The compleat social physician

For years I have lectured new medical students at @uOttawamed that the best physician Twitter accounts reflect the whole personality of the individual. I argue that maintaining separate professional and personal accounts has little benefit, creates a false dichotomy and can dilute your voice.

Even before the COVID-19 pandemic I noted a growing trend for physicians and others to be more willing to share elements of their own personal life on Twitter in additional to their views on issues.

It’s a trend that has not gone unnoticed both on and off social media.

In a recent interview, CMA president-elect Dr. Alika Lafontaine (@AlikaMD) said this sharing by physicians has been powerfully cathartic. “I’ve never heard so many physicians actually share the pain that they go through day after day. I’m both sad, as I hear the stories, and hopeful, because we’re sharing the lived reality of what we’re going through.

“In supporting colleagues across the country, I’d say keep sharing your story. I hear you, I see you, I feel what you’re going through. The other side of that is figuring out how to take these stories and actually have them impact the thoughts and beliefs of decision makers who create the structures that we work in.”

This perspective contrasts somewhat to views voiced by Drs. Eric Topol and Abraham Verghese (@EricTopol and @Cuttingforstone) in a recent discussion at least when it comes to social media. They made the point that Twitter is not well suited to sharing personal narratives, in large part because of the constraints imposed by the 240 character count on tweets. While it is true that books and other long forms of literature can more completely reflect a person’s story, one should never understimate the ability of smart people to create powerful narratives in just a few words.

I would argue that the most compelling physician Twitter accounts for both their peers and the general population manifest the personality of the person doing the posting. Dr. David Naylor and his dog (@CdavidNaylor), Dr. Brian Goldman and his ruminations on the failings (and very occasional triumphs) of Toronto sports clubs (@NightShiftMD), and the baking adventures of countless other physicians during the pandemic, all come to mind.

The whole issue of physicians maintaining separate personal and professional accounts has recently been given attention by two Canadian physicians @BlairBigham and @sarahfraserMD in a blog post on the BMJ Opinion site.

They argue that while many top medical organizations still recommend that physicians maintain separate personal and professional social media accounts, physicians should “embrace authenticity and reunite their personal and professional selves.”

“In times like these, we must … make a therapeutic relationship with the public to advocate effectively, and the work of advocacy requires revealing our true selves,” they write.  They say this is particularly important when physicians are advocating on public health issues or advocating for social justice.

Recent research suggests the public is more willing to trust pronouncements from individual physicians than professional organizations on issues relating to COVID-19 and surely trust can only be strengthened when the physician posting can clearly be seen as an individual.

Of course, imbuing your Twitter account with personality entails risk and physicians must think hard about how much they are wiling to share. Many draw the line at posting anything about their family on Twitter and this can confer a degree of security against trolls or worse.

And the call to maintain one Twitter account that reflects your whole personality does not mean you should do the same on many social media platforms. Physicians should consider which platform works best for them and use them. Many keep Facebook purely for close, personal interactions and use LinkedIn only for career-oriented interactions, and that makes perfect sense.

However when it comes to Twitter at least, keeping both a personal and professional account can be done but if you want your voice and opinion to count being the whole you makes a lot of sense. And when it comes to professional behavior, the same rules apply no matter which account identifies you.

Albert Camus didn’t tweet … but Dr. Eric Topol (@EricTopol) does

Twitter will never produce great literature … but it has become an invaluable tool in keeping the world better informed and educated during the COVID-19 pandemic.

That was one of the conclusions that could be drawn from an intriguing discussion recently that brought together two of America’s best know physician authors – Dr. Abraham Verghese (@cuttingforstone) and Dr. Eric Topol (@erictopol).

Sponsored by the Bellevue Literary Review (BLR) and Medscape and hosted by BLR Chief Editor Dr. Danielle Ofri, the discussion on YouTube was titled “Covid Writing Goes Viral: How Literary & Social Media Writing Became a Lifeline during the Pandemic.”

The discussion actually split into two distinct threads – one steeped in literature and works such as Albert Camus’ The Plague (which I re-read in the bathtub over several sessions last summer) that dealt with great writing about pandemics – the other discussing the value social media and especially Twitter has brought to helping people deal with the pandemic.

