Intro (Nina Jablonski): Evolution involves more than the survival of the fittest. It's also about the survival of the most cooperative and mutually beneficial relationships are critical to the survival of every species. Welcome to The Symbiotic Podcast, where we will explore the collaborative side of life and work to consciously evolve science itself.

Cole Hons: Greetings, fellow Homo sapiens. My name is Cole Hons, and I'm the Director of Communications at Penn State's Huck Institutes of the Life Sciences. Today I'll be talking to two of my colleagues here at Penn State about a unique project that combines their expertise in biology and communications to take on the increasingly important topic of antibiotic resistance. Andrew Read is Evan Pugh Professor of Biology and Entomology, Eberly Professor of Biotechnology, and Director of the Huck Institutes of the Life Sciences. His research focuses on the ecology and evolutionary genetics of infectious disease, particularly pathogen evolution related issues that may harm human health.

Cole: Erina MacGeorge is a professor of communications, arts, and science. She is a social scientist specializing in interpersonal health communication. Her research examines social support and social influence with a particular focus on advice. Welcome, Erina and Andrew. Thanks for joining us today.

Andrew Read: Sure.

Erina MacGeorge: Thank you.

Cole: In part one of this conversation, we're going to talk about why is antibiotic resistance an important topic for life sciences research? Andrew, would you care to kick us off with that?

Andrew: Sure. Antibiotics were first discovered and developed in the '30s on. Almost as soon as they were first used in public health, we saw resistance with bacteria evolves resistance to the drug so the drug doesn't work anymore. That's been a continuous problem for all of the 20th century, but it's mostly been offset by the discovery of new antibiotics to replace the ones that have failed in the past. Now, that is getting much, much trickier, more expensive, harder to find new drugs. It's increasingly looking like the pot is starting to get awfully empty. So, it was a question of, well, how are we going to continue to get the lifesaving advantages of antibiotics without the very use of them causing them to become less effective in time?

These are really critical parts of modern medicine, not just for ear infections or sinus infections or whatever, but also in medicine involving, for example, cancer chemotherapy. People have suppressed immune systems. They're very vulnerable to infections. Increasingly, these drugs are becoming an important part of modern medicine and it's going to be one of the challenges of 21st century medicine to keep these things going. People die from drug resistant infections now and that number is going to rise unless we find other ways of figuring this out beyond just drug discovery.

Cole: Thank you. Erina, what do you see as the primary challenge of antibiotic resistance from a communications perspective?

Erina: I think there are a couple. One is that, I don't think people understand it very well. A lot of prior research indicates that the general public just doesn't really get the idea that antibiotics will stop working because bacteria have evolved to be essentially immune to them, and then even for a public that understands the phenomenon, they are relatively clueless about the risk involved. They overestimate the utility of antibiotics for a wide variety of illnesses, and they underestimate both the risks of antibiotics in terms of short term side effects, but the longterm problem of antibiotic resistance. You have a twofold problem of informing the public and making them aware of the problem and then convincing them that it's something they should actually be concerned about. I suppose I should be adding on to that, then convincing them to take appropriate action, which in this case, largely means avoiding unnecessary antibiotics.

Cole: Thank you. Thanks a lot. Andrew, when did you first start diving into this challenge in your career? What did that look like for you?

Andrew: I guess, around the turn of the century, I got interested in using drug resistance actually as a way of experimentally of tackling a very different problem. It was a vehicle that we could use to do experiments that would help in this other problem, but after a while, I began to realize that we were actually doing things that were directly informing how one might use the drugs to minimize the emergence of drug resistance. Around 2005, I got more and more just of the drug resistance problem itself. Then after moving to Penn State in 2007, I guess it was around 2012 that the university health service here, the one that provides the health services to the student population, they reached out to us about whether we could do something to help them reduce what they were viewing as unnecessary antibiotic use at that time. We got into that problem off that basis.

Cole: Thank you. Erina, tell us a little bit about your background before you started working with Andrew on this. When you approach health communications, what does that mean? What were you looking at and what did you learn?

