Managing the Confident but Incorrect

“It's kind of like we opened a Pandora's box and trying to close it up again is going to be very hard.” —Dr. Zachary Rubin

Dr. Zachary Rubin joins Dr. Mariam Hanna for a candid look at the “difficult and misinformed” patient — the growing phenotype every allergist now manages weekly. A double board-certified pediatrician and allergist-immunologist with a massive social media footprint, Dr. Rubin breaks down how misinformation spreads, why it resonates, and how clinicians can approach these encounters without burning out or burning bridges. From TikTok-fuelled certainty to patients demanding full panels, he offers a practical, clinician-first playbook for navigating the mess.

On this episode:

• Why today’s misinformation is stickier, faster, and more emotionally charged than a decade ago, and how parasocial trust amplifies it.
  
  
• How the “nugget of truth” inside misinformation gives it power and how to dismantle it without escalating conflict.
  
  
• A clinic-ready strategy to approach resistant patients: open-ended questions, triaging what must be corrected now, and focusing on one actionable change at a time.
  
  
• Why continuity, follow-up, and small pieces of information over time often outperform a single “big correction.”
  
  
• How to use shared decision-making to reframe testing and treatment choices, especially when patients arrive convinced they need “the full panel.”
  
  
• Practical tools to support patient understanding, including targeted education resources, structured discharge summaries, and multimodal materials for different learning styles.
  
  
• How teams can protect each other through debriefs, preparation, and collaborative communication during high-stress encounters.

A grounded, real-world conversation for clinicians who balance patient frustration, digital misinformation, and the realities of modern allergy practice.

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Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca

The Allergist is produced for CSACI by PodCraft Productions

Transcript

Dr. Mariam Hanna: 0:01

Hello, I'm Dr. Mariam Hanna, and this is The Allergist, a show that separates myth from medicine, deciphering allergies and understanding the immune system. Forgive me, but I'm tired. I've had this frustrating run of this seemingly sane discussion. I'm tired of having it. There's a few different versions, but it actually goes all the same. Here's how it goes. I've heard what you had to say, Doc, but you do know about steroid withdrawal syndrome, don't you? Well, I don't like steroids. What's this food immunotherapy? All right, yes, yeah, I spoke with some of my friends on social, and I'd like to do it on my own, at home, like Jenny, my friend on social. Okay, how about this one? I'm here for testing. I actually need the full panel this time, not just the one or two foods. The full panel, please. Finally, is this airborne? No, no, no, let's not go there. We're not going to go there tonight. Okay, again, I realize I'm tired, but there's this challenging patient phenotype. I can't even define it for you. Well, not like a personality disorder or even type. It's the difficult and misinformed patient. And so in my search for the person to address this, I thought of actually only one character that could do this with justice. Someone on social media who talks to the general public for seemingly fun, to bust some myths, or to right a wrong. So it's my pleasure to introduce today's guest. Dr. Zachary Rubin is a double board certified pediatrician and allergist immunologist extraordinaire who practices at Oak Brook Allergist in the Chicago area. A nationally recognized medical educator and public health advocate, he shares evidence-based accessible advice on allergies, asthma, and he even goes into vaccines. With over four million followers under the handle at Rubin underscore allergy for anyone that's following. Outside of medicine, Dr. Rubin has a busy schedule. He's already published a book and it's coming out. Dr. Rubin has published All About Allergies, which is the first book that offers a clear and compassionate guide to managing allergic diseases. All right, Dr. Rubin, thank you so much for taking time out of your busy schedule and welcome to the podcast.

Dr. Zachary Rubin: 0:12

Thank you so much for having me. It's really exciting that we got to meet in person because the thing is that folks don't realize is we were interacting on the sidelines on the days of MedTwitter when we would talk about various allergy issues or COVID. And so finally seeing the person behind the avatar, it just made me so excited. I was really giddy to finally meet you.

