Twitter Dec. 20, 2022: Diminished but not extinguished

Perth, Ont. emergency physician Dr. Alan Drummond (@alandrummond2), the invaluable curator of the current crisis Canadian emergency rooms and gun control advocate has successfully undergone knee replacement surgery and is home. And Ontario physician Dr. Mary Fernando’s (@MaryFernando) young bouvier had a great time experiencing the first major snowfall of the year last week.

It is these and thousands of other postings to Twitter in the last few days and not the ongoing soap opera that is Elon Musk’s hands-on (mis)management of the platform that assures me that Twitter continues to be valuable if not invaluable to those interested in what Canadian physicians, other healthcare professionals and patients and caregivers are currently doing and feeling. While both Drs. Drummond and Fernando live close to me and I know them, I am not close enough personally or professionally to have heard their news otherwise.

Of course, it has been hard to ignore all the recent turmoil surrounding Twitter of which the following are just a few examples:

  • The reinstatement of many accounts that were removed due to persistent posting of discriminatory, unscientific or unprofessional comments. Unfortunately we must include among these, Dr. Drummond’s nemesis, former politician and antivaxxing advocate Randy Hillier.
  • The documented significant increase in racist, misogynistic, and homophobic tweets.
  • The temporary (?) silencing of Twitter Spaces
  • The revamping of Twitter Blue to entitle all subscribers to have a verified blue checkmark and also to be the only ones allowed to vote on Twitter policy polls. Surely a cruel blow for physicians who fought so hard during the pandemic to be verified on Twitter so they could post scientific information and science-informed opinions.
  • The cancellation of several high-profile accounts of journalists critical of Musk or his policies (subsequently often reversed)
  • The ban on tweets linking to other social media platforms (subsequently reversed)
  • The poll taken by Musk asking if he should cease being CEO of the company (the majority said yes)

All of this anecdotally appears to have led to a reduction in use of Twitter by Canadian physicians and others in the healthcare system. It has also resulted in some totally abandoning Twitter. Just this morning I received notification that a retired physician and former Alberta Medical Association had left Twitter as had a respected Canadian medical journalist. Also sorely missed is Australian rural physician Dr. Min Le Cong @Ketaminh who was an outstanding curator of physician activity in that part of the world was as well as an unparalleled poster of breakfast meals at restaurants around the country (you can find him now on Mastodon).

Others, such as physician leadership guru Dr. Johny Van Aerde (@neon8light) have not left Twitter yet but have set up a Mastodon account with the possible intention of moving there permanently. And perhaps more worrisome is that alternate physician voices such as Dr. Ontario radiologist Dr. David Jacobs (@DrJacobsRab) say they will depart public social media completely if they leave Twitter.

Every loss of a Canadian physician or healthcare advocate from Twitter means a diminishment of a community that has taken more than a decade to build and the associated reduction in the value of what is left.

It’s not all bad. Twitter turmoil has given a profile to other platforms such as Mastodon which have proven useful for some clinicians and others to share information and grow community although much of the posting is still mirror-posting of tweets. It has also led to the emergence of other unique communities such as the Give a Duck community initiated by patient advocate Sue Robins to allow health advocates to encourage and support each other.

In addition to community-building, Twitter continues to be the go-to platform for timely news about healthcare issues such as the current crisis in pediatric and adult emergency care, the funding feud between the provincial and territorial and the federal government, and countless clinical controversies. Even with a reduced number of postings from credible sources, Twitter still gives you credible news – be it political or clinical – faster than TV, radio or any newspaper.. For instance, this morning there was an earthquake in Ferndale, CA which I read about on Twitter within minutes of it occurring.

The reality is very few Canadian medical organizations or associations such as the Canadian Medical Association (@CMA_Docs) have yet established footholds on any other nascent social media platforms such as Mastodon. In fact, one is hard-pressed to name any other platform apart from Twitter where such organizations could find such a reach for their messages outside of their own internal communications channels or dependence on third-party media.

Hand in hand with curated information is advocacy and here again advocacy on Canadian healthcare issues continues unabated on Twitter be it concerns about new funding rules for virtual care in Ontario or the plight of the homeless as cold weather strikes across Canada.

So, on Dec. 20, 2022 it is clear the uncertainty and confusion around Twitter will continue and probably for some time. But as I stated in my last blog, I feel it is still worth maintaining a presence there for professional if not personal reasons.

