CMA (@CMA_Docs) ups social media ante

Quebec City

The Canadian Medical Association (CMA) celebrated its 150th anniversary in Quebec City by moving boldly into the 21st century in terms of the organization’s use of social media and digital communications.

The CMA has always attempted to keep up with communications trends and many years ago designated a Twitter hashtag to the meeting (#CMA150 this year) as well as making live broadcasts of most sessions at the meeting available online for some time.

This is in keeping with the ethos of the volunteer, national organization which represents more than 80,000 doctors. At the very first meeting in 1867 (the same year as the birth of Canada), delegates noted the media had been excluded from the meeting and were quick to invite them to attend. Ever since – even on issues as heated as abortion or medical assistance in dying – the meetings have been open to the media.

But this year represents somewhat of a seismic shift for the CMA in line with a fundamental re-think of how the annual General Council meeting can remain relevant. Interestingly it came at the same time as delegates tackled head-on issues of “incivility” that have marked interactions between some of Canada’s doctors on Twitter and Facebook.

Not surprisingly, the meeting was heavily tweeted (graphic courtesy of Symplur). While only a small minority of Canadian physicians use Twitter professionally many of these were in attendance at the meeting.

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But this Twitter activity was accompanied for the first time by live discussions of the most important topics on both Periscope and Facebook live. In fact, a discussion of senior’s care issues with Federal Health Minister Dr. Jane Philpott was driven by questions from those who follow the CMA’s Facebook page.

Discussion in the Council chambers was also informed by questions from doctors participating via a conference app – another first for the CMA. This app was heavily promoted both as a way of participating during the meeting but also as an opportunity to continue the discussion on various topics after the meeting concluded.

The discussion of physician’s improper use of social media to attack colleagues was the subject of a panel discussion nested within a broader debate about developing a first professional code of conduct and professionalism for Canadian doctors. Examples of such conduct were available even in the days leading up to the meeting.

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Those who had been challenged on social media appeared willing to forgive their colleagues and attribute the negative comments to the excessive stresses and challenges facing doctors in Canada today. But what many might consider unprofessional conduct on Twitter continued even during CMA’s meeting and was commented on by the Speaker for the meeting.

While CMA’s has always been seen as the foremost national advocate for doctors and indirectly the interest of patients, its latest strategic plan puts an emphasis on being “patient-centred” and there is even discussion of considering putting patients on the CMA Board of Directors.

Quebec City is where the CMA began but this year demonstrated that the organization was definitely not planning its future by looking back.

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Optimistic outlook and a lesson on wellness: An interview with Dr. Ali Jalali

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(This is the first of a planned irregular series of interviews with Canadian physicians who are regular users of social media)

Almost four years ago, Dr. Ali Jalali (@ARJalali) uploaded a video for the Royal College of Physicians and Surgeons of Canada dealing with the value of social media for physicians and how to get started. With more than 2,600 viewings it has hardly gone viral but in many ways it set out the rationale and standards for the professional use of social media by Canadian doctors.

Since making that video, Dr. Jalali has arguably become the leading Canadian academic physician when it comes to professional use of social media by physicians and has published several papers and studies with a special focus on the impact of social media on medical education and its use by medical students and residents.

I recently visited Dr. Jalali in his office at the University of Ottawa where he serves as director of the division of functional and clinical anatomy and we discussed the evolution in the use of social media by Canadian physicians over the past four years.

Despite the fact that use of social media remains static with only 5%-10% of Canadian physicians using channels such as Twitter for professional purposes, Dr. Jalali believes social media has become much better accepted within the profession.

“I don’t think the idea was to get more and more doctors on social media,” he said, “but rather to make them more aware of what social media is.” With more patients using social media and posting queries for physicians, he said, it was important to make physicians aware of how to deal with these interactions.

“We managed to open the discussion,” he said.

As a turning point in Canada, Dr. Jalali points to a 2014 publication by the Canadian Medical Protective Association (CMPA) – the organization that provides malpractice support for physicians – which acknowledged the reality of social media in medical practice.

“Whether doctors choose to engage in social media or not, they cannot ignore the implications,” CMPA CEO Dr. Hartley Stern wrote at that time.