Dr. Mariam Hanna: 0:15

It was lovely to meet you as well. And you know what? A lot of times when I go on social media, you will notice I vent my frustration of like this is what's happening. And so your approach has always kind of been interesting to me in that you tackle the misinformation where I just vent and say this is wrong. This is misinformation. But you try to deal with this difficult person. So I want to actually start with how we define this difficult patient. I tried in my intro, but I don't know if I did it justice. So how do you define this difficult patient in clinical practice? Are there different types? Are they all the same?

Dr. Zachary Rubin: 0:20

Well, you know, it's really a flavor of the same thing in the sense that a lot of people are looking for information online to try to answer questions that are not easily accessible to them, because when it comes to their health in general and especially allergic diseases, which is an evolving field with allergy and immunology, there's so much conflicting information online. And so I don't really blame patients for trying to take charge of their health, especially if they don't have good access to health care or it takes months, if not years in some cases, to get in. They may not be able to interact with their physicians on a regular basis. And so they may already come in with preconceived notions about a particular test, a particular therapy, a particular supplement. And when we come in and just say, hey, this is wrong, a lot of people don't like to hear that.

Dr. Mariam Hanna: 0:23

And has this changed? Like, is this fundamentally different than 10 years ago? Like, when I speak to other colleagues, do I say, like, this is actually something that is unique over this past decade that we are dealing with today that we have not dealt with before?

Dr. Zachary Rubin: 0:25

So I look at it actually from the standpoint of the past 20 years, that there's been a huge change from the birth of really social media as a whole and accelerating that right in the beginning of the pandemic, because there are these platforms like TikTok where people are doing short form videos and everything became more video based rather than text and photo based, where people start to develop parasocial relationships with whoever is creating that information and sharing it online. If you see that same person over and over again, they're going to appear more trustworthy and people are more receptive to that information, even if it's not accurate at all, because they're able to evoke emotional responses. And those emotional responses tend to go viral on the Internet. And when there's more eyes on that, there's a higher chance that somebody is going to be influenced into making a poor decision.

Dr. Mariam Hanna: 0:28

What contributes to them getting to this point? And do I need to, like, evoke an emotional response out of them to get them out at this point?

Dr. Zachary Rubin: 0:30

You know, the way I think about it, and this is kind of how my content's been going over the past couple of years, if I see a piece of misinformation that is clearly causing an emotional response, there's a debate about whether you should show that in your content and then refute it or just give information. And in my opinion, because of how computer generated algorithms work on social media, where their job is to keep you on the platform as much as possible, they're not going to share the nuanced, fact based, dry information. They want to get people have that shock and awe where they're more likely to be glued to their phone and interact and engage with that piece of content. So I'm not afraid to show it and then say, hey, I'm not taking this out of context. This is what they said. Now I'm going to explain to you what are the nuggets of truth, because a lot of misinformation actually has a nugget of truth to it and why it's incorrect and what's the actual alternative explanation if there is one to be able to address this issue. But I want people to know that they're falling into this potential trap and we need to show why is this something that could be very problematic? And so getting that initial hook will help people hear what that is and then get an immediate comparison with the correct information that comes from an expert. And because I've done this for five years and I repeat myself multiple times because you will see it's not just one person saying this message, it's multiple people will say they may not have seen your video. It doesn't hurt to repeat yourself and showcase why this is incorrect information. What is the alternative correct information? Because you'll eventually reach a larger audience and because people see you on a regular basis, you develop that parasocial relationship where now I get tagged in a lot of videos and people will say, Dr. Rubin, what do you think about this story? Dr. Rubin, what do you think about what you're seeing in front of you? You know, what's the diagnosis? And I'm not going to diagnose them on the Internet because you can't give specific medical advice. But if they say this is the disease, I'll give clinical context to help educate the public. So if we see cold induced urticaria clearly on the screen, I'll show that and then I'll say, hey, this is what this disease is about. A lot of people are told, oh, it's in your head. But cold induced urticaria is absolutely real. And here's what's happening, the pathophysiology behind it. And I do that in a way that's approachable, nonjudgmental, and try to break it down into as as much of a digestible format as possible, because it's very difficult to take these complicated subjects that we took years to learn, but then make sure that as many people as possible understand it.

Dr. Mariam Hanna: 0:38

Yeah, you have kind of like a science to how to approach misinformation, get them with a hook, right, be approachable, right, and then and then start to debunk or work through this. Now, how does health literacy impact patient understanding?

Dr. Zachary Rubin: 0:40

Well, it makes it even more difficult as our therapies become more complicated. But even if you're listening to this and you're saying, well, I'm not posting on social media, how does this apply to me in clinic? I think if we take a step back, we can still apply the same principles that we use in social media to the clinic setting, which is when you have a patient who is either not adherent to their medications, they're not taking it correctly, they don't understand their health or they're resistant to change because of what they're hearing on social media. You need to take your time and say, look, I may not be able to reach them on the first visit, but I need to be able to connect with them first and understand their concerns and listen and then say, hey, let's have you come back as soon as we can get you in and we're going to talk about these other issues. I know that can be difficult because the census of a practice could be very large and the ability to get appointments could be difficult. But even if it's just a quick check in something to show the patient that, you know, we really, I mean, the vast majority of physicians and other health care workers, they really care about their patients. The system makes it hard to be able to accommodate everybody. But even if you get a little bit of additional time to be able to listen to their concerns and then add a little bit more information, add a little bit more a lot of people will end up coming around if you are able to establish that continuity.

Dr. Mariam Hanna: 0:44

Yeah, establishing continuity and being patient. So how do we balance this like therapeutic relationship and correcting this information?

Dr. Zachary Rubin: 0:46

Right. So I think the first thing you always have to do, especially if you suspect that this could go in a negative direction, is start off by saying, what have you heard about this? What are your thoughts on this? Don't make it a yes, no question, but make it very open ended. So they have an opportunity to open up and give you those pieces of information that you then need to triage in your mind. Is this something worth correcting or not, because not everything has to be corrected right away, right? We have to see what is the can't miss issues, right? Is it that they're not adherent to their inhaled steroid or is it they're over using their short acting beta agonist or they're taking a supplement? I mean, it could be a million and one things, but you have to triage in your mind of the list of things that you're hearing, what is the one thing that you really want to make sure that you're addressing because you don't want to you don't want them to land in the hospital because they're not doing it correctly or whatever it may be. Focus on that one thing after you've heard that. And if you've got other people in the room, you might want to involve them. All the other family members can also help out with this and try to make this a collaborative effort. Try to do your best to give options and not pigeonhole them into one particular option, saying this is the only one that I recommend. You oftentimes, if you have time to be able to go through the risks and benefits of multiple treatment options and then the alternative not doing anything helps open up the discussion towards generally the right pathway. And I, and I see this a lot in my practice with food allergy testing, because so many people come in wanting the full panel of things. And then I really carefully explained to them, okay, well, if we do this, then if it's positive, do we really know it's positive? Is that truly it? Or, you know, if it's negative, you're going to feel really good. Yes. But if it's truly positive, is it falsely positive or not? You could be getting a problem that you didn't want to coming in the door. My goal is to clarify things for you. I don't want you to leave my practice with more problems than you came in. That is always my goal. I want to clarify everything that's going on. And if there is a gray zone, we address that together.

Dr. Mariam Hanna: 0:55

I love that kind of. Okay. So you've kind of hinted at it. Shared decision-making that's the buzzword of 24. I feel we've moved away from it in 25, but shared decision-making is inherent in all of our discussions. And, you know, it's part of the open-ended questions and offering them options. So do you use a lot of shared decision-making then, I take it, in your practice where you're presenting open-ended questions, let's talk about all the different ways or approaches, that kind of part of the dialogue that happens there?

