Why be involved in social media?

June 18, 2012

When I speak with fellow physicians about my social media activity (blogging on this site and on my personal blog, Twitter, Tumblr, etc), I am often met with skepticism.  Why should we bother?  What is the point?  What value is there in adding another task to one’s busy day?

These questions are even more relevant if considered in the context of social media use outside the US–especially in developing nations and other parts of the world where internet access is not as easily available as it is here.  The #hcsmLA Twitter conversation (healthcare communications and social media in Latin America) involves a number of participants in Latin America, and issues of technology access and the digital divide (as well as the more hierarchical and paternalistic doctor/patient relationship often seen in Latin America) have been discussed in this context.  Although in the US we do not face the same barriers as in much of Latin America, there are benefits from social media that apply in both settings.

Here are some suggested reasons why physicians should be engaged on social media–even if technology is not always accessible or if the prevailing culture does not encourage engaged, informed, active patients:

  • Partnerships and collaborations: by engaging in social media, physicians can meet like-minded colleagues as well as interested (and interesting) peers in other disciplines including research, public health, and health policy.  By interacting with one another via social media, people can get a sense for where affinities and mutual interests lie.  This can then lead to further in-depth discussions that can lead to partnerships and collaborations on research projects, publications, health outreach projects, etc.  Over time, these collaborators and partners may help develop new ideas, suggest new ideas for research or practice, or encourage one’s steps in new directions.  Some of these collaborators may eventually become friends.
  • Speak the truth: there is a great deal of bad medical information out there.  If one searches a medical topic, a number of sponsored results will top the list of the search results.  Many of these sponsored links will be flawed or inaccurate.  Physicians can be a resource to their patients and their communities by bringing their expertise and experience to bear on healthcare issues, and by helping point people toward accurate and reliable resources.  Blogging or participating in TweetChats can also help ensure that accurate information is available online.
  • Stay up to date: by following trusted medical resources, physicians can keep up to date on topics including clinical practice, basic science research, and healthcare policy.  A number of journals, such as the New England Journal of Medicine and JAMA regularly update their Twitter feeds with recent articles focused on clinical practice and biomedical science.  Physicians First Watch posts their daily updates about hot topics in clinical medicine.  The Commonwealth Fund and the Kaiser Family Foundation regularly post updates focused on healthcare policy.  While these examples are focused on the US, other countries likely have similar useful resources.  By finding and following trusted resources, physicians will not have to go out to find information–the information is delivered directly to their social media accounts.  This simplifies the process of trying to keep up to date with a fast-moving biomedical world.
  • Broaden your horizons: conversations on social media and healthcare involve physicians, but also a number of other participants: patients, nurses, pharmacists, medical students, health policy folks, researchers, etc.  Interacting on social media allows one to learn about others’ perspectives on key issues, and can help increase one’s understanding of the issues at hand.  Especially as we promote more and more team-based care, it is important to be open to others’ approaches to care.  Expansive and open social media conversations help facilitate this learning and awareness.

I believe that one of the goals of social media engagement is to help patients become better informed, better able to participate in their care, and better able to team with their healthcare providers to develop plans of care that meet their individual needs. Having said that, even if physicians are not ready to take those steps, there are very tangible benefits from physicians’ activity in social media. I think these benefits are even more likely to be relevant in parts of the world where patients might have less access to social media, and physicians and other healthcare workers might play a larger role in the conversation. The benefits listed above would be available to any clinician who is active in social media, even if they are widely dispersed or digitally isolated in areas without much social media penetrance.

Networking, collaborations, keeping current with relevant information, and expanding one’s understanding of key issues will benefit all physicians…and their patients.


Guiding Principles for Physician Use of Social Media

March 13, 2012

“Art is not a mirror held up to reality but a hammer with which to shape it.”  — Bertolt Brecht

In two prior posts, I have discussed the issue of professionalism and social media.  These two posts can be found here (professionalism) and here (physician online behavior).  I have also taken issue with medical organizations’ extant social media guidelines.  In some of these posts’ comments, it has been noted that there is no corresponding guideline or document that expressly discusses appropriate, positive use of social media in health care communications.

As a result, I am taking the liberty of making some suggestions as to what I think are important guiding principles for effective physician use of social media.  This will include some cautions that I feel are especially useful, but I would also like to explain how and why I think physicians can use social media in positive and useful ways.

