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.

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)

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.

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)

Safety not convenience needs to guide use of virtual care: CMPA

CMPA Panel on Virtual Care

Safety not convenience should determine when to offer virtual care, according to a new white paper from the Canadian Medical Protective Association (CMPA). The CMPA document places a strong emphasis on the need for the development of clear and consistent professional and clinical guidelines and standards for delivering virtual care.

The document was released in conjunction with CMPA’s annual meeting which hosted an information panel of experts discussing the medical-legal realities of offering virtual care emerging from the COVID-19 pandemic.

In its white paper, the association called on guideline development to be done by specialty societies and by regulatory authorities who should “adopt consistent licensure requirements for virtual care delivered from another province or territory.”

“Physicians must be allowed to continue to use their professional judgment about whether virtual care is appropriate in the circumstances of each patient,” states the white paper. “However, guidelines and standards can help physicians make these decisions in a way that enhances both access to, and safety of, care and minimizes medico-legal risk.”

The report details some of the ongoing challenges with rolling out virtual care in Canada:

• the fragmented approach across the country with respect to interprovincial licensure requirements;
• an inconsistency in standards and guidelines for the reasonable to use virtual care;
• lack of proper infrastructure and training about the various modalities of virtual care; and
• lack of access to secure virtual care platforms.

While the decision when to offer virtual care rests in the hands of the physician, the CMPA also notes patient preference and autonomy should be respected.

It was CMPA CEO Dr. Lisa Calder who perhaps most accurately summarized the panel discussion and current state of virtual care in Canada in her remarks after the panel when she noted the lack of clear focus and direction for the appropriate use of virtual care.

Speakers in the panel session such as CMA President Dr. Katharine Smart and College of Physicians and Surgeons of Ontario CEO Dr. Nancy Whitmore noted the huge advances made in the use of virtual care made necessary by the COVID-19 pandemic. Dr. Smart also suggested that if regulatory hurdles could be overcome then virtual care could help address the current crisis in healthcare staffing.

“The reality is we know there’s areas that are very well resourced and areas that aren’t and and I think there’s some potential for virtual care to bridge that,” she said, “(and) I think there are also opportunities to be providing virtual supports in places that don’t necessarily have a physician.”

Cautionary notes were struck by CMPA panel representatives who noted the impact of the huge increase in the use of virtual care on the medico-legal landscape is still not clear. “I think many of us intuitively think there are risks (but) we haven’t seen the hard data to confirm that at this point in time,” said Dr. Pamela Eisener-Parsche, executive director of member experience.

“The judgment that physicians need to bring to deciding how they implement virtual care in their practices is actually different today, than it was in April or May of 2020 when many of us were in lockdown,” said Dominic Crolla, senior legal counsel for CMPA. “Although we’re in Western Canada (the CMPA meeting was being held in Vancouver), it’s not the Wild West. Virtual care, for physicians at least, has real, ethical, legal and professional standards.

Another cautionary note was struck by one physician in the audience who commented “I’m seeing virtual care being used for the convenience of physicians, and not in small ways.” However, Dr. Smart countered that when it comes to virtual care “the vast majority of people are going to do a great job and the right job and make good decisions.”

While Dr. Smart spoke enthusiastically about the positive impact of virtual care on her pediatric practice in Whitehorse it was her comment that “there is no substitution still in medicine for a good history and physical exam” that seemed to resonate most with those commenting on the session through Twitter.

Discussion during the panel also touched on the need for appropriate remuneration, the problematic nature of virtual walk-in clinics offering only episodic care, the important role of equity in delivery of virtual care services and the toll providing virtual care has taken on some physicians.

Equity and diversity addressed in new social media guidance for Ontario doctors

For the first time, Ontario physicians are being given advice by their regulatory body on how to use social media to support equity diversity and inclusiveness (EDI).

The guidance is contained in a companion document to a new policy on social media published last month by the College of Physicians and Surgeons of Ontario (CSPO). The new policy puts an emphasis on preventing conduct on social media that could harm the public’s trust in individual physicians and the profession especially the publication of misinformation.

The updated CPSO policy and companion materials show the regulatory body continues to keep pace with the current social media environment and also drops what I saw as some of the more controversial aspects that were contained in draft materials published a year ago as detailed in an earlier blog post. The reference to physicians swearing on social media as an example of disruptive behavior has been dropped. Also dropped is advice for physicians to maintain separate professional and personal accounts.