And a reminder that personal tweets for physicians are not just documenting life landmarks or sharing pet pictures. To quote, CMA President Dr. Alika Lafontaine (@AlikaMD) from earlier in the pandemic “I’ve never heard so many physicians actually share the pain that they go through day after day. I’m both sad, as I hear the stories, and hopeful, because we’re sharing the lived reality of what we’re going through.”

(The title of the blog has a date in it as events are so fast moving with Twitter at the moment that it is probably wise to date-stamp any commentary)


Doppelgänger docs of the Rockies

A physician’s reputation is one of their most important and prized assets.

The advent of the Internet and social media have produced a vastly increased scope for physicians to increase their reputations. To quote Texas pediatrician Dr. Bryan Vartabedian, “the democratization of media has made every physician an independent publisher …physicians now have to learn to manage and maintain their identity in the public space.”

While social media has produced huge opportunities for enhancing reputations, at the same time it has created a whole new set of challenges and threats to how physicians are seen by prospective patients, their communities, and others. This would explain why the College of Physicians and Surgeons of Alberta (CPSA) has chosen to allot such a large segment of its updated advisory to physicians on social media to the topic.

In the document released in August which updates earlier advice from 2014, the CPSA notes that “recent studies show that up to 50% and that being impersonated online in a negative manner can have devastating consequences, both personally and professionally.”

The College goes on to provide a list of tips on how physicians can protect themselves against such fraudulent accounts. These include:

  • Providing a detailed professional biography in their social media profile
  • Checking comments and messages daily (emphasis mine) to see if fraudulent activity has been noted by contacts
  • Checking security settings to ensure your posts and account information are only visible to the people who you want to see them.
  • Enabling two-factor authentication on accounts
  • Not linking your social media accounts so posts from one account automatically post on another account
  • Using secure passwords

The College also provides advice on what to do if you think your account has been taken over and goes as far as to provide an example of suggested wording of what to post to your legitimate social media accounts if you have been a victim of a fraudulent account.

All of this is sound advice, but it demonstrates how the various physician regulatory Colleges across the country have taken very different approaches to what they choose to emphasize when talking about social media. The Alberta College renewed guidance comes at about same time that the College of Physicians and Surgeons of Ontario also published revised guidelines on social media. The new CPSO guidelines make no reference to fraudulent accounts choosing rather to emphasize the need to publish only evidence-based materials (However both Alberta and Ontario as well as regulatory bodies in other jurisdictions stress the need for physicians to act professionally and protect patient confidentiality if they speak to the social media at all – and some still do not).

Oh, if you are concerned about having your own accounts hijacked or in checking your online reputation Googling yourself regularly to see how you are portrayed online is a tried and true method of doing so.

Physicians using social media in 2022: What’s to know

Every year for the last decade I have been privileged to give an orientation lecture to first year medical students at uOttawa about the professional use of social media for physicians. The following is a long blog post but severely abridged version of this year’s lecture.

This year’s presentation focused on two key themes:

  1. The social media world has evolved incredibly in the decade that physicians have been using the platforms professionally
  2. The principles for using social media professionally have not really changed at all

Nothing demonstrates the first point better than the stark change between 2013 – when physicians and medical learners were urged to get on social media and try it out because they were smart people who would quickly learn the ropes – and 2022 when physicians must have a good understanding of social media in order to use the platforms safely.

To use a preaching analogy, this year’s lecture was built around two key texts:

  1. New guidelines on the use of social media for physicians published by the College of Physicians and Surgeons of Ontario (CSPO) in June of this year.
    1. This new guidance is particularly important because it represents the pre-eminent guidance physicians in Ontario must follow if they want to avoid charges of professional misconduct
    1. The guidance reflects the realities of practice in 2022 as the CSPO has been diligent in keeping up with the times.
  2. Remarks made by Dr. Katharine Smart, a Yukon pediatrician who until recently president of the Canadian Medical Association.

In key quotes that follow, Dr. Smart lays out the rationale for why physicians must use social media channels to advocate for evidence-based care. The quotes are from a podcast interview given by Dr. Smart this summer to the CHA Learning – the educational arm of HealthcareCAN – the organization representing Canada’s healthcare institutions.

