Pew continues:

“People with down-the-line ideological positions – especially conservatives – are more likely than others to say that most of their close friends share their political views. Liberals and conservatives disagree over where they want to live, the kind of people they want to live around and even whom they would welcome into their families.”  63% of “consistently conservative” people say that “most of my friends share my political views”; 44% of “mostly conservative” people say the same.  Twenty-five percent of “mostly liberal” people, and 49% of “consistently liberal” people, report that most of their friends share their political beliefs.

Such ideological silos, reinforced by our own respective echo chambers, have contributed to an antipathy to the kinds of political compromises that are necessary for government to work, breeding self-reinforcing cynicism and anger about our political system and our politics.

(On a more positive note, Pew finds that “the majority [of Americans) do not have uniformly conservative or liberal views. Most do not see either party as a threat to the nation. And more believe their representatives in government should meet halfway to resolve contentious disputes rather than hold out for more of what they want.  Yet many of those in the center remain on the edges of the political playing field, relatively distant and disengaged, while the most ideologically oriented and politically rancorous Americans make their voices heard through greater participation in every stage of the political process.”)

So what will it take to turn around the polarization that is dividing the country between uncompromising ideologues, paralyzing the political process, and poisoning our politics?

Well, the obvious answer is to seek out people who don’t think like ourselves, and diversify our sources of news and opinion to seek a range of opinions.  This, of course, is easier said than done, when many Americans say they want to be surrounded only by people who think the same way, when the news media and social media feeds on and fans such divisions.  Yet each of us can make the choice, on our own, to take a step outside of our own echo chambers, and encourage others to do the same.

In my own case, in my role as a spokesperson for the politically-diverse 143,000 members of the American College of Physicians, I make it a point to step outside the Washington DC echo chamber and travel to ACP chapters throughout the country, red state, blue state, and everything in between, to converse with physicians who represent the full spectrum of political persuasions.  This fall, for instance, I will be traveling to chapter meetings in Omaha, Nebraska; Wichita, Kansas; and Osage Beach, Missouri, all red state chapters; and Monterey, California and Seattle, Washington, blue state chapters.  I know from experience I will get an earful from internists whose political views span the spectrum from right to left (just like the comments I get on my blog posts)!

Nicholas DiFonzo, a psychologist who has studied the echo chamber effect, found that “when Republicans and Democrats were put in separate groups and each group was asked to discuss a derogatory rumor about the other party (e.g., ‘Republicans are uneducated;’ ‘Democrats give less to charity’) beliefs in these rumors polarized in predictable directions. When the discussion groups were mixed, this did not happen.”

Advocacy organizations that want to step outside their echo chambers must therefore ensure that the decision groups where policies are discussed and debated are inclusive of people who hold different policy and political perspectives.

To illustrate, ACP’s Health and Public Policy Committee (HPPC), the committee that developed recent policy papers on firearms, the Affordable Care Act, vaccine exemptions, LGBT persons’ access to care, and other controversial issues, currently has a membership of 13 physicians and one medical student.  HPPC’s members hail from Pennsylvania, New York (upstate), Texas, Wyoming, Kentucky, Washington (state), Minnesota, Tennessee, Arizona, Nebraska, and Wisconsin, a true mix of red, blue and swing states.  From what I know of their views as expressed by their comments at committee meetings, HPPC’s membership is just about evenly divided between conservative- and liberal-leaning physicians, Republicans and Democrats. HPPC’s members include physicians who own guns for hunting and personal protection and physicians who would never consider owning a gun.  It includes internists who live in small rural towns and internists who live in big cities; academic physicians and private practice doctors; young medical students through more senior physicians; physicians who own their own practices and physicians who are employed by large systems, men and women, the whole wonderful diversity found in ACP’s 143,000 members!  In addition, HPPC conducts an evidence-based review of the research literature before recommending policies to the Board of Regents, ensuring that ACP’s policies are not based just on the personal opinions of its members, but the evidence of what is effective in improving healthcare.

