Wednesday, August 03, 2011

a more perfect union

I was working on my Grand Rounds (about the ever-scintillating topic of perioperative antibiosis--a topic that I personally find engaging and endlessly fascinating, mostly due to the influence of Drs. Garvey, Prince, Lowy et al., but I understand most people find...uh, pretty dry) when a couple of colleagues steered me instead towards the admittedly sexier topic of the role of social media in medicine.  It's a topic that other people have covered much more extensively, and I daresay with much more eloquence and expertise than I; though I've personally been writing online for coming up on eleven years, in some ways I feel like Willy Loman, who built his little house in the middle of a field and later found himself surrounded by skyscrapers.  I'm not an expert by any means, and I'm not a pundit, nor do I aim to be.  But do I have any opinions about the interface of social media with medicine?

Why yes, yes I do.

Let me say first that medicine, above all fields, is slow to adopt change.  Sure, medical technology is evolving rapidly, but the culture of medicine, the technological change within our own ranks, moves at a glacial speed compared with other industries.  See, for example, the excruciating pace with which we have moved to adopt electronic medical records.  No other field in which the essential importance of recorded orders or observations, and the critical nature of interpretation error would be so inextricably tied to the the ability (or, as I see every day, the utter inability) to legibly hand-write notes with paper and pen.  And don't even get me started on dictation.  Or pagers.  Who else in this day and age still carries a pager?  I could go on, but at this moment I am chained to my dictaphone, hand-writing a patient note with quill on parchment while working the butter churn with my feet.  Fresh butter in an hour, guys!

But the fact that medicine is slow to change does not mean that the rest of the world will follow suit.  As we all have seen, the evolution of technology and how we use it has progressed at a blistering pace since I started writing this online journal as a med student in 2000.  The year 2000 was before Friendster and MySpace--remember those?  It was before Facebook and Twitter.  It was before YouTube, Flickr, LinkedIn, and whatever other incorrectly punctuated, problematic vowel/consonant ratio site has evolved in the last decade.  It was before blogs.  Really, it wasn't that long ago, but the Internet was a very different place since then, and as both the Internet and the way we interface with it has evolved, the learning curve has been steep, particularly when it comes to the world's oldest profession (no, not prostitution) dealing with the world's newest media.

In many ways, medicine is like the military.  It is a combination of a hugely public and yet extremely private field, and both are intensely scrutinized and regulated.  So it is not surprising that medicine has been slow to adopt (or to even acknowledge) the Internet.  Sure, the medical world has long viewed the Internet as an incredible repository for information--even the most steadfast of medical Luddites will use PubMed and be the better for it--but when it comes to social media in medicine, I think I'm safe in saying that at best, most established doctors think: why bother? and at worst, think that the personal and professional risk of engaging in social media is well beyond whatever marginal benefit can derived from it.

Do doctors have to have a web presence in order to do their jobs?  No, of course not.  Having a blog does not help me take care of my patient with the ruptured abdominal aortic aneurysm.  Having a Twitter account does not help me intubate my patient with the critical airway.  In some ways, interaction over the Internet is utterly peripheral to my everyday life of taking care of patients and my family, and possibly a distraction from those essential tasks.  Medicine is about triage, and over the course of a busy day, with a lot of other pressing obligations, it's easy to look at something as seemingly frivolous as social media and think: it's not important.

But it is important.  Certainly it's important to patients, who by overwhelming majority, and for better or worse, look to the internet as a source of medical advice before seeing any of us.  It's important to hospitals and medical schools, who are finding out more and more how indispensable a strong web presence is from a business and marketing point of view.  And I'm willing to bet that young doctors-in-training, most of who are in that key 18 to 34 year-old demographic, think that social media is very, very important.  Look at this infographic from Mashable about how we interact with Facebook and tell me what you think.  You can decry it, you can shake your head in rue, but you have to at least acknowledge that this is the direction in which society is moving.  And then either bury your head in the sand and wish it away; or, as our training in medicine has taught us to do, you can observe and adapt your treatment plan.