The new CPSO policy stresses the need for physicians to act professionally on social media by not posting misinformation and only posting information that is “verifiable and supported by available evidence and science.” The policy also acknowledges the important role physicians have in advocacy and states “while advocacy may sometimes lead to disagreement or conflict with others, physicians must continue to conduct themselves in a professional manner while using social media for advocacy.”

The new policy places an emphasis on protecting patient information and not sharing individual patient information without very clear, explicit consent from the patient. The policy also states physicians must refrain from seeking out a patient’s health information online without patient consent. However, the policy details several exceptions including if the information is necessary for providing health care or if accurate or complete information cannot be obtained from the patient and obtained in a timely manner.

The new section on EDI states “It is also important for physicians to be aware that their conduct on social media (including liking, sharing, or commenting on other content) may be visible to others and that unprofessional comments and behaviour (which can be overt, or more subtle, like microaggressions) have the potential to make others feel marginalized and impact their feelings of safety and trust, and potentially impact patients’ willingness to access care.” The section references cultural safety and humility and says the CPSO supports physicians “striving to foster” an inclusive environment.

The advisory document notes physicians may choose to keep professional and personal accounts on social media but acknowledges the professional and personal are not always easily separated and says it is important that physicians act professionally in both contexts.

In addition to the specific reference to advocacy in the new policy, the CSPO also addresses this at more length in the companion document. For example, it notes that “if you practise in an institutional setting, you may be subject to their policies or guidelines around social media use. Some institutions may require express permission before engaging in advocacy activities on social media that could be interpreted as directly involving them.” When advocacy efforts on social media could impair a physician’s ability to deliver quality care or collaborate with others, the CPSO says the physician should consider whether their advocacy activities “are in fact in the best interests of patients and the public.”

The College also recognizes physicians can experiencing personal attacks or harassment online due to their advocacy activities and supplies a link to a list of health and wellness resources as well as urging physicians to be aware of privacy controls and reporting mechanisms they can use.

#AI: Risks and Challenges (June 2022 edition)

Last week’s virtual e-Health conference and tradeshow featured some intriguing examples of how AI and machine learning are being used in the Canadian healthcare context – from developing a screening blood test for breast cancer to helping public health officials to manage the COVID-19 pandemic.

Perhaps more significant was a panel discussion on “practicing responsible” AI which noted that while AI has the potential to expand health services in underdeveloped regions globally, it also creates risks of creating “data poverty” by not properly including populations in the databases used to create the algorithms running clinical programs driven by AI.

A just published report by the European Parliament Panel for the Future of Science and Technology provides more of a deep-dive into the risks and ethical and societal impact of AI and machine learning touched on in the panel discussion at e-Health.

The European report was based on “a comprehensive interdisciplinary (but non-systematic) literature review and analysis of existing scientific articles, white papers, recent guidelines, governance proposals, AI studies and results, news articles and online publications.”

The report notes that “AI has progressively been developed and introduced into virtually all areas of medicine, from primary care to rare diseases, emergency medicine, biomedical research and public health. Many management aspects related to health administration (e.g. increased efficiency, quality control, fraud reduction) and policy are also expected to benefit from new AI-mediated tools.”

In the clinical setting specifically, the European report authors state the potential of AI “is enormous and ranges from the automation of diagnostic processes to therapeutic decision making and clinical research.”

The report goes on to identify and elaborate upon 7 main risks associated with the use of AI in medicine healthcare:

• patient harm due to AI errors
• the misuse of medical AI tools
• bias in AI and the perpetuation of existing inequities
• lack of transparency
• privacy and security issues
• gaps in accountability
• obstacles in implementation

“Not only could these risks result in harms for the patients and citizens, but they could also reduce the level of trust in AI algorithms on the part of clinicians and society at large,” the authors state. “Hence, risk assessment, classification and management must be an integral part of the AI development, evaluation and deployment processes.”

Even with large-scale datasets with sufficient quality for training their AI technologies, the report says there are still at least three major sources of error for AI in clinical practice.

