Doctor dissent: This time it’s personal

Dissent

Two weeks ago a newspaper report noted that the Board of Directors of Doctors Nova Scotia (@Doctors_NS) – the association representing physicians in the province – had removed Dr. Monika Dutt as a sitting Board member.

The incident was reported the same week Doctors Nova Scotia appeared before a Senate committee to protest against planned federal government tax changes which will have a significant financial impact on some physicians. Dr. Monika Dutt (@Monika_Dutt) was one of a small group of physician who has spoken in favour of the elements of the tax package and had promoted an open letter to the federal finance minister generally supporting the government’s proposals. The inference made by many was (despite the absence of any factual information) that Dr. Dutt was removed for taking a stance at odds with the majority viewpoint of the medical association.

The announcement about Dr. Dutt prompted a lengthy thread on Twitter about physicians holding minority views – especially women physicians and medical students and residents – being bullied or intimidated by their colleagues.

Meanwhile last weekend in Ontario, a small but vocal group of opponents to the current leadership of the Ontario Medical Association published a series of tweets highly critical of the association for developing a new code of conduct stating physicians could be disciplined or reported to the provincial licensing college for making remarks deemed to be “hurtful”, “disrespectful”, or “rude”.

Remember, it was in Ontario last year that it was widely reported that the minority of medical students and physicians who supported a proposed new fee deal with the government had been subject to just the type of bullying and intimidation on social media for their views that the OMA appears to be moving address. Nonetheless, this new code was being portrayed as an attempt to stifle those who opposed the current leadership.

All of this is occurring at a time when the Canadian Medical Association (@CMA_Docs) is in the process of developing a new Charter of Shared Values for physicians and its president-elect Dr. Gigi Osler (@drgigiosler) has been active on Twitter stating the CMA wants “want a culture of respect & collegiality, self-care & support, inquiry & reflection, leadership & mentorship, and diversity.”

For its part, the CMA is also strongly opposed to the federal tax cuts as is the OMA and the doctor’s group that opposes the current leadership. However, the CMA has also sponsored open and thoughtful discussions about the deterioration of intra-professional relations between Canadian physicians and the need to create a place for open discourse by physicians with opposing views.

While very different in their details and hiding a complex web of other interwoven issues, these incidents in Ontario and Nova Scotia show just how strongly current cultural and societal changes are impacting the world of Canadian medicine.

Canadian medical politics is no stranger to highly polarized debates. From abortion through to the discussion on medical aid in dying, physicians have often held deeply differing views on what is right. Throughout the 1980s and 1990s, physicians argued vehemently and very publicly about the value of a single, payer health care system and the need for private funding within the system – often during CMA annual council meetings.

However none of these discussions prompted the degree of ill-will and rancour that has surrounding the current discussion over proposed federal tax changes (and at a more local level – the OMA negotiations last year).

Something or things have changed.

Part of it can be attributed to social media and the capacity of individuals to express their views and reach a number of people on platforms such as Twitter not designed for polite, in-depth discourse. As with many social media discussions across all of society, interaction among doctors about politics often deteriorate into simplistic restatements of extreme views. The widely-read nature of blogs also gives some individual doctors a huge, ongoing audience for their particular perspectives.

Also, rather than ethical or moral issues, recent debates have centred on issues that directly threaten the income or financial security of some physicians. Those who are threatened resent the prominence given to the minority views of those who oppose them and also feel physicians who are not directly impacted by the changes should not have a right to comment. A similar argument was made during discussions about fee changes in Ontario where some students were told not to comment on fee issues that did not yet directly involve them. This is a huge slippery slope for physician advocate organizations who want to be able to speak for the profession as a whole.

At a more fundamental level, the male-dominated hierarchical structure that defined the practice of medicine for many decades is being swept away both by the balance in gender numbers between male and female physicians but also societal changes bringing equity and equality to the forefront.

Just as there is talk in society about safe spaces and the need for minorities of any type to have the right to expression without a sense of being intimidated, so some doctors are calling out others for making them feel unsafe about speaking even when no overt intimidation has taken place.

“If you can’t stand the heat, get out of the kitchen” may be the view of some older (or not so old) medical-politicos but it will not stand up today. And while it is commendable for the CMA to state it wants to create a space for open discourse, unless that space is seen as ‘safe’ from the broadest possible perspective it is not likely to attract those who feel they cannot speak up.

Also, while a code of conduct which makes it clear bullying and intimidation does warrant some form of disciplinary response, the OMA is embedded in such a bitter internal battle with some doctors that any such code will be portrayed as stifling free speech rather than helping enshrine it.

At a time when the medical profession feels under threat from governments and society as a whole and Canadian doctors are suffering from burnout in unprecedented numbers, the need for the profession to sort out these issues is paramount. Physicians need organizations that can advocate for them and which they can trust, even when they may disagree personally with some policies.

And this cannot be done unless the profession in Canada acknowledges and moves with the seismic shifts underway in Canadian society that define how members of that society interact with each other.

 

 

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I have seen social media’s future – and it’s full of chest physicians (#CHEST2017)

Poster

Last week, I spent valuable time jealously guarding the only power outlet in a conference hall of about 3500 people so I could live tweet the presentations without fearing suddenly losing power in my laptop. At least at that meeting I had a chair pilfered from the rows of interlocking seating rather than having to sit on the floor next to the outlet which has often been the case.