Some medical institutions around the country have taken the stance that they will not allow their trainees to partake in social media at all.  And forgive me for being blunt, but: that's dumb.  First of all, most of our future doctors are already engaged in Facebook or Twitter probably both.  Most of them read blogs, some of them may write them.  So you can either ignore that, and place a blanket edict stating NO SOCIAL NETWORKING EVER, YOU KIDS DON'T KNOW WHAT'S GOOD FOR YOU AND WE DON'T TRUST YOU ANYWAY SO SIT DOWN AND SHUT UP AND READ YOUR DAMN SYLLABUS.  Or we could start talking about it.  We could start educating our medical students and residents about what is appropriate interaction with social media, and what could be construed as unprofessional.  Instead of closing our eyes and wishing it away, we could start to be proactive and do what we were trained to do.  Educate.  React.  Adapt.  Here's a start.  So is this.  And this.

Let me just say right here that if there is ever anyone who was in the position to make mistakes with respect to social media in medicine, it's me.  Having come of age writing a blog way before there were conversations about this topic (let alone newspaper articles, lectures, or studies) I just had one thing, and really it's all that each of us are left with and the end of the day when the noise dies down and the dust settles.  That thing, quite simply, is common sense.  You can't tell doctors to stay off social media entirely, and many would argue (myself for instance) that you shouldn't.  Because social media has tremendous power for good.  Dissemination of quality information.  Access.  Building community.  Breaking down barriers between practitioner and patient.  Humanizing the practice of medicine, and humanizing the experience of those in our care.  But with the incredible power of social media comes great responsibility, particularly for those who see the human condition at its most vulnerable.  And we need to start teaching our young medical trainees, from an earlier age, about common sense when it comes to its use.

Because common sense is not obvious.  Sometimes it needs to be learned.  Now, as an attending, if I have a patient in the OR now who is desaturating, I instinctively go through a series of "common sense" steps to troubleshoot the problem.  At this point, it is ingrained.  But would it have been as obvious to me as a medical student, or even a resident?  Of course not.  I had to learn it.  Someone had to teach me.  It feels like common sense now, sure, but only through experience did it become instinct.

The world outside of medical school is changing, and it will continue to change over the next few decades in ways that we can't imagine.  The Internet isn't going away, and the way we interact with it as individuals is only going to get more fraught and more inescapable.  This is progression.  This is fact.  So  sure, we can hide or dismiss or disdainfully pretend we're above it all.  Or, we can do what we do best, which is to roll up our sleeves, learn for ourselves how to deal with this brave new world, and then teach a new generation of doctors to do the same.


  1. You are so right, Dr. Au! Medicine is ridiculously slow to fully embrace change. I think people just like to throw around words like "diversity" and "well-rounded" as part of a politically-correct checklist. And I love how they consider Asians over represented in medicine. Umm, relative to which other racial groups? If there's just too many of us in medicine, where are all the Asian American department chairs, division chiefs, and deans of medical schools?

  2. Well said.
    There can be an educational element involved, not only for patients, but also medical students and junior doctors. The honesty with which you wrote about your clinical experiences over the years, and others like you, gave me an insight as a medical student, but also, surprisingly supported me as a junior doctor. An example that comes to mind is a post you wrote when you anaesthetised a patient for transplant retrieval, and how you felt about. I read it as a medical student several years ago, thougt about it at the time, then it fell into the recesses of my mind. A few months ago, in the middle of the night, I had to transfer a patient for transplant retrieval to theatre, then provide the anasesthetic in the middle of the night. That post came back to me then, and supported me in the sense that I didn't feel alone, the emotions I felt others had felt, etc. I wouldn't have got that from textbook. Might have got that from literature. But the internet can provide an access that is unique. It's ok to share, as long as it is done responsibly. There is a lot of rubbish out there, but there are gems to be found. It's about how we use the net. Not whether we use it.