I believe that ACP’s approach to policymaking is a model that can and should be embraced by other physician advocacy organizations.  Before adopting policy, make an effort to visit physicians around the country to find out their concerns.  Make sure that the physicians who are elected or appointed to the governing bodies that develop your organization’s policies have a good mix of political perspectives, types of practice, age, gender, race, ethnicity, career stage, and age.  Put their opinions to the test by reviewing the evidence from research studies, some of which may uphold their initial views, others may cause them to reconsider them. Seek broader input from your membership and outside parties, continue to debate the issues, as informed by the evidence and the diverse views provided, and then reach a consensus. Once your organization adopts its policy recommendations, continue to welcome dissenting views.

Call it the anti-echo chamber approach to developing policy!

Today’s question: what will you do to step outside your echo chamber?


james gaulte said...

One of the characteristics you use to describe ACP that you recommend for other physician organizations to emulate is that the "Organization's policy have a good mix of political perspectives". Could you tell me what policy positions put forth by ACP reflects anything other than a modern liberal (i.e.Progressive) viewpoint?

B Doherty said...

Whether ACP's positions on particular issues are considered "liberal" or "conservative" is in the eye of the beholder, and certainly varies by the issue. For example, ACP's positions on firearms, including support for universal background checks, has the support of over 9 out of 10 voters, according to the Pew Research Center, including most gun owners. Last year, the Annals of Internal Medicine published a survey of internists that found that the overwhelming majority agree with our views on sensible firearms regulations. Polls also show that ACP's support for same-sex marriage has the support of most Americans, especially younger Americans, self-identified Republicans and Democrats alike. Even on "Obamacare" (the ACA), ACP's support for income-related tax credit (premium) subsidies to help people buy qualified private insurance--the central feature of the ACA-- is hardly a far-left position (many liberals prefer a single payer system), and Republicans used to support a similar approach (Obamacare is based on the Massachusetts plan proposed by Governor Romney, after all) until President Obama made it his issue. I can say for certain, as I stated in my blog, that each of these, and other policy proposals, came through a balanced process where conservative, liberal and centrist physicians views were heard, and debated, leading eventually to an evidence-based consensus. These physicians arrived at what they determined to be the best policies for patients, regardless of whether they might be labeled liberal or conservative.

B Doherty said...

There are plenty of issues where ACP's positions can hardly be characterized as "liberal" (or that defy ideological characterization at all), including:

Support for tort reform including caps on non-economic damages, see:

Support for easing the hassles associated with clinical documentation in electronic health records, see

Advocacy to ease Medicare meaningful use requirements including our recent call to postpone implementation of meaningful use stage 3, see:

Support for the Medicare SGR repeal bill, which was championed by the GOP congressional leadership.

Our participation in a coalition to challenge the high price of prescription drugs, called the Campaign for Sustainable Rx Pricing, see:

Our advocacy with Congress to continue the Medicare primary care incentive payment program, set to expire at the end of this year, which provides primary care physicians with 10 percent bonus payments for their evaluation and management codes.

Our advocacy for Medicare to pay for chronic care management, transitions of care management, and advance care planning codes.

Our advocacy to require stronger FDA regulation of e-cigarettes.

Our new position paper on integration of behavioral health into primary care, see:

Our advocacy for loan forgiveness and repayment for physicians who go into primary care.

Our advocacy for adequate funding of GME.

Our advocacy to eliminate non-medical vaccine exemptions, see:

Soon, ACP will be releasing position papers on retail health clinics and telemedicine that I think most internists would strongly support, and that don't easily fall into the liberal or conservative labels.

So Dr. Gaulte, I think if you went to ACP's advocacy section on our website, you would see the breadth and depth of ACP policy and advocacy on issues that are in accord with the views and concerns of the overwhelming majority of ACP members, some of which might be labeled as liberal, some of which might be labeled as conservative, and most which defy easy ideological categorization. What unites them is they were developed through a policy process that ensures that all views were heard, informed by the evidence of what is best for patients.

james gaulte said...

Mr. Doherty
Thank you for your reply, the promptness and detailed nature of which suggest that just maybe you and ACP's leadership have been "accused" of being progressive before.

If I mischaracterized you ,I stand corrected.