Part of this task includes defining physician professionalism.  There are various definitions (click here for the first defintion, click here for the second definition, and click here for the third definition), but they share the common themes of respect for patients’ autonomy, individualism, and privacy; response to and concern for societal needs; embodiment of humanistic values of altruism, empathy, compassion, honesty, and integrity; focus on the scientific basis of medical knowledge; accountability to peers; and commitment to professional development and competence

With those guiding principles, here are my suggestions for how physicians can effectively use social media:

  1. Do not discuss patient’s illnesses, medical conditions, or personal information online.  Unless you have a patient’s express permission to share their information, then do not discuss anything about them online.  The simple fact is that even if we believe we have made information anonymous, it is hard to do so completely (as this doctor discovered).  If a patient has given you their permission, make that clear in the post.  Otherwise, do not discuss real patients’ information via social media.  Rather than choosing to discuss a specific recent case that you might have seen, it would be better to offer a broader perspective or discussion on the issues at hand.  This is especially true in a smaller community, where even broad descriptions of patients and clinical situations might allow patients to be identified.
  2. Use social media to share information that promote quality health care and up-to-date medical information.  There is a wealth of information available on Twitter, for example, that provides current information regarding medical research and treatments.  The New England Journal of Medicine, the Journal of the American Medical Association, the American Academy of Family Physicians, the National Institutes of Health, and the Centers for Disease Control (among many, many others including individual medical specialty organizations and journals) all have accounts that provide regular updates with a focus on basic science and clinical care.  By following these accounts and sharing relevant and actionable information, we promote its dissemination.
  3. Address those societal needs that you think are most important, or that motivate you.  Social media use will undoubtedly be an added responsibility during your free time, and so using it to focus on issues that are relevant to you makes it easier to sustain the effort.  For example, I am a strong believer in the need to enhance our primary care workforce via family medicine and I support the Patient Protection and Affordable Care Act (PPACA) of 2010.  As a result, my Twitter feed focuses on these topics.  I share updates about how the PPACA will enhance patients’ access to health care and reform health insurance company practices, about the importance of family medicine (and primary care) and the need to reform our system to support and train more family physicians, etc.  Each of us will be motivated by our specific interests, but we should use social media as tool to call for necessary change to benefit society as a whole.
  4. Recognize that you represent your profession, and help others recognize that they do, too.  When someone views your social media posts, they will likely see the post through the lens of your profession.  If they see my posts, it might not be seen as “Mark Ryan thinks such-and-such” but rather “Dr. Mark Ryan thinks such-and-such.”  It might then be tempting to presume that others in the same profession feel the same.  So, take care not to post updates that would violate the definition of professionalism identified above.  If you see someone else posting updates that seem unprofessional, I think it is appropriate to connect with them and discuss this issue–not in a punitive way, but rather to help promote the proper use of social media tools.
  5. Promote the humanistic values identified as congruent with medical professionalism.  Be honest, forthright, helpful, and compassionate.  Offer help, answer questions, and suggest resources when you are able to do so.  Be open to contact from others, and participate in discussions when time allows.
  6. I do not think it is necessary to separate personal and professional content online.  My social media presence is a reflection of who I am, and expresses my beliefs and my priorities.  These are what make me the person and the physician that I am, that define the societal needs that I seek to address, and determine my perspective on any number of issues.  To be personal, my social media presence must reflect my beliefs.  However, I do use a disclaimer to note that my opinions are mine alone (not those of my employer), and I understand that there are those who will disagree with me.  Social media is an opt-in phenomenon: if someone wants to read my opinions, they will have to come find my accounts…and they can choose to ignore me and any of my posts.
  7. I do not think we must keep our social media content locked behind tight privacy restrictions.  My accounts’ privacy settings depend on my anticipated use: I keep my Twitter and Tumbr accounts public because I intend for the information to be public.  I keep my Facebook account private because I do not intend to use it for public information, but rather to keep up with friends and family.
  8. Do not practice medicine via social media.  It seems self-evident, but it is worth making clear.  I do not provide any individual, specific medial care or medical advice via social media.  The most I have done is to provide links to already-available online resources for people to review and to help them make their own decisions as to how to proceed with any given medical issue.  I do not knowingly interact with any patients on Twitter but, if I did, I would interact with them the same way I interact with anyone in a public setting.  I do not friend patients on Facebook because of how I choose to use Facebook
  9. Presume that everything said online can be found if someone looks hard enough, and is going to be available forever.  This might be an exaggeration, but it provides guidance when thinking about what information should be shared.  I assume that nothing is actually private, and so I do not post any information (even via direct messages) that I would be bothered if it were made public.  For the same reason, I choose not to use any anonymous accounts: I assume that someone out there could identify me if they tried hard enough.  This helps me edit what I put online and what stays in my head.

