Continuity of care trumps instant access to virtual care: Poll

Canadians like the convenience of having instant access to virtual care through virtual “walk-in” clinics but the majority place a higher value on having an established relationship with their own primary care physician.

That’s one of the conclusion that can be drawn from findings of a new poll by Ipsos conducted on behalf of the Canadian Medical Association.

The study focused specifically on the perceived value of the continuity of care that is a cornerstone of the traditional doctor-patient relationship between primary care physicians and patients in Canada. This continuity of care was also the focus of a recent report by the College of Family Physicians of Canada which was highly critical of for-profit virtual care.

The online Ipsos poll of 2,000 Canadians was conducted conducted between September 14-23, 2021.

It found that 81% of respondents agreed it is important to have an ongoing relationship with a family doctor who understands their changing needs, while 79% agree it is important to have an ongoing relationship with a family doctor who understands them as a person.

Asked whether they placed a higher priority on an ongoing relationship with a family doctor or team or on having care that was more convenient, 59% of those polled favoured the ongoing relationship while 33% gave equal importance to continuity of care and convenience.

Asked about virtual walk-in clinics where patients can receive care by phone, video or other means when they want it, only 9% of respondents placed the value of this service above having an ongoing relationship with a family doctor. However about a third of those polled said they are less concerned about having an ongoing relationship with one family doctor, if the doctors and health care providers providing their care had electronic access to their health records.

Of the 36% of Canadians who said they had used a virtual walk-in clinic, 48% said the experience was positive – a rating that falls below the 59% of who report an overall positive experience with a family physician. While only 28% of all those surveyed said they would consider using a walk-in clinic, 40% said they would be more likely to use a virtual walk-in clinic than a family physician for minor illnesses or injuries or for prescription refills. The same percentage said they would trust a doctor in a virtual walk-in if they did not have an established relationship with a family doctor.

Despite the problematic findings about virtual walk-in clinics in this poll, other findings confirm how virtual care is becoming a standard feature of medical care in Canada since the COVID-19 pandemic began. Six in 10 of those surveyed said they were aware their family doctor offers virtual services, an increase from before the pandemic when only 12% knew their family physician offered this service. In addition, more than half (54%) said it was very/somewhat important to them that their family doctor offer virtual services.

While the telephone remains both the preferred means and actual way in which patients access virtual services, the survey did find the percentages of patients wanting to communicate by either video, email or text were significantly higher than what their physician currently offered.

Based on the findings in the survey and more in-depth conversations with a smaller group, Ipsos concluded that “continuity of care is important for the majority of Canadians … but virtual episodic care has a role to play in providing more timely access to health care and it is seen as somewhat overdue in today’s digital world.”

Virtual Care in Canada: An update from organized medicine

The COVID-19 pandemic has catapulted virtual care into the mainstream of healthcare delivery but there is still “much work” to be done to establish high quality virtual care as an integral part of the publicly funded Canadian healthcare landscape.

That’s the conclusion from representatives from Canada’s three main medical organizations – the Canadian Medical Association, The Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada working in conjunction with patient representatives to produce the just-released Virtual Care Task Force (VCTF) report.

Acknowledging that virtual care has not benefitted everyone equally during the pandemic, the report’s authors also emphasize the need to make equity a foundational principle for the delivery of virtual care going forward.

The report is the second from the VCTF which released its first report exactly two years ago, the same day the World Health Organization put a name to COVID-19. At that time, virtual visits by telephone, text or video formed only a small portion of how care was delivered despite the capacity to do so having been in place for some time.

As the second report documents, the COVID-19 pandemic drastically changed the situation. With the imperative to offer physically distanced care in order to protect both patients and physicians, the report shows how fee structures were amended almost overnight in all Canadian jurisdictions to encourage physicians to offer care virtually. The report quotes a number of Canadian surveys showing the dramatic increase in the number of virtual visits as well as generally high levels of patient and physician satisfaction with virtual care.

The report goes on to trace how the “virtual first” philosophy in 2020 evolved over the following months to the extent that by the fall of 2021, governments and regulatory bodies were urging physicians to offer more in-person care and to gauge when it was appropriate to offer virtual care. The report also shows just how much effort has been invested by the federal government and a number of other organizations in the last two years to assess and recommend how to best provide virtual care.

As with preparation of the first report, the task force created subcommittees and considered virtual care from four perspectives; interoperability and governance, licensure and quality of care, payment models and medical education.