Dr. Zachary Rubin: 0:59

Yeah. Especially when it comes to, are we going to test or not? I feel that the science has changed where instead of just saying, let's test everything under the sun, we're really trying to have a concerted effort of targeted testing towards allergens of all sorts of kinds, right? And so presenting the options of saying, what's the risks and benefits of doing this test, which is not a hundred percent accurate versus not doing it and exposing yourself to that particular allergen, whatever it may be. What are the risks and benefits of both? What do you think about these options? And then same thing with treatment options. You know, what's the risks and benefits of doing an inhaled corticosteroid versus a leukotriene receptor antagonist? Let's talk about those potential options. And you can kind of lead them in one direction or another, depending on how you soften or harden the language of it. And I provide oral immunotherapy in my practice, and I think it'd be really a great tool for some patients. I don't offer to all of my patients, or at least I will present it, but in a way to say, hey, this is available, but given your lifestyle, you're a three-sport varsity athlete, I don't know if that's going to be the best choice for you because of X, Y, and Z reasons, but this is what it would look like. This is what it would entail. What do you think about that situation? How do you think that's going to impact your family life, your quality of life?

Dr. Mariam Hanna: 1:05

Are there particular tools or resources that are helpful for this? So in my ambition to give people lots of options and talk about the pros and cons while they seem engaged in the office, it breaks my heart when they're like, so this is all like written down, right? And you're going to like write this all for me and I'll take this home.

Dr. Zachary Rubin: 1:07

So there's multiple ways that I go about doing this. Number one is in the United States, we have the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology, and I'll point them towards those websites to say, you know, we have some great resources that give you one to two page summaries about whatever we're talking about, right? So they can look at those to get a primer to them. I also am lucky that I invested a little bit into having an AI software that is a dictation service. So when I speak, it picks it up, the patient knows this, and it will create a discharge instruction of those risks and benefits, transcribes it down, and I can print that out at the end and give that to them. So then they have a summary of what I literally said, because that informed consent process that essentially we're trying to do in this to be fully transparent, they now have that written down and they don't have to feel stressed about taking a million notes. I find that to be very useful. We also have, as a practice, had a few handouts that we've just been using over the years that we hand to patients, and I encourage everybody to have some of those written documents. And, you know, I have created so much social media content that they will also have video versions if they're interested in going on to my social media pages to learn a little bit more about some of the nuances or discussions. And I'm really excited that my book's going to be coming out soon because that's going to go over the breadth and depth of allergic diseases in my book called All About Allergies. It's 18 chapters that goes into, you know, the science and the anatomy and the pathophysiology of allergic diseases and the treatments and the future directions in a narrative format for people to learn from the patients that I've seen or from my followers who I got a chance to interview.

Dr. Mariam Hanna: 1:12

No, and as people that are involved in patient education or educators in general, having different resources in different formats helps the different learning types and patient types that we see. And I love the plug for AI that's incorporated in there. Again, like we are learning how to incorporate this to assist us, but also to assist our patients in these encounters. So it's not just about my documentation, but it also helps them to document what it is that we discussed. Great tips. Okay. Well, after my encounters with my, I'm still calling them a little bit difficult patients, difficult, I feel like sometimes I need to debrief with my staff if there's been a particularly challenging patient we've faced or other physicians that do the same specialty, or it's like a vent session for lack of a better word. How can clinical teams and practices support each other is the more scientific and nicer way of asking that in managing these encounters? How can we be supportive both before, during and after these encounters?

