ChatGPT, unnecessary paperwork and Canadian physicians

Inevitably some innovative Canadian physicians are already using ChatGPT to help produce written documents for use in their practices.

However, when it comes to how and when to use such Artificial Intelligence (AI) tools or language models to help write letters to third-parties or assist in preparing clinical summaries for patients, Canadian physicians are currently pretty much on their own when it comes to specific official guidance.

The use of AI in clinical situations to assist in making diagnoses and prepare treatment options has been creeping up on the medical profession for the past decade. In contrast, ChatGPT appeared in a blaze of light on Nov. 30, 2022 and has supercharged debate about just how it and similar language AI tools can or should be used. In Canada, where the Canadian Federation of Independent Business has just released a report identifying unnecessary paperwork as a huge unnecessary burden on physicians, the potential of ChatGPT and similar tools seems obvious.

Developed by the US company, OpenAI, ChatGPT has the capacity to instantly tailor and write documents across the spectrum of written language and mirror human conversation. To date it has been available for free use and recently topped 100 million active users. 

It is important to note upfront that ChatGPT has severely limited applications in clinical medicine because it only sources information available up to the end of 2021 and it also cannot produce references and has been known to make them up. However, there are indications OpenAI and other organizations such as Google are moving swiftly to overcome these barriers and it’s also worth noting that ChatGPT has already shown itself able to pass the US Medical Licensing Exam.

Reflecting the frenzied interest in this new technology, articles such as this one are appearing at an accelerating rate looking at the potential impact of ChatGPT and similar AI tools in medicine.

In an article published Feb. 2, the US publication Medical Economics quoted Dr. Ali Parsa, founder and CEO of Babylon, a global AI and digital health platform, as saying that conversational AI tools such as ChatGPT “can be trained to draft letters seeking prior authorizations, appeals of insurance denials, and other claims.” He also identified improving patient education by simplifying medical notes as another potential use of these tools.

Writing in Stat, Rushabh Hi. Doshi and Simar S. Bajaj, students at Yale School of Medicine and Harvard University respectively, gave a brief overview of the promises and pitfalls of using ChatGPT in medicine and identified administrative work as one of the potential areas of benefit. “ChatGPT could be used to help health care workers save time with nonclinical tasks, which contribute to burnout and take away time from interacting with patients,” they wrote. However, they added that ChatGPT gave several wrong answers when asked to supply US billing codes.

A prominent Hungarian futurist Dr. Bertalan Meskó (PhD) released a YouTube video in early February on potential uses of ChatGPT in which he predicted such tools could help relieve the shortage of physicians. With a global shortage of 5 million doctors, he said, “the risk of missing care due to capacity shortages … will soon outweigh the risk of (medical chatbot) algorithms being wrong.”

Dr. Meskó focused on the ability of ChatGPT to be “trained on a dataset of medical records to assist doctors and nurses with creating accurate and detailed clinical notes… it could also potentially take a bigger bite and help facilities with summarizing medical records or analyzing research papers.”

Noting the current unreliability of some information generated by ChatGPT, he said, “If you as a doctor sent a letter generated by ChatGPT to an insurance company, and the diagnostic test gets rejected because it doesn’t cite the proper literature, it’s pretty problematic. On the other hand, the letter itself looks fine. If you’re not too lazy to actually oversee it and include real references, it can still save you some time. This way is not much different from using templates.”

A sounding of Canadian national medical associations found specific policies on ChatGPT and other AI language tools have yet to be developed.

The Canadian Medical Protective Association (CMPA) produced the most detailed statement noting in part that “CMPA is aware of the existence of ChatGPT as an emerging AI communication tool. We are closely monitoring its emergence, as well as other AI tools, which may impact doctors’ medical practices.” The statement recommended a structured approach by physicians to using AI technologies based on three considerations:

• Critically reviewing and assessing whether the AI tool is suited for the intended use and nature of the doctor’s medical practice.
• Being mindful of a physician’s legal and medical professional obligations, including privacy and confidentiality obligations.
• Being aware of bias and seeking to mitigate it when possible by pursuing alternate sources of information and consulting colleagues.

The CMPA statement concluded that “in today’s environment, and for the foreseeable future, AI is not intended to replace a doctor’s clinical experience and appropriate assessment of a patient’s condition. The healthcare provider remains accountable for the information and care provided to the patient.” The CMPA statement complements what the association had already published in 2019 dealing with the use of AI in clinical decision-making.

Dr. Alika Lafontaine, president of the Canadian Medical Association (CMA), which has identified reducing the administrative burden on physicians as a top priority, released a statement in response to a request about the association stance on ChatGPT. Dr. Lafontaine acknowledged that while the association does not have an official position of ChatGPT to support physicians in their daily administrative tasks, it “recognizes the role that technology has always had as a disruptive force in healthcare.”

“ChatGPT and similar AI tools may eventually transform the practice of medicine, but those tools must be properly matched to problems. Addressing the administrative burden on physicians will not only require application of new technology, but redistributing the workload amongst health-care team members and investigating whether current administrative demands are necessary or useful.”

Dr. Eric Cadesky, a BC family physician and keen observer of medical technology advances says ChatGPT is “potentially revolutionary” in easing the burden of administrative tasks and democratizing medical education. But he adds that “just as CT is not a replacement for a thorough history and physical examination, AI is still (just) complementary to what we do” and can also suffer from the same biases as seen in society at large.

A spokesperson for the College of Physicians and Surgeons of Ontario said the College does not currently not have a specific policy covering the use of ChatGPT and other AI tools but noted a number of principles involved in providing care would apply. “Physicians have a responsibility to ensure that their work is complete and accurate. So just like if they’re using a scribe to do their records or if they’re delegating tasks to someone else, (physicians) are responsible.”