In addition to stressing the need for equity, recommendations in the new report call for:

  • Ensuring that appropriate virtual care services are funded as part of the publicly funded health care system.
  • Promoting guidance for providers and patients on the appropriate use of virtual care
  • Having governments and medical associations work together so
    • physicians are paid at the same rate whether care is provided virtually on in-person
    • there is support for an appropriate balance of both in-person and virtual care
    • payment is made for virtual care services provided asynchronously via secure email/text messaging

Recommendations in the initial report called for the need for a framework for pan-Canadian governance of virtual care and the need for medical regulators to establish standards to support “competent and safe virtual care” and these were reaffirmed in the new report. On the issue of governance, the report notes there continues to be a need for “the adoption of true patient co-design in developing a virtual care governance model as a standard of being”.

However, the task force notes, pan-Canadian licensure for physicians, which is seen by many as a necessity to allow doctors to provide virtual care across provincial borders, is no closer than it was two years ago. “While development of a pan-Canadian medical licence remains of high interest to many, little concrete action has been taken in advancing this initiative since the release of the initial VCTF report,” says the report. “In fact, when it comes to virtual care, some regulatory authorities have strengthened their requirements that physicians must be licensed in their jurisdiction to offer care to patients in that jurisdiction.”

In addition while governments were quick to allow physicians to bill appropriately for virtual care, the report notes these changes to fee schedules have only been made permanent in one jurisdiction to date.

The report concludes by stating:

While events since February 2020 have done much to advance many of the recommendations made by the VCTF and its working groups, incorporating virtual care optimally into the Canadian health sector requires more work on the part of the federal/provincial/territorial governments and national organizations. Specifically, there is a need for universally endorsed principles of virtual care design and deployment, and an aligned virtual care governance and policy approach across all jurisdictions.

The report’s authors also finish with a warning about the continued growth of private companies offering virtual care services outside of the publicly funded health care system and state this requires urgent attention. “This trend is just one of several issues that must be addressed to ensure that virtualized services improve access while maintaining safe and equitable service — something that the VCTF feels is currently lacking.”

The VCTF was co-chaired by Drs. Ewan Affleck, Kenneth Harris and Gigi Osler. Task force membership included representatives from many medical organizations as well as patient representatives.

Medicine: Job or Calling

Nothing bares the soul of medicine more than a discussion about whether being a physician is a job or a calling.

And nothing demonstrated this better than what occurred earlier this week when a US physician with 44,000 plus followers on Twitter posted the following series of tweets, thereby igniting the day’s health care Twitter firestorm:

Many if not most of the hundreds of responses to these tweets from other physicians expressed outrage or disappointment with the views expressed. To quote a couple:

  • I’m sorry I don’t buy this at all. I’m fulfilled when I have a healthy balance between my work, my home life and my pastimes. Doctors staying late and long after others have left would actually signal to me …that they might be in difficulty.
  • In my experience it’s the people who set themselves on fire to keep the hospital warm that get the most burnt out.
  • Giving 100+% every day is exhausting. And it becomes more & more exhausting when you’re told that it’s never enough, you’re easily replaceable & you need to do better. I love caring for patients, but I am reaching my limits. Most of my colleagues have already reached theirs.
  • The belief that medicine is a sacred calling where one must sacrifice your family, your friends, and your mental health, or else you are not a truly committed professional… is one of the most hideous and toxic ideologies out there.

While such a visceral response is to be expected to controversial tweets, it is not the only example of how deeply this particular issue can divide dedicated professionals.

Whether medicine is a job or a calling was also featured as the closing debate at the Canadian Conference on Physician Leadership in April, with physician speakers from across the age spectrum. Even though these debates are always formally structured with speakers selected to argue a particular perspective in a good-humoured way, the intensity of perspectives on the issue came through clearly.

The question of calling or job is never going to be answered definitively. Those of us who are not physicians can only hope that those who choose medicine continue to maintain and support the health of the individuals and populations they serve without fatally impairing the health and wellbeing of themselves or their families.

@OntariosDoctors burnout report targets technostress

A white paper from the Ontario Medical Association (@OntariosDoctors) produced by a task force on physician burnout is one of the first in Canada to deal explicitly with the toll on physicians from practicing in a digital environment and identifying potential solutions.

A number of studies and policy documents from the US over the last few years have documented how use of electronic medical records (EMRs) and hospital point-of-care systems have contributed to physician burnout due the requirements for additional documentation and record-keeping.