1. Having AI predictions significantly impacted by noise in the input data during the usage of the AI tool. Eg. Scanning errors when using AI in ultrasound scanning.
2. AI misclassifications due to dataset shift that occurs when the statistical distribution of the data used in clinical practice is shifted, even slightly, from the original distribution of the dataset used to train the AI algorithm.
3. Predictions can be erroneous due to the difficulty of AI algorithms to adapt to unexpected changes in the environment and context in which they are applied.

The report authors outline the potential for misuse of medical AI tools and potential mitigating factors in the chart below:

From: European Parliament : Artificial Intelligence in Healthcare

When it comes to the know well demonstrated potential for bias in AI, the report suggests mitigating these risks by:

• Systemic AI training with balanced and representative datasets
• Involving social scientists in interdisciplinary approaches to medical AI
• Promoting more diversity and inclusion in the field of medical AI

The report notes accountability is key to the greater acceptance of AI in the field of medicine. “…clinicians that feel that they are systematically held responsible for all AI-related medical errors – even when the algorithms are designed by other individuals or companies – are unlikely to adopt these emerging AI solutions in their day-to-day practice. Similarly, citizens and patients will lose trust if it appears to them that none of the developers or users of the AI tools can be held accountable for the harm that may be caused.” For this reason, the report authors state: There is a need for new mechanisms and frameworks to ensure adequate accountability in medical AI …”

Of course, the European report is far more comprehensive than the summary above and also provides detailed suggestions for mitigating the risks it identifies – some specific to the European policy environment and others not.

Building the health data system Canada needs (#VCAHSPR22 #Ehealth2022)

From: Expert Advisory Group Report 3: Toward a world-class health data system

Canada may be in desperate need of a world-class, person-centric health data system but the drive to implement such a system certainly isn’t making headlines … even though patients are being harmed and sometimes dying without one.

A month ago, the Pan-Canadian Expert Advisory Group (EAG) released its third and final report on developing such a system, to what can only be described as a total lack of media attention. The EAG was established in the fall of 2020 under the chairmanship of Dr. Vivek Goel with support from the Public Health Agency of Canada.

While Canadians may badly need and strongly support the set of common principles outlined in a Canadian Health Data Charter – endorsement of which was the first recommendation of the advisory group – it’s hardly a topic to knock Ukraine or even  the Ontario election of the front pages of newspapers.

However this week the EAG did have an opportunity to give a comprehensive account of its work and the issues involved at the annual meeting of the Canadian Association of Health Services and Policy Research (#CAHSPR22).

Serendipitously, the e-health 2022 Virtual Conference & Tradeshow (#ehealth2022), occurring at the same time, featured a panel discussion in which representatives from Canada’s main players in the digital health space – Canada Health Infoway, the Canadian Institutes for Health Information (CIHI) and Digital Health Canada – discussed how they were collaborating to address interoperability of health systems. As those working in digital health have know for years, interoperability is one of the key facilitators needed to overcome some of the barriers spelled out by the EAG in its reports.

As part of the EAG presentation, Eric Sutherland noted that the currently health data in Canada is “as protected as possible and as open as necessary” and a radical culture shift is required to flip this paradigm. Dr. Ewan Affleck, another member of group, made a strong case for core principles in a Data Charter to make this happen. “We have a moral obligation to do this because we are failing Canadians if we do not,” said Dr. Affleck.

While there is not space here to outline all that the EAG proposes for such a charter, the highlights include the need for:

• Person-centric health information design to ensure that health data follow the individual across points of care to support individual, clinical, and analytical access and use.
• The quality, security and privacy of health data to maximize benefit and reduce harm to individuals and populations.
• Literacy regarding health data and digital methods for the public, decision-makers and the health workforce.
• Harmonization of health data governance, oversight, and policy.
• Support for First Nations, Inuit and Metis Nation data sovereignty.

As for implementing the strategy, the EAG calls for endorsement of the principles in the charter as a first step with other incremental advances being made towards implementation of the full strategy in a decade. The EAG also acknowledges the importance of collaboration among key players, including levels of government and the public, to bring about the strategy.

The full text of the EAG’s third report can be accessed here.

For their part the e-Health panel noted that the availability of health data in a common, standardized and structred format is the key to interoperability. Abhi Kalra, VP, Portfolio Management, Virtual Care Programs, Canada Health Infoway acknowledged, the journey to interoperability has taken some time but key organizations are now leveraging their assets and working collaboratively to bring it closer to reality.