The latter focused predominately on Dr. Topol and his work on Twitter. As editor-in-chief of Medscape, founder and director of the Scripps Research Translational Institute, and successful author of several books on new trends in medicine, Topol has been one of the most credible U.S. physician voices on Twitter since the pandemic began.

I first heard Dr. Topol live in an address to the Health Information Management Systems Society (HIMSS) meeting in New Orleans in 2013 when he effectively stated “I’m on Twitter and you should be to.” In the year of the pandemic, Dr. Topol has doubled-down on his commitment to the platform and with more than 400,000 followers he has a large audience.

“Back in late February or March (2020), I made a conscious decision that I was going to get deep into this,” Dr. Topol said, adding that he wanted to serve as navigational guide for those in the scientific or medical community.

“I started to double or triple the number of posts I would do in a day and that’s been maintained for the year and sort of took over my life.” Dr.Topol added that he has also come to appreciate the educational value of social media in linking him with other experts around the globe and across disciplines.

“Twitter has introduced me to scientists I am not sure I would have ever known but they have emerged on Twitter as reliable sources of information.”

Dr. Verghese acknowledged the importance of what Dr. Topol was doing in noting the sources of information he had traditionally used to keep track of events were insufficient to keep him informed about the fast-moving events of pandemic.

“The sources that I might go to were already old by the time I saw them compared to Twitter.” Dr. Verghese said his views on Twitter shifted from seeing it as “cute and fluffy” to an essential lifeline in keeping informed.”

However, he also sounded a cautionary note but talking about the need to filter all of the information coming through on Twitter so as to only deal with credible information.

While the COVID-19 pandemic has provided a basis for many people to tell their own narratives and raise awareness within medicine of the important roles played by others in the health care system, Dr. Topol acknowledged Twitter was not the best place to find these stories.

He talked about the inability of Twitter to reflect nuances concerning ambiguity or vulnerability in tweets.

“There’s no storytelling on Twitter or any social media.”

“You don’t need a room to do rheum” – Canadian rheumatologists and virtual care

Canadian rheumatologists are conducting virtual visits to a significant degree during the COVID-19 pandemic but most are not using video – which many feel is the best platform for this specialty – and the majority are still not comfortable with telemedicine.

These were a couple of the conclusions that emerged from a discussion of telemedicine and virtual care at the recent annual meeting of the Canadian Rheumatology Association (CRA) framed as a “great debate”. As those who have attended annual meetings of clinical medical societies know, these debates are often positioned with amusing graphics, good-natured personal attacks, and protagonists often asked to defend positions opposite to their true beliefs.

When one cut into this particular confection there were some productive insights about virtual care and rheumatology. More came from the numerous comments posted in the associated chatroom during the debate.

In the debate, Dr. Tommy Gerschman, a pediatric rheumatologist in North Vancouver and member of the CRA telehealth working group described telemedicine as “excellent care in brand new, patient-centred packaging.” In BC, Dr. Gerschman said rheumatologists last year provided about three-quarters of their visits virtually during the pandemic period – a far higher percentage than any other specialty.

A survey by clinicians from the rheumatology division of The Ottawa Hospital and presented at the conference as a poster showed that 89% of patients said they were satisfied were satisfied with phone visits undertaken during the first 3 monhs of the COVID-19 pandemic.

In the debate, Dr. Alexandra Saltman, a Toronto rheumatologist, noted that clinicians can take a number of measurements remotely such as weight, blood pressure and swollen joint counts. She also said evidence suggests use of virtual care is not likely to miss serious diagnoses or issues when used in rheumatology.

Tasked with arguing against telemedicine, Dr. Brent Ohata, co-chair of the CRA working group on telehealth argued “we’re not ready as a community ready to provide telehealth,”. He noted that providing virtual care properly requires training, specialized knowledge, proper equipment and preparation – on the part of the patient as well as the rheumatologist.

Dr. Ohata said a survey of Canadian rheumatologists done in December found that while respondents said about 47% of their current patient appointments were being done by phone, only 19% were done using video. Even during the pandemic, the remainder (34%), were being done as in-person visits. In addition, the survey showed only 45% of rheumatologists said they were comfortable or very comfortable using telemedicine.