While similar concerns have been voiced in Canada, country-specific data has been lacking, as have advocacy initiatives and proposals to address the issue.

“Healing the Healers: System-Level Solutions to Physician Burnout White Paper” deals with the issue head-on. One of its five recommendations for addressing physician burnout calls specifically for seamlessly integrating digital health tools into physician workflows. The first recommendation from the report concerning documentation and administrative work also addresses the burden placed on physicians by EMRs and hospital administration systems.

Chaired by physician health expert Dr. Mamta Gautam (@PEAKMD), the task force that prepared the document references the finding that physicians spend two hours on electronic documentation for every one hour of direct patient interaction.

To address this issue, the task force identifies the use of medical scribes as a means of relieving the burden on physicians by having someone else document patient encounters in real time. However, the task force notes that significant additional expense is involved with this approach and states that individual physicians should not have to pay for this means of reducing their incidence of burnout. The report goes on to note that “virtual scribes” or AI scribes might provide innovative solutions at a lower cost.

Finally, the task force discusses simplifying the multiple log-on process required for physicians to access a number of different systems as an effective way of saving a significant amount of time and frustration.

On the specific recommendation of integrating digital tools into physician workflow, the task force states this is essential to reduce the stress for physicians associated with using EMRs and other digital systems. More specifically the report recommends “implementing interoperability standards to ensure physicians can seamlessly access patient records and share patient health information among care providers.”

Another recommendation which hearkens back to the very start of the EMR era calls for physicians to be key partners from the start in the procurement, design, implementation, and ongoing optimization of digital health tools to ensure usability.

A third recommendation in this section dealing with change management, which had been a key tenet of the best physician EMR implementation programs in Canada in the 1990s and 2000s, is to “equip physicians with comprehensive and ongoing training on digital health tools.”

@cpso_ca draft social media policy profoundly challenging

The College of Physicians and Surgeons of Ontario (@cpso_ca) has published its new draft policy statement on the use of social media by physicians and, I fear, if implemented as written it could have a chilling effect on how physicians represent themselves. In proposing strong new language to enforce professional behavior when using social media, the CPSO risks alienating many of its members and could see doctors in Ontario abandon social media platforms to which they contribute so much.

It’s a fine line because many of the changes proposed are being done for the right reasons to discourage the posting of health information that is not evidence- and science-based and to discourage posts that could be described as harassing, bullying or discriminatory. The new draft can also be applauded for containing a preamble discussing how physician professionalism supports equity, diversity and inclusiveness and also includes specific acknowledgment of the importance of advocacy.

The CPSO has always been in the forefront among Canadian regulatory authorities in considering the impact of social media on physicians and their patients. The current policy statement dates from 2013 and was opened for revisions last year as I noted in a blog at the time. The impact of the policies cannot be overstated because contravening them can leave physician open to charges of professional misconduct.

As noted in a document for its June Council meeting, 366 responses were received from the external consultation on the new draft document with the majority of these coming from physicians. This briefing document also noted that since the original 2013 statement “social media use among physicians has increased significantly and presents new risks and challenges for physicians to navigate …”

Many of the proposed changes are aimed at addressing concern about the current statement being too vague in defining unprofessional behavior by physicians on social media. The council briefing note also explains that the draft policy includes new requirements around disseminating general health information, recognizing the concerning spread of misinformation on social media in past years (e.g. anti-vaccination views, misinformation related to COVID-19).

The new policy statement has a lot of “must and must nots” that were lacking in the current statement, such as:

  • Physicians must conduct themselves in a respectful and professional manner while using social media
  • Physicians must consider the potential impact of their conduct on their own reputation, the reputation of the profession(emphasis mine), and the public trust
  • Physicians must not engage in disruptive behavior … including use of profane language (i.e. no more swearing)

The new draft policy hits all the right buttons linking physician professionalism with values such as altruism and cultural humility. But one wonders how this new statement will be interpreted by those who see strong-handed enforcement of professionalism as maintenance of the traditional, parochial approach to medicine that runs so counter to the outlook of the many women physicians who have taken to social media to advocate for more gender equality.

The statement about not sullying the reputation of the profession on social media also raises a big red flag as we have seen how another health profession in Canada unsuccessfully tried to use this to stop an individual from voicing legitimate concerns on social media about the delivery of care.