Dr. Jalali said this was a huge change from the earlier stance of CMPA as being totally opposed to physicians having anything to do with social media.

“That gave a huge boost to our work in promoting the use of social media by physicians. It’s not as exclusive as it was.”

Dr. Jalali also talked about how pervasive social media has become in medical education and medical conferences with every conference now having a specific hashtag and making conscious efforts to have delegates engage in social media.

Despite some anachronistic attempts by the organizers of some medical conferences to still prevent people live tweeting, Dr. Jalali said an intelligent social media presence is now a reality in medical education and this has immensely benefited those unable to attend major conferences in person.

“In medical education, it has now become part of the conference.”

Dr. Jalali said he continues to advocate professional behavior by physician delegates at these meetings. “If someone had the conference says don’t tweet my stuff, you shouldn’t tweet their stuff. It’s as simple as that.”

Dr. Jalali also pointed to the incredibly active social media debate and discussion around the Ontario Medical Association and its interactions with the provincial government as well as its own internal politics as another indicator of the growth in influence of social media.

“The younger generation is saying I can use this tool to my advantage.”

Despite this growth, he said it remains uncertain whether social media has actually done anything to improve health outcomes or the health status of the public as a whole.

For his own part, Dr. Jalali took a conscious break from social media earlier this year when he took paternity leave. He said this was a very positive move which made him realize how important it is for the purpose of wellness and personal relationships to maintain a balanced approach to social media use.

“It definitely was a good thing to do.”

He has now returned to use of Twitter and other social media tools but acknowledged he is not as active as it was.

Dr. Jalali says in talking to students and residents about social media now in addition to discussing professional use, he also talks about wellness and how to manage time properly by not letting social media dominate one’s life.

“FOMO – the Fear of Missing Out – is real,” he said, and must be consciously addressed.

(Picture by @pathologistmag – Dr. Jalali delivering closing plenary at #CAPACP2017)

 

 

 

 

 

 

I’m shocked, shocked to see live tweeting going on at this conference

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One has to have some pity on the American Diabetes Association.

This highly prestigious and influential organization drew the wrath and scorn of Twitter aficionados worldwide last week when they asked people to delete tweets about their scientific sessions showing images from presentations at the meeting (Medscape has a nice gated account of the fiasco here).

Some pity … but not a whole lot because we are in the latter half of the 2010s after all. Live tweeting from medical conferences is not just the norm but a now, a well-established form of knowledge transfer.

A lively twitter chat at the Philippine-based #healthxph last Saturday showed just how unanimous social media advocates have been in condemning what the ADA attempted to do.

The rationale used by the ADA was that they were just protecting the copyright of presenters and as such could not permit photographs of presentations which often contain as-yet unpublished data. Following the events of last week the ADA said they would be re-evaluating their policy, and so they should.

In a world where major medical conferences (including the ADA) go to some trouble to establish hashtags and encourage people to tweet from their meetings, policies which restrict this free flow of information and ideas are doomed to failure.

The ADA is not alone in fighting a rearguard action to restrict wider circulation of information presented at their meetings. More than once in the last six months I have been at meetings where repeated attempts to ban taking photos of presentation images have been made. In addition, I have heard speakers ask people to not more broadly circulate some but not all of their remarks (“Then, I adulterated my lab mate’s Petri dish so as to render his experiment invalid. Oh, but please don’t Tweet that.”)

Having attended medical conferences for 40 years, it is clear social media is dramatically changing the world within which such conferences operate.

Conferences are often financially important for the organizations that host them so it is logical to see them wanting to restrict the benefits of hearing presentations to those who have paid to attend. The fact this is no longer possible or even necessarily desirable could render moot the business model upon which these meetings are based.

Alternately – and this is a scary idea raised by someone at the #healthxph chat – conference organizers could start blocking transmission from the conference rooms during presentations so live tweeting would be impossible.

In the #healthxph chat I made two other points that bear repeating, I think.

  • Since attendees to a meeting are going to repeat the information they hear anyway, wouldn’t you rather have them do so through direct images of your data rather than rely on their scribbled notes.
  • If you are presenting at a conference for reasons other than the broader dissemination of your findings, then you are probably in the wrong place and in the wrong business.

