The @CMA_Docs election and Twitter redux


Five years ago, I wrote about how the two physician candidates to be president-elect of the Canadian Medical Association (@Dr_ChrisSimpson and @GailYentaBeck) were effectively making use of social media and especially Twitter to get their message to prospective voters in Ontario.

It was the first time candidates to lead the national organization for Canada’s physicians had made significant use of social media in their campaigns.

Fast forward (well, slowly advance really) to 2018 and we see four physician candidates in Ontario once again using Twitter to campaign for the president-elect position. But what is spotlighted most significantly is the continued hesitancy of doctors to effectively use social media and digital tools. (The lead article in that 2013 magazine in which I featured Drs. Simpson and Beck talked about challenges for patients in using email to communicate with doctors in Canada – challenges that remain to this day).

Since 2013 there has been only limited use of social media in CMA election campaigns and this is the first time since then that Twitter is being used effectively on the campaign trail by all candidates.

Only one of the current candidates Dr. Darren Larsen (@LarsenDarren) had a long-standing and very strong presence on Twitter but the other three, Drs. Sandy Buchman (@DocSandyB), Atul Kapur (@Kapur_AK)and @PeakMD (Mamta Kautam) have wasted little time in getting up to speed on how to use the platform effectively.

This time around it is not only the candidates who are making use of Twitter but also some of their dedicated supporters and other physicians who are using Twitter to ask questions about where the candidates stand on various issues. The comments and discussions that have been prompted are all informative. Doctors from elsewhere in Canada who are not eligible to vote have been weighing in as have non-physicians.

Sadly it remains a debate in a vacuum… and without a hashtag. With about 34,000 doctors in Ontario eligible to vote in the election, a couple of the candidates still have only a few hundred followers on Twitter so it is unlikely many who will vote are paying attention to any of this discussion and debate. Which is a shame.

While social media use by Ontario doctors in the last year has represented somewhat of a nadir in intra-professional behavior (see my Broken Windows in the House of Medicine), this election so far has shown how a respectful exchange of ideas can take place on Twitter.

Certainly, the webpages of each of the candidates present a much more comprehensive picture of their platforms and positions on important issues. But Twitter and Facebook are being used by these doctors to interact and attempt to differentiate themselves from their colleagues and more voting Ontario doctors should be paying attention … really they should. With the disappearance of most objective medical journalism in Canada, social media is really one of the only places they can find out what their future leaders are saying.

It’s good to see Twitter in use again for this purpose but passing strange that it has taken five years to get back here. Drs. Simpson and Beck? In their own fashion they continue to be two of the most effective physician users of social media in Canada.



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


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.

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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.


The patient as expert: What does that mean?


A fast-paced tweetchat based in Ireland and held recently provided many insights into the current status of patient involvement in the health care system and the role of ‘expert patients.’

The chat was held at #Irishmed, a health-related tweetchat, hosted by Dr. Liam Farrell (@drlfarrell), an irrepressible former Irish GP, and columnist for the British Medical Journal.

Over the course of one hour and more than 1200 tweets, about 100 participants from Ireland and as far afield as the Philippines and Canada debated five questions concerning the role of expert patients and the challenges they face.

Participants included several patient advocates as well as physicians, nurses and other health care providers.

First up was a discussion of what it means to be an expert patient and whether the term is a useful one.

Many pointed out that patients are the experts in their own condition and that this needed to be acknowledged by health care providers and the system.

“It’s about valuing the expertise of the patient with lived experience alongside clinical expertise,” was one comment.

“Some patients can know more than treating practitioner about their condition. Listen to them. Learn from them,” was another. “The better informed they are, better they learn their conditions, the more they can contribute,” another person added.

However Farrell expressed concern about the growth in the number of patient advocates and the system’s need for such individuals. “Bit concerned that Expert Patients will become yet another HC profession, another layer of bureaucracy,” he tweeted.

Asked the role of expert patients, participants identified the value of involving them in everything from health policy planning and decision making to more informal roles. “…we educate strangers on our challenges, talk to the newly diagnosed and coordinate our care,” said one person.

Noirin O’Neill (@Noirin0Neill) a leukemia survivor and Irish patient advocate who participated extensively in the chat through her husband, tweeted that health care providers (HCPs) “complain about lack of resources, time, blah blah – create a new generation of patients to help.”

Others noted that all patients – not just experts – “should be listened to, informed, respected, and involved in their care.”

The chat then went somewhat off-script with a discussion of whether expert patients should be paid for playing formal roles in the health care system. Most argued that because of the time-commitment and importance of their roles, patients should be paid for this work.

“Many have suffered financially through their conditions. We should not make that worse …” was one comment.

Lack of remuneration was identified as one of the main challenges involved in being an expert patient.

Asked to enumerate these challenges one person tweeted: “trying to manage poor health with involvement activities, being taken for granted, only person in room not paid for time.”

“Juggling work, health, finances, bureaucracy, stigma, tokenism … may need more than 140 characters for this on(e)” another person tweeted.

“Being a patient advocate is a full-time job. Lots of invites, lots of phone calls, lots of talk – for no pay. Unfair,” tweeted O’Neill.

Others talked about everyone wanting patient participation at conferences but questioning their expertise or just having them serve as ‘token’ patients.

At the end of the debate, there were optimistic comments expressed such as that “ working with expert patients should lead to new era of optimism, opportunities and solutions to improve health outcomes for all.”

Finally, it was stated that those advocates currently serving as patient experts “need to send the elevator back down to the next gen of experts.”

 (Those wishing a more comprehensive overview of the chat can see the excellent Storify prepared by Marie Ennis O’Connor, (@JBCC) 







Mind the gap: social media and #meded


Two small but intriguing Canadian research studies have documented the wide gap between teachers and students and educator users and non-users in their perceived value of social media as learning tools in medical and health education.

The studies were presented at this year’s annual meeting of the Canadian Conference on Medical Association (#CCME16) and the research involved two leading physicians in the social media and digital health world in Canada, the University of Ottawa (uOttawa)’s Dr. Aliraza Jalali and the University of British Columbia (UBC)’s Dr. Kendall Ho.

The uOttawa study conducted by medical education researcher Dr. Safaa El Bialy with Jalali evaluated feedback from 72 medical professors and 63 second-year medical students on their use of popular social networking sites (Twitter, Facebook etc.).

The UBC study presented by second-year medical student Karan DSouza evaluated feedback from 270 health educators at 8 global institutions on their attitudes towards the use of social media in teaching.

The uOttawa study found the medical students were about three times more likely to use the social networking sites for medical education than the professors (67% vs. 23%).

While 94% of students said they felt the sites facilitated learning, only one third of the professors said they used such sites in their teaching practices.

Despite established social media platforms being more than a decade old, El Bialy and Jalali noted “some of the educators did not even know about social media use for educational purposes” and many expressed concerns that such sites were distractions and promoted time wasting.

Just as the uOttawa study documented the gap between medical students and professors, so the UBC study showed sharp differences in perspectives between educators who use social media in the classroom and those who do not, in a variety of countries.

That study documented that health educators globally have concerns about the lack of guidance and support for using social media for educational purposes and also the lack of evidence showing the value of such tools. Even among those using social media in teaching, only 11% said they had received training in using social media for teaching.

DSouza and Ho also echoed the uOttawa study in their introduction when they noted “students have already adopted social media informally to share information and supplement their lecture-based learning.”

They also documented that adoption of social media is not consistent within faculties, even at the same institution.

Both research teams provided suggestions on how the use of social media in the classroom could be encouraged and facilitated.

(Artwork by @Aga_ta_ta on display at CCME16)



To the EMR … and beyond


For a conference that was about health information technology, it was all about health IT.

Allow me to explain.

The annual meeting of the Canadian Agency for Drugs and Technology in Health (@CADTH_ACMTS) is a showcase for health technology assessment (HTA) and the mission of the organization is to provide credible, impartial advice and evidence-based information about the effectiveness and cost-effectiveness of drugs and other health technologies.

What was noteworthy about this year’s meeting in Ottawa –  the largest yet for the organization with about 750 attendees – was the number of times electronic records (either EMRs or EHRs) were referenced as an essential feature for both gathering and for disseminating credible information to support evidence-based medicine.

Physician speakers repeatedly noted the need to have easy, point-of-care access at the time of the patient encounter, and to all of them this meant embedding that information in the electronic record.

More than one family doctor talked about being overwhelmed with guidelines and best practices and the need to integrate this information into the physician workflow to be useful – and EMRs as the natural place to do this.

The Canadian Association of Radiologists creates world-class clinical practice guidelines, but as Dr. Martin Reed, a pediatric radiologist from Edmonton told the meeting, one of the problems with these guidelines is that it is very hard to get people to use them.

He said there is now a feeling in the medical imaging community that the best way to do this is to integrate the guidelines into CPOE (computerized physician order entry) systems.

Given that some Canadian physicians still do not use EMRs and some (many?) hospitals are not using CPOE this could raise concerns about the quality of care being delivered.

On this information gathering front, the new focus on real-world data has placed an increased emphasis on the value of EMRs or EHRs to gather useful information to evaluate the effectiveness of drugs and technologies, the meeting was told.

“The starting point is having an EHR covering all of the caregivers. At that point the world is your oyster,” said Dr. Murray Ross (@murrayrossphd), leader of the Kaiser Institute for Health Policy in Oakland, CA.

Dr. C. Bernie Good (@CBGood23) who holds numerous roles with the US Department of Veterans Affairs gave numerous examples of how the extensive database gathered on VA patients through EHRs has helped support evidence-based drug prescribing.

And it does not end there.

As Anil Arora, assistant deputy minister in the Health Products and Food Branch, of Health Canada told the meeting it is not just the information being gathered in patient records that will need to be taken into consideration in the future – but also the wealth of patient data now being collected through wearables and other devices as well as through social media.

Given that we have by no means maximized the value of EMRs to gather this information in Canada, the challenges of extending the information sources to other digital repositories of patient information is currently problematic to say the least.

(Picture – Anil Arora. Courtesy CADTH)


From #HIMSS16 to #ehealth2016 – new work, new roles and a new language


“We need the Intelligence Augmenter, stat!

“The diagnostic algorithm’s out of whack and the Transition Specialist wants to know how the interface outflow is correlating the patient’s Fitbit data into the Director of Decentralized Asset Management’s new discharge interface. And we can’t reach the Business Analyst for Patient Workflow.”

The above is not a conversation you are likely to have heard in your hospital lately.

But if you listen to Mark Casselman (@markcasselman), the CEO of COACH (@COACH_HI), Canada’s Health Informatics Association, it is the type of exchange that could be a reality in the not too distant future.

In a recent address at the #HIMSS16 conference in Las Vegas, Casselman gave a thoughtful overview of how the changing landscape around how digital health care is going to fundamentally change not only how care is provided to patients but also the roles and responsibilities of those providing that care.

Casselman noted we are currently in an environment where we have two distinct health care delivery ecosystems working simultaneously – the traditional health care delivery system based on face-to-face interactions between provider and patient in either an office or hospital setting, and the new and evolving consumer-based digital health system – the world of virtual care, apps, engaged patients and the quantified self.

“The traditional health care delivery ecosystem is mostly operating distinctly and differently from these fantastic innovations. They’re operating at different clock speeds.”

He notes that virtual care is evolving along the whole continuum from the traditional clinician/patient interface through team-based care to the new personalized patient-centred approach to care.

“It’s almost impossible for these things to be embedded in the traditional system because they’re changing so quickly,” he said.

These evolving forms of digital care and the underlying beliefs and concepts that support them are creating dynamic tension for those used to working in the traditional health care environment.

In part, he said, this is because the traditional evidence-based model of care which relies on the randomized controlled trial as the gold standard, cannot adapt quickly enough to assess and absorb the changes being brought about by digital health innovations.

To Casselman – and seemingly to the 42,000 delegates to the Vegas meeting – the new reality is one Canadian physicians, hospital administrators and all others employed in the system must start to acknowledge.

“Health care professionals, teams, and organizations must consider what novel skills and capabilities are needed to deliver virtual care effectively,” he said.

Casselman’s organization – COACH (one of the main sponsoring bodies of the upcoming #ehealth2016 conference in Vancouver) has done much to define the 65 existing roles and responsibilities involved in health informatics in Canada today and as developed a professional skills matrix for those roles.

But with the emerging digital health world, he said, there is now a need to re-examine this and determine the new roles that will be needed to provide care in the new world of health delivery.

Using artificial intelligence to augment care with algorithms, harvesting big data for insight, precision medicine, and digital care provided through mobile in the home and the community will require many different skills sets and roles –the type of currently fictitious roles noted by Casselman in my introductory vignette.

But Casselman goes beyond this onto more dangerous ground when he questions whether the patient electronic record of the future will even be the primary point around which patient care will be focused

“We’re digitizing our physiological indicators, we’re sharing them and its creating a real tension in the world of health informatics,” he noted.

Maybe the physician-owned patient record in the EMR is only a segment of what will really be needed to deliver care in the future as the patient tracks his or her own indicators and brings this to the table.

Much to think about and we can only be thankful that Canadian informatics leaders such as Casselman are giving it some thought, especially when he prefixes it all by stating “At the end of the day, it’s all about the care.”

(The summary sides from Casselman’s full presentation can be accessed here).