Dr. Katharine Smart

“We have assumed that Canadians have access to a trusted source of medical information to make their health decisions. But more and more, that’s not the case. Over 5 million Canadians don’t have access to a family care physician, which has always been that source of trusted health information. In parallel we’ve had this evolution of that social media environment where so many people now are going to get information. So we’ve got declining access to experts (but) increasing access to information and we know that on social media health information is often poor.  A recent study showed that 87% of posts about health on social media contain some sort of misinformation. We have to reimagine ourselves a bit as physicians and what our role is in terms of stepping into the public to share information and to counterbalance misinformation, in an effort to improve the health of the public as a whole and communities.”

We’ve got to be on spaces like TicTok, Twitter, Instagram, where a lot more people are interacting, and package our information differently for different ages and different segments of the population.

When you’re in public spaces, and people know you’re a physician, you are representing the profession, whether you want to be or not.  It’s just part of what goes along with the privilege of something like being a physician.”

Dr. Smart also makes the points that social media is not for all physicians but those who choose to use the platforms need the appropriate education to do so – something that is often lacking at the medical learner stage. She also talks about how useful social media has been for her in networking with her peers.

Dr. Smart’s comments are mirrored by the new emphasis that the CPSO guidelines place on physicians only sharing information on social media that is evidence-based. This new emphasis comes directly as a result of the COVID-19 pandemic and the proliferation of non-scientific views by some physicians.

Why consider using social media or social networks professionally as a medical student or physician?

Social networking is a key component of the digital world where physicians now have to practice. To quote Dr. Bertalan Mesko, a Hungarian physician and leading futurist, from a few years ago: “Today’s medical professionals must be masters of different skills that are related to using digital devices or online solutions and mastering those skills is now a crucial skill set that all medical professionals require.”  Changes forced upon medical practice by the pandemic have made this even more important.

I believe part of what Dr. Stern is referring to is the fact that patients use social media extensively to talk about medical matters in general or even their own health. Broader conversations about health policy are also happening there. This has been particularly true since the pandemic.

So, arguably to understand or to participate in those conversations you need a social media presence.

I list here what I believe to be the key ways in which medical learners and physicians can use social media to stay informed

  • Follow selective media outlets who often post news first on social media channels before more traditional outlets.
  • Follow trusted individuals who curate useful medical information and provide links to original sources.
  • Monitor selected journal releases in a timely fashion.
  • Up to date clinical information can be obtained following medical conference hashtags. The recent European cardiology conference #ESCCongress is a great example of this.
  • Interact with experts
  • Monitor important conversations around medical issues – everything from masks in the pandemic to proper airway management

Social media is not only a great way of networking with peers, colleagues, experts and patient advocates but social media channels can also be a powerful way of building alliances. Through networking and use of social media women physicians and racialized physicians have become far more empowered and they have used their social networks for support when challenged by others.

Social media can also be a powerful means of providing inspiration and just provide “feel good” moments at a time when the medical profession needs this more than ever.

Social media is IRL and more and more physicians and others are sharing their lives – not just with friends on Facebook but even in the world on Twitter and LinkedIn.

They’re sharing life changing events in their lives on Twitter. Births, deaths, breakups and breakdowns. They are also sharing what they see and feel and this has been particularly event in relation to COVID-19.

I would argue this is part of a bigger picture. The role of physicians in society is changing – as is the way the medical profession views its own commitment to society.

Unlike a decade ago physicians often maintained separate existences on social media with different accounts for their personal and professional lives – now more and more they are merging the two. The CPSO guidance acknowledges this while stressing that physicians should act professionally however they are using social media.

This personalized approach has been indirectly endorsed by a court decision in Saskatchewan Court of Appeal – the province’s highest court, in a case involving a nurse which stated in 2020 that “Nurses, doctors, lawyers and other professionals are also sisters and brothers, and sons and daughters.” Mr. Justice Brian Barrington-Foote went on to say: “They are dancers and athletes, coaches and bloggers, and community and political volunteers. They communicate with friends and others on social media. They have voices in all of these roles. The professional bargain does not require that they fall silent.”

In an interview in 2021, new CMA president  Dr. Alika Lafontaine said this sharing by physicians has been powerfully cathartic. “I’ve never heard so many physicians actually share the pain that they go through day after day. I’m both sad, as I hear the stories, and hopeful, because we’re sharing the lived reality of what we’re going through.