Finally, there are still some grey areas. While mobile phones and other devices make it impossible to prevent taking images from presentations, there is a stronger case for banning live transmission of talks through Periscope or Facebook due to more significant issues of copyright.

Even though only a minority of medical conference delegates make use of social media, live tweeting is changing this very fundamental channel for the dissemination of medical information. How it will all play out, remains to be seen.

(For another excellent view of this issue please read @JBBC (Marie Ennis-O’Connor)’s: How The American Diabetes Society Unleashed The Streisand Effect

Patient engagement with muscle

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When Dave deBronkart (@ePatientDave) wanted access to his own medical record several years ago in the US, he didn’t just fill out a form requesting this information or politely ask the hospital involved, he went public in a big way, loudly demanding “Give me my damn data!”

While his act was not unique it can arguably be seen as initiating a new era of the muscular type of patient engagement currently prevalent in the US. These are patients who are not prepared to sit meekly and wait for an invitation to participate in decisions about their own health care or the health of patients in general.

Engaged patients are demanding their place at the health care decision-making table and have little patience for policy makers or conference organizers who want to keep discussions of patient engagement at theoretical level.

Look at the growth of the #patientsincluded movement in which conferences globally are being told they should include patients at all levels of planning and presenting health care information in a way that accommodates patients.  Anyone who dares hold a conference on patient engagement without having patients on the planning committee and speaker list risks being loudly shamed on social media. Even one element of #ehealth2017 has not been spared such criticism.

Similarly, recent discussions on social media are asking very pointed questions about why patient are often the only ones at the table who are not being paid for their time to provide their input.

This new form of patient engagement is transforming how health care is being planned and delivered in Canada but frankly we still trail the US in truly integrating this approach. Canada has several engaged patient leaders but none with the profile of their American counterparts.

Which bring us to the June 2 pre-conference symposium on Consumer Digital Health at #ehealth2017.

The keynote speaker will be Lygeia Ricciardi (@Lygeia), a US based expert in consumer engagement and digital health. Lygeia established and directed the Office of Consumer eHealth at the Office of the National Coordinator for Health IT (ONC) in the US federal government and is a compelling speaker. The presentation promises to deliver an update on major emerging trends in patient engagement

COACH, Infoway and the Canadian Institute for Health Information (CIHI) will follow Ricciardi’s keynote address with breakout sessions on different aspects of empowering healthcare consumers. This symposium should provide an invaluable snapshot of where Canada will be heading in the next few years.

Health Quality Ontario (for which I work), is currently one of the national leaders in providing the tools and infrastructure to meaningfully involve patients in health care decision-making.

It’s not a straightforward or easy task.

As Health Quality Ontario CEO Dr. Joshua Tepper wrote in @HealthyDebate blog post two years ago, “simply ‘commanding’ or ‘expecting’ health system providers and leaders to engage with patients is unrealistic.

In addition, he noted, “the patients we need to hear from the most are often the hardest to reach. Those who face economic, social, language, cultural, physical and psychological challenges to engagement will need thoughtful and respectful partnership efforts.”

For all of this, he concluded “courage is going to be a pre-requisite.”

Even as more patient involvement in health care planning and delivery is mandated in legislation and becoming embedded in the culture of quality care in Canada, hearing from US experts like Ricciardi is important to help us map where things are heading.

In a digital world, health care delivery models may be determined by jurisdictions but trends such as patient engagement effortlessly cross borders and Canada’s engaged patient community are quick to learn from their peers elsewhere and apply the lessons here.

Broken windows in the house of medicine

Vancouver

At a time when physicians are feeling besieged from all sides it hardly seems fair to write about the lack of civility demonstrated by some members of the profession on social media.

But it’s still an important issue that needs to be addressed – with the caveat that no profession or segment of society is blameless when it comes to such behavior and the focus is due to the focus of this particular blog.

The post is prompted by a recent workshop held at the annual Canadian Conference on Physician Leadership (#CCPL17) held in Vancouver titled “Professionalism and respect within the profession: demonstrating leadership and creating a safe space for debate”.