  3. Anonymous2:07 PM

    It's hard to think of a way psychiatry could participate in social media in a way that would preserve the fundamental confidentiality of the field -- i.e. there's a boundary between the personal life and professional identity of the physician in a very strict sense (i.e. an internist can chat breezily about his or her own kids with the patient; a psychiatrist's job is to bring the focus so much on the patient that nobody knows if we have kids or not. etc). So - not to lose perspective on that view. Not every specialty can cope similarly with social media.

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  5. You are so right about having to learn about how things like social media work. I still find it shocking how many people think anonymous means they can say whatever they want without repercussions. I remember some kids in my class wrote some really unprofessional course evaluations using crude language, and were SHOCKED when they got personal emails reprimanding them from the administration. "But they were supposed to be anonymous evaluations!" they all cried.

    Folks, there is no such thing as anonymous, and you better act like it and get used to the idea

  6. Anonymous8:48 PM

    medicine + military = iceberg slow!!

  7. Anonymous10:14 PM

    It may be a sad thing to admit, but I only have the vaguest idea of what a pager is. I'm showing my age here. I've glimpsed them on the belts of a few physicians, but that's it. I have absolutely no idea how to use one.

  8. When I trained there was a terrible disconnect between things that faculty knew were important but just could NOT communicate to students/housestaff/younger faculty in a meaningful way. They tried through didactic lectures, oh, did they. But to young physicians (I'm a pediatrician and trained in a huge children's hospital), the sexiness of medicine lay in the urgency of the now, which in pediatrics (and I suspect most other programs) was embodied by the sicker-than-sick kids upstairs, not by the lecturer, especially if he/she was trying to talk to us about development (yawn...) or the business (personal and cultural) of medicine (eyes...glazing).

    Only later did I realize how important these things were. I called them my "Sheeeit" moments. After I had a child and saw how much of my office time was spend talking about normal development. Sheeeit. After I realized I had no idea how to view my own finances, or understand what HMOs and capitation were. Sheeeit. After I realized that well child care WAS going to be my forte, not crafting brilliant checkouts and recounting endlessly how the kid on 4E crashed. Sheeeit.

    The only thing that our director did that came close was having a group of recent residency grads (who we all still knew) come back and tell us what they wished they'd listened to.

    That's what docs need to do with re to social media. Have young docs come to residencies and recount to current students and residents how to view social media with common sense. (This should be done for high schoolers and college students too, imo). These same young docs can also school older docs and faculty on both how to deal with social media with common sense and why it's pissing in the wind to "forbid" its use. The old men and women who are the culture of medicine can its own young people to teach them. Or they'll be in for their own "Sheeeit" moments.

  9. What role do residents play in healthcare?
    Do we really need them?

    Please join the discussion!



  10. Dr. Au, the impact of social media has made a huge difference in the way patients approach medicine. I have written a blog since 1998, but never considered the information advantage of it until I was diagnosed with breast cancer in 2004. Interacting with other cancer patients through forums, chats and blogs I was directed to the information that was relevant to make decisions and the questions I should be asking. I haven't gone to medical school and am unaware of many issues. Sometimes my lack of knowledge obscures the availability of options that wouldn't be discussed. A recent example is that I received a diagnosis and was told of a few over the counter measures that I could use. But because I had been of forums and read blogs by other people who have the same condition I learned that a medication that I'm already taking at a higher dose was an effective. I would not have known to ask about it without social media, and neither of the 2 specialist that I saw for this condition mentioned the treatment to me. We become involved in our treatment through knowledge, but sometimes it takes social media to alert us to this knowledge. Blogs where physicians discuss, but don't necessarily recommend treatments, patient forums and chat rooms and chat rooms with other patients are essential to us, simply because we just do not know what to ask about. Thank you for blogging, but every time I see an anesthesiologist I'm asleep. I really don't get a lot of information from you. However, I enjoy your blog anyway.

  11. New reader here! (Because I live under a rock?) I'm an M1 on medical leave right now, and I'm relieved to have read this post. I've started blogging but I'm hesitant to use my real name/location/med school because of incidents like this:

    How did you confront this? Or was this almost a non-issue when you started this in 2000?