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 21st 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)

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.

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)

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.

Misinformation on social media threatens healthcare reform: @CMA_Docs president

Dr. Katharine Smart

Widespread dissemination of misinformation about healthcare on social media is threatening the capacity of Canadians to transform and improve how healthcare is delivered.

That is why Canadian physicians have an obligation and not an option to be active on social media platforms.

This statement was made by Canadian Medical Association (@CMA_Docs) President Dr. Katharine Smart (@KatharineSmart) at the Canadian Conference on Physician Leaders held recently in-person in Toronto. It represents one of the most high profile and strongest statements supporting physician involvement on social media made to date in Canada.

It was probably no coincidence that the #CCPL2022 hashtag was used extensively by physicians and others throughout the two-day meeting – and beyond – with both those in attendance and many others remotely commenting on and retweeting proceedings.

In her address, Dr. Smart singled out as an emerging threat to healthcare “the ineffectiveness of traditional communication tactics in a social media world, the rising threat of misinformation, a loss of trust with experts, and increasing polarization even amongst experts themselves.” She added “I think these issues threaten not only health, but pose fundamental threats to our democracy and civil discourse.”

Dr. Smart asked how physician leaders and physician organizations can compete in this new environment. “Our traditional press conferences are really no match for a well done Tiktoc video or Instagram story. Social media has become the source of information and truth for many people, youth and adults.”

“One of the lessons we’ve learned through the pandemic has been around the critical role of health communication, how much we struggled to do well, and how powerful the misinformation movement can be,” she continued.

“I think we need to recognise that social media is where we’ve evolved in terms of our community gatherings or town halls and how we distribute information and communicate with each other. If we don’t evolve and show a presence on social media to educate and impart our knowledge about health, medicine, science to the public, and even things about the health system itself, other less qualified non medical individuals will.” Dr. Smart said the CMA has made a conscious effort as part of its modernization process to become more involved and engaged on social media and has a result garners millions of impressions monly across its social media platforms.

However, with more physicians and other healthcare providers speaking out and advocating on social media, Dr. Smart acknowledged the number of personal attacks and abuse has risen. At the CCPL last year, past CMA president Dr. Gigi Osler and gun control advocate Dr. Najma Ahmed gave a workshop on just how to deal with this abuse.

Dr. Smart showed a word map demonstrating it is the most emotive words on Twitter that create the most engagement. “I believe that this is driving polarization and can negatively impact information sharing and discourse. People that are yelling are often getting the most attention and the people that actually have productive things to say … don’t always stand out in these spaces.”

She told physicians that “angry advocacy” is not the way to go and that physicians must work to counter the current “infodemic” that “threatens to disrupt and undermine our work.”

Tweets signaled COVID-19 outbreaks

Twitter and other social media platforms can serve as powerful tools to help predict outbreaks of both infectious and non-infectious diseases and should be viewed as more than just a breeding ground for misinformation.

This was recently confirmed in work by Gina Debogovich, senior director at the United Health Group and Dr. Danita Kiser (PhD) at Optum which they discussed at a session during last week’s Health Information and Management Systems Society (HIMSS) meeting in Orlando, FL.

Their assessment of several million US tweets in the early stages of the COVID-19 pandemic, showed that information contained in tweets about COVID-10 was 7-10 days ahead of public case data.

The work of Debogovich and Dr. Kiser was based on the hypothesis that “social media conversations may contain insights into COVID prevalence and may be a leading indicator for cases and hospitalization.” Debogovich said Twitter was chosen as the social media platform to evaluate because meta-data with the tweets often contains the geographic location of the tweet.

In their study, natural language process techniques were used to identify COVID-19 related tweets and classify them into different categories. Statistical analysis and machine learning was then used to determine if the tweets were leading indicators of COVID-19 spread in a community.

In their initial work,  more than 15,000 geo-located tweets that contained either an address or the latitude and longitude of the tweeter were hand classified into 7 primary categories and further divided by proximity or no proximity.

The categories used were:

  • Confirmed (the tweet stated the subject had or believe they had COVID-19)
  • Showing symptoms (the tweet indicated the subject had symptoms of COVID-19)
  • Perished (subject had died as a result of COVID-19)
  • Recovered
  • Quarantine (subject was in quarantine)
  • News (usually about a news article related to COVID-19)
  • Hoax (message contained misinformation)

Tweets were further categorized by whether they contained location data or not.

Having developed the categories, Debogovich and Dr. Kiser then assessed 100 million tweets posted from February 2020 to February 2021. They found that in the first phases of the pandemic public case data lagged tweets by 7-10 days on average. However this was reduced to 2 days in second wave of pandemic.

As a result of these findings, Debogovich and Dr. Kiser concluded that Twitter data could be useful for predicting future COVID-19 cases but the accuracy depended on the dynamics of the pandemic and tweets were most beneficial during times in which cases were rising or trending up.