Erina: I was trained in graduate school in the study of interpersonal communication. There, I focused both on processes of social support, how people try to help each other, and on social influence, how they try to change each other's behavior. I studied that in my early career, principally in personal relationships, so people dealing with everyday problems, but I also began, over time, to increasingly focus on problems of a health-related nature. I've some work on women's health issues like miscarriage and breast cancer and both influence processes in those contexts and support processes in those contexts. When I came to Penn State and was introduced by a colleague to the topic of antibiotic resistance, there was a pretty natural leap from the kinds of theoretical and practical issues that I've been thinking about to this, different, but still relevant health issue.

Cole: Thank you. Very cool. We're just going to take a quick little break and come back with a part two of our conversation where we talk about how the two of you got together and what kinds of things you learned from one another as you did this really cool project. We'll be right back.

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Cole: Okay. Welcome back to Symbiotic. The part two of this conversation we're going to be learning a little bit about how a communication professor and an infectious disease researcher end up working together on something like this. How did the two of you meet? How did you first become aware of one another?

Erina: Yeah, so I remember Rachel Smith from my department saying that I needed to come over and meet you, and setting up a meeting and coming over and talking with you in our office, or your office, about the early stages of one of the projects we were thinking about working on.

Andrew: Yeah. When the university health services reached out to me asking for help on this antibiotic resistance problem, as they saw it, within a few conversations with them, it was quite clear that this was a small part life science and a big part communication science. This was going to be about behavior change, how do people think and how can we alter their thinking, and therefore their behavior. Rachel Smith was the only communication scientist I knew at that point. I reached out to her, "This is a problem," and then she put us together and so it went from there.

Cole: Right on. Had Rachel been at Penn State a long time?

Andrew: Yeah. She'd been interacting with Center for Infectious Disease people in a variety of different contexts and actually had been housed, her office was in one of our buildings, and so she was interacting a lot with fol, but the demands on her time were getting bigger and bigger because so much of what we are trying to achieve when we study infectious diseases is going to involve or does involve behavior change, human behavior change. Yeah, it's an increasingly big part of what we do.

Cole: Erina, what was your relationship with Rachel Smith at that point?

Erina: Yeah. Rachel Smith was one of my colleagues and I wanted to point out here that what Rachel did is one of the really key things for interdisciplinary science in tackling major social or health issues, where people who have expertise in one area notice that another person has a different kind of expertise and pull them into the picture. Rachel, essentially said to me, I work on public health in these ways, but you think about public health issues at an interpersonal level. For you, thinking about how doctors and patients interact around something like antibiotic use is a little bit more natural and I think you should get involved in thinking about this problem too. And I said, "What's the antibiotic resistance?"

Cole: It's that social network of scientists as people knowing one another and sharing their work that is really critical, I think, it sounds like, to be able to put the right team together.

Erina: Absolutely. And recognizing that different people have different things they bring to the table.

Andrew: It's actually quite hard to recognize in disciplines that you don't know much about either. In my case, communication science all looks the same, much as it, I guess, to you, a microbiology community looks much the same, whereas to me, microbiology communities are made up of lots and lots of subsets of communities and different specialties and so forth. It's really important in those early phases to find the right set of expertise, and it's often not that easy to do when you're looking in from the outside. So you need somebody who's got the overview of the area to say, oh, you need to talk to this particular person. A lot of what we do at Huck is matchmaking in that way, trying to find the right type of expertise for somebody who doesn't exactly know what they're looking for.

Cole: So a lot of people will end up playing sort of an ambassador role more or less.

Erina: Absolutely. Yeah.

Andrew: The matchmaker is very key.

Cole: Right on. Thanks. Well, that's what we're all about at the Huck, right?

Andrew: Exactly.

Cole: That's what we're trying to make happen. Once you did start working together, can you tell me sort of the initial stages and how you started to teach one another a little bit about that? Would you like to start, Erina, a little?

Erina: Well, I think, Andrew and I were actually talking on the way here that in some ways our initial collaboration was stimulated by a third party by the perceived need at university health service to reduce any over prescribing of antibiotics that they were currently engaged in. There, when we began, or at least when I entered the conversations with them, they wanted essentially to do some self-study. They wanted to look at their prescribing over a period of time and see what the trends were and what the predictors were. So, I agreed to assist with a type of study called the chart review where we go back through old charts and look in this case set, bronchitis prescribing and predictors of bronchitis prescribing, to try to determine if there were any patterns involved there.