Both the College of Physicians and Surgeons of BC and the College of Medicine in Quebec noted they currently have no policy or standards in this area.

As for medical publishing, ChatGPT has already had an immediate impact. Once again physicians and other researchers have been experimenting with using the tool, this time to prepare and in some instances publish papers in medical publications using Chat GPT . Not surprisingly this has prompted a lively debate about the feasibility and acceptability of this approach as well as how to acknowledge use of the tool.

For example, the official journal of the Radiology Society of North America Radiology has just published an article and editorial dealing with ChatGPT and medical writing. The article author, Dr. Som Biswas, a pediatric radiology fellow at the Le Bonheur Children’s Hospital, University of Tennessee Health Science Centre, Memphis, said the article was written by ChatGPT and edited by himself. In the accompanying editorial, Dr. Philipe Katamura, head of applied innovation and AI at Dasa and affiliated professor of neuroradiology at Universidade Federal de São Paulo wrote “there is a hypothetical future in which this article will be one of the last to be written without the help of AI.”

The World Association of Medical Editors (WAME) has been quick to address the issue and on Jan. 21 published its recommendations on the use of ChatGPT and Chatbots in relation to scholarly publications.

“While ChatGPT may prove to be a useful tool for researchers, it represents a threat for scholarly journals because ChatGPT-generated articles may introduce false or plagiarized content into the published literature,” the document states. “Peer review may not detect ChatGPT-generated content.” The paper goes on to note that what ChatGPT does can “go against the very philosophy of science.”

The first and most important recommendation made by WAME is that Chatbots such as ChatGPT cannot be authors on scientific papers “as they cannot understand the role of authors or take responsibility for the paper.” The second recommendation from WAME states “Authors should be transparent when chatbots are used and provide information about how they were used.”

Canada’s most important general interest medical publication CMAJ is a member of WAME and has said it will be guided by the recommendations from the association in dealing with ChatGPT involvement in submissions to the journal.

Meanwhile academic institutions including medical schools are wrestling with how to deal with the fact that students can now use ChatGPT to produce credible written assignments that cannot yet be reliably detected by software tools. While some feel they are bowing to the inevitable and wrestling with how the learning process should be adapted to change how students learn, others such as the Paris Institute of Political Studies, or Sciences Po have announced a total ban on students using ChatGPT or other software for academic assignments “without transparent referencing.”

Currently experimentation with the potential uses of ChatGPT in medical practice and academia is running far ahead of policies and standards to guide such usage as more doctors actually make use of such tools the situation is likely to chage.

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Primary Care: A 30 minute drive away but virtual options also needed

Having the right to a relationship with a primary-care team within 30 minutes of home or work is the main recommendation coming from the first major Canadian health policy paper to be published this year.

But while stressing geographic proximity to primary care, the Public Policy Forum document “Taking Back Health Care” is noteworthy for its emphasis on the need to incorporate virtual care into care delivery in a reformed and modernized healthcare system..

The report and its recommendations also merit attention because of the prestigious list of physicians which includes; Dr. Jane Philpott, dean of health sciences at Queen’s University; Dr. Vivek Goel, president and vice-chancellor, University of Waterloo; Dr. Alika Lafontaine, president of the Canadian Medical Association and; Dr. Bob Bell, former Ontario deputy minister of health.

The document notes that during the COVID-19 pandemic there was a “rapid, positive shift” in how Canadians accessed health services. “Video visits, phone calls, online engagement (including the use of bots and automation to support online interactions), remote monitoring, etc., quickly ramped up to support care when being in person was not safe,” the report continues.

While use of these virtual tools had both advantages and drawbacks, the authors state “we cannot rely solely on in-person access in a modernized, effective health system.”

“We need to put virtual into the continuum of care in a way that reinforces patient relationships with care providers, based on a clear understanding of when it is appropriate to use it and when it is not. It is on our system leaders and providers to ensure virtual care is integrated, convenient, of high quality, AND equitable.”

In addition to referencing the need to integrate virtual care, the report also talks about the importance of people having the ability to access their health data. “Empowering individuals with their data includes the ability to seamlessly and securely share information within that individual’s circle of care and for that individual to have an integrated health record that follows and is tied to them,” the authors write.

Noting that health data often currently exists in siloes, the report emphasizes the need to make health information available to providers and policy makers while first addressing “legitimate” data governance and privacy issues. The Pan-Canadian Health Data Strategy is identified as a roadmap to how this can be accomplished.

The Public Policy Forum paper is one of a series that will be published this year as part of the Future of Health Care Project.

Electronic medical records are great but paper still OK too

As we hurtle towards the quarter century mark of the 21^st century it is puzzling that use of electronic medical records (EMRs) by Canadian physicians is still not considered by provincial and territorial medical regulatory authorities to be the only standard for the acceptable provision of care.

There is currently an almost universal call for more sharing of medical data to improve individual and population health that is only realistically possible if records are stored electronically. It is also recognized that providing quality care can be enhanced if records are kept electronically. Yet all physician licensing authorities continue to state it is acceptable for physicians can keep records either on paper or electronically.

The discussion about whether use of EMRs should be the standard of practice for Canadian doctors has been going on for years if not decades.

It’s interesting to look back two decades to when a debate about whether it should be mandatory for physicians (and other healthcare providers) to be part of e-health initiatives formed the centrepiece of the eHealth Conference held in Toronto in May, 2003 (this year’s eHealth Conference and Tradeshow will also be held in Toronto).

David Kelly, then a Victoria, BC consultant and one of the participants of the debate, noted that the uptake of electronic record use by physicians at the time was “disappointingly slow” with fewer than 10% of Canadian physicians using or planning to use some form of EMR. (Fast forward almost two decades to 2020 when almost 86% of all physicians and 96% of family physicians were using EMRs).