The bottom line is that you can maintain and professional presence on social media and interact professionally while also being a human being and sharing – to whatever degree you feel appropriate – your personal life.

I liken it to being a physician in a small community. You care for patients but you also shop in the local grocery store and take your kids to soccer practice.

The whole issue of whether physicians should maintain two separate personal and professional accounts on social media arises here as well. Two Canadian physicians Drs, Blair Bigham and Sarah Fraser addressed it in a blog post on the BMJ Opinion site. They state physicians should “embrace authenticity and reunite their personal and professional selves. In times like these, we must … make a therapeutic relationship with the public to advocate effectively, and the work of advocacy requires revealing our true selves.”

For every why there is a why not. Ten years ago I didn’t dwell on this but the world has changed and social media have become far more malignant and risky for physicians to use.

Social media has become an ugly, nasty place inhabited by trolls, spamBots and others It can make physicians feel unwelcome and unsafe. There are also any instances in last few years where physician camaraderie has broken down and pitched doctors against each other especially along seniority and gender lines. This has helped highlight fundamental inequities that continue to exist within the practice of medicine.

It takes a certain fortitude and outlook to be able to advocate strongly on social media about divisive issues and it’s not for everyone. It’s impossible to have heated but constructive discussions within the confines of Twitter or other limited social media channels. And the abuse has caused some physicians to abandon Twitter for the relative professional safety of LinkedIn or just to retreat to their small personal social circles on Facebook.

Physicians who plan to use social to promote social causes need to be prepared for abuse that far exceeds what we consider acceptable.

Advice on how physicians should respond to harassment on social media must now, unfortunately, become part of any educational exercise. The following tips come from Dr. Najma Ahmed, a Toronto trauma surgeon and founder of Canadian Doctors for Protection From Guns.

Over the years I have reworded and whittled down advice on how medical learners and physicians can and should use social media professionally, but the advice has remained the same.

Respecting patient confidentiality remains the number one tenet of this advice. Never post anything that will identify a patient unless they very clearly and explicitly request it.

The CSPO and other physician regulatory bodies wants physicians to act on social media in a way that won’t damage the reputation of the profession. On the other hand we have many physicians, especially women, pushing back against the idea that professionalism means being well-dressed, well-behaved, polite, and deferential to authority.

This may be best represented by the hashtag #MedBikini movement which emerged a couple of years ago. Leading social media commentator and pediatric gastroenterologist Dr Bryan Vartabedian blogged about the issue and I quote him at length here:

“A study published in the Journal of Vascular Surgery line itemed the apparent transgressions of a group of surgical trainees. The study, Prevalence of unprofessional social media content among young vascular surgeons, cited breaches of professionalism including wearing swimwear (medbikini), drinking alcohol, profanity and commenting on controversial social topics. Their criteria for unprofessional were based on previously published studies from as recent as 2017. As news got out medtwitter had its own 2020 cancel culture moment under the hashtag MedBikini with thousands of tweets showcasing the unprofessional elements identified in the study. Then bending to post-publication review, the study was retracted on the basis of its methodology and concerns for bias. The faulty foundation of this paper is its failure to understand the standards of medicine’s digital culture. The assumptions about alcohol, bathing suits, language and the public discussion of controversial subjects reflect dated standards about how doctors engage and communicate in a global community. And so this paper is something I might have seen a decade ago when the medical world was petrified that Twitter might be used to share pictures of doctors in bikinis. Times, of course, have changed.”

Dr. Jessica Pearce, an ob/gyn had a more blunt take in a different blog post at the same time:

“Our bodies may have tattoos, ride motorcycles, or compete in pole fitness competitions for sport. None of that impacts our practice of medicine negatively. It’s past time we start celebrating the strength of our bodies and hold accountable those who try to negate our accomplishments with an ill-perceived attitude of sexism and misogyny.”

I closed the 2022 lecture with a quick overview of what I see as current trends relevant to the use of social media by physicians.

Social media channels continue to provide a valuable resource for medical learners and physicians who choose to make use of them.

But more so than ever in 2022, physicians must take the time and make the effort to use these channels in ways in which they are comfortable and feel safe. And more so than ever, they need the education to do this safely.