Having gotten started on that, we launched into a conversation then about, well, if we're over prescribing from the provider's perspective, there's the concern that patients really want the antibiotics and they don't have the necessary communication strategies to inform and persuade patients that antibiotics are not actually in their best interest. I said, well, that's me. That's something I can help you with. I said, rather than designing an intervention to change what the providers are doing, let's start with a study of what's going on in your clinic right now. With assistance from the Huck and then from funding from Merck we were able to launch a study where we sent recorders into medical visits for patients and listened essentially to what doctors and patients were saying to each other about antibiotics.

Cole: Then what was your piece [crosstalk 00:13:05] Andrew?

Andrew: I would say that the key thing there is that we were brought together around this problem, which we were jointly interested in solving, and so there was different perspectives on how we might solve this. For me, the really important initial issue was that we didn't actually understand in any real depth what the source of the problem was. We didn't know who was getting antibiotics unnecessarily and who was not. Then, we didn't know what was actually going on in these doctor patient consultations. We've all been to a doctor, we've all had our own, so we've got our own personal experience, but these are basically anecdotes. You want to know what's the general things that are going on, what's happening most of the time or much of the time. To me, the idea that the behavioral subtleties that we needed to look at potentially very significant, that was a bit of a nightmare to me.

The other thing was, the physicians involved had very strong views about what was going on. The subsequent analysis has, I think not verified a lot of those initial strong views that very strong experiences stick in people's minds, very impactful events stick in people's minds, but they're not the average practice. They stick in your mind because it was quite shocking that some student sat down and refused to leave the room until they got antibiotics. That's a shocking event if you're a physician, but it's not happening every day. In fact, it isn't happening in any of the things we've looked at. It's a rare event, it had a big impact on physicians. They don't want it to happen nor do we, but it's not the main issue. To me, that quantification of behavior, figuring out what was actually going on was a really important first step.

Erina: Patients do report, utilizing a variety of strategies to try to influence the of treatment that doctors give. Students will report that they told the doctor about a prior antibiotic prescription or that they questioned the treatment that was being recommended, things like that. But Andrew is absolutely right. It was striking how little overt arguing was going on in these interactions. One of the things that we can say back to providers is, on the whole, patients are not probably going to come in and confront you and demand things that you know are not medically appropriate, but that doesn't mean that we ... That still also shows us that we need to give providers a way to respond appropriately to more implicit and subtle forms of pressure that patients may try to put on them because they believe that antibiotics will help them when they won't, and providers need better ways to talk to patients about what will be useful and why antibiotics are not only inappropriate, but potentially harmful.

Cole: As you began to collect this data and began to get a clear picture of what was going on at the student health center here at Penn State, I imagine you began to learn things from one another. I'm curious to know, Andrew, what kinds of things did you learn through this collaboration with Erina that wouldn't have otherwise come up for you?

Andrew: I think the biggest message to me is that, when you're a scientist, a life scientist, and you think, okay, we just got to sort out the facts, and then you're going to lay the facts down in front of folk and, hey presto, they'll do the thing that's best for them or that is best for the community. To me, it's very clear with their collaboration that that is not true. Moreover, that it's not the case that any one person has a good understanding of why people hold beliefs or how to change them. People have often very strongly held views about what needs to be done, but often those are really, really wrong.

Even when, if it's something we all experience, if we try to teach the students, we're engaged in teaching students continuously, it's what we do in a university. On this particular topic, it's not just putting up a couple of PowerPoint slides and saying, hey, this is what you should do guys. It's much harder than that. Likewise the physicians, to me it was a quite a shock to discover that the physicians who are seeing the same patients, same sort of patients have wildly different prescribing rates. Some physicians will be down at a few percent, others up at 75% for the same clinical presentation. To me it was shocking that there's that much variation in medical practice and medical belief for the same, exactly the same patients. That was an eye opener to me. It's at the heart of the problem if we want to get unnecessary antibiotic usage down, one of the issues is why are some physicians prescribing so much.

Cole: Erina, what kinds of aha moments did you have working with Andrew in terms of his expertise and this whole topic?