Dr. Michael Guerriere, then physician-in-chief for the Sunnybrook and Women’s College Health Sciences Centre in Toronto, argued in favour of physician involvement with electronic health records. He said using electronic records must be mandatory for physician to deliver a high quality of care and that there was a large emerging body of evidence providing proof the two were connected.

“We have no choice but to make this mandatory,” Dr. Guerriere said, pondering how physicians could be allowed to opt out and thus continue to offer substandard care.

Howard Waldner, then executive vice-president and COO of the Calgary Health Region, countered that mandating use of electronic medical records was “unrealistic and unachievable” and that policy makers needed to move away from the language of compliance and talk about incentives and effective change management strategies. Dr. William Sibbald, an Edmonton family physician said evidence of the benefits of electronic records was not yet sufficiently robust and that a powerful coalition with a shared vision was necessary to fully engage physicians.

As we know, what did happen over the next two decades was that provinces implemented programs at various times that incentivized physicians to adopt electronic medical records, but no jurisdiction made their use mandatory. However, the peer support and change management strategies mentioned by Dr. Sibbald in the debate often formed a large part of these programs.

To date, the College of Physicians and Surgeons of Manitoba (CPSM) is the only provincial licensing authority that refers to making the use of an EMR the standard of care.

In its standard of practice for the maintenance of patient records effective last February, the College notes:

CPSM recognizes the adoption by registrants of Electronic Medical Records (EMRs) compatible with the provincial government’s electronic medical records systems … significantly contributes to the provision of good patient care. While working with an EMR compatible with provincial systems has not yet been made a requirement in this Standard, CPSM considers this arrangement the current standard of care and it is expected that it will become a requirement pursuant to this Standard for all registrants when the Standard is reviewed again in or around 2026. In the interim, it is expected that all registrants will make efforts to adopt an EMR and establish links with provincial systems as soon as reasonably possible, if they have not already done so.

So while there is much talk of connectivity and the benefits to physicians, patients and the system from use of electronic records physicians are still free to scribble or type their notes on paper making somewhat of a mockery of the shiny digital health future of which we hear so much.

(This is the first of two posts that will look back two decades to the 2003 eHealth conference)

Twitter Dec. 20, 2022: Diminished but not extinguished

Perth, Ont. emergency physician Dr. Alan Drummond (@alandrummond2), the invaluable curator of the current crisis Canadian emergency rooms and gun control advocate has successfully undergone knee replacement surgery and is home. And Ontario physician Dr. Mary Fernando’s (@MaryFernando) young bouvier had a great time experiencing the first major snowfall of the year last week.

It is these and thousands of other postings to Twitter in the last few days and not the ongoing soap opera that is Elon Musk’s hands-on (mis)management of the platform that assures me that Twitter continues to be valuable if not invaluable to those interested in what Canadian physicians, other healthcare professionals and patients and caregivers are currently doing and feeling. While both Drs. Drummond and Fernando live close to me and I know them, I am not close enough personally or professionally to have heard their news otherwise.

Of course, it has been hard to ignore all the recent turmoil surrounding Twitter of which the following are just a few examples:

• The reinstatement of many accounts that were removed due to persistent posting of discriminatory, unscientific or unprofessional comments. Unfortunately we must include among these, Dr. Drummond’s nemesis, former politician and antivaxxing advocate Randy Hillier.
• The documented significant increase in racist, misogynistic, and homophobic tweets.
• The temporary (?) silencing of Twitter Spaces
• The revamping of Twitter Blue to entitle all subscribers to have a verified blue checkmark and also to be the only ones allowed to vote on Twitter policy polls. Surely a cruel blow for physicians who fought so hard during the pandemic to be verified on Twitter so they could post scientific information and science-informed opinions.
• The cancellation of several high-profile accounts of journalists critical of Musk or his policies (subsequently often reversed)
• The ban on tweets linking to other social media platforms (subsequently reversed)
• The poll taken by Musk asking if he should cease being CEO of the company (the majority said yes)

All of this anecdotally appears to have led to a reduction in use of Twitter by Canadian physicians and others in the healthcare system. It has also resulted in some totally abandoning Twitter. Just this morning I received notification that a retired physician and former Alberta Medical Association had left Twitter as had a respected Canadian medical journalist. Also sorely missed is Australian rural physician Dr. Min Le Cong @Ketaminh who was an outstanding curator of physician activity in that part of the world was as well as an unparalleled poster of breakfast meals at restaurants around the country (you can find him now on Mastodon).

Others, such as physician leadership guru Dr. Johny Van Aerde (@neon8light) have not left Twitter yet but have set up a Mastodon account with the possible intention of moving there permanently. And perhaps more worrisome is that alternate physician voices such as Dr. Ontario radiologist Dr. David Jacobs (@DrJacobsRab) say they will depart public social media completely if they leave Twitter.

Every loss of a Canadian physician or healthcare advocate from Twitter means a diminishment of a community that has taken more than a decade to build and the associated reduction in the value of what is left.

It’s not all bad. Twitter turmoil has given a profile to other platforms such as Mastodon which have proven useful for some clinicians and others to share information and grow community although much of the posting is still mirror-posting of tweets. It has also led to the emergence of other unique communities such as the Give a Duck community initiated by patient advocate Sue Robins to allow health advocates to encourage and support each other.

In addition to community-building, Twitter continues to be the go-to platform for timely news about healthcare issues such as the current crisis in pediatric and adult emergency care, the funding feud between the provincial and territorial and the federal government, and countless clinical controversies. Even with a reduced number of postings from credible sources, Twitter still gives you credible news – be it political or clinical – faster than TV, radio or any newspaper.. For instance, this morning there was an earthquake in Ferndale, CA which I read about on Twitter within minutes of it occurring.