As with the existing policy, the new policy also deals with the area of professional relationships and boundaries stressing that physicians “must” maintain professional boundaries with patients, persons closely associated with patients, and colleagues while using social media. While the existing document has an end-note saying some physicians may choose to do this by maintaining separate online presence for personal and professional networks, the guidance document for physicians about the draft policy is more forthright in stating “having a separate professional account can help you maintain appropriate boundaries on social media.”

This advice seems outdated in an era when physicians are moving to be more well-rounded individuals on social media blending professional and personal interests. Some of the most respected physician social media accounts share personal details and professional views in a compelling manner.

I would argue that in any community, a physician can be themselves with personal interests while at the same time maintaining therapeutic relationships with patients. Some of my favourite Ontario physician Twitter accounts mix strong views on a wide variety of topics with questionable cooking tips, wine reviews, family snapshots and more.

Bifurcating physicians on social media is not the way to go. And has been argued recently by two Canadian physicians, creating this artificial divide could impact the effectiveness of physicians as advocates.

While I believe it is flawed, the new @cpso_ca document is a brave attempt to wrestle with defining how physicians should be using social media in 2021 – a world that has changed profoundly since the guidance of 2013.

Those interested have until the end of August to comment on the new draft statement. Given how much there is to unpack in this new important document – beyond what has been discussed in the confines of this current blog – I would urge reading the new draft policy and background document here.

Twitter sings a new healthcare tune

Like a fish emerging from the primeval swamp to take it first breaths on land, something new has emerged from the depths of healthcare social media that could represent an evolutionary step in networking on Twitter.

Interestingly, from my perspective this development has come from two widely separated groups geographically and in two slightly different formats.

Call it Tweet chat with a new voice.

Tweet chats were long the mainstay for healthcare discussions on Twitter fostering both live, interactive discussions of informative health issues and serving as a regular network and community for those who participated on a regular basis.

In its most mature form, Tweet chats involved a well-established hashtag, regular hosts and scheduled times for the chat. A blog was posted online to inform the discussion with a series of questions that were addressed during the chat with moderation by the hosts. However, as these chats were generally administered by dedicated volunteers (think @drlfarrell at #irishmed and @colleen_young at #hcsmca) and topics became repetitive, many of these Tweet chats were retired.

The form lives on successfully with healthcare chats such as #hcldr and #healthxph in the Philippines but in the latter case an evolutionary jump as recently taken place.

Since earlier this year, the dedicated physicians who co-ordinate #healthxph have paired the social media chat with a Twitter Spaces live audio discussion of topics for their regular Sunday chats. Twitter Spaces is the new functionality that allows groups to talk together in real time. An invitational platform called Clubhouse offers very similar functionality.

Now with #healthxph weekly chats, one can discuss the questions raised through tweets as usual/discuss the questions through the audio platform or do both. To improve coordination, #healthxph has a volunteer summarize the points made in the verbal chat and post them as tweets.

At the same time this development was occurring, two physicians (@SGaibrie and @NaheedD), health navigator @Leeanninspires and health advocate @SabiVM  launched @hcinCanada, a Twitter account dedicated to hosting chats on Twitter Spaces (although the group initially started the concept with Clubhouse).

Forgoing the traditional trappings of the Tweet chat, the @hcinCanada hosts welcome high-profile guests to discuss socially relevant health policy issues in Canada at a set time using the #hcinCanada hashtag. Some earlier chats have welcomed several hundred participants and after a brief hiatus the group is hosting its 9th chat tonight (June 24) on Truth and Reconciliation in Healthcare.

Combining Twitter and live audio chats has both upsides and downsides. There is a sense of immediacy with actually talking with other people that was lacking with Twitter chats but at the same time having the chat on Twitter allows people to participate who are not comfortable with talking to a group. Being able to talk live from Canada with friends in the Philippines or listen to someone, for instance, relate their experience with COVID-19 in Nepal (as they did last week) is a big plus.

However, the technology with Twitter Spaces and Clubhouse is not yet perfect and connections are often garbled or lost which can be frustrating and detract from the communal experience. Also, without a dedicated scribe such as #healthxph uses, it can be challenging to coordinate the live audio discussion and the tweets. These new hybrid chats also require dedicated and experienced moderators to keep everything moving smoothly.

However it is heartening to see new initiatives such as these re-invigorate the networking experience that healthcare professionals value so highly on Twitter.