Erina: Yeah. I was literally introduced to the topic of antibiotic resistance when I came to Penn State. Even for me, there was that learning moment that, because I didn't know that this thing existed and that it was a problem that we needed to address. For me, it's just been inspiring to try to work on a public health problem and try to bring communication theory and principles and research methods to this. In terms of aha moments, I work, as a mentioned earlier, in the area of interpersonal advice. Learning things from the study of doctor-patient interaction about what kinds of things providers should be talking about when they give advice to patients on antibiotic use or non-antibiotic treatments. That's been pretty exciting, to see that what providers say during the interactions does influence, for example, whether patients feel capable of monitoring their own symptoms after the visit and knowing what's a real problematic symptom or something that's just going to go away over time and also how to I manage them. That's been exciting.

Cole: Right on. Now, I know that in the past we have discussed an app that is being developed as well with this. Can you tell me a little bit about that, where that is and what that looks like?

Erina: Sure. Just as a little bit of background, the study in which we observed what doctors and patients were talking about in the clinic set up some follow on efforts to test potential interventions to change provider behavior, to change student behavior around antibiotics. One of those that we've undertaken this past year is to test the utility of a medication reminder app. Our thinking was that, for students who are, who have not lived away from home for very long here at university, the challenge of taking care of themselves can be significant, and that then when a provider says, no, you don't need an antibiotic, what you need to do is take this cough medicine and this decongestant and you need to drink water and you need to sleep this many hours.

Cole: It's a lot.

Erina: It's a lot. Right? We thought that perhaps if students had help remembering to do all of the things that will them feel better while their body naturally takes care of the viral infection that they might do better. We collected data this past year where it's typical experimental field, field experimental design where some students were assigned to a condition where they were provided with a medication reminder app, instructed in how to use it and we assisted them in entering all of the non-antibiotic treatment recommendations that the providers have given to them. Then you have another group who gets normal standard of care treatment and without the app. We're in the early stages of analyzing the data to see whether the app had an impact on those students' satisfaction with care and subsequent antibiotic seeking behavior potentially from urgent care or other places here in town.

Andrew: Yeah. This app I like to think of as mom. It's a sort of a mom replacement. It came out of these early analysis of what's going on in these discussions with the patient and the provider. To me, it is an interesting issue that these students, many of our students in the study were freshmen. So their first year at college, the first time away from the family support, which goes with even the empathy and make sure you get to bed, all that sort of stuff. Often dorm room life is not consistent with that. I liked the idea where you randomized to have an electronic mom or not.

Cole: With digital natives, I mean every generation that comes on, they get something in their hand at a younger and younger age. It seems there'd be an app for everything these days. It'd be very interesting to see, when the data comes back, if that intervention is effective. That would be very interesting. Cool. Well ...

Andrew: I should say perhaps one of the things that's exciting about an intervention like that is it's potentially very scalable. Doing it on a small scale at Penn State campus can easily go to the full Penn State campus, but then the big 10 and then all student facilities could work like that. If we could find the magic way that this mom app would work, then we could roll it out very easily and very cost effectively on a vast scale. It has big potential impact. Just got to figure out how to make it mom electronic successfully.

Erina: Right.

Cole: Very cool. I'm really curious to know what challenges emerged to your normal way of thinking and working through this collaboration?

Erina: know we had an interesting moment when my graduate students and I were starting to design a brief animated video as an intervention that could be used in the clinic. It could be used pre-visit to clue patients in on the utility and risk associated with antibiotics, a little bit about antibiotic resistance and that sort of thing. I wanted to be able to emphasize the risk that antibiotics pose to individual patients. We do know some things about the risk involved. We know that antibiotic resistant infections are escalating. The CDC figure is 23,000 deaths per year, 2 million extended illnesses. We think that's probably a significant underestimate. But the thing that I went back to Andrew to say was, well, what can I tell individuals about their individual risk? What is their individual susceptibility to an antibiotic resistant infection? What is the severity of their potential outcomes from using antibiotics. Andrew had an interesting response to that.

Andrew: Yeah. I just assumed that we would have that well under control. That was well known. What Erina is looking for there is a sort of statement we say about smoking, that smoking takes 10 years off your life. So we would like to be able to say something like that, antibiotic use when you don't need it, does this. We went looking to you, does this to you, and we weren't looking for that. As Erina said, there's very good data on the number of people dying and sickened by antibiotic resistant infections. Just to give you some idea of scale, in the US, more people die of drug resistant infections and die in car crashes each year. Currently, the number of deaths is roughly in line with the number of opioid deaths, so the problem is large and growing as these bugs spread.

The question is how do you relate that population level catastrophe, growing catastrophe, to the individual behavior where you're in the clinician's room and you're making a decision about taking antibiotics or not. It turned out that in fact that was very poorly understood and that we have lots of qualitative understanding of how this can be risky. It can cause resistant infections in you, you can transmit them to others, urinary tract infections can be hard to treat. But putting numbers on those things, the equivalent of smoking does this, antibiotic use now does this, it turned out we don't understand the risks in any quantitative sense.

That's been quite an eye opener to me. It's a big scientific knowledge gap. We've just written a paper on, precisely this knowledge gap, pointing out that actually we don't know this, and if you want to really make an impact here, it's a lot easier if you can say to an individual, you're at 10 fold increase of a hard to treat urinary tract infection if you take antibiotics unnecessarily now, but we don't know what that number is for this patient population. We do somewhat for pediatrics for very young children, but beyond that, the individual risk is not well understood, even though that clearly leads to the 70,000 or more dying each year in the US. The connection between the big population problem and the individual decision is very, very poorly understood. In my wheelhouse, that's not a communication problem. That's, yeah, but what are the bugs doing? It's a microbiology problem.

Cole: The microbiologists have a lot of work to do. There's a lot more to do here.

Andrew: Much to my surprise. It turns out that the communication people have a lot of good understanding in this space that needs to be applied to this problem. I think we have rather poor understanding of the underlying microbiology and evolution that we can apply to this very dramatic population health problem.

Cole: Well, it's heartening to know that folks like yourself are getting together and starting to ask these hard questions and help one another out to frame these questions in useful ways that can have real efficacy in people's lives. Right?

Erina: Absolutely.

Cole: I'm glad we're starting. You got to start somewhere, and I see you starting, so that's terrific. We're going to take a quick break and we'll be back with part three and we'll look towards the future of next steps in this work and where you want to go with it. Also, just talk about what you would tell others who want to get in the game and do this kind of work, not just on this topic, but any big challenge that we're facing. We want to promote this transdisciplinary approach and I'm very interested to know what you would tell others out there. Thanks a lot. We'll be right back in just a little bit.

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Cole: Welcome back to Symbiotic. I'm Cole Hons from the Huck Institutes of the Life Sciences here with Erina MacGeorge and Andrew Read. Thanks again for being with us. In this last part of our conversation we're going to talk about where do you see this research going next and some best practices that you could maybe share with other scientists out there who want to tackle big challenges like this and work together across disciplines. With that in mind, I would like to know what were your biggest challenges in terms of working in this transdisciplinary fashion?

Andrew: Well, for me at least, vocabulary and language, that we often use the same words to mean different things. Erina's ideas of what constitutes a theory and the way she would use a theory are different from the ways we would do that in the life sciences. I'd say that there was a fair chunk of getting on the same. That's a question of sort of ongoing conversation. I would also really help when we got down to writing our first grant together, I think because you got to put something concrete down there so you got to actually see the words and agree what you mean. That process was pretty good in the end, but it definitely took some interactions. I'm still learning. There is a whole lot of things that we continue to discuss that just explain that stop, stop, stop.

Cole: Right. Slow down, make sure we're on the same page here. What about you, Erina?

Erina: I feel like the challenges we face were mostly external. I felt like Andrew, as a life science, was very welcoming to the social science perspective on this problem, was genuinely interested in what communication science had to offer, and that made it really easy for me to come in and try to provide what assistance that I could. Working with a student population, a patient population in a high volume clinic in the middle of a university campus and with all of the concerns for patient privacy and for sort of university regulations and policies, we encountered a number of challenges along the way in dealing with all of those things. I think having that sort of external challenge that we were both focused on, not to mention the challenges of science itself, at least for me, made it feel like working with Andrew was the least of my problems.

Andrew: I have to say that the university health sciences people, the folks, especially Michelle [Zuken 00:31:26] and [Robin Oliver 00:31:26] really made this project possible because they were hugely good on opening doors, solving endless day-to-day problems, but also keeping the group's focus on the big picture and their welcoming attitude. When Erina says high volume environment, we're talking 50,000 patients visits an academic year. So, it's very fast moving.

Erina: Exactly.