The reality is very few Canadian medical organizations or associations such as the Canadian Medical Association (@CMA_Docs) have yet established footholds on any other nascent social media platforms such as Mastodon. In fact, one is hard-pressed to name any other platform apart from Twitter where such organizations could find such a reach for their messages outside of their own internal communications channels or dependence on third-party media.

Hand in hand with curated information is advocacy and here again advocacy on Canadian healthcare issues continues unabated on Twitter be it concerns about new funding rules for virtual care in Ontario or the plight of the homeless as cold weather strikes across Canada.

So, on Dec. 20, 2022 it is clear the uncertainty and confusion around Twitter will continue and probably for some time. But as I stated in my last blog, I feel it is still worth maintaining a presence there for professional if not personal reasons.

And a reminder that personal tweets for physicians are not just documenting life landmarks or sharing pet pictures. To quote, CMA President Dr. Alika Lafontaine (@AlikaMD) from earlier in the pandemic “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.”

(The title of the blog has a date in it as events are so fast moving with Twitter at the moment that it is probably wise to date-stamp any commentary)

Twitter is still my medical home

For more than 12 years, Twitter has been my medical home. Just as family medicine sees the patient’s medical home as a vision for patients receiving comprehensive and proper care on an ongoing basis in family practice, so Twitter has provided me with the best place to foster two-way communications about medicine and healthcare in a comprehensive way.

The purchase of Twitter by Elon Musk and his subsequent actions threatens this vision. In recent weeks several credible and respected physicians and other healthcare experts have talked about abandoning Twitter for other platforms, with Mastodon being the safe haven of choice to date. Despite having many positive points, Mastodon is not Twitter and its shortcomings have shown us what we will lose if Twitter goes away. The recent proliferation of promotions for other platforms only shows how fragmented the healthcare and medical community will become without Twitter.

Also, Canadian physicians who are generalists now have few sources of credible, timely information curated just for them, with the online daily subscriber newspaper offered by The Medical Post (@Medical Post) being the only example that comes to mind. Mainstream Canadian journalists such as Andre Picard (@picardonhealth) and Aaron Derfel (@Aaron_Derfel) are best-in-class in curating and transmitting medical information to both the profession and the public but their numbers are dwindling. Twitter has provided physicians with the ability create their own information channels with links to sources they trust.

As @cmaer I helped the Canadian Medical Association (@CMA_Docs) on its road to using social media which it has done with increasing sophistication. Now, while sinking fast into semi-retirement, I continue to monitor Twitter for healthcare news, curate information, and on occasion live tweet medical conferences.

Twitter has connected me with a global community of medical experts and those with lived experience from the UK and Ireland to the Philippines and Australia. Unlike other forums where physicians connect as fellow specialists or talk among themselves, Twitter has created a place where physicians and patients can exchange views and expertise to the advantage of both. It is also a place where in recent years we have been able to see physicians as whole individuals and not just medical practitioners. As Tricia Pendergast wrote in a blog 3 years ago: “Welcome to the future… where doctors and nurses are no longer dispassionate enigmas; we’re humans      with online lives, dog pictures and grief that we need to process.”

Some aspects of Twitter such as tweet chats and live tweeting are less relevant today than previously. However, groups such as #healthxph in the Philippines continue to use scheduled tweet chats productively to continue to have respectful discussions on issues of importance to medical learners and physicians. And depending on the meeting and audience, even the chat function of virtual meetings has not totally eliminated the value of live tweeting to engage those not actually attending those meetings.

Social media have evolved over the past decade. Facebook, LinkedIn and Instagram have started to borrow innovations from each other. Like overprotective parents, social media platforms such as Twitter and Facebook now use algorithms to spoon-feed us posts they feel will be interesting to use based on previous history. While occasionally useful, this activity not only clutters our feed but can also increase the echo-chamber effect by feeding our biases and pre-conceived notions. Other platforms such as TikTok have successfully emerged to establish their own distinct niche.

While I have more than 9,000 followers and support unpopular (to some) pro-science stances such as masking mandates against COVID-19 (even in the context of such highly charged environments as the recent school board meeting in Ottawa), I have been spared abuse and threats maybe because I am not a physician or high-profile. I fully sympathize with those forced from Twitter because of such abuse and have no argument against those who no longer feel safe being here.

I also accept that a clarion to stay on Twitter or find a better platform is not universally accepted by others.

Social media pioneer and pediatrician Dr. Bryan Vartabedian (@Doctor_V) recently wrote that “the value with Twitter has devolved from a place of real community to an echo chamber for our own ideas. In discussing Mastodon he wrote:

Now we move to Mastodon. We celebrate our great exodus into the Promised Land. The problem is that we bring the same baggage and motivations with us. And all of our habits. The race for influence is a story as old and predictable as social media: Grab first mover advantage, evangelize the platform in the service of raising our game, and battle desperately for followers.

However, I would also like to quote an Australian scientist Dr. Manu Saunders (@ManuSaunders), who, as the Twitter/Mastodon situation emerged, wrote:

Twitter has been a beacon, a haven, an inspiration, and a cornerstone for me. I’ve tried insta and tiktok, but they never worked for me. Twitter is different. It is outward facing and hyper connected – whenever I felt alone or excluded in my local discipline or institutional networks, I always felt welcomed and connected on Twitter. It helped me grow my blog audience, found me new collaborators and new ideas. It kept me up to date with local and global news and events. I’m an ecologist, but I’m also a person, and Twitter kept me connected with all the communities that I felt connected to, however indirectly – academic twitter, ecology twitter, ag twitter, landcare twitter, insect twitter, nature twitter, Australian twitter, climate twitter, conservation twitter, journalism twitter, writing twitter, politics twitter, history twitter, the list goes on…

If Twitter becomes unviable, I think, it will be in one of three ways:

• Disruptions to the organization of Twitter as a result of Musk’s corporate actions will cause the engineering infrastructure to collapse
• Attempts to turn Twitter into a right-wing platform will make it unusable for anyone not sharing those views. Some actions by Musk such as the reported imminent “opening of the gates of Hell” and reinstating all accounts banned for flagrantly abusive behavior points ominously in this direction.
• The hyper-evolutionary nature of communications science in the 21^st century will cause it to be supplanted by something that better meets people’s needs for being simultaneously educated and informed. Until the Musk situation arose this is what I always thought would happen.