Waste-water analysis and other tools are helpful in predicting infectious disease outbreaks but digital surveillance could be more effective in predicting spikes in symptoms, said Debogovich.

The study confirms early research done during Twitter’s infancy in which researchers showed how tweets could be used to predict outbreaks of influenza and other diseases. During the presentation, Debogovich said the rapid analysis of the huge amounts of data available on social media platforms remain underutilized for research and public health purposes. Mining data from social media is “hard work” and complex but could be the next big thing in predicting disease outbreaks, she concluded.

Being a doctor on Twitter in 2021

Being a doctor on Twitter in 2021 meant trying to provide the most accurate and timely information possible regarding COVID-19 and the pandemic. But it also meant facing an unprecedented number of personal insults and threats from bullies, bots, anti-vaxxers and others unhappy with what the science indicated.

If you are the president of the Canadian Medical Association (@CMA_Docs), a pediatrician and mother (@katharinesmart) it also meant taking a high profile stance on the value of vaccinations for children and so being called a child-abuser and other names as a result. It also meant being stalked.

Also at the end of 2021, two other prominent COVID-19 physician communicators (@NaheedDosani and @NathanStall) found themselves facing a bounty for urging responsible action in the face of the pandemic.

All of these attacks have resulted in an unprecedented outpouring of support from both other physicians and the rest of the Twitter community as well as support for legislative initiatives to protect doctors and other healthcare providers from abuse both on Twitter and other forms of social media and from those protesting in front of hospitals and other healthcare settings. This reinforced the perspective that Twitter can offer physicians strong supportive communities when they need them.

Being a doctor on Twitter in 2021 meant sharing the good and bad moments in your life from births, marriages and deaths to personal mishaps such as broken ribs (get well soon @DrJenGunter), unfortunate incidents involving racial abuse when you and your partner try and occupy your rental property in Arizona (@DrMakokis) or just the sheer weight of exhaustion and frustration from trying to treat COVID-19 patients with often inadequate resourcing. It also meant making a personal decision about whether you wanted to

  •  present a well-rounded profile to the Twitter world as both a professional and as a person.
  •  maintain two separate Twitter accounts – one personal and one professional (as at least one regulatory College in Canada is now recommending and which virtually no physician that I know does)
  • confine yourself strictly to commenting on professional issues.

While some physicians found Twitter a particularly powerful medium for sharing their stories in broad strokes or as focused anecdotes others such as @EricTopol argued that effective story telling was not possible on social media given the limitations of the platforms. Some prominent and generally well-respected physicians learned the hard way in 2021 how just one Tweet and its 240 character limit can generate a huge Twitter storm of opposition and critical comment after being misinterpreted.

Being a doctor on Twitter in 2021 meant advocating for your patients and especially populations such as the homeless who may not be as well-equipped to advocate for themselves. It means speaking out for Indigenous populations, racialized communities and those in long-term care homes who often bore the brunt of the COVID-19 pandemic especially in the early stages of the pandemic. It also meant amplifying the voices of powerful patient advocates (such as @suerobinyvr) who were already present on Twitter.

For others it meant to continuing to speak out about uncomfortable issues for the profession such as the ongoing structured racism or sexism in medicine or to maintain unpopular perspectives not held by the majority of the profession.

For some physicians (@NaheedDosani @Sgabrie) it meant exploring a new element of Twitter (Twitter Spaces) to expand the scope and audience for this advocacy.

Being a doctor on Twitter in 2021 meant using pictures, memes and inspirational quotes to try and maintain the morale and well-being of your colleagues.

It also meant sharing powerful professional experiences and beautiful pictures so a those posted by public health and preventive medicine resident @yipengGe from his elective rotation in Iqaluit.

Being a doctor on Twitter in 2021 meant using the platform to communicate the already powerful messages you were already relaying so effectively in prominent newspapers and books (@nilikm and  @GillianHortonMD) or in radio broadcasts (@NightShiftMD). It also meant amplifying those messages by posting more personal reflections on what had been said elsewhere.

Being a doctor on Twitter in 2021 meant continuing to foster productive conversations between the profession using the platform (the regular weekly tweetchat #healthxph in the Philippines continues to stand out in this regard) or to provide a consistently thoughful physician voice on more general platforms (thinking of you, @gailyentabeck and #hcldr). It also meant continuing to fill a valuable role in live tweeting from what proved to largely be virtual medical conferences in 2021 – although none will probably ever being able to match the productivity of @rheum_cat and the volume of her tweeting at #ACR21.

Being a doctor on Twitter in 2021 meant continuing to explore the value of Twitter and other social media platforms in medicine and in advancing this knowledge in academic publications. As always @TchanMD from McMaster continues to excel in this regard from a Canadian perspective.

Being a doctor on Twitter in 2021 meant, for some, choosing not to be on Twitter any more and to either confine oneself to other social media platforms (especially LinkedIn) or avoid social media altogether because of the growing toxic nature of the platform. In fact I saw more physicians leave Twitter in 2021, some temporarily others for good, for this reason. It’s a view I can totally appreciate.

