In science communication,why does the idea of a public deficit always return? How do the shifting information flows in healthcare affect the deficit model of science communication?

1. Introduction: Science communication in the healthcare field and the context for this essay

The healthcare field contains a multitude of opportunities for science communication. It isn’t just communication of health information from healthcare professionals (e.g. doctors, nurses) to patients but also from patients to the healthcare professionals (e.g. telling doctors their symptoms), and communication between healthcare professionals and patients with administrators, government officials or academics.

Given the multitude of stakeholders dancing together in this multidirectional tango of communication, we need to ask how much does the deficit model apply to the health field?

At first glance, history dictates that healthcare professionals are the holders of all knowledge (i.e. the wise all-knowing sages), and the patients and other stakeholders are the ones that need the scientific information communicated to them (i.e. the consumers of the information). So in this regard, the deficit model should hold true. However, this essay will explore why the deficit model is falsely held true, and why the emerging paradigm of shared decision-making and patients and other stakeholders as partners in healthcare is challenging that old model to a certain extent. The multidirectional flow of knowledge, where the public and other non-expert stakeholders also communicate important information to the ‘experts’ in healthcare decision-making, provides evidence that the deficit model should not hold as much importance in the healthcare field as traditionally thought.

2. The tradition of the deficit model in health

The tradition of the deficit model is long-standing in the healthcare field. Healthcare professionals, specifically doctors, have been the bastions of medical knowledge while patients were considered biological systems that needed to be treated or manipulated in some way to achieve acceptable health and homeostasis. Healthcare professionals obviously deserve their position as holders of medical knowledge, as they are the only ones who are formally trained to learn and use healthcare knowledge. From the founding of the Hippocratic Oath to modern surgery to the rise of preventive health, healthcare professionals are the trusted masters of medical knowledge. Traditionally, the public were thought of as not usually being trained in any scientific method nor in any medical disciplines, and usually had no regular access to healthcare information anyway. Apart from direct experience, or hearing about what happened to friends and family, people didn’t seem to have any structured and regular way to gaining healthcare knowledge. This imbalance in which groups held medical knowledge was likely the basis for the persistence of the deficit model in the health field.

Apart from healthcare professionals being the traditional bastions of medical knowledge, we must acknowledge that even within the healthcare professions, there is a lot of medical knowledge to know, and this has required the ever-increasing sub-specialisation of healthcare. Healthcare information is not only broad, but deep. For example, a medical doctor may choose to specialise in surgery, and sub-specialise in microsurgery. Given the broad and deep nature of medical knowledge, it may be presumed that if specialists spend decades learning their craft, how can we expect the public to understand the complexities and nuances of medicine or even their deep subspecialties? This could further support the validity of the deficit model.

Experts find it hard to keep up with advances in medical knowledge, so it might stand to reason to ask how can the lay person hope to understand even a little of this deluge of information? If healthcare professionals need to communicate medical information with the public, they usually need to start with the basics and communicate information from a deficit model standpoint, assuming the public has next-to-no-idea about the topic. whether or not this is true is not considered. And the rate of published scientific literature keeps rising past the point where healthcare professionals can actually read it all. From the sheer volume of information being produced, the deficit model may be justified, but it may also apply to healthcare professionals as well nowadays.

A deficit model in health communication is not necessarily due to experts and healthcare professionals thinking that the public know nothing or are stupid. Properly communicating information is of critical importance in the healthcare field, and any miscommunication or omission of facts is a risk for litigation if something goes wrong. The medico-legal concept of ‘informed consent’ might be a common justifier for adopting the deficit model of science communication because it may be safer to assume the audience knows nothing or very little, and ‘dump’ as much information on them as you can to cover your legal duties.

By communicating from the basics up to the advanced information, healthcare professionals can be seen to be doing their ‘due diligence’ by ensuring the patients and public understand the information they are telling their audience. It may also be much quicker to communicate ‘everything’ rather than to try to understand where the audience is at in their understanding of the science. For busy healthcare professionals, it may just be too time consuming to engage in a deep two-way dialogue with the audience at their appropriate knowledge levels, and just ‘dump’ information on the audience from a deficit model perspective. Given the time and reimbursement-per-patient-seen pressures on family physicians and general practitioners nowadays, it might be unsurprising to experience this type of brief communication. Assuming a deficit model may be the quickest approach to health information communication for them.