(A caveat: This presentation was built for an audience of medical learners. As such it does not stress the critical role social media channels have played in helping patients and caregivers also build communities and information channels to strengthen their roles on the health care team)

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

CMPA Panel on Virtual Care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Beyond Jimmy Buffett: The New Medical Conference

The new reality of medical conferences shaped by the COVID-19 pandemic requires not only a new language but also a fundamental rethink to make these major showcases of medical organizations and societies a place where physicians and patients can share their experiences and perspectives.

We can no longer characterize medical conferences as – in the words of an old Jimmy Buffet tune – “a Holiday Inn full of surgeons” who meet there every year and “exchange physician stories and get drunk on Tuborg beer.”

That is the unavoidable conclusion to be drawn from a webcast held earlier this week featuring Len Starnes, a Berlin-based digital healthcare consultant and close observer in medical conference trends. The webcast is part of a regular series hosted by Peter Llewellyn for MedComms Networking.

A year ago, Starnes presented to the same webinar series and outlined how the COVID-19 pandemic had caused most medical conferences to become virtual in nature. Then, he predicted all medical conferences hosted by associations or societies would be held virtually until at least the last quarter of 2021. In reality, few if any major medical conferences were in-person only 2021 due to the ongoing pandemic and this trend is now extending into 2022.

The new reality – which dominated much of the current webinar discussion – focused on the ascendance of “hybrid” medical conferences featuring a combination of in-person and virtual components. With physicians having discovered the benefits of virtual meetings and now wanting a choice in how they experience conferences, this approach that allowing both synchronous and asynchronous learning is here to stay.

One of the major features of the new medical conference, said Starnes, is that they now feature “more opportunity” for including patients and “could be a radical breakthrough for patients and patient organizations.”

Despite patients having had a presence on the agendas of some medical conferences for more than a decade and the formal Patients Included movement putting its stamp of approval of medical meetings since the mid-2010s, what we may be seeing is a more fundamental shift.

“Basically now, there’s no more discussion about the value patients bring,” said Starnes.”It looks like we may be moving into a new area of patient participation.”

“Patients and patient organizations have told me it is important (to acknowledge) patients are not just there to listen, they are also there to present. They can present their experiences of being on a drug … or whatever it is and explain to doctors what it means, for them. Patient organizations say it’s very important that doctors understand what they’re doing from a patient perspective.”

In the webcast, Starnes was joined by Ilan Ben Ezri, CEO of G-Med, a social physician-only community with 1.5 million members from more than 160 countries. A survey of 1206 physicians from countries conducted by G-Med in 2021 showed an even split between preferences for in-person, virtual or hybrid medical meetings with the preference for in-person meetings being greatest in the youngest (aged 20-40) group of physicians.

In discussing the future of medical conferences, Ben Ezri implied the drive for patient-inclusion may get pushback from physicians who still want to discuss their study findings in a peer to peer environment.

However, Starnes noted there is a counter-view that “excluding patients is not really appropriate”. He cited a European Medicines Agency statement that input of real world patient data is “absolutely crucial.” The opportunity to share perspectives in order to support the paradigm shift to shared-decision making is something health care “can’t avoid,” he said.

Another fundamental challenge to the more active participation of patients at medical conferences is a regulatory one that can restrict physicians from reporting data from new drug trials to audiences that include non-physicians. However, Ben Ezri pointed out the fluid nature of the new hybrid medical conference could get around this by creating some sessions restricted only to physicians (although patient groups could well argue that it would be much more appropriate to change the regulations concerning reporting of pharmaceutical data).

Cost is another issue. Medical conferences saw attendance skyrocket early in the pandemic when there was no registration fees and patients benefitted from this. But with medical societies facing the necessity of having to reinstate often hefty registration fees to cover costs, many patients or patient organizations with no financial backers may once again be left in the cold.

And let’s not forget equity and the reality that may patients who should be in the room at a conference to present their unique perspectives may have neither the time or capability to attend – although here again the virtual option may present new opportunities.

Many questions indeed but those witnessing the dominant social media participation of the Creaky Joints arthritis patient community at last fall’s American College of Rheumatology meeting or IBD Moms at last month’s Crohn’s and Colitis Congress are seeing how this new future looks.

A full recording of the webcast with Starnes and Ben Ezri can be accessed here.

Being a doctor on Twitter in 2021

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lead illustration courtesy of The Cut

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.

@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.

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.