Twitter may go away in the short-term or become totally hostile to intelligent life as spelled out in the first two bullets. And inevitably at some point it will be supplanted by something better. But in the interim, I’m staying.

(Image: Tent room in the Esterhazy Palace, Tata, Hungary)

“Data can save lives” The 2022 @Infoway Partnership Conference

One in five clinicians spend more than an hour daily beyond what they think they should be spending in looking for patient information either within or outside their own patient record system.

This finding comes from the Canadian Interoperability Landscape survey conducted by Canada Health Infoway in April with 808 clinicians of whom half were either general practitioners or specialists. Results were released in early November and further discussed as part of the Infoway Partnership conference held in Montreal this week – the first time the conference had been held in person since 2019.

The findings underscore the ongoing challenges physicians can face in accessing the patient data they need even with the prevalence of electronic medical records (EMRs) and was a main theme underlying the Infoway meeting. While the conference focused heavily on the success of recent Infoway initiatives, physicians will be encouraged to hear many speakers over the course of the meeting acknowledged the profession’s concerns.

Four years ago, at the same meeting Infoway positioned itself as an advocate for building a coalition committed to promoting “a future where all Canadians have access to their health information through the availability and use of digital health tools and services, which will empower patients and improve health outcomes.” The whole initiative was branded under the banner ACCESS 2022.

That initiative has now morphed into an emphasis on Connected Care (the more user-friendly term for interoperability) and the need to give all Canadians to ability to access and share their health information while at the same time improving the flow of better and timely data to increase care coordination and help system planning and improved performance.

According to Infoway, a savings of $350 million annually could be gained by having health care providers access complete patient information in one place thereby allowing them to spend more time with patients.

Despite seeing the normalization of virtual care delivery during the COVID pandemic, Dr. Rashaad Bhyat, a Brampton family physician and clinician leader at Infoway told the meeting fragmented and siloed information systems have worsened physician burnout. For example, the Interoperability survey found that more than half of the specialists polled (54%) and 36% of family physicians said they continue to rely on faxes as one of the means of receiving patient summaries from outside their practices.

Other speakers noted that ongoing frustration with digital tools and the administrative burden of maintaining EMRs continues to feed physicians’ ambivalent or negative attitude towards digital care.

In addition to the challenges facing physicians in easily accessing the patient data they need, speakers from OntarioMD noted the majority of primary care physicians currently do not capture data in their EMRs in a codified or structured format that can uploaded to benefit the system and they do not have incentives to do so.

“Health data can save lives” federal health minister Jean-Yves Duclos bluntly told the conference in backing the call for a national framework to better share health data. His fireside chat at the meeting came just days after provincial and territorial health ministers rejected an offer for more healthcare funding from the federal government in part in exchange for supporting a national health data system.

While the whole Infoway conference focused on the need for more health data to be shared more effectively, it was acknowledged during a session on cybersecurity that such increased sharing would likely lead to more cyberattacks on hospitals and other healthcare organizations. The same session heard just how challenging it can be for those schooled in using electronic systems to revert to using paper if electronic systems are unavailable due to a cyberattack.

Doppelgänger docs of the Rockies

A physician’s reputation is one of their most important and prized assets.

The advent of the Internet and social media have produced a vastly increased scope for physicians to increase their reputations. To quote Texas pediatrician Dr. Bryan Vartabedian, “the democratization of media has made every physician an independent publisher …physicians now have to learn to manage and maintain their identity in the public space.”

While social media has produced huge opportunities for enhancing reputations, at the same time it has created a whole new set of challenges and threats to how physicians are seen by prospective patients, their communities, and others. This would explain why the College of Physicians and Surgeons of Alberta (CPSA) has chosen to allot such a large segment of its updated advisory to physicians on social media to the topic.

In the document released in August which updates earlier advice from 2014, the CPSA notes that “recent studies show that up to 50% and that being impersonated online in a negative manner can have devastating consequences, both personally and professionally.”

The College goes on to provide a list of tips on how physicians can protect themselves against such fraudulent accounts. These include:

• Providing a detailed professional biography in their social media profile
• Checking comments and messages daily (emphasis mine) to see if fraudulent activity has been noted by contacts
• Checking security settings to ensure your posts and account information are only visible to the people who you want to see them.
• Enabling two-factor authentication on accounts
• Not linking your social media accounts so posts from one account automatically post on another account
• Using secure passwords

The College also provides advice on what to do if you think your account has been taken over and goes as far as to provide an example of suggested wording of what to post to your legitimate social media accounts if you have been a victim of a fraudulent account.

All of this is sound advice, but it demonstrates how the various physician regulatory Colleges across the country have taken very different approaches to what they choose to emphasize when talking about social media. The Alberta College renewed guidance comes at about same time that the College of Physicians and Surgeons of Ontario also published revised guidelines on social media. The new CPSO guidelines make no reference to fraudulent accounts choosing rather to emphasize the need to publish only evidence-based materials (However both Alberta and Ontario as well as regulatory bodies in other jurisdictions stress the need for physicians to act professionally and protect patient confidentiality if they speak to the social media at all – and some still do not).