Another healthcare situation is in pharmaceutical advertising, particularly in the United States and New Zealand, which allows direct-to-consumer advertising. Presuming public ignorance (and therefore public deficit) seems to be the norm, with advertisers encouraged to provide as much information as possible about the product (e.g. consumer medicines information sheets, references to clinical trials usually in the small print, websites for the product, etc.) and also encouraging patients to ‘please, ask your doctor’ or ‘please, ask your pharmacist’ for more information (Herxheimer, 2012; US Department of Health and Human Services (DHHS), 2015).

3. The shifting paradigm of the empowered public – Apparent rejection of the deficit model

4. Public participation in healthcare decision-making

In healthcare research, we are now seeing a new public participation model. Apart from the aforementioned participation in healthcare policy decision-making, the public is now also getting involved in healthcare research. For example, crowd sourcing has been used in the systematic review process for screening of published research literature.

To further elaborate on the example of public participation in health policy decision-making, it could be argued that a deficit model of science communication might be needed for people who initially join a committee. But this model is soon made redundant as the participants learn the facts and processes for decision-making regarding the issues at hand. In these circumstances, it may be a question of when to abandon the deficit model of science communication with these people. In many cases, lay people who are selected for high-level committees already have some basic level of healthcare knowledge or experiences that give them some unique expertise to contribute to policy discussions.

From personal experience, I have worked with cancer patients who are more knowledgeable than I on cancer research matters. In fact, some patients are collaborators on various research projects and research publications. Consumers and the public are regularly consulted on government policy papers, for healthcare NGO projects and on consumer advisory committees for healthcare service providers. In the healthcare field, there is an increasing recognition of the public’s knowledge about health and the healthcare journey. For this audience, I do not believe the deficit model respects the level of expertise they hold.

Health consumer groups can also be producers of health information (Ko, 2010). Health advocacy groups, like the Consumers Health Forum of Australia, release policy papers and provide feedback to various health issues. If we take this to the ‘extreme’ end of public empowerment, we see celebrities publishing books about diets and healthcare information – healthy lifestyle books by Gwyneth Paltrow and Suzanne Somers, or healthy recipe books every other week by one celebrity or another. On the other end of the spectrum are those non-healthcare professionals who have learnt a more analytical approach to healthcare information and are famous for sharing it with others, such as famous American health bloggers and podcasters Jimmy Moore, Dave Asprey and Mark Sisson.

5. Final points: The rise of Dr Google, podcasters, writers and celebrity ‘experts’ in health. Is this a good or bad thing for the deficit model?

Does the deficit model of science communication dominate healthcare information flows? I would say yes it has, and still does. Healthcare professionals by their medico-legal duty may be required to adopt this model of communication. However, the modern public are far from uninformed consumers of previous decades. The rise of ‘Dr Google’, access to health information and more sharing of health information and experiences between people via podcasts, books and newspaper and magazine articles have led to a more knowledgeable public. However, there may be a question of sorting out between the accurately informed masses versus the misinformed masses. This might be a reason why the deficit model still is relevant in the healthcare field. Even with a flood of information available, healthcare professionals and science communicators do not know whether the public has the correct baseline understanding of medical facts. This complex mix of various levels and various accuracies of understanding may be a key reason why the deficit model is a recurring model in healthcare communication.

However, I would also argue that nowadays with the flood of ‘noise’ people are exposed to, it is not the lack of knowledge that communicators must address, but rather the tackling or ‘negotiating with’ the health misinformation, myths and incorrect beliefs that is the problem. The shifting information flows in healthcare and empowerment of the public have shifted some traditional inequalities in science communication and public knowledge of health and medicine, but also created new problems for science communication of health and medicine that still probably require a deficit model of science communication.

So, how are the many forces as discussed in this essay shaping the medical field, and where is the field going to end up? My guess is that the deficit model will still be dominant in the healthcare setting, with healthcare professionals being encouraged to provide as much information as needed due to medico-legal requirements. However, patients/consumers will have more knowledge, experience and/or power, even if it is based on pseudo-science in some cases, to challenge the information being presented to them. Interestingly, provided consumers/patients are encouraged to actively question their healthcare professionals, it may be this ‘adversarial’ dynamic that could increase the rigour and quality of patient-professional shared decision-making in healthcare.