For those of you who choose to stay, I believe 2022 will show Twitter to be just as rewarding, frustrating and generally cantankerous as ever.

Lead illustration courtesy of The Cut

The (healthcare) social CEO: Now more than ever


The social CEO: Now More Than Ever

Social media can make you a stronger healthcare leader – especially in times of crisis such as the current #COVID-19 pandemic.

One need only look to individuals such as @DrJoshuaTepper, the current president and CEO of North York General Hospital and former CEO of Health Quality Ontario. Over the past few years, Tepper has shown seemingly effortlessly how he uses Twitter to engage with different audiences, espouse views that matter to him, and amplify messages from the organizations which he is represents.

But Tepper and others like him continue to be the minority in the Canadian healthcare system.

Which is why Damian Corbet’s book The Social Ceo: How Social Media Can Make You A Stronger Leader (@TheSocialCsuite) released last year is particularly relevant. In the book, Corbet provides strategies and techniques leaders can use to develop and maintain strong social media platforms.

Corbet also provides a number of first person case studies of CEOs in various industries who have harnessed social media to advance their agendas. For the healthcare sector, Corbet could not have chosen a better voice than that of Julia Hanigsberg (@Hanigsberg), the President and CEO of Holland Bloorview (@hbkidshospital) in Toronto.

As with Tepper, Hanigsberg, has proven adept at using social media and especially Twitter to develop a respected presence and expand her role as CEO to incorporate new communications channels.

As she writes in the book, “my approach has been to use social media as an extension of transparency in my leadership … If you imagine the quintessential open-door leadership approach, how much more effective is it if that door is open to all of Twitter?”


CEOs such as Hanigsberg and Tepper have been able to use their strong presence on Twitter and other social media platforms to become trusted and credible voices when it comes to COVID-19.  It is easy to find many other good examples in Canada such as @AlexMunter, the president and CEO of the Children’s Hospital of Eastern Ontario and relative neophyte social media presence @BrucePSquires, the President of McMaster Children’s Hospital.

In national or provincial healthcare organizations examples again are easy to find, such as @DorisGrinspun, CEO of the Registered Nurses Association of Ontario and @EGruenwoldt, President and CEO of Children’s Healthcare Canada.

They all bring an an authentic presence, transparency, and credibility to the discussions taking place.

But social media is not for all healthcare CEOs.

If it does not fit your personal style and if you do not have the support of a strong communications team, social media can be at best an onerous additional burden and at worst a public relations nightmare. Communications staff can help with providing strategic guidance and monitoring of social media accounts but those CEOs who abdicate their personal accounts totally to the control over others are missing the point, big time.

It needs particular skills and presence to be willing to put yourself forward on social media and to be the target of every member of the public (and/or staff) who are unhappy about your particular organization. Also, in many Canadian organizations and associations, the CEO is not the official spokesperson for the group and that often precludes them having a strong professional role on social.

Some healthcare organizations such as Michael Garron Hospital in Toronto took an organized approach some years ago and trained the C-Suite as a unit on how to use social media effectively. This paid off with individuals such as hospital VP @IreneAndress continuing to use Twitter to great advantage.

However, many healthcare organizations continue to struggle to develop comprehensive social media strategies and find a fit for the CEO in those strategies.

After reading Corbet’s book I quickly roughed up a list of pros and cons for healthcare CEO involvement on social media:

Why the CEO should be on social.

  • Raise profile of CEO as chief spokesperson for the organization
  • Amplify work of the organization
  • Provide a more personalized approach
  • Permits more engagement with others than corporate account
  • Potential to increase credibility of the organization
  • Provide ability to network/connect with other senior-level health care administrators
  • Allows use of other social strategies such as tweet chats
  • “Go where you stakeholders/constituents are”


  • Needs personal attention to be effective (e.g. posts not done by corporate staff)
  • Can be time consuming to monitor and manage
  • Can open CEO to attacks and unpleasant interactions
  • Can raise unreasonable expectations from those expecting direct action from CEO
  • May not match personal style/approach of CEO

As noted above, social media is not for all CEOs.

But for those or are interested and looking for a handy primer, The Social CEO is a good, current primer.

Help for the helpers: #Covidwellness tips


Last Thursday evening, a small but dedicated group participated in a #COVIDWellness tweetchat and shared tips and advice for supporting healthcare providers during the current COVID19 pandemic.

Organized by @ChildHealthCan, the chat was co-hosted by @BrucePSquires, president of McMaster Children’s Hospital, @DrGigiOsler, past-president of @CMA_DOCS, and @KathyReid5, nursing leader at Stollery Children’s Hospital.

The hosts and others shared not only useful information on dealing with today’s situation but also for one hour created a positive community

Much of the information provided reinforced what other credible individuals have been saying about maintaining good mental and physical health during this time while striving to stay safe but connected.

A small sampling from the chat follows: