BJKS Podcast

61. Eva Krockow: Social dilemmas, antimicrobial resistance, and the value of qualitative studies

August 13, 2022
BJKS Podcast
61. Eva Krockow: Social dilemmas, antimicrobial resistance, and the value of qualitative studies
Show Notes Transcript Chapter Markers

Eva Krockow is a lecturer in psychology at the University of Leicester, where her research focusses on the psychology of antimicrobial resistance. We talk about her educational background, her work on the Centipede Game, social dilemmas, antimicrobial resistance, and the value of qualitative studies.

BJKS Podcast is a podcast about neuroscience, psychology, and anything vaguely related, hosted by Benjamin James Kuper-Smith. In 2022, episodes will appear irregularly, roughly twice per month.

0:00:04: How Eva ended up studying psychology in Leicester
0:07:16: Before her PhD, Eva worked in international relations
0:13:06: The Centipede Game/Eva's PhD work
0:23:49: What is 'antimicrobial resistance' and why is it a problem?
0:41:52: The social dilemma of antimicrobial resistance
0:52:05: The benefits of qualitative studies
1:04:53: What can we do about antimicrobial resistance?

Podcast links

Eva's links

Ben's links

The Centipede Game:
AMR studio podcast:

Colman, ... (2019). Medical prescribing and antibiotic resistance: a game-theoretic analysis of a potentially catastrophic social dilemma. PloS one.
Flood (1958). Some experimental games. Management Sci.
Hardin (1968). The tragedy of the commons. Science.
Harring & Krockow (2021). The social dilemmas of climate change and antibiotic resistance: an analytic comparison and discussion of policy implications. Humanities and Soc Sci Comm.
Krockow, ... (2022). Prosociality in the social dilemma of antibiotic prescribing. Cur Op in Psych.
Krockow (2020). Nomen est omen: why we need to rename ‘antimicrobial resistance’. JAC-Antimicrobial Resistance.
Krockow, ... (2016). Exploring cooperation and competition in the Centipede game through verbal protocol analysis. Euro J of Soc Psych.
Krockow, ... (2016). Cooperation in repeated interactions: A systematic review of Centipede game experiments, 1992–2016. Euro Rev of Soc Psych.
Pulford, ... (2016). Social value induction and cooperation in the Centipede game. PloS one.
Pulford, ... (2017). Reasons for cooperating in repeated interactions: Social value orientations, fuzzy traces, reciprocity, and activity bias. Decision.
Pulford, ... (2021). A five-factor integrative model of strategic reasoning in dyadic games. Eur J of Soc Psych.
Rosenthal (1981). Games of perfect information, predatory pricing and the chain-store paradox. J of Econ theo.
Tarrant, ... (2021). Drivers of Broad-Spectrum Antibiotic Overuse across Diverse Hospital Contexts—A Qualitative Study of Prescribers in the UK, Sri Lanka and South Africa. Antibiotics.
Tarrant, ... (2020). Moral and contextual dimensions of “inappropriate” antibiotic prescribing in secondary care: a three-country interview study. Front

(This is an automated transcript that contains many errors)

Benjamin James Kuper-Smith: [00:00:00] Uh, by the way I wanted to, I was just curious as a kind of very, fairly generic question, just because you, as far as understand you grew up in Germany and then you started in Lester. Uh, so how, why psychology and Lester kind of, or why England or, yeah. 

Eva Krockow: Yes. So, um, I guess I was just quite driven early on. So I went to quite a competitive boarding school in Germany for the past three years of school. So I went to like a well for high achieving students, basically. So it was a selective school where I had to do entry exam to get in. I think after that, I just didn't want to go to just any kind of normal university. 

And I wanted an extra challenge and I also wanted to get a bit more gain a bit more independence and freedom, I suppose. And another fact that was that I really enjoy languages. So I've always, um, been really into language learning and I really just wanted to get to grips with the English language really. 

So, um, yeah, lots of different factors. I, uh, had a close friend of mine who came from the UK initially and he told me a bit about the UK kind of UK university system, how you apply cause it's quite a [00:01:00] different system from Germany. So I think that's what, um, presents a key barrier to people actually exploring that as an option. 

And um, with his help, I looked at different options basically. And then just got out a general university ranking and well, I applied to different universities. Lester was one of them. Lester was a bit of a not choice. I'd never heard of Lester before in Germany. Actually. I think a lot of people don't even know how to pronounce it. 

Uh, so I get a lot of people who kind of try Chester Chester. That's a common one. no. So for me, actually, it was a bit of a strategic, um, geographical question. Cause I didn't want to be right in London, but it's really expensive and really sort of busy. I wanted to be somewhere that's sort of in the middle, you know, where you can travel from quite easily that you can get to quite easily. 

And obviously less itself was quite renowned for psychology within the UK as well. So that was a main factor. So yeah, lots of different factors in there really, but. I guess it was kind of curiosity, kind of developing sort of independence, uh, learning language properly, always liked English. So yeah, I haven't regretted it weirdly, cuz I wouldn't say that Lester's the most exciting [00:02:00] place to live in it's definitely not the most scenic city of the UK. 

it's alright. I would say it's a very welcoming place though. So it's a multinational it's uh, just really convenient and comfortable. So it's got everything that you need, but if you want a bit more excitement and there's bigger cities around that you can travel to. And obviously the university is a, is a, quite of a now very good one, especially in the area psychology, so yeah, 

Benjamin James Kuper-Smith: Yeah, it's interesting. How, uh, I guess to some extent we have like some overlap in the sense that I also grew up in Germany and Southern in England, I guess for me it was just because my father's English, I knew about the university system. Uh, but I agree. I mean, in the UK, you have to apply a year before in Germany. 

You just kind of sign up three months or whatever, before it. 

Eva Krockow: You have to be a lot more prepared. So by the time I even considered it, um, the applications for Oxbridge had already passed, for example. So some universities you have to apply for even earlier, um, than the others, uh, through the UK system. So it's, it's a very specific system, I guess. 

And it's yeah, you have to be very prepared and know what you're doing. [00:03:00] and obviously tuition fees are a lot higher as well. So 

Benjamin James Kuper-Smith: Right. Yeah. I mean, that's a huge difference. Yeah. Um, and, uh, yeah, the other difference is I did go to London, which I, I think in H I don't regret it, but in hindsight, it would've been smarter to go to a more affordable place because I'm not from a rich family, which means, 

Eva Krockow: yeah, 

Benjamin James Kuper-Smith: you know, London can be a bit, uh, restrictive. 

If you don't have lots of money. 

Eva Krockow: Absolutely. And, and equally, I don't think I would've gone to the UK actually. Um, at this point in time where the tuition fees are even higher than they used to be. So when I studied in the UK, it was, uh, 3000 pounds a year, which I thought was very high at the time, but now it's actually 9,000. So it's tripled and I think that's just a huge, it's really off putting. 

And in addition to the whole Brexit situation, I think it's a, it's a huge issue. 

Benjamin James Kuper-Smith: Yeah. Yeah. I mean, I, I dunno whether I would study in the UK now, if I was, I don't know. Yeah. But I was, so the very first thing you said really surprised me because having grown up myself, boarding schools, aren't really a thing. And, uh, so usually, and I, I know of [00:04:00] one or two people who went to one, it was usually kind of topic specific and know one guy who was really into music and then went to a kind of school that specialized on music and that kind of stuff. 

But, um, yeah. So maybe for, I dunno, I guess every country has a different education system, but in Germany you don't really have private schools. I mean, So it's funny if I say that because my mother teaches at one, but , um, in Germany we don't really have private schools. We don't really have boarding schools. 


Eva Krockow: So yeah, maybe a bit more background on this. So I'm from the federal state Hessan and I think it was a bit of a pilot project of one of the, the previous, um, federal state ministers, really. So they wanted to come up with a new way of promoting excellence in federal state. So they came up and, um, I was actually the first year group for this particular boarding school. 

It is quite an elite sort of selective process. The idea was that it's still accessible to everybody. So, um, you didn't actually have to pay much for it. You just had to pass quite a selective application procedure. And, um, yeah, I think, well, I was the first year group, um, taken in 2003. And, um, [00:05:00] it was a special experience, obviously. 

So you said we don't have many boarding schools in Germany. I wasn't really sure what I was letting myself in for. Um, but it was a very, um, I dunno, it was a very, quite very important experience all my life, cuz it really shaped the way that I sort of developed obviously. So just being surrounded by fellow students for three years, really, and only having a few sort of weekends, um, every three weekends, we go and visit home and obviously with it being a selective at lit shore a school, we, um, had additional subjects, um, a larger curriculum. 

So I was learning Chinese, for example, we had, um, Saturday school as well. So it just had a wide range of options. Um, we were sort of encouraged to participate in sort of international competitions and stuff. So there was a lot of extra training and extra, um, teaching available. It was competitive and it was tough I would say, but it was also really a really useful opportunity to make really long standing connections I would say and make really good friends. 

Benjamin James Kuper-Smith: Okay. [00:06:00] Boarding school also means like, uh, kind of the stereotypical English example of a manner in the countryside or was it, you know, there's like nothing else around it's just a school or was it more in a town or 

Eva Krockow: So , they found a, a little, um, abandoned castle. Okay. It sounds really grand. It's not that grand. like a little, um, nice little castle in, uh, you know, the Rango region near sort of, um, it's about an hour away from Frankfurt and sort of near, I really don't know how to describe it, but basically it was kind of surround surrounded by kind of, um, hilly landscape with lots of vineyards. 

Benjamin James Kuper-Smith: You mean like the mines area a little bit 

Eva Krockow: like that. Yeah, exactly. Yeah. So I think the idea was a. You were a bit separate, you know, you had your kind of your little bubble, um, yeah. A lot of time to spend studying , but you could also escape if you wanted to, it wasn't that bad and obviously people signed up for, you know, they, they, they obviously wanted to be there, so , it was all very motivated students. 

Who'd undergone the selection [00:07:00] procedures and really wanted to be there. So it's not like it was some sort of punishment that was sent away from home. 

Benjamin James Kuper-Smith: Yeah, yeah, yeah. 

Eva Krockow: Sorry. overall. It was a very, um, positive experience, I would say 

Benjamin James Kuper-Smith: Okay, cool. Um, one, uh, kind of last question just on the, before we get to actual science and topics and stuff. So you did a MSC. Wait, was it called international studies, which sounds duly vague. And, uh, then you, I, I, so you worked for four years at an international organization, which also sounds very vague. 

Uh, yeah. I'm just curious. What, what is international studies? Why did you do that after psychology 

Eva Krockow: So I don't have your kind of very typical academic career, I would say. So I did, um, after my psychology degree, I just realized, you know, how I said, I was always very driven to kind of explore different cultures and languages and, and so on. I guess that was always an interest of mine. And, um, international studies was actually politics degree, so international relations, that sort of thing. 

Um, so there were options to specialize within the program, which is why I think they kept [00:08:00] the, the title of the program quite vague. So you could do kind of international relations, middle east or European studies, whereas I kind of the general masters, but I also added, uh, French studies to my degree. So basically I was interested in, um, international relations and international politics, international development, all that stuff, really. 

And, um, I know a lot of people ask me, you know, that's quite different from psychology, but to me it's really not. I think psychology plays a huge role in international politics and. I pursued that career for a little while. So that's why I moved to Brussels and I worked for different NGOs. So for example, the U N P, which is United, um, always get this wrong unrepresented nations and people's organization 

So it's basically a human rights organization that is lobbying, um, European institutions, like the European parliament, formal visibility to improve the rights and access of minority populations, such as for example, the Wego population in Western, um, China. So I worked with them for [00:09:00] a bit. So, um, all of that was kind of political lobbying and it led to another opportunity in international development when I spent some time in Africa, actually. 

So after my, my time in Brussels, I moved to Western Africa to support a project by the German development organization, GIZ, I dunno whether you've heard of them, but basically they're the biggest German organization to, um, conduct kind of development programs abroad. So for international, um, So for developing countries that don't have the same sort of industry resources that we have, they conduct sort of development programs, for example, in the area of agriculture or in hygiene and sanitation. 

So that would go out to those countries and try to improve their livelihood by running certain programs to improve sustainability and so on. So I was there to support a project in the area of cashew farming, which is really random. And, uh, I really don't have any background in agriculture, but I was there the sort of political sort of organizational level supporting the project and just helping with communications. 

So again, that's when my language skills came in because [00:10:00] I, um, helped translating and, and communicating with media, for example. Um, so I spent some time in both Ghana and Benin. So Ghana is English speaking and Benin is French speaking, Western Africa, where I've worked with them and supported the project. 

After that I moved back to their headquarters, GIZ headquarters in, in Frankfurt, near Frankfurt in Germany, worked, um, again in a sort of strategic organizational, um, consultancy matter. So I supported the sort of Africa, regional department in their, um, grant acquisition and the kind of strategic yeah. 

There's kind of positioning of their, their development projects and so on. But during that time I realized, you know, I was, uh, missing the search and, uh, quite honestly, um, the main reason why I returned to academia is probably my PhD supervisor, professor Andrew Coleman, because I'd stayed in touch with him. 

He's based at the university of Lester, say in touch with him ever since my bachelor's degree, my [00:11:00] first degree in the UK, because he thought my, uh, undergraduate dissertation study was very outstanding and he wanted to publish the results. And he'd been working on this, um, and on this topic for a long period of time, always in the background while I was doing other things. 

I just realized I really enjoyed it. And I had enough of some of the very bureaucratic structures that encountered in GI Z in that very huge organization that was partly government funded. So public funding sometimes, you know, comes with certain bureaucratic procedures and 

Benjamin James Kuper-Smith: universities. 

Eva Krockow: Oh yes, don't get me started but yeah, I decided to return to academia to kind of leave my safe job where I was earning quite a good amount of money, you know, and, uh, become a student again and do a PhD. 

And that's how I ended up back in the UK, back at Lester, doing a PhD. 

Benjamin James Kuper-Smith: It's interesting to me that, I mean, you mentioned that international relations and politics can be very related to psychology. I mean, I guess especially game theory and those kind of studies are really intertwined with it [00:12:00] is, I mean, was that also part of why you wanted to do research again also because it, it did relate to this like other stuff you were interested in or. 

Eva Krockow: I do think they're so interrelated. It's all about kind of wider decision making, basically political decision making. It it's hugely important. And I just kept seeing the parallels really between game theory. It was just the area where it came from in research and sort of real life applications in politics. 

So I think the two go hand in hand really, and I just thought be really interesting to dig a bit deeper, to kind of get those foundational issues really straightened. 

Benjamin James Kuper-Smith: Yeah. And I guess, I mean, the, I think what we're spending the bulk of today's conversation on will be your work, your current work on aro resistance, which I guess again goes more towards the larger scale political, um, 

Eva Krockow: of policy work. So again, that kind of area comes back in. I think it's all overlapping. It all kind of matters. So, um, a lot of people have asked me, like, you know, like I said, how does it, how does this go together? But I do think all of these areas [00:13:00] kind of go really well together. 

Benjamin James Kuper-Smith: Yeah. So, I mean, uh, before we get to your current work, I just, uh, you know, wanted to ask a little bit about, about the centerpiece game, just because you did, um, for what I could tell, I, I downloaded your PhD thesis and read the abstract and yeah. So 

Eva Krockow: people would've done. 

Benjamin James Kuper-Smith: uh, yeah, I was also curious whether your thesis was actually on the centered game because, you know, sometimes people have thesis on slightly different topics and the papers they published and that kind of stuff. 

Um, but yeah, I mean, I guess you did that, that's kind of what you spent your PhD time doing. Um, so maybe first, yeah, I'm just curious what is the centered game and yeah, what what's, what's kind of the specific reason for using that versus a different game. 

Eva Krockow: Yeah, no, that's a, it's a really good question. So a lot of people, so like you said, I really did spend my entire PhD focusing on that very, very game. And obviously I published from, from the studies, uh, a lot of people when they first hear the sent to be game, they think it's a worm ologists studying [00:14:00] worms. 


Benjamin James Kuper-Smith: Yeah. Yeah. 

Eva Krockow: that is not the case . So the center Fe game is, uh, really a model, a decision model for reciprocal interactions. So kind of turn taking and cooperative actions between two people in some cases, potentially more than two people. So it models any kind of a situation where you have a relationship with another person and you kind of help each other out on regular occasions, kind of taking turns. 

Helping the other person basically. And, um, the question is really why these relationships are sustained because the, the theoretical model or the game theoretical model suggests that is actually not rational to, um, persist in relationships like this. I dunno how much, you know, about game theory or how much the, the listeners will know about it, but they're basically, um, they proposed games as abstract models of interactive, um, context, decision context. 

And I suppose a very famous game is the business to dilemma game, where you can decide between [00:15:00] cooperation and defection and why corporation benefits, both people in the game defection single they're cited defection can, um, benefit the defector at the cost of the other person. So, um, the center peak game is a bit similar to this, actually. 

It just means rather than being a one shot, a single interaction, it's actually repeated, uh, across a, a series over time. 

Benjamin James Kuper-Smith: So does the one thing I was wondering about, um, does it have a like specific payoff structure? Because I guess you could, you can have iterated prison dilemmas. You can have prison dilemmas where people take turns. Um, so I'm not entirely sure right now what the, yeah. How it's exactly different from, let's say an iterated prison dilemma where 

Eva Krockow: similar to the iterated prison dilemma. The difference is that the, um, payoffs actually increase over time. So basically players have to decide on each kind of occasion where they interact with one another. They have to decide between a cooperative move, which is a go move and non-cooperative move, which is a stop move. 

Now the [00:16:00] cooperative move go, keeps the game going. Whereas stop immediately ends the interaction. So again, an integrated business dilemma. You would probably just keep on playing games. Whereas the stock move is quite a finer action and it basically limits, um, the extent of which you're going to interact with one another. 

And then every game move actually also leads to, well, it depends on the particular payoff structure that we're looking at. Cuz there are different versions of the cent peak game, but in a, in a common, uh, version, the total payoff part available to both players will actually double at on each occasion that the person chooses go. 

So there's a really big incentive for the team to keep going in the game. Because as, as a collective, there will earn a lot more money in the long run. The problem is though that making a go move. So by contributing to the team's payoff, you also slightly reduce your own payoff from the previous node, even though you're benefiting a group overall, you're making a small sort of sacrifice, which could obviously backfire if the person [00:17:00] choses the next person choses to stop at the next node. 

So there is a bit of a trade off and a bit of a balancing action going on here. Do you kind of, um, and I guess that's the underlying, uh, theme for all social dilemmas, which I'm interested in, you know, do you benefit the wider team, the pair of players, both of you in the long run, or do you go for your own kind of advantage and, uh, play it safe and make sure that you don't sacrifice any of your own, uh, payoff in the short. 

Benjamin James Kuper-Smith: How is it different from a trust game then? Because that's, I mean, I guess in trust game, you have the option of returning, but it sounds like it can be. 

Eva Krockow: it's similar again. Yeah. It's similar to a trust game. I think in the centerpiece game, again, it's more, um, that the payoff are actually already fixed. So the, the, the trust game, you can sometimes decide how much you give back basically. Whereas the, the centerpiece game is, is more structured over time. 

So it's quite a specific, uh, function and it's always over more instances. So I think the trust game is usually just kind of two intervention or something, so it won't actually continue, whereas the centerpiece game. And I think that's what makes it really [00:18:00] interesting to study as well. It can continue for a long time. 

And really, if you have exponentially increasing payoffs, there is an option to really earn a lot of money. Towards the end. So I did, uh, I did investigate certain games, you know, again, you know, they're very payer function, but the ones that I looked at there wasn't option to earn up to 390 pounds. If you really, you know, went along cooperating all the way, and that's a crazy amount of money for mostly student participants. 

So I think it's just a really fascinating sort of context to be making decision then 

Benjamin James Kuper-Smith: Why it sounds to me, like in this case, there's a very strong incentive to keep going. Right. If you can, if it's an exponential increase, why wouldn't you 

Eva Krockow: every go move also reduces, uh, the own payoff at the next node. So if the, if the 

Benjamin James Kuper-Smith: by how much 

Eva Krockow: again, that depends, it, it depends, but usually, um, it's significant enough for people to worry. So 

Benjamin James Kuper-Smith: I guess, yeah. 

Eva Krockow: so that's, that's a whole point because you have to trust the other person to then keep continuing cuz [00:19:00] otherwise your, your own move won't pay off individually. 

It will pay off for the team overall, but it mainly benefits the other. 

Benjamin James Kuper-Smith: I mean, so this game is not, uh, a super new game, right? I think, uh, I think in your thesis it said 1981, I believe 

Eva Krockow: you've done 

Benjamin James Kuper-Smith: so, uh, yeah, I think that was even page one, but I'm just, yeah. I just, what I wanted to get to is just like, what, um, did you do kind of to that game? 

Eva Krockow: so interestingly it was developed in 1981, but it was never really properly studied that much. And it, it was used in a lot of theoretical discussions because you can apply sort of, um, Well theoretical, um, formulas or like reasoning, basically such as backward induction reasoning, which is a common theme in game theory. 

So I think it attracted a lot of, um, attention from, you know, theoretical economists, but it was very rarely actually studied in the lab. So I think I would say that the bulk of experimental studies on the game have probably been conducted by myself. not just by myself. No, that's [00:20:00] okay. That was an overstatement, but a lot of the work I've definitely contributed to the number of experimental studies on it. 

And I think I really wanted to see, you know, in addition to the theoretical arguments around corporation defection, um, that come from backward induction logic, I wanted to see what psychology can offer. So I looked at specific variables and factors that might influence behavior in the game and, uh, specifically social value orientation, which is a very common concept, kind of measuring how much people are willing to, um, Give to others basically. 

So how, how their kind of how their preferences lie when it comes to the distribution of resources. And, um, I did find that, well, maybe not at surprisingly, but altruists and cooperative people who are very happy to, to share with the team tend to cooperate, uh, for much longer in the center peak game. So, um, there are definitely, so basically I proved that there were certain psychological variables that really played a role and that it's not just all about, uh, economic, rational reasoning that [00:21:00] determines behavior. 

Benjamin James Kuper-Smith: Is, um, I'm curious because you said like, it's, it's not been studied all that much. Do, do you think it's a good game? Like, is it a game that should be studied more? Um, or is it, does it, I dunno. Is it maybe too similar to other games or is it yeah, like why hasn't it been studied more? I guess maybe that's part of the question I. 

Eva Krockow: I don't know why it hasn't been studied more. I do think it deserves more attention because there's a lot of, um, potential to vary the payer function in really interesting ways. And I've done that in some studies and it just shows that even small variations can have huge effects. It's really fascinating to see, and I believe it is more interesting because it allows for those kind of exponential increases that really, um, lead a massive increase in the potential payoffs to be earned. 

And it. Very surprising that I, I think it's a stark kind of contrast between the theoretical predictions that people should incorporate at all. And then, you know, the, the actual really high incentives that are to be [00:22:00] gained that is just really counter intuitive, I think. And that's what makes it so interesting to study for me. 

So I do think it deserves more attention. I think it was possibly overlooked because it was mainly . I don't know, mainly just studied by the economists. I'm not sure. I'm not 

Benjamin James Kuper-Smith: Yeah. I mean, I feel like this is the way, the thing that I find really weird, uh, in, I guess, is probably in most research areas, but especially some of the game theory stuff, um, that I feel like a lot of the, you know, it feels like there's this research literature that's existed for like 50 years from economists psychologists, evolution, biologists, and. 

And other people, um, but you know, there's this, all this discipline studying this thing. And yet there are so many of the very basic questions that haven't even been addressed yet. I mean, the, the one thing that I presented at a conference where we met is the, to me, it's like one of the most basic questions, like losses and gains how that influenced the whole thing. 

And yeah, it hadn't really hasn't really been done properly 

Eva Krockow: like the prisoner dilemma again has been done to death really. I feel like so many, [00:23:00] very, very similar studies, only very slight variations have been done. And I think, I think, um, well obviously we're gonna talk about how I've transitioned away from this very sort of 

Benjamin James Kuper-Smith: exactly. I was, I was gonna ask you 

Eva Krockow: in, in a 

Benjamin James Kuper-Smith: if it's such a good game, why are you? 

Eva Krockow: I think, I think what I would argue for now is actually, instead of just focusing on one particular theoretical game is actually to make them more applicable to real world decision context, and ensure that, you know, they're map more closely to existing factors, more real world factors. 

And take those into account to actually model specific contexts and, um, address specific research, uh, research questions rather than stay very generalizable, if that makes sense. So, um, yeah, obviously I've, I've become a lot more applied in my work. 

Benjamin James Kuper-Smith: Yeah, I mean is, um, to maybe then start, start moving towards your current research? Did you, um, uh, I mean, so there, there was this, like this theoretical paper about antimicrobal resistance from Andrew Coleman [00:24:00] and, uh, the lab, including you, I think during a PhD that came out or something like that, I can't 

Eva Krockow: Yeah, I was already, so I was still, I'm not quite finished with my PhD and I was, um, already working as a post-op minute next project and really the project. Um, I mean, some people see it as a leap from going from game theory to under micro resistance, but the entire time, and the project that I worked in was really drawing on the theoretical principles of game theory. 

So it was always, you know, using main knowledge on social dilemmas that I gained throughout my PhD and then apply it to a very specific. Real world problem. That is anti resistance. So yes, there was a bit of a change obviously, and there was a, in a way I've, I've become a lot more applied in my work and I've moved into health related decision making, but I've really applied all those principles that I've learned about and studied throughout my PhD. 

So I don't think it's, it's all that unrelated. It's just that I've moved away from the very specific centerpiece game context to wider games and, and, and wider wider decision context, I guess. 

Benjamin James Kuper-Smith: To an [00:25:00] actual railroad real world context. Um, so maybe we've, we've mentioned. Antimicrobial resistance a few times now, um, you wrote a, uh, kind of, almost more of a commentary, um, paper saying that, uh, the name isn't good and we should change it and get a new name. Uh, so what exactly is the problem with the beautiful term antimicrobial resistance? 

Eva Krockow: I hate that word. Honestly. I think when I first started out with my research, I just, I literally stumbled across it. Every single time I tried to pronounce it. I still struggle with it. And you know, at the conference where we met, actually one, one colleague came up. Um, I won't, I won't name him here. it was a 

Benjamin James Kuper-Smith: Yeah. 

Eva Krockow: but he did say, well, you're doing such interesting stuff in a resistance. 

I really admired. I think it's so important that man would never attempt to go into this field of research. Cause I simply can't say it 

Benjamin James Kuper-Smith: Yeah. 

Eva Krockow: you just can't talk about it. I think it's just not a nice term to be, to be using. It's not very, you know, it, it's very hard to pronounce. It [00:26:00] sounds very abstract. Uh it's it's a long word. 

Um, it's difficult to translate into different languages. There's a whole host of issues. And um, maybe since we are talking about it, I dunno, does it, would it be helpful to actually define, tell the, the listeners what anti 

Benjamin James Kuper-Smith: Yeah, I was gonna say, can we maybe actually say what we're talking about? Yeah. 

Eva Krockow: so this very complicated word is actually, um, refers to a biomedical problem. 

Um, namely that, uh, bacteria become resistant to the available, uh, to current drugs or, or medication that currently exists. Now, this is a natural process, so it would happen anyway, but any use of, um, antibiotics kind of accelerates that process. So the more antibiotics we use, basically the more, uh, bacteria become resistant. 

So the stronger they get basically, and they, the more able they become to withstand current treatment. Now, the kind of consequence of that is that as antimicrobial resistance progresses more and more infections or [00:27:00] bacteria infections become untreatable because the drugs no longer work. And that is a massive issue. 

So it's, it's a major global health threat because. We can start dying again from very simple, I infections that were incurable before the discovery of antibiotics. So penicillin, the first antibiotic was discovered in the 1920s. And before that, you know, people were dying from cuts, from simple bacteria infections and, uh, you know, we could regress to state or similar to that potentially if all antibiotics stopped. 

In addition to that, I think something that people don't realize is quite how often antibiotics are really used. So it's not just for those, you know, acute infection when someone comes in and they have a bad cut or they they've caught pneumonia, but they're used in a whole lot of different settings, for example, for elective surgeries. 

So someone has a hip surgery, you know, you give them antibiotics to prevent infection and it will be extremely difficult. It will be extremely risky to conduct a, a surgery without antibiotics having antibiotics on, on, you know, as a backup basically. Cause otherwise they might just [00:28:00] die from infection afterwards. 

So you might have fixed the problem they came in with, but then they get an infection and die from that. But similarly they're used in conditions. Um, for example, during cancer treatment, when people are immuno compromised. So they are not as, you know, they are not as able to fight off bacteria as usual. 

So they are kind of longer term antibiotics just to help support the immune system. So basically antibiotics are used across a wide range of different areas in healthcare and. If we lost working functioning antibiotics, it really would have very, very damaging and dire consequences. 

Benjamin James Kuper-Smith: I mean, it, it sounds like basically the consequence would be like, In specific cases, you, we, yeah. We'd basically lose large parts of modern medicine. I mean, you you'd still have obviously some apparatus around it and other ways to deal with stuff, but yeah, it sounds like basically you're just like, you know, just like, oh, this disease now we're back to yeah. 

1920, whatever. 

Eva Krockow: Absolutely. Yeah. And, uh, [00:29:00] people have compared it to kind of fraternity to the middle ages almost. I mean, we see, we don't really know at what point we'll get there. So it's, it's really hard to sort of quantify and predict and, and, you know, make forecasts. And obviously there is ongoing biomedical research looking at potential new treatments. 

So trying to find new antibiotics or trying to find alternative options. So they're experimenting phages, which are sort of deactivate deactivated viruses that can attack bacteria. A lot of that work is, is infancy. And a lot of the work specifically looking into the development of new antibiotics has actually not really been successful in the past. 

So there haven't been many new drugs on the market in a long time. And part of that actually is that is simply not very lucrative market or lucrative business because antibiotics on the whole are quite cheap. So pharmaceutical companies don't really invest in the development or drug testing rate basically of those types of medication. 

So the whole host of issues, but basically it's it's at the moment, it looks like [00:30:00] we won't have working antibiotics by like 2050, basically. So that's when, when, um, economic forecast predict, uh, for antimicrobial resistance or related infections, basically to overtake cancer as a leading cause of death. 

And, uh, it's not looking good in summary 

Benjamin James Kuper-Smith: Nice. exactly. And, um, I guess the, the whole point of your research then is to, you know, not from the biomedical side, solve the problem, but rather from the, the side of how can we use less or is, is that a good summary or. 

Eva Krockow: Yeah. So I think antimicrobial assistance is obviously not a new topic and it has been studied widely and discussed widely in sort of niche areas, uh, such as microbiology, which is obviously the, you know, the kind of area it comes from. And a lot of medics are aware of it, but I think it is essentially a behavioral problem because if we can't [00:31:00] produce new treatments, new drugs, basically we have to be able to manage the existing ones. 

And that's really the, the kind of the kind of work that I'm interested in, the topic that I'm interested in, how we can, we manage the resource of effective antibiotics using the knowledge from psychology and fun theory and behavior economics as. 

Benjamin James Kuper-Smith: And so I wanna talk a bit more about that, but I have just one back to the name just very briefly. Uh, so first of all, uh, these are kind of two related questions. The first is what are some good suggestions for this name? And secondly, so I always name the episode of my podcast with the name of the guest. 

And then I have like the three main top. We talked about what should I put for this one? Should I put antimicrobal resistance or is there a better word I can use that. 

Eva Krockow: oh, excellent question. So I've recently I've done a service study. That's not actually quite published yet. The kind of last stages of writing up the manuscript, but that entire study focuses on the name of antimicrobial resistance and, um, [00:32:00] I guess previously that one of the things, um, that's wrong with the term I haven't mentioned yet is actually that there are a lot of variants of the, of the term. 

So there are different terms that are used interchangeably almost to describe the same thing. So in addition to antimicrobial resistance, there is a slightly similar related concept of antibiotic resistance. It's just slightly different, but a lot of people don't know the difference. And so it's confusing. 

In addition to that, people use the terms of bacterial resistance, drug resistant infections or superbugs, which specifically refers to very powerful, very super resistant bacteria, basically. So there's a whole host of different names out there. Firstly, and so in that study that I mentioned, I actually compared those names and, um, compared perceptions of, of lay people of those names. 

Um, and then again, Looked at those compared to other risk, uh, um, and health risk terminology, other health risks, such as cancer. I basically other other risk terms to kind of look at how [00:33:00] effective the antimicrobial resistance terms are compared to other health risks, other threats that there are. And I found that all the terms to do with AMR with anti micro resistance were extremely difficult to remember for people. 

So they found it very difficult to recall them to actively recall them or even passively recognize them when they were kind of presented with it afterwards. They also didn't seem to think just looking at the word that it was a health risk, so they didn't associate it a threat with it. Whereas if they saw 

Benjamin James Kuper-Smith: sounds good, right? Resistance. Oh yeah. I've got some resistance. Sounds 

Eva Krockow: exactly. How would you know that that's something to be worried about? So if you see that term in the media, you know, then it doesn't actually spark any, it doesn't cause any alarm, it doesn't signal alarm. Whereas, um, I guess other other things such as heart disease, it's very specific, you know, it's about the heart. 

So you can imagine it's a, it's a big deal. Obviously you can coronavirus disease COVID has been in the media as well, so it's slightly confounded, but basically other terms, um, are doing much better in, um, [00:34:00] suggesting that there's a, a substantial risk or threat. So basically, uh, what I found in that study is that all the existing terms are pretty bad and you ask what we should, what we should actually name it instead. 

you know what I've been doing so much thinking about that. So some researchers have suggested to use the term drug resistant infections, which is an existing term, and they say it has got the advantage that it's got infections in the title. So. You know, thereby signaling, signaling, um, a health risk. So it's, it's a bit more concrete than perhaps antimicrobial resistance. 

But I did find in my study that it's one of the terms, that's probably the least memorable simply because it's a very long one and it's complicated to spell, I guess. So I'm really not sure that's the way forward. I think, um, there needs to be a specific, actually a new study to really purposefully design a new name. 

And, um, I'm specifically thinking about recent examples in this because, um, if you maybe remember, uh, the, the kind of beginnings of COVID [00:35:00] 19, it was initially initially referred to as the novel Chinese Wuhan coronavirus disease. So it had a very sort of stigmatizing title. And for that reason, they all kind of came together the big kind of political heads to kind of create a new name. 

And that was COVID 19. Um, obviously they kind of did a full, slightly different reason because they wanted to remove the stigma from the name. But I think a similar sort of a similar effort needs to be done in terms of aro resistance. So, you know, there needs to be some sort of, um, agreement amongst political leads that there is a, is a need for change in, in the name. 

And then there needs to be that international buy-in as well. So. I think, yeah, there needs to be a, like I said, there needs to be that buy-in potentially like a research study with sort of political input as well, because me saying, you know, I think this term should be should be used useful now and is not going to cut 

Benjamin James Kuper-Smith: I mean, if you've got a good term radio catch 

Eva Krockow: I've got some ideas, but I'm actually, I'm actually here thinking about potential study like this. So I'm not gonna give those away just yet. 

Benjamin James Kuper-Smith: Okay. [00:36:00] Okay. 

Eva Krockow: that might be one of my next projects. So 

Benjamin James Kuper-Smith: But it, it sounds like this is really like a, uh, um, it's almost like. The w H O or something should hire market research company or something 

Eva Krockow: much, I think 

Benjamin James Kuper-Smith: really look at like, 

Eva Krockow: to really make an impact. And, um, you know, they lead consult infectious. People, they need to consult some, some linguists as well. Who can, you know, you, you can advise on a, on a specific linguistic dimensions that going to matter that such as or, um, concreteness of familiararity and so on, because there are a few linguistic dimensions that have been shown to promote memorability in words, for example. 

So I think it needs to be a sort of a team effort, including a high level buy in from political leaders, as well as research input from different disciplines. 

Benjamin James Kuper-Smith: okay. 

Eva Krockow: be an easy fix. Unfortunately, I don't. 

Benjamin James Kuper-Smith: Yeah. And you didn't answer my question. What I should put in the title, I guess I just have to put antimicrobial resistance then 

Eva Krockow: stick with that one. Um, I think to be honest, it's always going to be the term that is used in, uh, [00:37:00] science, because it is the most, um, probably yes. Yeah. It's probably the most accurate term. And, uh, for that reason, I, I would say it's probably fine for academic use because we know what it, what it describes. 

It's just not pop, it's just not a suitable term for public health communication. So I would differentiate between those two areas of use. 

Benjamin James Kuper-Smith: Okay. Okay, 

Eva Krockow: that answer your question? 

Benjamin James Kuper-Smith: yeah, I think then I, then I can just use that. Um, it's funny that you mentioned, like it's not memorable because I kept looking at the way I typed it up in my notes and it keeps, it looks like I mistyped it, but I think it's correct. It's like every time I look at it, it's like, did I spell this correctly or not? 

I'm not sure. Yeah. 

Eva Krockow: I think it's just really not suitable it's yeah. 

Benjamin James Kuper-Smith: Okay. Anyway, that's the term we're using right now? Uh, I guess we can use AMR if you wanna make it. Uh, in general, I don't really like abbreviations too much because they usually. 

Eva Krockow: I did a search for AMR previously and it stands for a whole lot of other things. So again, it's not really that useful, again, it it's [00:38:00] really common in a science background, but yeah, if you use it for kind of wider population, people who have not heard the beginning of this podcast, , it's probably not that useful. 

Benjamin James Kuper-Smith: Yeah, but I guess this is, is a continuous podcast. So people who will listen to the later part will probably listen to this part. So I guess, uh, from, I guess we can call it AMR, uh, just briefly about, so the actual problem of AMR itself is then, uh, I guess I just wanna define that a little bit more. I, you mentioned some problem areas already, like how it comes about I, uh, one thing you did mention, which I thought, I dunno where I got this from, but I thought that was also a huge problem is just, uh, the meat industry. 

So, um, cows or whatever, just, or chickens or whatever, being regularly just given or not even regularly, just like always given, uh, the stuff that I, is that correct? 

Eva Krockow: agree. So, um, that's true. So you talk about a one health approach, which means, um, antibiotic uses not just problem in, in human healthcare. It's also a problem in animal health and, and the environment. So it's, it is used [00:39:00] for, uh, to promote, to promote growth of animals, for example, um, in, in a agriculture and it's used the environment sometimes, and they obviously use in one area has a huge impact on the use in all other areas, because antibiotics, it doesn't matter, you know, to bacteria where antibiotics are used, um, the re. 

Happens anyway, in my work at the moment, I mainly focus on the healthcare sector of human health simply because it's not possible to study everything. I completely agree that the other areas are important. Maybe just as important it is. Yeah. It just, I, I don't have enough time to study everything and uh and they actually think also that, uh, antibiotic use in human healthcare presents, um, different ethical challenges or slightly different challenges compared to meat, production, agriculture, and, and animal health, because whereas in agriculture is fairly clear cut. 

So, you know, it's fairly obvious that antibiotic use, um, is a, is a very selfish [00:40:00] thing to be doing 

Benjamin James Kuper-Smith: It's an economic argument, 

Eva Krockow: It is a purely economic argument. Whereas I think the healthcare sector, healthcare overuse of antibiotics is, is more interesting because it is not simply based. On, uh, self selfish motivations. It is influenced by a whole host of different, um, variables, really lots and lots of different factors, lot of psychological variables that really come into play. 

And, uh, that's where I think the social dilemma sort of, um, context is also the most applicable and most interesting. So that's my reason for focusing on the, on the human healthcare sector. But I agree that there's a lot more to this issue and I agree that other people should be doing more work on animal health as well. 

Benjamin James Kuper-Smith: Yeah. That's always the nice thing for people want to do research. Here's an entire topic 

Eva Krockow: there you go. 

Benjamin James Kuper-Smith: that you can throw yourself at 

Eva Krockow: it's just, it's just such a big, big topic. Honestly. It, it just warrants so much further of a search. And like I said, I'm only one, one tiny part of this. I'm a behavioral scientist, a psychologist who looks [00:41:00] into this, but like I said, you know, we need more input from. Different sciences. 

And it's actually really interesting to see how multidisciplinary the work has gotten. So there is, if people are interested in this, there's actually really interesting other podcast in addition to yours, that I 

Benjamin James Kuper-Smith: what there's more. 

Eva Krockow: Yes. It's called the AMR studio podcast. I believe it's, uh, hosted somewhere in Sweden. 

And, um, they do really well in highlighting interdisciplinary contributions to the topic. So we have all that biomedical research, but then there's, um, there's research from, from the arts, for example, where they try to, um, illustrate or visualize anti micro resistance or engage with people on different levels. 

So I would say, you know, there's, there's a whole range of different research areas out there. And if you're interested at there's lots of options to get involved, in really fascinating. 

Benjamin James Kuper-Smith: Perfect. Um, you mentioned already the social dilemma aspect, and I think, I guess that's kind of also why, I mean, I guess that's why I saw your talk at the conference. Um, and that's also the aspect I'm probably most interested in. So, um, [00:42:00] yeah, maybe can you, um, give a brief overview kind of what is, or why, or how is, um, aro resistance, a social dilemma? 

Um, yeah, maybe let's just start there and then kind of maybe contrast it, how it relates to other dilemmas, the one you, the talk you gave. Relation to climate change. Um, 

Eva Krockow: So, I guess a safe dilemma scenario, let's, let's define that to start with. So it's any situation really where the kind of individual interests of, of a single person are sort of at odds with the collective interests of, of overall society. So, um, the sort of theoretical typically example that's usually given is, um, that of, um, of such a harden. 

So he kind of coined the term of a, a public dilemma game or a public goods game, or the tragedy of the commons, which are all very related. And basically it presumes that there is a common, a good. Commons such as a public meadow. That's the typical example and this good can [00:43:00] be used by lots of different people. 

So in the common example, there are lots of neighboring sort of farmers send their sheep to Gras on the meadow and obviously benefits everybody because they get free food for their sheep, but then the more sheep they send, obviously the, the farmers are getting more out of it, but the more they send also, uh, the more the meadow becomes degraded. 

So if everybody kind of does the same and acts in their own best interest, that means the common good gets depleted. And in the end, nobody, um, benefits from it or all of them actually suffer as a result. So the same underlying structure, I believe, applies to the decision making dilemma of antibiotic resistance. 

So if we, in this context, belief or conceptualize, um, antibiotic efficacy as the common good. So, um, we are interested in preserving. Effective drugs, basically effective drugs that can kill bacteria affects that can treat bacteria infections and [00:44:00] maintain our healthcare system as it is. So that's the common good. 

And, um, all of us use antibiotics. Well, not all of us, but a lot of people use antibiotics on a, on a sort of regular basis. And some of that use, you know, is probably tolerable or appropriate. I would say tolerable is probably the wrong word, but appropriate given the circumstances. So a lot of people would argue that, you know, if you're almost, if you're close to dying from a, from an infection, then it's appropriate to use an antibiotic. 

But then in other circumstances, antibiotics are overused. So they're used when it's maybe not necessary where completely inappropriate, because they're not medically indicated. And then all that overuse basically contributes to a depletion of the common good that is drug efficacy. Because like I said, initially, you know, the more we use antibiotics. 