I hope that this post accomplishes its goal: to provide some suggestions and guidelines on how to use social media effectively and professionally as a physician.  Social media is not simply a way to reflect what is happening around us, but rather a way to play an active role in changing society for the better.

Please provide comments and suggestions below.


The FDA’s First Social Media Guideline: Off-Label Is On The Mark

January 5, 2012

The FDA has finally dipped its toes into the digital waters by providing its first draft guidance that implicates social media. Entitled, “Guidance for Industry Responding to Unsolicited Requests for Off-Label Information About Prescription Drugs and Medical Devices,” it advances the dos and don’ts on how to handle unsolicited requests for drug or device information that concerns unapproved uses. Written in fairly straight-forward terms, the guidance specifies what constitutes requests that are unsolicited from those that are, and the FDA provides concrete examples for helpful illustration. Throughout the guidance, it is clear that the FDA has thought seriously about the consequences of its advisories upon the pharmaceutical industry and has also secured the public’s safety by requiring answers that are truthful and balanced.

While many in the social media and healthcare community had hoped for grander offerings from the FDA,  they have tackled a clear danger. Besides, any action on social media for the FDA is a good thing, as much ambiguity still exists on what constitutes proper behavior by drug companies online. A bit of housekeeping for those unfamiliar with the FDA’s jargon: the term “off-label” refers to uses of a drug or medical device that is not sanctioned by the FDA. In the normal course of drug and medical device development, once the FDA approves such  items, they are approved for a particular indication. So if a drug is approved to treat headaches, for example, that means it is only approved for that use. Any other purpose would have to be separately studied through rigorous clinical trials to obtain approval.

Online chatter regarding drugs and devices sometimes includes references to uses that lie outside the official FDA sanction. Whether on a blog or a medical site, there are plenty of places to read someone’s opinion about how a given drug or device has helped them with some medical ailment which may not be a use listed on its official label. While doctors commonly prescribe approved drugs for uses other than their intended original purpose, no drug company can promote off-label uses.  The risk of someone using a drug or device for an off-label purpose discovered online could present a dangerous situation and has drawn the FDA’s attention to create its guidance. When a person requests information about an off-label use of a given drug or device, the manufacturer now has a set of directions on how to handle that matter.

When does the guidance kick into play? If a person privately requests information about a drug or device directly from the manufacturer or if the request is publicly announced (online or at a public setting), then an “unsolicited request” has been made. The FDA broadly construes a public-generated request to include those, “directed to a firm specifically or posed to users of a discussion forum at large.” This grants pharmaceutical organizations a wide berth to weigh in even if the requester was chatting to others on an open forum.

By the way, if pharma companies receive solicited requests, then the companies are obligated to respond—this has always been the case. This includes situations where the drug/device company has invited patients to post YouTube videos on how they used a drug or device, which in turn triggered requests for information about off-label use or resulted in videos showcasing off-label use. The same is true if a drug company posts clinical study results that suggest off-label use of its product as being safe and effective which spurs questions  from the public regarding off-label uses. Basically, if the drug/device company incites or provokes questions about off-label use, then it must respond. In contrast, the new guidance pertains to unsolicited requests and gives drug/device manufacturers direction on handling these situations if they choose to respond.

The FDA has always granted drug makers the power to provide, “truthful, balanced, non-misleading, non-promotional, scientific or medical information that is responsive to the specific request,” concerning their products. Moreover, no matter how the request was made, publicly or privately, when pharmaceutical companies choose to respond to unsolicited requests, those responses must be made privately to the inquiring individual.

The FDA advises that when responding to an unsolicited private request, the pharmaceutical company should make sure the communication be privately sent to the person making the request and that it answer only the questions posed. So, if someone asked about an off-label use of product “x”, then the company should answer that without elaborating on other off-label topics regarding the product. The FDA goes so far as to encourage a narrower definition of the question even if it is broadly phrased. However, the FDA makes an exception when it comes to the risks posed by the product.  So, if a given product poses known or suspected risks that bear relevance to the person’s question, they must divulge that information. This is common sense that keeps the public safe and the drug companies honest.

The FDA requires that the, “Information distributed in response to an unsolicited request should be truthful, non-misleading, accurate, and balanced.” That means providing information that casts doubt on the safety and efficacy of an off-label use. Providing medical texts and scientific peer-reviewed journal reprints are advised so reliable information gets in the hands of the person seeking valid answers. The agency further instructs pharma companies to use a scientific tone and to avoid gimmicky promotional messaging. To ensure the last point is credibly undertaken, the FDA has advised that the responses, “should be generated by medical or scientific personnel independent from sales or marketing departments.” This is a brilliant stroke by the agency, though this could result in highly academic communications that are too obtuse to be understood by the lay public. Nevertheless, this is a move in the right direction that shields the public from slick marketing.

As part of any formal response, the FDA encourages the provision of the official label, a prominent statement that the off-label use is not approved, a clear statement for which uses the product is approved, safety information, and a list of references of all the information provided. Finally, the FDA advises that all responses be documented by noting the nature of the request, the contact information of the person seeking the information, what information was provided, and any follow-up inquiries or questions from the requester.

When a pharma company encounters questions regarding off-label use of its product online (as on public website or social media forum) it can choose to respond in the following manner:

  •  It can provide the firm’s contact information, inviting the requester to seek more information from their medical advisor, but cannot provide off-label information in that same public forum.
  • The contact information provided to the requester must be specific to that medical or scientific personnel (e.g. e-mail address, telephone number, facsimile).
  • Recordkeeping requirements described above also apply here.
  • When a pharmaceutical company chooses to respond to an online episode of an “unsolicited request,” that company representative must identify himself when providing the contact information.
  • These responses cannot be promotional in nature.
  • Direct links to the current FDA-required labeling should be provided, but no other links (e.g. product websites). The sites where FDA-required labeling is available cannot be promotional either, so you can’t have a URL that reads “www.TheCureForCancer.com”)

Taken altogether, the FDA has given a clearly defined set of actions on how to handle unsolicited off-label questions. This draft guidance was issued on December 27, 2011, so the public has 90 days within which to respond provide feedback to the FDA. So for now, this is merely suggestive, not mandatory, but has provided a transparent view of the agency’s direction.


How Twitter Enhanced My Conference Experience

December 3, 2011

Over time, this blog has been focused on when, how, and where social media (SocMed) could impact healthcare. THis time, I am writing a short post focused on another benefit that has arisen out of social media engagement.

I am currently in California, attending the Society of Teachers of Family Medicine (STFM)’s Practice on Conference Improvement. I don’t have any personal connections with this part of the state, and given the conference’s location in a tourist-focused area there is not much here for me to do outside the meeting. To be honest, I would never have come here if not for this conference. Normally, then, all I would have done would have been to attend the meeting sessions, and then spend a lot of time in my hotel room. I’m fairly bad at mingling, networking, and the like.

This time, though, I mentioned on Twitter that I was coming here. As a result of my ongoing conversations on Twitter–whether in the context of organized Twitter chats, or on the fly–folks in the area contacted me to meet up in real life.

Ben Miller (@miller7) and I co-presented a talk on SocMed at this meeting, so we met up on arrival. Of note, Ben and I met on Twitter, and our ongoing collaborations (talks, the OccupyHealthcare Project, etc) grew out of our SocMed connection…before we had ever met in person.

During the first day of the meeting we met Jay Lee (@FamilyDocWonk), someone we had both been in touch with for nearly a year online. Jay joined us later that night for a tweet-up with Gregg Masters (@2HealthGuru) and Fred Trotter (@FredTrotter) during which we spent a lot of time discussing the nature of the OccupyHealthcare movement…and brainstorming how each of us can contribute to the cause.

This morning, Jay met Ben and I again as we were joined by Mark Harmel (@MarkHarmel). Mark is a photographer and an MPH student, and we had an active discussion abthat opportunities to participate in healthcare reform and system redesign.

Ben, Jay and I went to lunch together, joined by faculty and residents from the residency program where Jay teaches and practices. From this meeting I might have found a resource to help identify physicians who can help in the international healthcare project I help lead.

Finally, tonight Ben and I are having dinner with Carmen Gonzalez (@crgonzalez). I have shared this blog with Carmen and Mark Dimor (@MarksPhone), and have not met either of them in person. I’ll finally remedy that…halfway.

Before I was involved in SocMed, this meeting would have been ho-hum…if I had come at all. Now, I can say that I have met new real-life friends, have strengthened ties with others, and have made connections and discussed new projects that will keep me busy–and thinking–for some time.

One of the criticisms of SocMed is the belief that connections made here are broad, but shallow. I would argue that the breadth of the connections we make via SocMed allows us to interact with people we would otherwise never meet, and that these interactions can develop into meaningful collaborations and friendships.


Is That An App Or A Medical Device In Your Pocket?