The good news from the discussion: social media is not to blame for outbreaks of incivility and bullying which can occur between physicians. The bad news? Incivility appears to be rampant throughout medicine and has yet to be satisfactorily addressed.

The impetus for the workshop was a fracas on social media last summer associated with a vote on a proposed fee deal for the Ontario Medical Association which saw a leader of the OMA student association subjected to threatening social media posts, and the subsequent public attention drawn to the dispute,

The decision was taken by conference organizers in Vancouver not just to focus on physician behavior on social media but rather to look at incivility and bad behavior in medicine in general and work being undertaken by the Canadian Medical Association (@CMA_docs) to address this in the spirit of professionalism.

During the discussion, Dr. Michael Kaufmann, the recently retired head of the physician health program in Ontario noted he dealt with problems caused by incivility between physicians on a weekly basis. It was also stated that hundreds of physicians across the country have been or will found guilty of unprofessional conduct by demonstrating disruptive behavior.

“The lack of civility in the medical profession is mindboggling,” is how one physician audience member described the scope of this behavior. Or, as Dr. Kaufmann put it more poetically, “we have some broken windows in the house of medicine.”

So, while social media is clearly not to blame for doctors behaving badly the point was also made that social media can breed incivility by prompting spur-of-the-moment outbursts, misinterpretations due to the sketchiness of the posts, and in some cases, the dimension of anonymity.

With the medical profession feeling under attack from all sides, views that break ranks with the majority are going to be challenged, often emotionally. Students and recent graduates are often the most common targets because they are said not to understand the realities of the situation.

The problem is that social media is not designed to promote measured, respectful debate.

“We will tell you when you can speak and what you can speak about,” is how panel member Dr. Dennis Kendel (@DennisKendel), a Saskatchewan physician and active tweeter described the response when he was seen as questioning that pro-physician unity.

Sadly, social media continues to be severely underused by physician as a professional tool for information gathering and networking (despite being used by peer leader in many areas).

It is also clear that the rules of engagement on social media platforms by their very nature can aggravate instances of poor communication and cause difficult situations to deteriorate.

Despite encouraging social media use at the Vancouver conference, organizers and speakers appeared very cognizant of this. Witness the fact that more than once, delegates were cautioned against tweeting certain remarks or asked to do so with a degree of exquisite sensitivity rarely taught professional journalists let alone well-intentioned civilian commentators.

Well, as the late Hunter S. Thompson might have remarked, this particular missive seems to be drawing to a close without pulling together all the narrative threads as required.

So:

  • It’s a tough time to be a physician
  • It’s a tougher time to be a young physician with unpopular views
  • It is to be hoped the CMA initiative will have an impact
  • Social media is impacting discourse across society in positive and negative ways we have yet to fully figure out.

(A) I, Radiologist

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Born of the discovery of the x-ray by Wilhelm Roentgen in 1895, the specialty of radiology is suddenly facing perhaps its greatest challenge with advent of artificial intelligence (AI) and machine learning.

Radiologists who have adapted to all manner of new diagnostic modalities over the generations now find themselves facing the prospect of machines which read and interpret imaging results quicker and more accurately than they can.

The Canadian Association of Radiologists (@CARadiologists) recently held its 80th annual meeting in Montreal and among the posters was one advertising that next year’s meeting would focus on AI. One wonders, given the speed with which AI and other technologies such as 3D printing are transforming radiology and medicine in general, whether next year is maybe too late to grapple with the issues raised.

The program committee of the CAR may have unconsciously acknowledged this as many sessions at this year’s meeting dealt with advanced technologies and at least two speakers dealt directly with the future role of the radiologist.

In addition, one of the highlights of the exhibit hall was IBM Watson Health (@IBMWatsonHealth). Last year, IBM created the Watson Health medical imaging collaborative, a global initiative with more than 26 leading health systems, academic centres, and imaging companies (they are currently looking Canadian participants) to bring cognitive imaging into daily practice. Earlier this year, IBM launched the Watson Imaging Review to reduce practice-pattern variation and reconcile differences between a patient’s administrative record and his or her clinical diagnosis.

One of the IBM staff was heard telling a CAR delegate, Watson “is not here to take your job away, it’s here to make your job easier.”