The more we, um, contribute to anti resistance. So the more we deplete the working drugs that are available and, uh, as a result, you know, it might serve individuals on a, on a kind of on their own [00:45:00] basis because if someone over prescribes or overuses antibiotics, it is often motivated by, um, by a wish to, um, avoid health risk. 

So usually there is maybe a suspected infection and they use antibiotics just in case, obviously, um, there's usually a motivation behind this and, and presumably is a selfish one, actually. So, um, all that kind of selfish overuse then leads to it as APLE of the, the public good, the common good that, uh, will affect everybody and have really bad consequences for the, for future generations of people. 

So that's a social. 

Benjamin James Kuper-Smith: Yeah. And I guess, yeah, I guess it is, I mean, you mentioned this in, uh, one of your articles that, um, by the way, for anyone new to the podcast, I always put like references and links to stuff we discussed in the description. So you don't have to look for the papers. Um, I guess the interesting thing that you, you mentioned how anti Maro resistance is a kind is a, is an interesting social dilemma that differs [00:46:00] from some other examples is that it's not just purely selfish, right? 

So there might be, I don't think, I dunno whether you mentioned this example, um, but like, you know, you could also ask a doctor to prescribe it for your parents or whatever who are maybe ill, right. Or for other people you're caring for, um, or the example you give there. That doctors do it because they want their patients to be healthy. 

Um, and you know, what is one, uh, um, you know, what is, what, what am looking for 

Eva Krockow: Well, I guess what you get trying to get at is what's single contribution to the wider problem really? Is that what 

Benjamin James Kuper-Smith: yeah, exactly. Yeah, yeah, exactly. Yeah. It's just like one, you know, this is not gonna 

Eva Krockow: gonna 

Benjamin James Kuper-Smith: any anti occur 

Eva Krockow: Exactly. Yeah. So, yeah, I, I completely agree. So, like I said, I don't think. This is a dilemma, which is black and white. So there's not one move that is cooperation. 

And one move that is defection. And, you know, you were already asking about differences between social dilemma. So I think that's how it differs from a lot of the theoretical theoretical models that we've [00:47:00] got, where one move is always a bad one. One move is always the good one. I don't think that is the case in, in the context of antibiotic use in healthcare. 

I think it is just so much more complicated and yeah, one of the motivation is definitely to help other people. So as doctors who are usually the gatekeepers of antibody, because they prescribe them for others, you know, they, um, Obviously, obviously they've kind of sworn an oath. They've taken an oath and, um, they are committed to protecting their patients. 

And a lot of it comes down really to their risk aversion. So in some, some circumstances, you know, they might not need antibiotics. The patient might not need antibiotics, but it's simply not clear. Um, we speak of clinical uncertainty in those cases. So sometimes a patient might present with symptoms of bacteria infection, but it's not clear if they really have one or if it's something completely different or it's also not clear if maybe that infection will clear by itself. 

So there are certain so, so called [00:48:00] self-limiting diseases that will just get better over time. So in those cases, antibodies aren't necessary or maybe it's actually a completely a different thing. You know, it's not a bacteria infection at all, and antibiotics are going to. anyway. So in those cases, prescribing is inappropriate. 

Now, um, I would argue that even though there's maybe a selfish factor to it because doctors want to maybe cover their own back and they want to make sure that patients don't come back and complain about, you know, the treatment they've received quite often, their decision making is motivated by a risk aversion and by their general wish to help the patient in front of them. 

So their kind of concern is obviously for the immediate need right in front of them, rather than for future generations of patients that they might not actually get to see after all. So, um, again, a difference here that'd like to outline compared, you know, antimicrobial resistance to more standard models. 

It's just that we have that sort of temporal distance here. [00:49:00] So a lot of it is actually in the future. Still antibiotic resistance is here to some extent. But to the, to the extent where we actually really see the, the kind of the impacts and the consequences that is probably only, only going to happen in, in, in a few decades, basically, because at the moment we usually have a backup antibiotic ready. 

That will still work if the first one doesn't. So it's, it's it, it's complicated by the factor that, you know, it's not an immediate sort of outcome, anti resistant. It's something that's going to happen over time. That's not necessarily visible immediately. And that, that is quite difficult to grasp. So lots of complicating factors going on. 

Benjamin James Kuper-Smith: Is the. From a, from a like scientific experimental or yeah. Even theoretical side. Are there any, like really good models of this or experiments you can do? Or is it the kind of thing where you feel like, I dunno, you wanna do a study on this to not, you know, use the exact context, but to generalize a little bit, and then there's just nothing you can [00:50:00] really use. 

Um, yeah. I'm curious, like, is there, what is the best model maybe to study this and how, how good of a approximation is it to the actual thing? 

Eva Krockow: Yeah. So, um, I'm glad you're asking because I've, I've got a study in preparation actually on this. So I'm involved in 

Benjamin James Kuper-Smith: Oh, really? Okay. 

Eva Krockow: driven by myself. I have to say I was approached, um, by a very talented PhD student from the Copenhagen lab. And, um, she's done some really fascinating work where she put a lot of effort in, into, um, organ into designing. 

What is essentially a public good scheme of lots of, um, adjusting variables, basically lots of different factors that kind of make it more similar to antibody re. And, um, I, I, I think maybe once it's out there, you can add it to to the, 

Benjamin James Kuper-Smith: Okay. 

Eva Krockow: list of links and, and references, but I think there is a way to model it. 

It's just, um, to take into account complicating factors and, uh, yeah. And, and kind of yeah. Different variable that aside different in, in 

Benjamin James Kuper-Smith: So like adding the time horizon aspect and these kind of things. 

Eva Krockow: yeah. And adding also the, the kind of [00:51:00] uncertainty. So one element that we wanted to capture was that, you know, at some point it might seem rational to take antibiotics, but actually it's not. 

And sometimes it's just about waiting and seeing how things develop, because it might appear rational to AVS antibiotics when you're very sick, but actually. Every use of antibiotics also has certain side effects like any medication, you know, you can get a really bad stomach. I've said we've heard a lot more about, you know, how important the microbiomes for, um, for mental health and then just general wellbeing. 

And all of that is really badly damaged by, by use of antibiotics. So there are also negative side effects are often sort of almost neglected, neglected and forgotten about. So we try to model those in actually in, in the game that we've, um, come up with in the end, because sometimes just waiting and seeing how things develop and monitoring symptoms can be the most appropriate way forward because you don't wanna use antibiotics when they're really not necessary. 

Benjamin James Kuper-Smith: Okay. Sounds like a good study, 

Eva Krockow: It definitely is. 

Benjamin James Kuper-Smith: have to wait until [00:52:00] that's out. H how much research has actually been done on the reasons for. People overprescribe. Oh, no, not even over prescribing per se, but just prescribing them in the first place. I mean, you mentioned some aspects like uncertainty that kind of is, is that I'm asking because I just dunno the field at all. 

Has there been like a lot, a lot of this where they ask doctors specifically examples and that kind of stuff 

Eva Krockow: has been a Bo for search mainly by the medical professions. To be honest, it's not really kind of informed by psychology, but there has been a lot of work. Some of it actually also placed by us. Um, so my kind of my own research group, so I was involved in a project. This was when I was postdoc, actually that, um, used qualitative methods interviewing, um, to. 

Doctors for their reasons of overprescribing or generally prescribing antibiotics. And I think the reason why there are a lot of studies and why there need to be a lot of studies is because this vastly massively depends on the context. It is a really contextualized issue. Um, it depends massively on the [00:53:00] healthcare context. 

So the study that we conducted was one, um, taking place across the UK, South Africa and Sri Lanka. And what we found is, for example, in Sri Lanka, they have firstly obviously they have much lower hygiene and sanitation, um, throughout, so generally higher infection rates, making meaning that actually antibodies are more important than perhaps, uh, in the UK. 

But we also noted that it was, um, very heavily influenced by a large private sector. And obviously there is a then a really big disconnect between private and public and in the private sector. The, the main difference is obviously that patients come in and pay for a service. So, um, patients play a much more central role in those contexts. 

And it's not just about the prescriber. It is about the kind of patient prescriber interaction. And if a patient who's paying to receive a service and who's then afterwards rating the hospital, perhaps on a, you know, a public site who who's, if the patient, if that patient is demanding antibiotics based on sort of misguided beliefs, then the doctor will prescribe [00:54:00] antibiotics, even if they don't believe they indicated. 

So I think it's, it's a topic that massively depends on the context and the, the kind of system that they're, you know, surrounded by, which is why a lot of contextualized studies actually need to take place. And I do actually believe that also. Qualitative studies have their place there. So, um, maybe noticed I kind of moved away from purely experimental methods here and they became involved in more qualitative work. 

I do think that they're really valuable for outlining of kind of highlighting very nuanced, um, kind motives motivations that otherwise would not be able to, um, to be pinpointed 

Benjamin James Kuper-Smith: Yes, it's funny to me like the. Kinds of studies because I mean, I've never done one. I don't, I dunno whether anyone I've worked with has ever, ever done one. Um, I've read, I mean, I've read one qualitative study, which to me to be fed seemed more like maybe the reason why you wouldn't use it, because it seemed very kind of, [00:55:00] I don't know. 

