No promises, but…

September 7, 2015

As I try to work back on getting my own blog up and running–hopefully with useful/interesting stuff–I have not lost track of this poor, lonely website. I will try and update here when I can, though it is a bit of a lesser priority.

I wanted to post this update here because there are a few things in the works that might allow me to re-engage more reliably here:

  1. I have met a researcher who is interested in assessing the use and impact of social media in healthcare. Having another more-experienced and active perspective may allow this site to gather a bit more steam–either because I will be more regularly engaged in these conversations, and/or because maybe I can convince her to write, some, too.
  2. I am part of a team finishing analysis and review of an AHRQ-funded project to leverage social media as a way to encourage physician use of non-branded, evidence-based CME.
  3. There is a developing project to look at how to actively leverage and use social media at the practice level to help engage patients, and look for any meaningful changes in patient’s health status, empowerment, etc.

So: no promises, but hopefully there will be more life here heading forward.

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.


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.


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.


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.

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.

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