The #DukeEBM sort-of almost experiment

March 16, 2014

On Friday, March 7 I ran something of an experiment in crowdsourcing information via social media.  At that time I was attending an evidence-based medicine (EBM) conference at Duke University, and during Friday’s closing session I was asked if I would discuss how we can use Twitter as a way to share and discuss EBM resources and information.

Two of the examples I gave were pretty straightforward.  The first example was showing that Twitter can reach broad audiences and share information outwards towards those audiences.  The second example was a discussion of TweetChats, including the #MedEd tweet chat and the BMJ Evidence-Based Nursing Twitter journal club.

The third example was a sort-of almost experiment.  Just about 12:30 pm, I posted this post on this blog.  At 1 pm I posted these tweets:

Within a few minutes, I began to receive responses to these posts.  These responses included:

 

 

 

 

 

 

Within these responses were actionable, easy-to-use, up-to-date evidence-based recommendations for care.  This was not truly an experiment: @btuttle knew that I was going to run this test, but did not know the precise time or content of the request, and I did mention the #DukeEBM tag during the #MedEd chat: folks were aware that this test was going to happen, but did not know the specifics.

Overall, I think we proved the point: the Twitter community can and will respond effectively when we ask for help.  I think we also showed that these responses can help advance the cause of evidence-based medicine and improve healthcare for all our patients.


Can social media help crowdsource evidence-based medicine?

March 6, 2014

I am going to use this blog post for an experiment.  I am currently attending an evidence-based medicine (EBM) conference at Duke University.  This conference is excellent, and I heartily recommend it for anyone interested in better understanding EBM and in being a more effective teacher of EBM.  (This is not a paid ad–they don’t know I’ve written this; it really just is a great conference!)

That, however, is something of an aside.

I am writing this blog post as part of an experiment I hope to run during tomorrow’s closing session.  We will be discussing new and interesting ways to work with EBM, and will be introducing participants to new EBM ideas.

The experiment, then, will be for me to tweet out a request for help and see how quickly and how well Twitter can respond.  I will share the results with those attending the conference.

If you respond, please use the following hashtag — #DukeEBM — and use S1 or S2 according to which scenario you are responding.

S1: You are a family physician working in a small rural emergency room.  An 18 year-old male patient presents in status asthmaticus.  He is tachypneic, and does not respond to 3 combined albuterol/ipratropium nebulizer treatments or to a dose of IV corticosteroids.  He is getting worse, and you do not know what other treatment options are available.  You remember hearing that magnesium might help asthma, but you do not know if it will help.  You do not have a medical librarian handy, and so you turn to Twitter for help: “Can anyone tell me if magnesium has good evidence recommending its use in patients with severe asthma?” #DukeEBM

S2: You just returned from a crackerjack EBM conference at a major research and medical university.  Your sponsoring institution is very excited to hear about what new and wonderful information and insights you have brought back to share.  As you are finishing morning clinic 30 minutes before the weekly noon conference, you get a call reporting that the planned speaker has cancelled and you are needed to step in!  The schedulers feel you will cover nicely, since thanks to the EBM conference you undoubtedly can discuss the Newest and Best evidence on anything…so why not COPD?  You panic, and with 3 patients left to see you have no time to search for anything!  In a moment of desperate hope, you tweet “Re: best evidence-based treatments for COPD–can anyone lead me to best evidence-based guidelines?” #DukeEBM

We shall see what happens…


VCU Internal Medicine Grand Rounds on Social Media and Healthcare

February 24, 2013

At my institution, I am one of the few physicians that I know that uses social media regularly and readily.

Last week, I was offered a chance to discuss social media and healthcare at the Virginia Commonwealth University’s Department of Internal Medicine Grand Rounds.  I hope to be able to find a recording, but for now I provide the presentation’s PowerPoint in case you would like to review it:


Family medicine should be a prominent voice in social media

July 16, 2012

Initially posted on the Society of Teachers of Family Medicine blog, July 16 2012.

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In this post, I described why I think physicians benefit from being active in social media.  The combined benefits of enhanced partnerships and new connections, keeping up to date with recent clinical and health policy information, and expanding one’s understanding of healthcare from the perspective of patients and other health care providers are valuable outcomes that all physicians should value.  After all, why do we read journals, attend CME, watch webinars and listen to conference calls?  To keep our clinical knowledge up to date in order to provide the best care for our patients and to learn from each others’ experiences.  Active participation in social media can provide those same benefits.

Over the last couple of years, I have seen more and more family physicians becoming active on social media, especially on Twitter.  I have been trying to keep a list of all the FPs (and GPs) I have encountered on Twitter, though I know that this must be incomplete.  A quick scan of the list, however, shows the breadth of perspectives and opinions held by family physicians, and gives insight into the challenges and the rewards of being a family doctor.

Many family medicine doctors on Twitter use the #FMRevolution hashtag as a way to organize and share ideas.  I believe that family medicine can, and should, be even more active on social media.  In fact, I believe that family medicine should be the prominent medical specialty in social media and especially on Twitter.  Here are the reasons that I believe should impel more family medicine physicians to be active in these settings:

  • Family medicine believes in empowering our patients to take an active role in their care.  Social media is a prime venue for patients who are seeking to learn from each other and share experiences.  The e-patient movement makes active use of social media to inform themselves and each other about health, wellness, and specific illnesses.  Physicians are all-too-rarely part of that discussion.  With the breadth of knowledge family physicians have, we can be an active part of these discussions, and we can help ensure patients have accurate and reliable information.  Family medicine’s bio-psycho-social approach to care, which enables us to provide capable and effective care for patients with chronic illness, would also be valuable in discussions with engaged and empowered patients who are seeking to improve their own health statuses.
  • Family medicine still suffers from a lack of understanding of what it entails.  As noted in this recent post, primary care and family medicine are not usually given starring roles in the media, and are often confronted with the argument that the role of family physicians can be easily assumed by NPs and PAs.  By talking about our careers, our practices and (within the bounds of patient privacy and confidentiality) our patients’–their illnesses, struggles, and victories–we can control the message and we can show the public what it means to be a family medicine physician.
  • Family physicians are taught to educate and inform patients, and to be a resource to patients who are seeking information about their health.  The Pew Internet Project has noted that, even if they would not necessarily consider themselves e-patients, large numbers of Americans are looking for health information online and are using peer-to-peer connections to find this information.  If our patients are already using social media, then why aren’t we?  Given family medicine’s whole-person orientation and patient-centered approach to care, we should strive to meet our patients where they are.  Increasingly, they will be online.
  • For many years, it has been difficult to recruit US medical students into family medicine.  Now that more and more medical students are using social media for their own purposes, we could act as virtual role models and mentors.  If there is a robust and vibrant family medicine community online, if we discuss what we love about being family physicians, we might encourage medical students (and premedical students) to look at a career in family medicine.
  • Family medicine can be a voice of advocacy online.  As seen in Mike Sevilla’s #SaveGME campaign, when family docs organize we can have a notable reach.  The #SaveGME initiative was a short-notice, one-time effort to discuss the importance of protecting GME funding, but even with this limited preparation the group was able to reach tens of thousands of people.  Imagine if all family physicians on social media organized to advocate on key positions: I suspect we could reach hundreds of thousands of people.
  • Finally, family medicine should be the most prominent voice on social media because we represent one of the largest medical specialties in the United States.  I think there are more members of the American College of Physicians (ACP) than in the American Academy of Family Physicians (AAFP), but this is deceptive: many of the ACP’s members are sub-specialty physicians (Cardiology, Pulmonary/Critical Care, etc) who do not provide full-service primary care.  The American Academy of Pediatrics (AAP) lists approximately 60% of the AAFP’s membership.  There are more primary care physicians in family medicine than in any other specialty…and we should be willing to use that fact to ensure that our voices are heard loud and clear.

Family medicine’s leadership has already understood the importance of strong family medicine voices on social media.  The AAFP’s President has a Twitter account, the AAFP Twitter account is updated regularly, various AAFP board members are on Twitter (Reid Blackwelder being the most active), and the STFM Twitter account is interactive and valuable.  Other family medicine physicians should follow these leads: with increased involvement, family medicine’s voice should be at the center of healthcare discussions on social media.


Balancing Social with Serious: One Doctor’s Prescription to Avoid Overload​

July 11, 2012

This post was originally published on the Albert Einstein College of Medicine Blog, July 10 2012.

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In a previous post, I made an argument as to why physicians should be involved in social media—especially on Twitter.  The purpose of this post is to describe how I use social media as a busy clinician and teacher of family medicine to keep up to date with clinical and policy information and also how I find the time to use social media. Yes, social media can fit into a busy schedule.

One of the most daunting challenges facing any newcomer to social media is the volume and scope of information that is available.  Once one starts following other social media accounts, the incoming “stream” of information can quickly become overwhelming. A number of social media participants have likened it to drinking from a fire hose.

In many cases, these streams of information are also not uniformly useful: friends’ updates may be personally important, but can make it harder to find relevant clinical or policy information.  It can also become quickly apparent that trying to keep up with every update on Twitter or Facebook is an exercise in futility and will take up the better part of your life.

Here are some tips that I have found useful:

  • Stop trying to read every update.  Early on, when I was new on Twitter, I would try to read every single update posted and visible in my timeline.  This took a ridiculous amount of time.  Instead, I have come to understand that I cannot read every update.  Instead, when I log into my accounts, I’ll glance at what updates are there and look back a bit at previous updates.  I trust that anything that is really important will be shared or commented upon more than once, and I have come to appreciate the randomness and serendipity associated with dipping my toe in the stream every now and then.
  • Organize your incoming information: this is one of the most valuable tricks that I have found.  Instead of trying to search my overall Twitter feed (I follow nearly 1,500) accounts, I have created lists that allow me to focus on certain themes.  I have a list for updates regarding health policy, clinical updates, family medicine-specific accounts, people in Richmond, etc.  Perhaps the most useful is the list I’ve titled “essentials”: this list includes accounts that have an especially high value for me whether it is because of the quality of material they share, the topics in which they are interested, etc.  When I have only a short window of time, I can skim the essentials list and get high quality information in short order.  Given that I use social media as myself and as administrator for a few organizational accounts, this list lets me find information I can share from various accounts.
  • Each social media user has different times of day when they might review their accounts: over breakfast, at lunch, etc.  However, you can make use of “interstitial time” (credit to Paul Tatum).  If you have a computer or mobile device available, you can glance at your stream during the time that you’re waiting for the nurses to room a patient, or if a patient no-shows.  These short windows of time can add up.
  • Look into using a third-party Twitter client, such as TweetDeck or HootSuite.   Twitter clients allow you to better organize the incoming information, and let you see multiple lists simultaneously.  If you are sharing information, Twitter clients also allow you to share on different platforms (Twitter, Facebook) and via different accounts.  This is a tremendous time-saver.  I am not beholden to any particular client: I use TweetDeck on my laptop, HootSuite on my mobile devices, as it seems to be a better fit for them.
  • Leverage your e-mail newsletters.  If you subscribe to any e-mail newsletters, you can use them to find resources that you can then share to your account’s followers.  For example, the American Academy of Pediatrics Smart Brief includes short capsules of useful information.  You can read the capsules, click to read the full article, and then share that directly to your social media accounts.  This prevents you from duplicating work, and allows others to see information you found to be relevant.  You can do the same with Physicians First Watch, and numerous other sources.
  • Finally, if you do not have much time to be on social media, look for relevant Tweetchats.  These live online conversations are identified by a “hashtag” (i.e. #hcsm stands for healthcare communications and social media ; #MedEd represents medical education , etc.—find a full listing here), scheduled at a pre-set time and day, and bring together a number of individuals and organizations with shared interests.  This can be an efficient way to make new connections, and to share information that can benefit the community of users.

In summary, do not be afraid that being on social media will inundate you with useless information and eat up any and all free time.  There are ways to compress and increase the efficiency of your social media use to ensure that you find what you want to find, share what you think is relevant, and make meaningful connections with other users.


What are the ethics of crowdsourcing a diagnosis?

July 3, 2012

About a month ago, I received a request from one of my practice partners.  They are working with a patient with a number of chronic, hard-to-treat medical illnesses that may or may not be part of a single syndrome or underlying problem.  Despite the fact that this physician is an excellent clinician, they have struggled to put the pieces together and are worried that they are missing something.

The e-mail they sent me reads “i have a patient with an odd constellation of chronic medical problems…it seems to me something might tie these together…i mentioned to the patient the crowdsourcing idea on twitter and he was open to trying this”

I have spoken with this physician, but I have not spoken personally with the patient yet.  I have not taken any steps to crowdsource this patient’s illness because I am honestly not sure how best to do it…or even if itshould be done.

So: I would like to crowdsource the ethics of crowdsourcing.  I am hoping to hear from other physicians, but especially from patients and patient advocates who have faced challenging illnesses and diagnoses.

  • Is it appropriate (with a patient’s permission, of course) to post a patient’s medical history in a public forum as a way to consider and evaluate possible diagnoses?
  • If so, what sort of permission is necessary?  Is there some sort of consent form that one can use to ensure that patients understand what it means to have their medical history posted on social media?  If a patient’s symptoms are unique enough, then they can presumably be identified by a reader, so how can this information be posted (or what sort of waiver/consent is needed) to ensure that HIPAA is not violated?
  • I would presume that making the information visible and accessible to the patient would be the best approach–for example, posting as a blog update that they can review and upon which they can comment even during the discussion among physicians.
  • How much do we need to vet this idea/process–if it goes forward–with our health system’s legal department?

I think that there could be great value in using social media as the world’s largest “curbside consult” in which we ask peers to provide suggestions and insight but the primary physician retains sole responsibility to determine treatment plans with their patient.  In essence, the crowdsourcing would be like an enormous brainstorming session to help come up with ideas that the primary physician might have overlooked or failed to consider.

Please send me your thoughts–feel free to comment below.  This feels like an awfully large step, and one that I do not want to take into thin air.

 


An Update Regarding this Blog

March 4, 2012

I wanted to take an editorial prerogative for a moment to comment on the recent action (or lack thereof) on the blog.

The three of us contributing to the blog (myself, Carmen Gonzalez, and Mark Dimor) have all been busy working on a number of other projects, with the OccupyHealthcare blog project at the top of the list.  However, we’ve just also been busy keeping up with life and new obligations.

We will still post and update the blog, but it will happen less frequently than before.

Thanks for keeping an eye on this space.


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 should physicians behave on social media?

December 20, 2011

Last week, Dr. Bryan Vartabedian (on Twitter as @Doctor_V) posted to his blog the narrative of a Grand Rounds presentation he gave in which he focused on the risks and benefits of physicians’ use of social media.

The post is long, but provides an overview of Dr. V’s approach to social media.  If you review his blog, you will see that this post (and the related presentation) neatly summarizes what Dr. V recommends as best practices to using social media.  I think it is a good read…but I do not agree entirely with his recommendations and conclusions.

I think it is easiest to start with the areas where I see that we are on common ground:

  • I agree that medical care in the future will be a very different culture than it has been in the past.  Technology and patient empowerment have already changed the way we practice, and will continue to do so.  The e-patient movement and the interconnectedness allowed by social media will further encourage patients to find out about their own illnesses, research treatment options, and discuss these issues with their physicians in different ways than has been the case up until now.  Patients are already changing the nature of this dialogue, and health care will need to adapt accordingly.
  • I also agree that the nature of social networks–varied sources of information, numerous perspectives, and various analyses–have changed the nature of how we receive information.  Many of us can recall recent major news stories that we first heard through social networks (Osama bin Laden’s death? Congressional budget deals adverting a shutdown?  Kim Jong-Il’s death?), both on the local and the national levels.  I learn about many developments in healthcare reform and clinical practice by following certain key accounts on Twitter: I see this information sooner than I would if I waited for traditional media or (gasp!) the evening news.  There is tremendous value to be found in using social media as a principle source of information.
  • Those doctors actively engaging in social media are still the minority.  This is something that needs to change–as noted above, patients are already looking for information on the internet.  If physicians are not there, then we are missing out on being a part of this discussion.
  • Finally, I agree that we must protect patient confidentiality and patient information–period.  I do not post/tweet about patients.  Period.  When I speak about “patients” (as I sometimes do on my personal blog) I speak in the aggregate, not as individuals.  Unless one has specific and direct permission to share an individual’s story, then it should not be shared.  I also agree that there is no acceptable way to practice medicine in any way on Twitter or via other social media.  Physicians can provide general information and/or point patients toward publicly-available resources (such as FamilyDoctor.org, or the Mayo Clinic patient information website), but we cannot and must not provide actual medical care via social media.

I disagree with Dr. V on some of his recommendations for how best physicians can properly use social media, though.  It might be that we see these issues from slightly different perspectives or through slightly different-colored lenses, but I think there is value in exploring the differences:

  • The largest difference might be around our views of professionalism, and how these views might influence how we interact on social media.  Dr. V notes, and I agree, that separating one’s professional and personal presences online is an incredibly difficult task.  However, the sense I get from his blog post is that he favors restraint and that he favors limiting one’s online presence to that that would be in line with the most professional setting.  In other words, behave online at all times as you would behave in clinic.  This is doubtlessly a safe approach, but where does it leave our personal voices?  Can I discuss politics?  I wouldn’t do that with my patients, but can I do it here?  Can I post silly pictures of me at a gathering of friends, wearing a silly fake mustache and having a beer?  No doubt many of those following my account don’t really care about that photo, one way or the other…but is it unprofessional?  I wouldn’t post it in my office, but is it OK to share here?  Does this violate my professional role as a physician?  I use my accounts to discuss personal interests, not just medical issues.  Can I personalize my account–my voice–without being seen as unprofessional?  Does it make me less professional, or more human?  If I identify myself as both an individual and as a physician, is it wrong to express both aspects of who I am?
  • Dr. V and I also differ on the role/value of anonymity online.  I would agree with him that we should not presume anonymity will actually protect us or our patients: I figure most anyone’s online pseudonym can be broken by someone smart enough and with enough time.  So I–personally–do not see the value in anonymity.  However, I do think there can be value in anonymity in certain cases.  What if a physician is criticizing the practices of a major insurer, or their employer?  What if someone wishes to discuss a sensitive personal issue without self-disclosing?  Even if this cloak of secrecy is not foolproof, it can provide a safer space for such discussions.  I think the content of an account will dictate whether or not it is trusted or considered valuable–not just whether or not it is anonymous.  I choose not to be anonymous, but that is my choice.  I can choose to ignore anonymous accounts…and others can do the same.  I do not think this is a one-size-fits-all situation, and I think individual users should have options as to how they can best and most productively engage.
  • I have even suggested (in this post) that there can be value in anonymous, “unprofessional” conduct.  Whistle-blowers, agitators, and critics may all have important perspectives and contributions to an issue under discussion, or might call attention to larger problems.  Raising these issues might strike some as unprofessional…raising the question of who will decide professional vs. unprofessional conduct?

This is not to say that anonymity protects anyone’s privacy–it is a cloak, but one that can be removed with enough effort.  Anyone posting controversial or questionable material online needs to be aware of the potential consequences.  As Dr. V notes, doctors have lost malpractice suits, their jobs, and their licenses for posting material online that was sufficiently controversial or that violated patient privacy.  This risk is real, as is the risk that one could face sanctions from professional organizations.  The American Medical Association’s social media guidelines advise that, “[w]hen physicians see content posted by colleagues that appears unprofessional they have a responsibility to bring that content to the attention of the individual, so that he or she can remove it and/or take other appropriate actions.  If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.”  The guidelines do not specify who “appropriate authorities” would be, but it could include hospital authorities, employers, or state-level Boards of Medicine.  There is need for physicians to be careful when interacting online, but this care is required whether one is posting anonymously or under their own name.

Take the @BurbDoc account, for example.  (Warning: this account is often not safe for work.)  BurbDoc posts anonymously, and criticizes much of what he (she?) sees in medicine–often with liberal use of profanity.  Many (most?) would consider this account unprofessional, and many are likely not fond if its existence.  My perspective on the account is that, although I do not personally appreciate everything that the account posts, BurbDoc has the right to post this material anonymously.  From following and interacting with the account, I feel that BurbDoc’s motivation to use social media comes from the right place: to expose inefficiencies and hypocrisy in medicine–especially on the part of insurance companies–of which patients might not be aware, and to discuss what they believe to be patients’ complicity in our dysfunctional system.  Personally, I could do without some of the language, and as a result I rarely share BurbDoc’s posts even if I agree with the sentiment.  But this is BurbDoc’s decision and his choice: he has chosen to use this approach, and he must come to terms with the fact that this choice might limit his audience and could create problems for him down the road.  Physicians who do not approve of this choice can simply choose to ignore the account; after all, BurbDoc does not claim to speak on behalf of anyone else.

I would argue that the best approach is more fundamental than the issue of whether or not we should be anonymous or whose definition of professionalism is most valid.  I think the best approach is this:

  • Be nice.  Don’t be a bully, don’t be scornful, don’t be rude.  Be engaging and respectful.
  • Be helpful.  When you have useful information or valuable insight, don’t be afraid to offer help or be a resource to the community.
  • Be careful.  Remember, as Dr. V has said, that this is all happening in public.  Don’t say anything you would be afraid for others to see…and stand behind what you say.
  • Be engaged.  Whatever your purpose for getting involved in social media, you should be here because you are looking to connect with others.  That means that you need to actually engage and connect with them.  Having an account that doesn’t interact with others has little value in my opinion.

I strongly agree with Dr. V’s call for physicians to become active in social media, both in this post in in this earlier post.  I have found there to be enormous value form my social media participation, and I do my best to add value.  But, I do not think that we need to separate or silence our individual voices to do this.  I think we can help each other be careful, and helping newcomers (or perceived outliers) stay out of trouble.  We’re all in this together, for our patients’ health and wellness.  But we are all human, and I think it is fair if our social media presence reflects that.


What will it take to get physicians using social media in healthcare?

December 6, 2011

(This blog was originally published on the Mayo Clinic Center for Social Media blog, 12/6/11)

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Medical education is based on the foundation of science.  Undergraduate premedical majors are required to take a number of science courses in order to be considered qualified applicants for medical school.  Once in medical school, students are exposed through all four years to scientific research: we are taught about seminal basic science experiments that helped establish the biochemical mechanisms, and were are taught about the process of clinical research and how the scientific method has helped develop current medical treatments.

At the same time, as we are steeped in the tradition of science, we do not always do a good job of following the scientific method.  One of the greatest examples is the continued practice of providing antibiotic prescriptions for viral illnesses, despite the clear knowledge that antibiotics will not affect how quickly patients improve.  Even though we are trained to approach questions from the scientific perspective, human nature can impact how reliably we follow evidence-based, scientifically-grounded recommendations.  Often time, the rationales given include either the fact that one might be uncertain about the nature of the illness being treated and/or the claim that patients expect antibiotics and that it is easier (and more customer-friendly) to just give patients what they expect as opposed to standing by the evidence.

The truth is that medical practice is a combination of science and human nature.  Hopefully we lean towards the evidence more often than not, but you cannot deny the human part of the process.  Add in the fact that many physicians are employers, small business owners, and breadwinners, and the balance can become more complicted.  As a result, many of the decisions we make are based on considerations from both sides of the issue.

I believe that this will also be true of efforts that attempt to engage physicians in communicating via social media.  To date, efforts to encourage physicians to engage in social media because it is interesting, fun, etc do not seem to have much traction.  I propose that it will require showing that social media has measurable benefits to patient care (scientific argument) and that it improves practice efficiency and/or practice income (human nature argument) in order to increase physician engagement.

  • If research programs that are well-designed, double-blinded studies investigate whether various approaches to social media engagement improve patient outcomes of some sort (disease-oriented outcomes like blood pressure or diabetes control, patient-oriented outcomes such as a global measurement of wellness) and show a beneficial result, then we will have scientifically-based evidence showing that social media can improve healthcare.  This will appeal to our self-perception as scientists.
  • At the same time, if it can be demonstrated that using social media improves how medical practices work (fewer calls back, more new patients, more satisfied patients, etc) and if they can increase the efficiency of medical practices (thus reducing costs), then we will have information that impacts the human nature side of the decision: physicians will have more profitable practices, or will be able to hire more staff, or will be able to offer additional services to their patients.  This appeals to the business/professional side of a physician’s worldview.

Needless to say, these two goals are not mutually exclusive.  Often times, interventions that improve medical outcomes also improve practice efficiency…and could become more important as medicine moves towards paying for quality of care as opposed to intensity or quantity of care.  But I think it will take arguments that satisfy our scientific training as well as business needs that will increase physicians’ involvement in social media.


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