That word again at #HIMSS21Europe

It was the word that highlighted discussions at last year’s virtual HIMSS Europe conference and trust was also the word heard again and again during the main presentations at this year’s #HIMSS21Europe meeting that has just concluded.

The big difference this year was that trust was used primarily in the context of encouraging COVID-19 vaccination to help end the pandemic and only secondarily with sharing of patient data.

This year’s HIMSS Europe meeting continued with the usual major topic areas showcasing advances in European countries and the UK with respect to digital health and virtual care. However, the keynote sessions focused to a greater degree on COVID-19 and the steps needed for Europe to adapt successfully to a post-pandemic era.

At last fall’s conference delegates and the health IT world in general were still basking in total transformation of health care delivery from in-person to a virtual basis because of the COVID-19 pandemic – a goal many had been working on fruitlessly for decades. Now as Dr. Ran Balicer, chief innovation officer at Clalit Health Services in Israel said on the conference’s first day “providing care at a distance is how you provide care”.  He added that the whole concept of telehealth has become some redundant as health systems have adapted to hybrid models of care delivery that combine in-person and virtual care.

Back to trust.

“The key to every vaccination program is trust,” said the World Health Organization’s Dr. Hans Kluge during the opening plenary session. This point was hammered home during a session of dealing with COVID-19 misinformation and fake news in which data was presented from surveys in several European countries indicating where trust in government was highest, people were also supportive of COVID-19 vaccines.

The importance of promoting digital trust in developing an inclusive society in the post-COVID-19 world was referenced during the main closing plenary session on global inequities by Dr. Ahmed ElSaaed, Focus Area Lead for Innovation Scaling at the United Nations Global Pulse Finland.

In the same session, Dr. Deborah Maufi, chief medical officer for Babymoon Care B.V. in The Netherlands, said trust was needed to build “key and targetted campaigns” aimed at specific communities to encourage vaccination.

Trust also surfaced in a sessions dealing with the use of patient data. Such trust is the key to sharing patient data for secondary use, said Seamus O’Neill, Chief Executive at the Northern Health Alliance in the UK.

People have been more trusting in sharing their personal health data during the COVID-19 pandemic, he said, because this was being done on an emergency basis to deal with an immediate, threat to personal health. However, he said, one should be wary in assuming people will continue to maintain the same high degree of trust over the longer term after the pandemic. “The volume of health-related data is increasing exponentially … and patients have to be convinced their data is being shared responsibly” said Dr. Rowland Illing, a radiologist and chief medical officer at Affidea in the UK, at the same session.

(Photo of Helsinki – where once again we are not meeting (but should have been) for HIMSS Europe because of COVID-19)

#HIMSS21Europe – Trusted physician voices needed

A strong call for physicians and other health care professionals to take a leading role in countering misinformation on social media and online regarding COVID-19 vaccines has come from a high-profile panel of European experts.

In the words of Tim Nguyen from the World Health Organization and one of the panelists – physicians need to be the “good” voices on social media challenging the “bad and the ugly” voices promoting misinformation.

The discussion on strategies to counter misinformation and fake news concerning COVID-19 vaccines dominated a keynote discussion on the role of digital public health on the second day of the virtual #HIMSS21Europe conference.

Repeated statements that physicians and others should play more of a role in promoting evidence-based information supporting COVID-19 vaccination came despite an acknowledgement that many providers are already overburdened and exhausted from dealing with the pandemic.

Underpinning the arguments favoring more involvement of health care professionals was the issue of the trust that patients have in their physicians and the fact vaccine hesistancy is associated closely with lack of trust.

While focused on European and World Health Organization speakers and initiatives, the discussions in many ways mirrored those held at the Canadian Immunization Conference held last December in which US and Canadian speakers made a similar call to action to the medical profession.

Speaking on the HIMSS panel were Dr. Jeffrey Lazarus (PhD), head of the health systems research group at the Barcelona Institute of Global Health (ISGlobal) Spain; Dr. Heidi Larson (PhD), professor of anthropology, risk and decision science, dept. infectious disease epidemiology London School of Hygiene & Tropical Medicine, UK; Carlos Mateos, a journalist and director at the COM Salud/Instituto #SaludsinBulos, and Tim Nguyen, head of unit high impact events preparedness at the World Health Organization, Health Emergencies Program, Switzerland.

“Managing the infodemic has become an important part of managing the pandemic” said Dr. Lazarus and Nguyen talked about the new information ecosystem in which the physical and virtual worlds are intertwined.