Imagine my awe to read that the American College of Chest Physicians annual meeting being held in Toronto this week was actually holding designated seating for live tweeters at its most important sessions. Wait, there’s more: Delegates were able to add an “I tweet” ribbon to their name badge at the conference as well as find designated selfie areas throughout the conference to take and share photographs.

In addition, many of the sessions were live-streamed via Facebook and YouTube, an educational tweet chat was held during the meeting and perhaps most importantly there was a clinical session designated to the use of social media in medical education.

In truth, many medical conferences offer some if not all (except for the designated Twitter seating) of these elements plus more to encourage social media use. As Dr. Ali Jalali, one of Canada’s leading physician voices in social media recently noted in an interview, social media use (at least to the extent of having a hashtag designation for the meeting) has become the norm rather than the exception at medical conferences.

However, the American College of Chest Physicians seems to pushing the boundaries both in terms of the supports for social media use as well as the research being done on the subject.

The  session on social media involved pioneering presentations on the use of Snapchat and Storify in medical education. The session also documented the significant growth in the use of Twitter at major U.S. critical care conferences over the past four years, with the abstract concluding that despite a slowing of growth by Twitter itself “the medical community usage of Twitter has grown significantly.”

As is often the case with social media and medical specialties, one physician – namely Dr. Christopher Carroll (@ChrisCarrollMD) seems to be a driving force in this growth. Dr. Carroll is a pediatric critical care physician at Connecticut Children’s Medical Center, Professor of Pediatrics at the University of Connecticut, and social media editor at the journal CHEST – which was one of the first journals to have such a position, I believe.

Social media tools and platforms are a long way from entering the mainstream of medical practice, but as CHEST 2017 indicates, the same cannot be said when it comes to medical conferences.

 

CMA (@CMA_Docs) ups social media ante

Quebec City

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

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

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

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

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

Screenshot (220)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Patient engagement with muscle

Print

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

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

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

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

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

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

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

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

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

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

It’s not a straightforward or easy task.

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

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

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

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

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

Broken windows in the house of medicine

Vancouver

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So:

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

A death on Twitter

shamji

I was on a train moving through the darkness of Eastern Ontario between Toronto and Ottawa when I saw the notification on Twitter that the body of Dr. Elana Fric-Shamji, a family physician at Scarborough General Hospital in Toronto had been found.

It was news that hit the small but active community of Ontario doctors using social media very hard because Dr. Fric-Shamji had been one of them.

For a couple of hours before the announcement of the body’s discovery there had been uneasy communications between some on Twitter after a news report that she had been reported missing. Those worried comments were quickly followed by expressions of sadness and dismay.

Her Twitter account reflected the vibracy of an individual who was enjoying playing with the media as well as becoming more engaged in the local politics of medicine in Ontario.

“What can I say, I love Lord of the Rings,” was her final tweet.

Days earlier, Dr. Fric-Shamji had found Twitter fame (such as it is) with a tweet posted as part of the #trudeaueulogies hashtag mocking Canada’s Prime Minister for praising Fidel Castro at his death, without remarking on the negative qualities of his rule.

“Saddened about the passing of Sauron who, while heavy-handed, did advocate for open borders and usher in industrial era,” tweeted Dr. Fric-Shamji in a tweet that yielded 622 retweets and 945 likes. (For those needing an explanation, Sauron is the main villain in Lord of the Rings)

A week previously, Dr. Fric-Shamji had participated in the council meeting of the Ontario Medical Association – the body which represents the province’s physicians. It was a cathartic meeting for an organization badly torn recently by internal divisions on how to deal with a government unwilling to negotiate on equal terms.

It is also an organization whose members have made transformative changes through the use of social media, and especially Twitter, as internal advocacy and networking tools.

Many who were in attendance at that meeting remembered Dr. Fric-Shamji and her excitement with her new roles and opportunities – in both the professional and personal spheres.

“Proud to represent #Scarborough physicians at #OMACouncil16,” she had tweeted. “Unity, change and advocacy on the agenda.”

The day after the announcement of her death, the Ontario Medical Association issued a news release from President Dr. Virginia Walley, also posted to Twitter, noting how the “close knit community” of Ontario doctors was stunned by the “tragic news” of her untimely death.

That community is now looking for a way to honour Dr. Fric-Shamji’s legacy and help her three surviving young children.

It took a couple of days for the print media to catch up but local and national newspaper are now filled by the story of her death and news that her physician husband had been charged with her murder.

Dr. Fric-Shamjii is not the first of the Twitter physician community to die this year.

Dr. Kate Granger (#hellomynameis) passed away after arguably bringing more humanity to the provision of medical care in the U.K. by asking those providing care to identify themselves by name. Tens of thousands have been touched by her message and her last days of life.

And there were others.  Dr. David Lewis (@DrPlumEU) who died a few years ago, for instance, lives on through his Twitter account which continues to curate news content based on parameters set by Dr. Lewis himself.

I did not know Dr. Fric-Shamji personally and I am not a physician but I was one of 157 people she followed on Twitter … and I followed her.

I felt a few words should be said from here.