Cole: That third party, in this case, were medical professionals, not researchers. There are often, with these collaborative efforts, you can have a third party that's even outside the academic field. Correct?

Erina: Absolutely, and absolutely essential in this case, if you don't have a clinic, you can't study doctor-patient interaction. I just want to echo what Andrew said about the university health services opening doors for us and doing everything they could to make the research possible within the constraints of their number one mission, which is taking care of Penn State students.

Cole: Thank you. What are your future plans for this project? What's next on the agenda?

Andrew: Well, at end of things, one of the questions that's really come up is what are the consequences of taking antibiotics when you don't need them? So, we are starting down the route of trying to measure with the bugs in the patient's bodies, particularly the ones that come out in the fecal samples, what's happening as a result of the antibiotics? These microbiome studies are starting now and we'll be looking at the resistance genes that are rising in frequency in these patients after taking antibiotics. Then how long those resistance genes continue to be shared in the environment. When they're shared, how far are they going? Do they persist? What are the consequences? There's a whole line of evolutionary microbiology that's been started by this that will definitely continue, but we've also got a whole bunch of other projects that can bud off around this current one.

For instance, the students often get flu and we weren't looking at flu, but now we've got researchers interested in looking at what flues are the students getting, and many of these students get flues from farm animals cause they're from rural Pennsylvania. Raises questions about what are they getting, what sort of strains, what are they doing, what's happening here? There's a whole lot of, what I would think of as more traditional life science projects that are building off of this. But in terms of the sort of question we started with yeah, we're looking for interventions that we can scale across Penn State system and then across the country as a whole with a view to overall reductions in drug resistance problems in the nation.

Erina: Yeah. I alluded earlier to this video intervention that we were designing. We've done the design, the video has been created. We've done quite a bit of pretesting, some of that's still going on, and we'll be rolling that into a study in the clinic this fall. That's coming up relatively soon. Beyond that we have projects designed and are waiting news of funding that will on the one hand target the social networks of students, specifically parents trying to influence their understanding of antibiotics. Because one of the things that we know from our research so far is that students talk with their parents and other social network members, friends, romantic partners and so forth about their illnesses.

In a striking number of cases they, about 30%, report that they get some kind of influence from those people to seek antibiotics. So, we need to, if we're going to change student behavior, we also might want to try to reduce the pressure on the students for antibiotic seeking. We have a number of things lined up to do there.

Cole: Also, you mentioned earlier about the doctors about that incredible wide range of prescribing methodologies for the same exact thing across different practitioners. It seems that would beg for some attention too at some point.

Erina: That's the other direction that we're going. Especially from that observational study that I talked about early on, we now know some things about how doctors are trying to explain antibiotics to patients and antibiotic resistance to patients and have some pretty good ideas about how to improve that. Not that our UHS doctors are doing poorly by any means, but we definitely have some concrete recommendations that we can make for them as well as how to handle recommendations around treatment and help patients see the value of non antibiotic treatment. Another set of projects that we have envisioned is essentially an educational brief video, educational interventions targeted at providers giving them little mini-skill trainings that they can listen to three or four minutes, maybe hear between visits or something like that and get a new idea about how to explain antibiotic resistance or a new idea about how to respond to patients' complaints of how sick they feel. It's going to, hopefully be a little package of skill intervention trainings for providers based on our empirical evidence.

Cole: Very interesting.

Andrew: If you're asking sort of the longer term picture too, one interesting proposition here is that these ... one of the things that's interesting about students is they go on to be parents within five to 10 years, most of them, and most of a very large chunk of the unnecessary antibiotic use in America is tied up with pediatrics. The decisions parents make about the antibiotics that their children get really [inaudible 00:37:20] in this space. If there are interventions, things we can do with the students here, which play out in the decisions they make for their children in five to 10 years time, that will be very exciting, potentially very impactful. Funding and so forth allowed, we'd like to get into studying that medium to long-term impact of interventions that we can make here on campus while the students are relatively captive audience and very educatable in principle.

Cole: Wow. So many different angles to this. So much going on. Let's talk a minute about the more traditional academic release of new knowledge and into the academosphere as you would. In terms of conferences, papers, that kind of thing, and sharing this data as you collect all that data that you're still collecting and we'll be able to share that with the broader academic community. What does that look like?