Both Drs. Lazarus and Larson cited different pan-European surveys conducted in the last year showing that those who had most confidence in their government activities against the pandemic were also most likely to support being vaccinated. “…where trust was higher, vaccine confidence at a country level tended to be higher,” said Dr. Lazarus.

“There’s not just a need for increased public trust in vaccines, but for increased public health community understanding of the dimensions of COVID-19 vaccine hesitancy,” he added.

Nguyen pointed out that not only does misinformation about COVID-19 and COVID-19 vaccines also undermines trust in health services and in healthcare workers themselves.

He noted that only an estimated 10% of healthcare providers have social media accounts. “They are not out there.”

Mateos reiterated his call for physicians and others to be active on social media to provide responses in real time to misinformation. He also noted that individual physicians are seen as some of the most trustworthy sources of information about COVID-19 vaccines and that they can also play a big role when communicating one-on-one with their patients.

In response to his point that telling doctors to become involved on social media can be a big ask for those who are already overwhelmed, Dr. Larson talked about the strength of peer-to-peer support and trust networks in helping them deal with the current environment.

Dr. Larson said a nuanced approach to dealing with vaccine hesitancy on social media and online is needed as just countering anti-vaccine arguments can actually magnify those views. What should be done, she said, is create alternate narratives with accurate information relevant to people’s concerns. 

In response to tweets about the session, Dr. Juan Turnes, chief of gastroenterology and hepatology at the Digestivo Pontevedra Hospital Universitario in Spain and social media editor of the Liver International journal stated that physicians should also use institutional accounts in addition to their personal accounts to share quality information.

Masterclass 2021: Doctors and social media

(The following summarizes part of a presentation given April 29 at the Canadian Conference on Physician Leadership with Drs. Najma Ahmed and Gigi Osler)

Nine years ago I gave a presentation to Canadian physician leaders addressing whether it was worth a physician’s time to get involved with social media.

Much has changed over the past decade and now questions revolve around not whether social media can be of professional value to physicians –  it obviously can – but rather how physicians can engage on social media safely and for what reason.

Summarizing developments in physician use of social media in recent years, and especially since the onset of the COVID-19 pandemic, I would highlight the following points:

  • The growth in physician use of social media
  • The changing landscape of social platforms and development of a more favourable regulatory environment
  • Growing emphasis on social media for advocacy purposes
  • Growing personalization of physician social media accounts
  • Acceptance of social media involvement in academic medicine

Not every Canadian physician – or even the majority – use social media for issues relating to medicine and healthcare but there has been a definite increase over time especially when it comes to Twitter. A poster presented at the virtual International Conference on Physician Health last week by Christian Guerrero and Christopher Khoury from the American Medical Association estimated that at least 100,000 US physicians and medical students use Twitter. Analysis of a cohort of 16,000 of these users found their tweets focused on work/life balance, patients, and socio-political issues.

Twitter, Facebook and LinkedIn have remained the primary platforms of interest for physicians although younger physicians have also taken to Instagram. Arguably not a social media platform, WhatsApp has also become hugely influential for physicians in Europe and other parts of the world for connectivity and offering health related engagement tools. During the decade other social media tools such as Twitter Periscope and Google+ have disappeared from the landscape while others such as TikTok and SnapChat have appeared with more and less impact respectively on the general physician audience.

Interestingly, over time there also seems to have been a shift away from engagement tools such as blogs and tweetchats to podcasts and new audio-based channels – Clubhouse and Twitter Spaces. The almost total transition of medical conferences from in-person to a virtual format during the pandemic has been accompanied with a drop in the use of Twitter exchanges associated with such meetings in favour of use of the chat function on the meeting platform. Virtual platforms to date seem to be having little success in making linkages with social platforms so far to broaden engagement to those not registered for the particular conference.

The changing landscape of social media offerings has been accompanied with a changed regulatory environment for physicians in Canada around their use. A decade ago, provincial physician colleges were ambivalent if not downright hostile towards any physician use of platforms such as Facebook. Over time these regulatory bodies have come to acknowledge that when used appropriately social media platforms can be useful engagement tools for physicians.

One of the biggest shifts in physician use of social media I have noticed over the past decade has been the increasing use of platforms such as Twitter to advocate on various medical, health and social issues.

While physicians have always used social for advocacy there has been a significant increase in this use in recent years especially for issues relating to equity, diversity and inclusion and more recently, to advocate for public health and science-based measures to control the COVID-19 pandemic.