“The gold standard in virtual care is video,” said Jocelyne Murdoch, a Sudbury occupational therapist with advanced training in rheumatology who has been using telemedicine since 2008. In another session at the conference, Dr. Ohata agreed that rheumatologists felt they could provide better virtual care through video than over the phone.

Dr. Ohata also presented data showing that while 66% of rheumatologists indicated they could evaluate swollen joints visually, there were a number of other investigations by rheumatologists that could be done in virtual visits that were not.

Murdoch who was also asked to argue against the value of telemedicine said the supports needed to provide telemedicine in rheumatology are not yet present. She noted that in rural and remote areas many clinicians and patients do not have access to to high-speed internet connections required to do virtual video visits.

Murdoch also noted how informal many patient visits have become since the pandemic and switch to virtual visits. This issue was underscored by a number of anecdotes from participants in the virtual chat room during the debate who described patients expectations of being able to meet virtually with their rheumatology while in the most unusual circumstances.

While other physicians have also voiced similar concerns about inappropriate patient behavior during virtual visits one should note this is not all one-sided – as evidenced by the case publicized this past weekend of the surgeon who tried to contest a traffic ticket in court via Zoom, while preparing to perform surgery in the operating room.

Becoming a doctors’ doctor: Dr. Michael Myers (@downstatedoctor)

When one of Dr. Michael Myers’ roommates died by suicide during his first year of medical school in 1962, Dr. Myers delivered the news to his classmates in class the next morning. The response?

“No one spoke a word. The professor broke the silence and awkwardly said: “So let’s return to the Krebs cycle.”

So began Dr. Myers journey to become a doctors’ doctor and provide care for his colleagues – a journey detailed in his recently published autobiography “Becoming a Doctors’ Doctor: A memoir”. It is a trip that has taken 40 years and seen Dr. Myers education and career span both sides of the Canadian/US border as both a psychiatrist and an educator.

In any ways, Dr. Myers journey of discovery mirrors that of the medical profession itself over the time period as it came to terms with the need to openly acknowledge that doctors do die by suicide, do become clinically depressed, do become burned out and often do require professional care and treatment.

As a medical writer in the 1980s and through into the first years of the 21st century it was often challenging to find a physician expert to quote on matters relating to physician health and wellbeing. In Canada at that time meetings dealing with physician health tended to focus on physicians with substance use problems and rarely, if ever, dealt with issues of suicide, mental health, or the broader issues of the challenges facing all physicians seeking to maintain their own health.

For me, Dr. Myers was that expert. He was able to speak with authority on issues of physician suicide, mental health, marital issues and more, as he was actually treating his colleagues for these conditions.

We now have the work of the Canadian Medical Association and other associations and leading clinicians such as Dr. Tait Shanafelt at Stanford University and many Canadians who have mapped out the magnitude of the situation and proven approaches to helping physicians stay well. But Dr. Myers book deals with a time when these issues were poorly understood if acknowledged at all.

It feels sometimes as if the book is hitting many of the emotional touchpoints that have impacted physicians over the past few decades – from AIDS to COVID-19. It also traces how medical education is wrestling with the reality of maintaining mental health for students and residents. While often a list of lectures given, conferences attended and accolades received, Dr. Myers’ book is also unflinching in dealing with his mother’s battle with alcohol, coming to terms with his own sexuality and treating physicians with, and without, success.

Throughout the book, with the permission of the patients families, Dr. Myers quotes the words of patients themselves. In his acknowledgements he notes “their permission is a present to physicians everywhere, rooted in a believe that there is too much misunderstanding out there, too much stigma, too much needless suffering.”

The core of what Dr. Myers has tried to achieve is, I believe, nicely stated by the author himself who writes:

“As a doctors’ doctor, I have spent decades listening to chilling and heartbreaking accounts of how shunned or judged my patients have felt by their peers and the institutional rules of the profession of medicine. Those of us who treat physicians have a moral responsibility to do everything in our power to fight these destructive forces by educating, advocating and working for policy change.”

For those interested in tracing the evolution of how the mental health of physicians came to be acknowledged as integral to the wellbeing of the medical profession and the health care system as a whole – as well as in following the life of a conscientious and dedicated physician –  Dr. Myers’ book is an important read.