Oh, if you are concerned about having your own accounts hijacked or in checking your online reputation Googling yourself regularly to see how you are portrayed online is a tried and true method of doing so.

In the US, physicians push hard for ongoing support for virtual care

Changes instituted because of the COVID-19 pandemic that relaxed the regulatory and payment environment for virtual care appear to have strengthened the support of US physicians for the use of digital health technologies.

The survey is being used by the American Medical Association (AMA) to bolster advocacy efforts calling on the US Senate to follow the House of Representatives and continue to flexibilities around Medicare payments for telehealth and regulations supporting telehealth, until the end of 2014.  Earlier this week, dozens of US medical associations (including the AMA), academic centres and insurers also sent a letter to the Senate also urging extension of measures introduced because of COVID-19.

The situation has been mirrored somewhat in Canada where medical associations have been negotiating to extend changes in the fee schedule to support virtual care as well as advocating for regulatory changes to make it easier to offer such services.

The new survey by the AMA involving 1300 physicians shows the number who feel there is an advantage in using digital tools for patient care has risen from 85% in 2016 to 93% now. This has been accompanied by a growth in the number of doctors using virtual care from 14% to 80% over the same period.

The letter sent to the Senate states “…patients now expect and often prefer telehealth as a key component of our health care system,” said the letter, adding “virtual care is now a fundamental part of the U.S. health care system, and it will improve patient access to high quality care and strengthen continuity of care well beyond the COVID-19 pandemic.”

“Virtual care is now a fundamental part of the U.S. health care system,” the letter goes on, adding “…many of the most compelling clinical use cases for virtual care are only now emerging, more communities than ever have experienced the powerful impact telehealth has had in bridging gaps in care … without statutory certainty for remote care the hard work of building infrastructure, trust, and relationships with these communities is beginning to stall.”

Interestingly, the AMA survey indicates physicians feel improved clinical outcomes and work efficiencies rather than improved patient engagement are the main motivators for using digital health tools. In fact, the ability of digital tools to give consumers greater access to their clinical data dropped in importance between 2019 and now in the eyes of physicians as an important reason for using digital tools.

More than three-quarters of physicians polled (76%) feel that digital health tools can help reduce stress and burnout up from 69% in 2019.

The survey also shows US physicians are starting to adopt more advanced digital technologies in their practices. Eighteen percent now say they are using augmented intelligences for practice efficiencies and another 76% said they plan to do so in the future. Similarly, 18% say they are using augmented intelligence for clinical purposes with another 36% saying they are planning to do so within the next year.

Physicians will have good opportunities to view the digital health landscape in Canada this fall as both OntarioMD and Canada Health Infoway hold major conferences with updated assessments of the situation.

Broken shield: Care for society’s guardians falling short

Broken Shield: Tim Green

The stark challenges facing first responders (paramedics, firefighters, police) and other public safety personnel (PSP )were the focus of the 2022 Canadian Academy of Health Sciences Forum just held in Montreal.

At least one speaker at this unique gathering of experts noted mental health issues compounded by the COVID-19 pandemic have been even more concerning in the PSP population than the well-documented challenges facing physicians, nurses, and other healthcare workers.

“First responders put their mental health at risk every day,” said Forum co-chair Dr. Alain Brunet, professor of psychiatry at McGill University. Dr. Nicholas Carleton, professor of psychology at the University of Regina and another Forum co-chair said PSPs today are expected to act like superheroes but feel forsaken by their communities.

Data presented at the meeting show PSPs report symptoms consistent with mental disorders at four times the rates expected in the general population as well as suicidal ideation or attempts at twice the rate of the general population. Several speakers also referenced other physical and mental health problems seen with PSPs ranging from an increased incidence of cancers, cardiovascular disease, musculoskeletal issues and miscarriages in firefighters, to the increases in physical attacks on paramedics and mental health issues suffered by Correctional staff.

However, these reports were often prefaced by statements about the lack of good quantitative data on health issues and PSPs as well as the lack of well-researched targeted therapies. As Dr. Carleton said, there are hundreds of programs across Canada supporting PSP mental health but little evidence any of them are actually working.

The conference did not paint a totally bleak picture as significant developments at the federal level to address health issues with PSPs were also noted as were innovative programs such PSPNET, a program offering Internet-based cognitive behavioral therapy tailored specifically to PSPs. Last year’s appointment of Carolyn Bennett, as the first federal minister of mental health and addictions was also applauded.

In fact, Bennett’s appointment is just one step in a series of federal initiatives to address PSP health since 2018 including:

• Federal Framework on the federal Post-Traumatic Stress Disorder Act adopted 2018
• Creation of a National Research Consortium between the Canadian Institutes for Health Research (CIHR) and the Canadian Institute for Public Safety Research and Treatment (CIPSRT) as a knowledge hub for PTSD. 
• Announcement in June, 2022 federal budget of $28.2 million for nine projects to address PTSD and trauma in PSPs including development of a knowledge creation hub.    

One caveat to this national positive focus noted by Dr. Joy Christine MacDermid, Forum co-chair and professor of physical therapy and surgery, Western University, was that PSPs often must still seek care within provincial or territorial jurisdictions where access to needed services is extremely variable. “There’s funding for medical services publicly, but mental and physical rehabilitation are largely not funded publicly, which results in medicalization of care,” she said. “This results in multiple sources of inequity, so the care that you get is very much dependent on your location in Canada, your income, your gender, and your employment status.”