Erina: Well, upcoming, for example, I have abstracts and papers accepted at the international conference on communication in healthcare. It's coming up in October in San Diego. Then, the communication disciplines national conferences called National Communication Association conference, and that will be in Baltimore, Maryland in November. Those are just the first of a series. They've actually had some conference presentations in the last six months as well.

Cole: Great.

Andrew: Yeah, and we're working on papers together at the moment now. In terms of meetings that I'm going to be going to, very much hope to go to the ID week in Washington DC in the fall, which is the big meeting, several thousand infectious disease practitioners and stewards and pharmacists, all of whom are tied up in some aspect of antibiotic use and reduction of unnecessary use. Then the big microbiology meetings, for example, the American society of microbiology is meeting in New Orleans in the spring.

Cole: That's terrific. Very exciting. We'll see what everybody thinks about this and what other kinds of work it inspires. I always ask this question on Symbiotic. We're going to be asking this of every one of our guests. How important do you think these sorts of transdisciplinary efforts are to tackle the big complicated questions that are out there plaguing humanity right now? How important are they and what would you tell others who want to dip their toe into these waters and take on something like this?

Andrew: I struggled to think of a single problem that's of any major significance to humanity that can be answered by a single discipline. To me, everything, food security, health security, health care, cancer, climate change, none of them are going to be solved by a single discipline. The days when you could get a bunch of physicists in a room and come up with a nuclear weapon, those sorts of problems that are already handled, they're done. Disciplines work well to solve those. The hard things now require lots of inter-discipline and almost all of the challenges that face humanity have at the root somewhere, human behavior, changing behavior or understanding behavior is going to be critical to the solution of, I think, every each single challenging problem that humanity faces.

Cole: That's a good insight. What do you think Erina?

Erina: I think Andrew took the words out of my mouth. I think it's very exciting as a communication scholar to bring what I know about communication to a major public health issue. It's brought some new life to my theorizing, to my thinking about communication. I have ended up moving into new domains of research, new terrain, both theoretically and pragmatically. It's been terrific and I think I would recommend that to essentially anyone, I think working as an academic, I think that interdisciplinary or transdisciplinary research is both essential for our major societal problems and becomes a point of inspiration for individuals working as scientists.

Cole: Terrific. I would like to know from both of welcoming is the world of academia right now in terms of a traditional academic career to this kind of work?

Erina: I was first coming out of graduate school, advice to young scholars was essentially to find a theoretical paradigm in which to work and contribute to that and crank out studies and get respect within your own community and publish in your own disciplines. People who tried to sort of venture out of that and do more applied work or interdisciplinary work or sometimes viewed with awe, sometimes with suspicion, it was a nontraditional kind of thing to do. It was scary because it wasn't well supported. You would get awkward questions about, well, why are you publishing in that journal? Those kinds of things. I think we're close to the tipping point where scholars, social scientists who do not have a connection to major public problems are going to be seen as having the inadequate research profiles.

But that's been over the course of the last 20 years. Do I think there are still challenges? We still, as scholars, sit within departments and disciplines and we have things like tenure homes. There is still tension sometimes between the kind of work that your people expect and the kind of work that you might be inclined to produce because of your engagement with a specific public problem. But the awareness of the need for those things to come together has grown immensely. I think increasingly, we're going to see people who tackle theoretical problems in major public spaces and whose work in major public spaces informs their theory in a more, shall we say, symbiotic kind of way.

Cole: That's what we're shooting for. That's right.

Andrew: From my perspective in the life sciences, I think that there's still a very strong pressure while people are on the tenure track process, that first seven or so years in their academic careers to make sure they're publishing very good articles in their specialist areas. That probably is not going to go away, that pressure. But there are more and more young people who are managing to do that as well as publishing in transdisciplinary. I sense a very strong hunger from many of them to have impact beyond their ivory tower specialties. After that tenure step has happened, then a lot of people start thinking, well, how are we going to make impact? How am I going to do something that's going to make a difference that I'll be remembered for?

That very quickly, for many people, is to transdisciplinary things, problems that are bigger than the individual lab, not always, and it's not one size fits all here. Some people are always going to be an inch wide and a mile deep. We do need such folk, but the portfolio of academia is getting broader and there are more and more people who are handling these sorts of transdisciplinary problems now and comfortable with doing that than perhaps any time in history of academia, many thousands of years.