Presentations on AI and machine learning were matched by discussions of 3D printing, another technology currently transforming radiology and health care delivery.

Dr. Frank Rybicki, chief of radiology at the University of Ottawa and chief of medical imaging at The Ottawa Hospital, gave a comprehensive overview of how 3D printing is transforming many areas of medicine. The Ottawa Hospital recently opened the first 3D printing program based at a Canadian hospital.

Dr. Rybicki predicted that soon every hospital would have such a program as 3D printing moves from niche interventions to a leading role in reconstructive surgery, and cardiovascular and neurological interventions as well as supplying models to improve physician-patient communications and reducing peri- and post-operative complications.

“3D printing is the information delivery system of the current radiology generation,” he said, such as the young radiologists from Memorial University of Newfoundland who presented a paper showing the value of 3D printing of blood vessels to help educate the public and medical students.

It was a past-president of CAR, Dr. Ted Lyons from the University of Manitoba who bluntly outlined the future facing radiologists as a result of all these changes.

He noted that one of the fundamental roles of radiologists – reading and interpreting x-ray film – has almost already totally disappeared with the advent of PACS (picture archiving and communication systems).  By 2035, he predicted, all x-rays, CT scans and MRIs will be read and interpreted by machines.

The way forward for radiologists is twofold according to Dr. Lyons; firstly by becoming more than a “faceless name” who interprets images in a darkened room and being more directly involved and engaged with other clinicians and patients at the bedside. The second fundamental need, he said, is for radiologists to become data scientists and lead the integration of AI into radiology practice.

Dr. Lyons presentation was complemented later in the meeting by a presentation from a SickKids Hospital, Toronto radiologist Dr. Erika Mann who reiterated how radiologists need to become more patient-centred if they wish to remain relevant.

 

 

Is failing to use an EMR unprofessional conduct?

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It has come to this.

Some hospitals in Toronto are starting to use virtual reality in patient care (to help ease pre-operative anxiety). Yet, there are still family physicians in the province using paper charts to record and monitor the health of their patients: Not many for sure and far, far fewer than a decade ago an (an increase from 37% to 73% between 2009 and 2015).

But nonetheless, in an era where the health technology envelope is being pushed harder and faster than ever before, the most recent international comparison of use of electronic medical records (EMRs) by family doctors shows Canada continues to lag behind countries such as the U.K. and New Zealand where use is almost universal.

This finding comes from a study released earlier this year by the Canadian Institute for Health Information (CIHI) in partnership with the Canadian Institutes of Health Research, and with co-funding from Canada Health Infoway looking at data from the Commonwealth Fund 2015 survey of 10 countries.

Maybe the time has come to seriously ask whether the acceptable standard of care for family doctors practising in Canada involves using an EMR and that failure to do so could be seen as failing to maintain that professional standard.

It is a question that was first asked quietly more than a decade ago, back in the twilight era when only the most forward looking physicians and jurisdictions were using EMRs routinely. Now, when EMRs have hugely increased functionality and proved their value in efficiently managing the health of populations, the question can surely be asked with more authority.

Of course, nobody wants to force some physicians to use technology they don’t like, don’t understand, and which can sometimes lead to gross inefficiencies in the use of their time. In fact we can imagine there may be parts of the country where a physician still cannot even purchase a reliable EMR. And we in Canada still struggle with interconnectivity and many family doctors remain stranded on ‘electronic islands’ unable to use their EMR to communicate effectively with others in their community.

But the reality is that electronic storage of patient data is here to stay whether the medical profession likes it or not.  With almost three quarters of Canadian family physicians now using EMRs for patient care the time has to come to ask medical licensing authorities whether they need to apply more diligence to observing those doctors who choose not to rely on paper records.

The failure of family doctors to totally embrace electronic records is hindering both patient care management and population health management. Even of those who use EMRs, the CIH report notes fewer than half routinely use the system for at least 2 of the following: electronic alerts or prompts about a potential problem with drug dose or drug interaction; reminder notices for patients when it is time for regular preventive or follow-up care; alerts or prompts to provide patients with test results; and/or reminders for guideline-based interventions and/or screening tests.

Surely the time has come for this to change.