Dr. Margaret McKinnon, Homewood Research Chair in Mental Health and Trauma, at McMaster University discussed the impact of the COVID-19 pandemic on PSPs noting that “in many instances the mental health burden on PSPs has been greater than on healthcare workers” . On initial cohort of 200 PSPs surveyed across the country showed:

• 2 in 5 had criteria for a probable diagnosis of PTSD
• 4 in 10 were suffering from clinically significant levels of anxiety
• 6 in 10 10 had clinically significant levels of depression.
• 3 in 10 reported using clinically significant levels of alcohol

“This is deeply, deeply concerning,” said Dr. McKinnon adding the survey also showed that “like health care workers, public safety personnel are also reporting social impairment in their everyday activities at work, at home, and with their families,” said Dr. McKinnon.

Researchers also interviewed about 100 PSPs to determine the top stressors related to COVID-19. These were found to include; tension around whether COVID vaccination should be mandatory for PSPs, concern about not being able to provide the required level of care, exhaustion and burnout, and concerns about bringing COVID-19 back to their families.

“It is not uncommon to hear from public safety personnel who (when they go) to see a mental health provider, that mental health provider, when they hear the stories of public safety personnel, may be crying (and) the public safety member may need to comfort the clinician. What we really need to do is have mental health care providers across the country who understand and know the stories of public safety personnel and are culturally sensitive and able to provide the care that is so desperately needed right now.”

Dr. Carleton reiterated points made by many speakers in his closing remarks.

“We need to go beyond our traditional notions of treatments and fixes to find more public health based solutions,” he said. “We have to learn to intervene at more than one level at the same time. We need to realize that it’s more than psychotherapy, it’s more than primary care that they (PSPs) are going to need. We need to address the systemic problems that they’re facing.”

He added: “At some point, if we have a toxic system in place that they must work within, that’s going to erode their ability to cope and ultimately lead to problematic coping choices and significant harms to their health, in addition to the significant stigmas that they are all facing. In the future, our public safety personnel are going to need to be maintained at the forefront of our thinking when we’re talking about government and community with respect to our public health interventions.”

Physicians using social media in 2022: What’s to know

Every year for the last decade I have been privileged to give an orientation lecture to first year medical students at uOttawa about the professional use of social media for physicians. The following is a long blog post but severely abridged version of this year’s lecture.

This year’s presentation focused on two key themes:

1. The social media world has evolved incredibly in the decade that physicians have been using the platforms professionally
2. The principles for using social media professionally have not really changed at all

Nothing demonstrates the first point better than the stark change between 2013 – when physicians and medical learners were urged to get on social media and try it out because they were smart people who would quickly learn the ropes – and 2022 when physicians must have a good understanding of social media in order to use the platforms safely.

To use a preaching analogy, this year’s lecture was built around two key texts:

1. New guidelines on the use of social media for physicians published by the College of Physicians and Surgeons of Ontario (CSPO) in June of this year.
   1. This new guidance is particularly important because it represents the pre-eminent guidance physicians in Ontario must follow if they want to avoid charges of professional misconduct
   1. The guidance reflects the realities of practice in 2022 as the CSPO has been diligent in keeping up with the times.
2. Remarks made by Dr. Katharine Smart, a Yukon pediatrician who until recently president of the Canadian Medical Association.

In key quotes that follow, Dr. Smart lays out the rationale for why physicians must use social media channels to advocate for evidence-based care. The quotes are from a podcast interview given by Dr. Smart this summer to the CHA Learning – the educational arm of HealthcareCAN – the organization representing Canada’s healthcare institutions.

Dr. Katharine Smart

“We have assumed that Canadians have access to a trusted source of medical information to make their health decisions. But more and more, that’s not the case. Over 5 million Canadians don’t have access to a family care physician, which has always been that source of trusted health information. In parallel we’ve had this evolution of that social media environment where so many people now are going to get information. So we’ve got declining access to experts (but) increasing access to information and we know that on social media health information is often poor.  A recent study showed that 87% of posts about health on social media contain some sort of misinformation. We have to reimagine ourselves a bit as physicians and what our role is in terms of stepping into the public to share information and to counterbalance misinformation, in an effort to improve the health of the public as a whole and communities.”

We’ve got to be on spaces like TicTok, Twitter, Instagram, where a lot more people are interacting, and package our information differently for different ages and different segments of the population.

When you’re in public spaces, and people know you’re a physician, you are representing the profession, whether you want to be or not.  It’s just part of what goes along with the privilege of something like being a physician.”

Dr. Smart also makes the points that social media is not for all physicians but those who choose to use the platforms need the appropriate education to do so – something that is often lacking at the medical learner stage. She also talks about how useful social media has been for her in networking with her peers.

Dr. Smart’s comments are mirrored by the new emphasis that the CPSO guidelines place on physicians only sharing information on social media that is evidence-based. This new emphasis comes directly as a result of the COVID-19 pandemic and the proliferation of non-scientific views by some physicians.

Why consider using social media or social networks professionally as a medical student or physician?

Social networking is a key component of the digital world where physicians now have to practice. To quote Dr. Bertalan Mesko, a Hungarian physician and leading futurist, from a few years ago: “Today’s medical professionals must be masters of different skills that are related to using digital devices or online solutions and mastering those skills is now a crucial skill set that all medical professionals require.”  Changes forced upon medical practice by the pandemic have made this even more important.

I believe part of what Dr. Stern is referring to is the fact that patients use social media extensively to talk about medical matters in general or even their own health. Broader conversations about health policy are also happening there. This has been particularly true since the pandemic.

So, arguably to understand or to participate in those conversations you need a social media presence.

I list here what I believe to be the key ways in which medical learners and physicians can use social media to stay informed

• Follow selective media outlets who often post news first on social media channels before more traditional outlets.
• Follow trusted individuals who curate useful medical information and provide links to original sources.
• Monitor selected journal releases in a timely fashion.
• Up to date clinical information can be obtained following medical conference hashtags. The recent European cardiology conference #ESCCongress is a great example of this.
• Interact with experts
• Monitor important conversations around medical issues – everything from masks in the pandemic to proper airway management

Social media is not only a great way of networking with peers, colleagues, experts and patient advocates but social media channels can also be a powerful way of building alliances. Through networking and use of social media women physicians and racialized physicians have become far more empowered and they have used their social networks for support when challenged by others.