It seemed, I guess I just wanted to talk a little bit about this cuz it's I am wondering like what yeah. What the specific use of qualitative studies is and how it can help in ways that quantitative can't. Um, so I'm curious, like what specific kind of, um, yeah. Why, why did you use qualitative study? Um, and not a quantitative one. 

And what did you kind of hope to get out for this specific study 

Eva Krockow: I guess I like to take kind of novel approaches to things that have been studied in the past, which my first sort of dive into stab into, um, politic methods was during my PhD was during the kind of centerpiece work cuz I have one study where I, um, investigated center, Pete reasoning, reasoning in center, Pete games, decision making those games 

Benjamin James Kuper-Smith: Yes. 

Eva Krockow: um, using, um, verbal protocol analysis. 

So that involves having people talk aloud. While they're making decisions. And it was a very small scale study as is very common [00:56:00] for qualitative studies. So I only had about 12 participants, I think, but the amount of data, the, the wealth and richness of the data that I received was really mind Bo boggling. 

I had not, I had really not anticipated against that much out of, so I have to say I'd had, I'm probably also an experimentalist, a quant quant person. And I was, uh, similarly, um, I dunno, qu qualitative stuff was always a bit suspect to me, but after that one, um, kind of attempt or that, that, you know, that one venture into qualitative work, I just realized that. 

I guess it is got a really sort of exploratory function. So it can sort of, um, help you to define research questions by just Le helping you to take stock of what is out there and just really exploring the breadth and depth of everything that might be underlying a problem. And then, you know, once you've kind of singled out a few key motives, you can then sort of hone in on those with experimented methods. 

I do, I do think in my mind, quantitative and qualitative work should always go together. [00:57:00] So I'm, I'm really a big fan of mixed methods. And, um, maybe to answer your, um, question of why we use qualitative and interview studies in that context of, of, uh, antibody prescribing, again, it comes down to just getting those answers and then, and really, you know, not coming in with a preconceived mind. 

So obviously, you know, when you design an experimental study, you have to manipulate certain variables. You have to know which ones to manipulate. You have to know which ones you're going to look at. Whereas with an interview study, you go in. Almost not blind. You have obviously a knowledge of the topic area and you ask certain, certain sort of structured questions, but you're just a lot more open to receiving new input, I would say. 

And, um, especially with it being such a complex topic, comparing motives for a prescribing across different context, cultural context, um, and so on, it just wouldn't have been possible to do that in a quantitative design. What you could do is, you know, collect data and then compare prescribing [00:58:00] levels. But that wouldn't tell you much about why they're overprescribed necessarily. 

Benjamin James Kuper-Smith: It's it's funny though. I only thought about this whilst you were giving answers that the, the very first kind of prison study by, uh, um, marrow flood, whoever it was like the, before it was even called prison cinema, that kind of stuff. Um, uh, I think that one actually, um, you know, he just had like a, the kind of the payoff matrix design, and they let them play like a hundred rounds or something like that. 

It's funny that one actually included the appendix, the transcript of what one of the people said. And it's really interesting to read because this one person kept saying like, you know, like on doesn't, like, why is he defecting? Doesn't he realize we can get more if we cooperate and, and you could really see like, all these motives play out when he was at some point's like, okay, I'm gonna defect now because you know, I'm not gonna like be the sucker every time. 

But, and then occasionally he was like, okay. But like, I have to remind him that this is important. like I have to like trade, teach him like that mutual cooperation is [00:59:00] the best outcome. 

Eva Krockow: honestly, it's fascinating. So like I said, that, that verbal protocol study on center peak games, it just came up. I mean, the things that you mentioned here, I mean that at least they're not, they're kind of rational. Well, suppose. They, they make sense those comments, but I had some comments that almost Unical or nonsensical, so people were having the weirdest notice for making moves in the game. 

And that, you know, I had initially done a comprehension test, so it's not like they didn't get the game, but some of them were, for example, arguing like, oh, I'm just gonna go. I'm just gonna keep continuing. Now. I just wanna feel like I get to the end, just so that I feel like I finished, you know, things like that, that weren't actually related to the payoffs at all. 

It was simply, you know, sort of a weird action bias that they just wanted to feel like. They've fun all the way in a sequential game and things like that. I think, as an experimenter, you wouldn't even never come up with just because you can't imagine sort of weird things that this sounds, this sounds negative now. 

I'm not, I mean, I'm not judging people cuz it's obviously a very sort of theoretical context and everybody looks at it very [01:00:00] differently, but all I'm saying is as an individual, you can't really anticipate what other people are going to think of it. Especially someone who's really not trained in those methods. 

And who's never seen a game before to them. It's it's something entirely different. So 

Benjamin James Kuper-Smith: Yeah. I mean, that's why I really like talking to participants after the experiment. I mean, we did one, you know, set of interated business tasks. And I mean, I didn't actually talk to this person directly and figure it out, but kind of indirectly, because I saw this one person always cooperated every single time. 

And there was a particular one interaction where the other person always affected. So there was like, you know, 50 trials in a row. One person cooperated are defected every single time. Like the like one guy was making so much money off of the other person. And, um, so I, I, you know, I just thought maybe the person didn't understand the task or whatever. 

Anyway, so then I remembered, uh, so the person. There was one participant who was, let's say visually recognizable, who took part in lots of studies at the Institute. And then one person said, oh, this person came in and [01:01:00] just told me like that they found Jesus and always wanted to be nice to people and forgive them was kinda stuff. 

And then I realized that was that I looked it up. It was exactly that one person who always forgave, basically the other person. It's like, that's not part of like your experimental design that you get someone who 

Eva Krockow: so many motives that can't be captured with constructs such as such social via orientation. You know, there's just no measure for it and you wouldn't, wouldn't be able to, to conceive of it. So, yeah, no, I mean, yeah, since you mentioned the repeated prisoner dilemma game, we had a study where we ran 300 prisoners dilemma games and it was a really, really long study. 

And just seeing how the emotions played out in the room, obviously they couldn't see each other, but then some of the emotional reactions people were, you know, using swear words and getting really aggravated and yeah, it's, it's really fascinating. And then equally, I, I agree. It's really valuable talking to participants afterwards. 

So one time. I had a participant who said, well, I just don't believe that you're going to give me the money afterwards. [01:02:00] They just, they had been deceived in a previous experiment where I had made a bad, you know, bad experience. And they just simply didn't believe that they were gonna get any money. So they just kind of made random choices. 

So again, something that, you know, I guess you could put it down as noise in the experiment, but it's something that you can't factor in really UN unless you explore it in a different way. 

Benjamin James Kuper-Smith: I guess the economists listen to this are very pleased with themselves right now, because that's exactly why they don't allow. Um, right. Yeah, exactly. But yeah, so, so, so are you in a way then using a qualitative study almost in the way that I informally. Usually talk for like a minute or two, but like, I don't, you know, because this is not part of the experiment. 

I don't like do it for five to 10 minutes or something. Right. I just kind of like ask them often, like what they thought about the experiment or whatever. And so is this kind of a more formalized, um, more systematic way of doing the same thing or, 

Eva Krockow: a systematic way. I think, um, obviously factor it in from the beginning. Uh, sometimes you even use it to potentially [01:03:00] then inform the design of an experiment afterwards. Um, but I, I think, yeah, it sounds like you're doing it at some level already. 

It's just about actually recognizing that this 

Benjamin James Kuper-Smith: but much less? Yeah. 

Eva Krockow: exactly. It is a really important step and it can be really valuable, but I agree that the kind of analysis is always a bit of a nightmare. So I, I understand people not wanting to dive into it. is, is challenging 

Benjamin James Kuper-Smith: I mean, that's one thing I always lack with online studies. So, you know, I, I, I mean, online studies are fantastic. Right? You can collect hundreds of people in, in like an hour. It's. Ugh. You can just sit there and just watch the data come in. It's fantastic. Yeah. But yeah, you do lack 

Eva Krockow: it all in one file. 

Benjamin James Kuper-Smith: Yeah. And then see your experiment and work or whatever. 

But, um, but the, you know, I really love, you know, that's, I mean, it's fantastic. Right. But yeah, you do always have the sense of like, did they get it? I mean, I, I do leave like an open, like comment thing at the end, and sometimes you get people say, like, I didn't get it, but I mean, I [01:04:00] have test questions. So I, I usually know if they understood it or not, but yeah, you do kind of lack. 

Eva Krockow: at the same time? I think it's just, it, it does lack of sort of, yeah, you, you, it is difficult to know what they were thinking at the time. It is difficult and, and, you know, I mean, I like the idea of having a common box, but then. It takes a certain amount of effort or, or even willingness to, to then fill that in if it's not a required sort of part of the study. 