Cole: Based on what you've learned through this collaboration together, what kind of advice would you give to other researchers who want to use best practices in making something like this work?

Andrew: Well, the lessons I've drawn from the experience we've had so far is that we came together around a very tangible problem, well specified problem. How do you reduce unnecessary antibiotic use in the student health clinic? It's a very well-defined problem and that gets us talking. Then needed repeated conversations. In particular, the Antibiotic Stewardship group at the UHS would meet monthly. We'd be having these conversations, repeated conversations while we're getting on the same page. I think that's a lot to be said for proximity in that sense. It's not easy to do these things remotely or by email. There needs to be conversation, while you're getting the language sorted out, while you're getting to figure out what the main issues are. Now I think we could probably function on Skype or something pretty easily, but back then, it was really important that we were seeing each other regularly and developing things.

I think having some tangible early, well-defined problems that we could get ahead around, Erina I mentioned earlier the chart review project we did, that was a tangible exercise where it was quite clear what we should do and why we should do it. Working through those problems, when we got to know each other better and we had this defined the goal, this defined deliverable, so I'm big on the sort of baby steps that are well-defined. When you've got this longer term goal, but you've got something to handle in year one, I think that was actually really critically important. We've also been on the receiving end of some very broad minded financial support for getting this, initially from the Huck Institute, and subsequently from the Merck Investigator Studies Program.

That's been a really critical part. Those funders could see the need for this and that we had complimentary skills that could allow us this work to grow. So, nurturing funding in the early phase has been an important part of that too. I don't know if there's anything you want to add to that.

Erina: Yeah, I would just maybe echo that patience is required to cultivate relationships, to learn how other people think. Risk taking is something that I've seen as a necessary component. I'm risk averse by nature, but to move projects forward, especially interdisciplinary projects, sometimes you have to sort of put crazy ideas, or not so much crazy, but be willing to try to do things you really haven't done before. Think about things in different ways. I've moved out into the area, really seriously out into the area of health campaigns rather than being specifically always focused on doctor-patient interaction, thinking about how you deliver messaging to patients or parents or things like that.

Then just perseverance. There are going to be challenges. Things are going to happen and you're going to have to find your way over roadblocks or around them. As a somewhat more junior scholar to Andrew at this point, I've really benefited from his mentorship watching him figure out how to knock roadblocks down is something I've really appreciated over time.

Cole: Good skill.

Andrew: Perhaps I could add too. I think the other thing is you need a lot of mutual respect and open-mindedness about somebody else's discipline. For us, I think that's been good because neither of us have the expertise to judge the other. It's like you just assume you know what's going in your area. The same with the physicians, they know what they're doing clinically and medically and we don't. So we're not trying to second guess them. We're going with whatever they ... Early on, that's hugely useful. Now I think we have enough expertise to look at each other's stuff and say, yeah, that was pretty cool, or that's not so good. But early on, you have that mutual respect and complementary skillset, which allows the whole thing to move forward without anybody feeling that they aren't bringing something to the table or they're being overshadowed. I think that's really important in the early stages.

Cole: Right. That human dimension.

Andrew: I think it's increasingly clear that for research academics, they need to balance portfolio of risk. You need some safe bread and butter stuff that's going to make sure everything keeps going and we should do that. We need you to do that. You need to have some stuff, which is varying degrees of crazy. That shouldn't be really all crazy and that should be some stuff that's semi crazy and some stuff that's really crazy. Then how you balance that time-wise is really a question of individual comfort. I do know people that are throwing everything into what I think is a totally crazy idea. Good luck to them, but that's not me. But having one day a week on something that might turn out to be a dud doesn't seem too bad to me. I think it's really a question of balancing this risk portfolio. That's of course, true for businesses, entrepreneurs, insurance companies, balancing risk is what it's all about.

Cole: Right. Even communication.

Andrew: Even communications folk.

Cole: Taking a risk right here. See if people are interested in learning about symbiosis and how researchers can be symbiotic with one another.

Andrew: Exactly.

Cole: Well, I thank you again for this wonderful conversation. I wish you the best of luck moving forward and hope to see you soon.

Andrew: Thanks a lot.

Erina: Thank you.