Social media can also be a powerful means of providing inspiration and just provide “feel good” moments at a time when the medical profession needs this more than ever.

Social media is IRL and more and more physicians and others are sharing their lives – not just with friends on Facebook but even in the world on Twitter and LinkedIn.

They’re sharing life changing events in their lives on Twitter. Births, deaths, breakups and breakdowns. They are also sharing what they see and feel and this has been particularly event in relation to COVID-19.

I would argue this is part of a bigger picture. The role of physicians in society is changing – as is the way the medical profession views its own commitment to society.

Unlike a decade ago physicians often maintained separate existences on social media with different accounts for their personal and professional lives – now more and more they are merging the two. The CPSO guidance acknowledges this while stressing that physicians should act professionally however they are using social media.

This personalized approach has been indirectly endorsed by a court decision in Saskatchewan Court of Appeal – the province’s highest court, in a case involving a nurse which stated in 2020 that “Nurses, doctors, lawyers and other professionals are also sisters and brothers, and sons and daughters.” Mr. Justice Brian Barrington-Foote went on to say: “They are dancers and athletes, coaches and bloggers, and community and political volunteers. They communicate with friends and others on social media. They have voices in all of these roles. The professional bargain does not require that they fall silent.”

In an interview in 2021, new CMA president  Dr. Alika Lafontaine 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.

The bottom line is that you can maintain and professional presence on social media and interact professionally while also being a human being and sharing – to whatever degree you feel appropriate – your personal life.

I liken it to being a physician in a small community. You care for patients but you also shop in the local grocery store and take your kids to soccer practice.

The whole issue of whether physicians should maintain two separate personal and professional accounts on social media arises here as well. Two Canadian physicians Drs, Blair Bigham and Sarah Fraser addressed it in a blog post on the BMJ Opinion site. They state 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.”

For every why there is a why not. Ten years ago I didn’t dwell on this but the world has changed and social media have become far more malignant and risky for physicians to use.

Social media has become an ugly, nasty place inhabited by trolls, spamBots and others It can make physicians feel unwelcome and unsafe. There are also any instances in last few years where physician camaraderie has broken down and pitched doctors against each other especially along seniority and gender lines. This has helped highlight fundamental inequities that continue to exist within the practice of medicine.

It takes a certain fortitude and outlook to be able to advocate strongly on social media about divisive issues and it’s not for everyone. It’s impossible to have heated but constructive discussions within the confines of Twitter or other limited social media channels. And the abuse has caused some physicians to abandon Twitter for the relative professional safety of LinkedIn or just to retreat to their small personal social circles on Facebook.

Physicians who plan to use social to promote social causes need to be prepared for abuse that far exceeds what we consider acceptable.

Advice on how physicians should respond to harassment on social media must now, unfortunately, become part of any educational exercise. The following tips come from Dr. Najma Ahmed, a Toronto trauma surgeon and founder of Canadian Doctors for Protection From Guns.

Over the years I have reworded and whittled down advice on how medical learners and physicians can and should use social media professionally, but the advice has remained the same.

Respecting patient confidentiality remains the number one tenet of this advice. Never post anything that will identify a patient unless they very clearly and explicitly request it.

The CSPO and other physician regulatory bodies wants physicians to act on social media in a way that won’t damage the reputation of the profession. On the other hand we have many physicians, especially women, pushing back against the idea that professionalism means being well-dressed, well-behaved, polite, and deferential to authority.

This may be best represented by the hashtag #MedBikini movement which emerged a couple of years ago. Leading social media commentator and pediatric gastroenterologist Dr Bryan Vartabedian blogged about the issue and I quote him at length here:

“A study published in the Journal of Vascular Surgery line itemed the apparent transgressions of a group of surgical trainees. The study, Prevalence of unprofessional social media content among young vascular surgeons, cited breaches of professionalism including wearing swimwear (medbikini), drinking alcohol, profanity and commenting on controversial social topics. Their criteria for unprofessional were based on previously published studies from as recent as 2017. As news got out medtwitter had its own 2020 cancel culture moment under the hashtag MedBikini with thousands of tweets showcasing the unprofessional elements identified in the study. Then bending to post-publication review, the study was retracted on the basis of its methodology and concerns for bias. The faulty foundation of this paper is its failure to understand the standards of medicine’s digital culture. The assumptions about alcohol, bathing suits, language and the public discussion of controversial subjects reflect dated standards about how doctors engage and communicate in a global community. And so this paper is something I might have seen a decade ago when the medical world was petrified that Twitter might be used to share pictures of doctors in bikinis. Times, of course, have changed.”

Dr. Jessica Pearce, an ob/gyn had a more blunt take in a different blog post at the same time:

“Our bodies may have tattoos, ride motorcycles, or compete in pole fitness competitions for sport. None of that impacts our practice of medicine negatively. It’s past time we start celebrating the strength of our bodies and hold accountable those who try to negate our accomplishments with an ill-perceived attitude of sexism and misogyny.”

I closed the 2022 lecture with a quick overview of what I see as current trends relevant to the use of social media by physicians.

Social media channels continue to provide a valuable resource for medical learners and physicians who choose to make use of them.

But more so than ever in 2022, physicians must take the time and make the effort to use these channels in ways in which they are comfortable and feel safe. And more so than ever, they need the education to do this safely.

(A caveat: This presentation was built for an audience of medical learners. As such it does not stress the critical role social media channels have played in helping patients and caregivers also build communities and information channels to strengthen their roles on the health care team)