Dr. Zachary Rubin: 1:16

Right. So I think like you just said, which is having these debrief sessions can be very valuable. I do them myself. Usually I do it with the nursing staff that works directly with the patients to either give them a heads up and say, Hey, we got this person coming in and this is the issues that are going on. Um, I've had some pretty challenging situations. Like the first month of my attending year, first attending year, uh, there was a gentleman who came in expecting that he was going to get started on allergy immunotherapy, you know, through subcutaneous immunotherapy. I didn't have any records. And I said, look, if we don't have any records, I'm going to have to test you. And he didn't, he didn't want to be tested again. And he ended up being very rude to my staff. And then he got up, he was a very big guy. And he just like slammed the door right in front of me, like almost hit me. And he ran out the door. It was, it was a very scary experience. Um, and one that I then went to the nurse who was initially harassed and we talked about it and said, you know, how are you feeling? Are you doing okay? And we checked in with each other and, and discussed this. And I, you know, told my office manager what was going on, you know, I think it's important to let your staff know that you're also vulnerable too, because I know in, in, in unusual situations like that, uh, our staff could be potentially terrified and, and, you know, that, that particular nurse that, that dealt with that with me was also just recently hired at the same time, like we came into the practice together, so it was nice to have that moment to, to be able to debrief and share that experience in a way that helped us grow together because I love the staff that I work with. They work really hard. Uh, we have a very collaborative effort and it can be lighthearted at times and fun at times. And, and it makes it for a great environment, one that, you know, I really don't want to go anywhere with, with how great, you know, everybody's been, um, and, and you foster that through those types of sessions.

Dr. Mariam Hanna: 1:24

You do, but it takes, it takes like a moment. You need to like regather yourself at the end of that.

Dr. Zachary Rubin: 1:26

Absolutely.

Dr. Mariam Hanna: 1:28

Okay. So my colleague, when I first started out, he's like, you know, in the news, allergy pops up all the time. Some of it is scientific and some of it is total like bunk. And we just need to be aware because our patients are hearing it as well. Am I supposed to spend more time on social media? Cause I was trying to limit that. Can we go back to where like patients would seek physician advice or those that were experts in a particular way?

Dr. Zachary Rubin: 1:32

Yeah.

Dr. Mariam Hanna: 1:34

What do you think?

Dr. Zachary Rubin: 1:36

It's kind of like we opened a Pandora's box and trying to close it up again is going to be very hard. I will tell you what an interesting approach has come out of China recently, which they're putting a law in place that if you are posting information online is deemed sensitive, including medical information, you have to be a medical professional and show your credentials in order to post it. Otherwise it will get completely taken down. Um, that's a really interesting approach, in the United States, I don't think that would ever fly though, because that would be seen as censorship, which is a big problem right now. Cause a lot of what happened in the pandemic was, you know, people were saying all sorts of nonsense, like take ivermectin and, and, and hydroxychloroquine, when we knew that that wasn't working. Or we're saying that, you know, COVID-19 vaccines cause you to be magnetized, like all this crazy stuff. And there was a concerted effort to try to, you know, quell that misinformation and slow down its reach. But now with the current administration, they're all about, no, no, we can't, we can't censor any of this kind of stuff, but only what we want to censor, you know, so it's, it's, it's kind of, you know, the pendulum swinging the opposite direction. And right now I don't think the United States or even Canada would entertain something like what China's doing with this. And I'm not saying that that's the right approach, but it just goes to show you how difficult it is to deal with this now that we're in the information age where anybody could pretend that they have credentials and say whatever they want and people will listen. I mean, I, in my talk that you heard, I showed a mom who said 15 seconds. That was potentially very damaging saying, you know, my, my baby had eczema and the doctor said, just put some creams on it, but I did my research. It's a very clear, clear, common buzzword. I did my own research and found out that it's often due to dairy. So when I got rid of dairy within 24 hours, the skin was clear. So you can't, you can't like really refute that in the sense that you're not there. Right. But we know that that's not really true, but it could also be potentially damaging for people for all sorts of reasons like nutritional issues and increasing the risk of developing an IgE mediated food allergy if you're delaying introduction, you know, so, so these things happen all the time. And so that's why it's so important that we're at least aware of it. So that when you hear that you're not caught off guard saying like, huh, the heck are they talking about?

Dr. Mariam Hanna: 1:44

Can we, can we do more in terms of public education space there? Because one of the things I have is, you know, is it just each physician going on social media and the, and the voice of each individual physician contributing to this misinformation discussion or debunking it, or is, should it be on a different level?

Dr. Zachary Rubin: 1:46

That's an excellent question. I think there's multiple ways that we could handle this. One is what you just said, that we need just more experts online. We just need to fill that void because for every expert that there is talking about this, there's at least 10 to 20 people who have no expertise in all the chiropractors and it's like, why are they talking about allergies? Like they're ordering IgG panel testing. It's not helpful. It's harmful. It's just making a quick buck off of people and causing more problems. Right. So there's a lot of people like that on there and we need more people to drown that noise out. That's one, but two is going back to an earlier issue we discussed, which is improving health literacy online. And also kind of just the, I think of it as like a core competency for how to use the internet proper. Like, you know, so, so it's a very different way that we process information. So we need to intervene at a younger age to teach people how to be careful online. You know, people are just sharing everything online and that's not necessarily safe and so this is going to take a generational shift to be able to adapt to all of this.

Dr. Mariam Hanna: 1:52

Yeah, a big shift. All right. Uh, time to wrap up and ask today's allergist, Dr. Zachary Rubin for his top three key messages to impart to patients and physicians on today's topic, medical misinformation, Dr. Rubin, over to you.

Dr. Zachary Rubin: 1:54

Number one, we need to make sure that people are critical of the information that they see online, that before you share it, before you interact with it, just take a step back and think, is this true? Even, even for me, a lot of people know me at this point. I have over 4 million followers, but I still encourage people to double check and to verify the information. So that that's really important because if we are sharing things, you're amplifying potentially misinformation. Number two, for patients, no matter what you hear online, you should always be talking with your doctor first. And if you hear about something, that's fine and it can, it can raise issues. And in fact, I've had a lot of feedback where people have said to me, you know, Dr. Rubin, I didn't know there was a black box warning on montelukast or Singulair or these depression and anxiety episodes. And I talked to my doctor about it and we stopped the medication and I feel a heck of a lot better because I heard about it from you. So you may get some information that could potentially be good, but you still need to talk to your doctor about whether it's relevant to you. You don't want to just stop things just because you heard it online and not consult with your physician. Otherwise you're leaving them in the dark and you could potentially have a lot of problems. And lastly, for physicians who are creating content online, I think it's really important that people come at it from a genuine perspective, that you are relatable, that it's okay to be yourself online. You don't have to pretend to be something else. I hula hoop on purpose so that people can see that I'm just a normal dorky guy, like everybody else. Like we all have our quirks and different talents. And, and I think it's okay to showcase that because we're not on some ivory tower, but yet at the same time, we do need to command a level of respect, but also break down those barriers.

Dr. Mariam Hanna: 2:01

Breaking down the barriers. I love it. Thank you, Dr. Rubin for joining us on today's episode of The Allergist.

Dr. Zachary Rubin: 2:03

Thank you so much for having me. It was really nice talking with you again.

Dr. Mariam Hanna: 2:05

This podcast is brought to you by the Canadian Society of Allergy and Clinical Immunology and produced in collaboration with PodCraft Productions. The opinions shared by our guests are their own and do not necessarily reflect the views of the CSACI. Please remember that this podcast is for informational purposes only and does not provide any individualized medical advice. For show notes and relevant links from today's discussion, visit CSACI.ca. While you're there, check out the Find an Allergist tool to connect with a specialist near you. If you enjoyed this episode, you can't go on social media. We'd love your support. Subscribe wherever you get your podcasts. That's your medium. Leave a review and a five-star rating. It helps others find the show. Thanks for listening. Sincerely, The Allergist.