A 2018 article in the New England Journal of Medicine, argued persuasively that the increasing use of social media by physicians could offer women physicians “additional coping mechanisms, provide new avenues for sharing information, and perhaps reduce stigma associated with sexual harassment, burnout and workplace culture.” Popular hashtags such as #IlookLikeASurgeon and #Medbikini and ongoing series of posts concerning the need for gender equity in compensating physicians and support for more women physicians in Canadian medical organizations support this statement.

Similarly growing advocacy efforts by physicians around Black Lives Matter, climate change, and gun control also reflect the trend. When it comes to COVID-19, physician social media use has built on an already strong network of physicians challenging antivaxxers, addressing vaccine hesitancy and calling for the promotion of science-based approaches.

Doctors, nurses and other healthcare providers in Canada may have an understandable concern about speaking out on social media for fear of being reported to their regulatory bodies for unprofessional conduct. However in a Saskatchewan Court of Appeal decision last fall, Mr. Justice Brian Barrington-Foote provided a measure of comfort for those who feel the need to speak out. He stated that “Nurses, doctors and lawyers and other prfessionals are also sisters and brothers and sons and daughters. They are dancers and athletes, coaches and bloggers and communty and political volunteers. They communicate with friends and others on social media. They have a voice in all these roles. The professional bargain does not require that they fall silent.”

In a somewhat related trend, physicians in recent years are tending to share more about their personal lives on social media and public platforms such as Twitter. Canadian physicians, @BlairBigham and @sarahfraserMD argued in a recent BMJ Opinion blog against physicians maintaining separate personal and professional social media accounts. They wrote that physicians should “embrace authenticiy 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.”

Births, deaths and health and well-being issues are shared on an increasing basis by physicians especially since the onset of COVID-19. While not referring specifically to social media, Canadian Medical Association president @AlikaMD recently noted that “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.”

My co-presenters @drgigiosler and @najmadoc make the point that social media platforms are also providing growing informal networks of support for physicians – especially women who are more prone to be targetted for abuse on these platforms.

The other area worth noting in the evolution of physician use of social media has been the growing acceptance of social media in academic medicine. To quote @TchanMD, a leading Canadian researcher on this topic: “Social media is a tool that the modern scholar and scientist should have in their armamentarium. Being engaged in social media can assist you in your academic work by cultivating mentors, raising awareness of your research and scholarship and facilitating scholarly collaborations.”

We are now at the point where scientific papers and even dedicated issues on social media appear regularly in peer-reviewed medical journals and having a physician social media editor has become the norm rather than the exception for these journals. Citation of articles on social platforms are being measured and some institutions have gone as far as considering social media activities when considering career advancement.

Unfortunately this has not be accompanied at Canadian medical schools by much of a focus on educating medical students and residents on how to use social media professionally and safely. As such, students and residents are more prone to run into trouble when using social media platforms despite growing up with the platforms.

I will not dwell on it here but the trends outlined above have been accompanied by the unfortunate reality that use of social media now can make physicians feel both more unwelcome and unsafe than it did in the past. Social media can be an ugly, nasty place inhabited by trolls, spambots and doxxers. To quote my co-presenter, @drgigiosle “social media is dark and full of terrors.”

There have also been numerous instances in Canada where physician cameraderie has broken down and pitched doctors against each other often along seniority or gender lines. Physicians have also sued physicians about social posts.

All of this underlines that fact that while use of social media can be hugely beneficial and satisfying for physicians it can take a certain fortitude and outlook to advocate on social media about divisive issues. – or even apparently non-divisive issues. Whether discussing the right way to intubate a patient or posting your favourite recipe for cookies and sometimes result in the most unexpected and virulent attacks on doctors.

However, one just need look to physicians advocates such as @najmamd and @DrJenGunter or high profile media commentators such as @NightShiftMD to see that these storms can be weathered successfully. A growing community of active physician participants on social media also means a growing number of allies for those who are attacked inappropriately. Blocking and/or reporting threatening individuals and posts can have an impact.

The Twitter of 2021 is not the Twitter of 2012 and the social media realities of the early 2020s will surely continue to evolve and mutate. Canadian doctors as a profession have come a long way in their use of social media in the past decade to the benefit, I would argue, of both themselves and of society.

The compleat social physician

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

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

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

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

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

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

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

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

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

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

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

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

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

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