So it does depend on the person's motivation and yeah, a lot of people, I think, I think it does depend a bit on the under survey provider or the kind of the online side that you're using as a host, basically the quality of the data that you get, but I'm sure you are aware of that. 

Benjamin James Kuper-Smith: Yeah. Yeah. I mean, for me, it's. Most important thing is, you know, lots of test questions then beginning to make sure they understand everything. And yeah. Um, back to, uh, I guess we have to finish at some point soon, but just briefly about AAL resistance, which still looks as if I [01:05:00] mistyped it. Um, yeah, sort of a weird looking word. 

Yeah. I guess I'm just curious about like, uh, in general, like, okay, so we, you know, it's this huge problem and what can we do about it? And maybe to ask us a question that relates to something you mentioned earlier with poor countries having, um, less sanitation average and therefore needing more, I'm curious is maybe the, one of the, you know, best ways to solve this to just, just quotation marks, increased sanitation for countries. 

Is that kind of the main way or. 

Eva Krockow: yeah. Yeah. So there, I think sometimes you can see nice overviews. There's really a multifaceted way of approaching it. So it is, it is partly of, um, improving sanitation. And so making sure that infections don't derive in the first place, because you don't have an infection, then you don't need to treat it and you don't need to need to use any drugs. 

So, yeah, absolutely. But, um, it's, it is, unfortunately, it's not as easy as that because it's obviously not possible to eradicate all infections. what you need to do is like you said, improve sanitation, improve [01:06:00] infection control. So make sure that infections don't spread. If someone has got an infection, make sure, you know, it's contained within that person rather than spreading it onto others. 

Um, but that's definitely one part of the I'm part of. Uh, challenge, I guess, um, additional parts are obviously looking at more, um, drug development, but also looking at best, better diagnostic tests. So one issue is, um, that, you know, I mentioned the clinical uncertainty one issue is that doctors often don't know what they've got. 

Um, what, what they've got the patient for another ma got. So there is that technical uncertainty, which then leads to what we call empirical prescribing. So it's basically prescribing on a hunch or experience basically just going on the symptoms alone and going on the, you know, going by the experience of that, of that doctor in question. 

And that can be a very, very challenging task. You know, often there are, um, other factors that are going on time pressure. So you don't have a lot of time to really fully investigate. And, um, this is actually a new study that I'm going to get involved in, which is a really more clinically [01:07:00] applied study. 

But we are looking at, um, current diagnostic tests, which are conducted using blood samples. So at the moment, you know, we do have microbiology lab tests. That can firstly determine whether it is actually bacteria infection, and then also what type of bacteria infection it is. So, you know, which specific antibody can we use to target more narrowly, you know, more specifically this particular infection. 

So we do have those tests, but at the moment, um, blood samples aren't always taken reliably. So part of that reason is that people are so, so much under time pressure or the patient looks so ill that they give antibiotics straight away. And then it's too late to collect blood samples. But then also they don't actually think there's much use to it because the results sometimes come back three to four days after, and sometimes they don't benefit the, the initial prescriber, the one who made the initial prescription, they benefits someone else down the line. 

So again, actually it's a mini social dilemma in the sense that you're having to do something that potentially it's a bit time [01:08:00] consuming because taking your blood sample in a busy environment, when you could be doing other things. It's not always easy. So it evolves some effort that, you know, benefits someone else because there are, you know, other prescribers, other doctors, the patient is going to see. 

So you might not actually ever get to see the benefit of this action. So I think a lot of the, the work really needs to focus on providing better diagnostic tests and maybe incentivizing running those diagnostic tests in first place, and really eliminating that large level of diagnostic uncertainty, which then leads to overprescribing OVS of antibiotics. 

So yeah, lots of different factors that come together, like you said, you know, hygiene, sanitation is one of them. Um, and then other sort of behavioral, um, aspects as well. 

Benjamin James Kuper-Smith: Yeah. I mean, I guess the, the, the, the, the cool thing about this seems to be that there's lots of different ways of addressing this problem. And I guess, or, you know, I guess it's about at least limiting it, not, you know, completely avoiding it, [01:09:00] but making sure that, you know, there's at least a few antibiotics left that work. 

Eva Krockow: of different perspec perspectives. Cause obviously my work on kind of terminology and so on, that's a different angle in it altogether as well, because it's all about how we communicate a risk and how we, you know, how we talk about it in the public domain and how we even draw attention to a problem. 

So again, that kind of goes into, well, I suppose it's obviously it's meant to address overuse of antibiotics, but it is actually through sort of information intervention, so to speak. So again, it's, it's another, it's another facet, I suppose, that comes in to the management. 

Benjamin James Kuper-Smith: Yeah, I mean is, uh, just a, a kind of as a last point. I mean, I, um, you know, I talked to, um, one of my earlier interviews was with Hannah Watkins. Who's part of the nudge unit in the Australian government. And, uh, she mentioned it like as a, just as an example of the kind of thing they did there, that they were doing something on. 

Um, uh, I think in that case, they, the study's [01:10:00] probably out by now actually. I think they, they, they basically, you know, they know how many antibiotics each doctor's. So they just sent a letter out to the, to the main, the people who really overprescribed and said like, Hey, there are, you know, probably there are many good reasons why you might overprescribe red, but, uh, just to let you know, by the way you are one of the people who's really driving this, or who's maybe not, they didn't use that word, but 

Eva Krockow: Yeah. 

Benjamin James Kuper-Smith: exactly. 

And I think they said that work quite well. Is there lots of stuff like that being done in all sorts of countries or. 

Eva Krockow: that, that, um, study, I think, has been done in a sort of different variations and in different context, I definitely know of a couple of UK studies that have sort of replicated that finding. So nudging can be an effective way, I guess. Um, it's sometimes around the sustainability of those nudges. So, you know, once you stop the intervention is it's still going to, to show, to prove effective afterwards. 

And I guess certain long term changes maybe are hard to address with not just because they, they really sort of, um, [01:11:00] boil down to very ingrained, um, yeah. Ingrained types of behavior that maybe are to simply not that you can't rectify entirely with, not just which in the end of the day, you know, obviously there are changes to environment they're not, um, obligatory in a way or man mandating any type of behavior, but in the way, they're obviously small changes to the environment. 

I'm not sure. Not just alone will be able to solve the problem. I think they can be part of the puzzle. And again, this is probably where, where it comes back to that sort of multi multi-prong. I think that's all they sometimes call it, you know, we have to go at it lots of different ways, not just can be part of it, but I don't think they're gonna save the issue entirely. 

Benjamin James Kuper-Smith: Yeah. I mean, as you said, if, if people were just getting infected all the time, what are you gonna do? Just let them die. it doesn't seem like a good solution either. 

Eva Krockow: Yeah. And obviously there's this another thing that, you know, if you compare different prescribers, it actually does. Um, there is a case that, um, the, the kind of caseload differs across different GP practices, for example. So in certain [01:12:00] areas you have a higher caseload with people with infections. So prescribing will have to be higher and just generally punishing everybody for high prescribing levels. 

Can't also be the, the way forward because often there's actually a real need or a real reason for it. 

Benjamin James Kuper-Smith: Yeah. And I guess that's part of why it's such a complicated problem because it's not just, yeah. It's not just people being lazy or, 

Eva Krockow: There's so many different aspects and then yeah. And different dimensions to it. I think that makes it truly fascinating. 

Benjamin James Kuper-Smith: well, I guess, um, If you can talk about it for hours, we do. You don't have the time today to do it. So, 

Eva Krockow: that. 

Benjamin James Kuper-Smith: yeah. Um, 

Eva Krockow: a while. 

Benjamin James Kuper-Smith: okay. Is there, is there anything else you wanna add? 

Eva Krockow: No, I really enjoyed the conversation, but yeah, you you're right. I mean, I could go on for hours, but, um, I'm not sure that will benefit the listeners necessarily. I think what I wanted to bring across [01:13:00] is that it really is a, a really, um, Complex field of research and that we as behavioral scientists have a really important role to play, which shouldn't be overlooked and more people should do it. no more people should get involved in this and, and realize that an resistance is a really important issue that I think sometimes is being overlooked compared to other issues such as climate change and, uh, maybe biodiversity and so on. 

Obviously those are important issues too. I just feel like, um, yeah, it's being overlooked and simply because it is not a very visible problem and it is a very abstract com problem and some something that is hard to understand, and you probably need a bit of scientific knowledge for it. Um, that means that we are not addressing it to the same extent that maybe other problems are being addressed.

How Eva ended up studying psychology in Leicester
Before her PhD, Eva worked in international relations
The Centipede Game/Eva's PhD work
What is 'antimicrobial resistance' and why is it a problem?
The social dilemma of antimicrobial resistance
The benefits of qualitative studies
What can we do about antimicrobial resistance?