August 23, 2011

At a recent Twitter chat of the Health Care Communications & Social Media group ( see the August 21, 2011 chat ) , one of the questions considered by the group prompted a heated discussion over the province of  the U.S. Food and Drug Administration (“FDA”) to regulate phone/iPad applications. For the uninitiated, there have been a slew of new apps that have entered the market, some of them approximating medical devices, while others have merely added to the wellness and personal diary category.  The growing sophistication of the apps into the medical device arena has prompted the FDA to develop a draft guidance to provide oversight and regulatory clarity.

During the Twitter chat mentioned above, some individuals thought the FDA’s action was intrusive and would stifle innovation. Given the potential for economic benefit in the growing health care field, I doubt this concern holds too much water. The fundamental issue at play here is if the app itself is a medical device. In section IV of the draft guidance concerning the rule’s scope, the FDA states that this concerns mobile medical devices defined as those app which:

  • are used as an accessory to a regulated medical device; or
  • transform a mobile platform into a regulated medical device

This was also affirmed by the FDA during its July 19, 2011 Twitter chat on its new draft guidance:FDA mobile device definition

The FDA goes on to say what its rule does NOT cover. I am paraphrasing below, but if you read the scope itself , it provides good examples in defining these exclusions: 

  1. apps that are copies of medical books, texts, or teaching aids (e.g. Physician’s Desk Reference or flash cards)
  2. apps that only log, record, offer evaluations or suggestions on “maintaining general health or wellness”
  3. apps that automate general office operations (billing, inventory, appoitments, insurance transactions, etc.)
  4. apps that are general tools and NOT marketed for a particular medical condition (e.g. an audio recording or note taking pad)
  5. apps that serve as electronic health records or a personal health record system

 A lot of the hubbub during the Twitter chat concerned stifling innovation in this burgeoning space. However, what many in the group did not recognize is that we already rely on the FDA to regulate medical devices, so as technology changes and encompasses apps, so too must the FDA’s purview of these tools.  A cursory look at some apps makes the FDA’s interest valid:

Smartheart: This is being represented by the manufacturer (SHL Telemedicine) as a self-service heart monitor, and as the smallest ECG. It operates by performing an electrocardiogram and allows the user to send the reading to his doctor.

IBG Star Monitor App: This involves an iPhone, an attachable iBGStar device, and the iBGSTar Monitor App. When used in concert together, the system allows patients to test their blood sugar wherever they are, record notes and send the data to their doctors.

diabetes-meter-iphone-app

Fujifilm Synpase Mobility: This app allows doctors to view radiology films in 2D, 3D and to use MIP/MPR as in a clinical setting from Androids, iPhones, and iPads.

Reliance on any of these tools to diagnose or treat patients makes them clearly medical devices, and well within FDA’s control.  What is still up in the air are those “wellness” apps that happen to encroach into the clinical space and are used to diagnose and treat patients. I posed that question during the FDA’s July 19th chat on Twitter concerning their new draft guidance:

Question to FDA regarding pedometer as a clinical device

FDA says: We'll get back to you on the pdeomter question

I’m still waiting. And therein lies the ambiguity that will beset developers as they race to market. Will they have to submit their apps for approval as a medical device? For the wellness apps that could be used as clinical instruments, the guidelines might not be precise enough. In the example I was thinking of I imagined a pedometer as part of an obesity treatment (exercise aid) or as part of an obesity clinical study where exercise logging was a requirement or an outcome. Plus there’s the issue of the long slogging process of device approval, involving clinical trials. Granted the process is important to ensure safety, but I openly wondered if a shorter path is possible.

Question to FDA on shortening the clinical trial process for apps

I am still waiting on that too. While the FDA sorts all this out, you are invited to offer your remarks at the FDA’s website where it is gathering public comments. Join in to get the last word. By the way, the docket number for this is FDA-2011-D-0530-0002 and at Regulations.gov you can enter your comments electronically.

FDA invitation to 1.usa.gov/MobMed


Further thoughts on HCSM

August 23, 2011

This year I’ve been invited to give a few different presentations on healthcare communications and social media (HCSM).  A co-presenter at two of these talks, Dr. Felasfa Wodajo (one of the creators and editors of iMedicalApps.com), kindly offered me the opportunity to further develop some of these ideas and post them on his site.

The post will be going up in two parts.  The first post can be found here, and the second part can be read here.


More Thoughts on Physician Professionalism in Social Media

August 1, 2011

This morning, the Mayo Clinic Center for Social Media published a new blog post of mine.  This post is long, but attempts to wrestle in greater depth with the issues surrounding physician professionalism online.

I hope you will take the time to read it, and comment here (or there).


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