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)

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Twitter is still my medical home

For more than 12 years, Twitter has been my medical home. Just as family medicine sees the patient’s medical home as a vision for patients receiving comprehensive and proper care on an ongoing basis in family practice, so Twitter has provided me with the best place to foster two-way communications about medicine and healthcare in a comprehensive way.

The purchase of Twitter by Elon Musk and his subsequent actions threatens this vision. In recent weeks several credible and respected physicians and other healthcare experts have talked about abandoning Twitter for other platforms, with Mastodon being the safe haven of choice to date. Despite having many positive points, Mastodon is not Twitter and its shortcomings have shown us what we will lose if Twitter goes away. The recent proliferation of promotions for other platforms only shows how fragmented the healthcare and medical community will become without Twitter.

Also, Canadian physicians who are generalists now have few sources of credible, timely information curated just for them, with the online daily subscriber newspaper offered by The Medical Post (@Medical Post) being the only example that comes to mind. Mainstream Canadian journalists such as Andre Picard (@picardonhealth) and Aaron Derfel (@Aaron_Derfel) are best-in-class in curating and transmitting medical information to both the profession and the public but their numbers are dwindling. Twitter has provided physicians with the ability create their own information channels with links to sources they trust.

As @cmaer I helped the Canadian Medical Association (@CMA_Docs) on its road to using social media which it has done with increasing sophistication. Now, while sinking fast into semi-retirement, I continue to monitor Twitter for healthcare news, curate information, and on occasion live tweet medical conferences.

Twitter has connected me with a global community of medical experts and those with lived experience from the UK and Ireland to the Philippines and Australia. Unlike other forums where physicians connect as fellow specialists or talk among themselves, Twitter has created a place where physicians and patients can exchange views and expertise to the advantage of both. It is also a place where in recent years we have been able to see physicians as whole individuals and not just medical practitioners. As Tricia Pendergast wrote in a blog 3 years ago: “Welcome to the future… where doctors and nurses are no longer dispassionate enigmas; we’re humans      with online lives, dog pictures and grief that we need to process.”

Some aspects of Twitter such as tweet chats and live tweeting are less relevant today than previously. However, groups such as #healthxph in the Philippines continue to use scheduled tweet chats productively to continue to have respectful discussions on issues of importance to medical learners and physicians. And depending on the meeting and audience, even the chat function of virtual meetings has not totally eliminated the value of live tweeting to engage those not actually attending those meetings.

Social media have evolved over the past decade. Facebook, LinkedIn and Instagram have started to borrow innovations from each other. Like overprotective parents, social media platforms such as Twitter and Facebook now use algorithms to spoon-feed us posts they feel will be interesting to use based on previous history. While occasionally useful, this activity not only clutters our feed but can also increase the echo-chamber effect by feeding our biases and pre-conceived notions. Other platforms such as TikTok have successfully emerged to establish their own distinct niche.

While I have more than 9,000 followers and support unpopular (to some) pro-science stances such as masking mandates against COVID-19 (even in the context of such highly charged environments as the recent school board meeting in Ottawa), I have been spared abuse and threats maybe because I am not a physician or high-profile. I fully sympathize with those forced from Twitter because of such abuse and have no argument against those who no longer feel safe being here.

I also accept that a clarion to stay on Twitter or find a better platform is not universally accepted by others.

Social media pioneer and pediatrician Dr. Bryan Vartabedian (@Doctor_V) recently wrote that “the value with Twitter has devolved from a place of real community to an echo chamber for our own ideas. In discussing Mastodon he wrote:

Now we move to Mastodon. We celebrate our great exodus into the Promised Land. The problem is that we bring the same baggage and motivations with us. And all of our habits. The race for influence is a story as old and predictable as social media: Grab first mover advantage, evangelize the platform in the service of raising our game, and battle desperately for followers.

However, I would also like to quote an Australian scientist Dr. Manu Saunders (@ManuSaunders), who, as the Twitter/Mastodon situation emerged, wrote:

Twitter has been a beacon, a haven, an inspiration, and a cornerstone for me. I’ve tried insta and tiktok, but they never worked for me. Twitter is different. It is outward facing and hyper connected – whenever I felt alone or excluded in my local discipline or institutional networks, I always felt welcomed and connected on Twitter. It helped me grow my blog audience, found me new collaborators and new ideas. It kept me up to date with local and global news and events. I’m an ecologist, but I’m also a person, and Twitter kept me connected with all the communities that I felt connected to, however indirectly – academic twitter, ecology twitter, ag twitter, landcare twitter, insect twitter, nature twitter, Australian twitter, climate twitter, conservation twitter, journalism twitter, writing twitter, politics twitter, history twitter, the list goes on…

If Twitter becomes unviable, I think, it will be in one of three ways:

• Disruptions to the organization of Twitter as a result of Musk’s corporate actions will cause the engineering infrastructure to collapse
• Attempts to turn Twitter into a right-wing platform will make it unusable for anyone not sharing those views. Some actions by Musk such as the reported imminent “opening of the gates of Hell” and reinstating all accounts banned for flagrantly abusive behavior points ominously in this direction.
• The hyper-evolutionary nature of communications science in the 21^st century will cause it to be supplanted by something that better meets people’s needs for being simultaneously educated and informed. Until the Musk situation arose this is what I always thought would happen.

Twitter may go away in the short-term or become totally hostile to intelligent life as spelled out in the first two bullets. And inevitably at some point it will be supplanted by something better. But in the interim, I’m staying.

(Image: Tent room in the Esterhazy Palace, Tata, Hungary)

Misinformation on social media threatens healthcare reform: @CMA_Docs president

Dr. Katharine Smart

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

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

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

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

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

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

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

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

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

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

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

Tweets signaled COVID-19 outbreaks

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

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

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

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

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

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

The categories used were:

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

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

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

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

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

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

Being a doctor on Twitter in 2021

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lead illustration courtesy of The Cut

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 9^th 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.

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.

Albert Camus didn’t tweet … but Dr. Eric Topol (@EricTopol) does

Twitter will never produce great literature … but it has become an invaluable tool in keeping the world better informed and educated during the COVID-19 pandemic.

That was one of the conclusions that could be drawn from an intriguing discussion recently that brought together two of America’s best know physician authors – Dr. Abraham Verghese (@cuttingforstone) and Dr. Eric Topol (@erictopol).

Sponsored by the Bellevue Literary Review (BLR) and Medscape and hosted by BLR Chief Editor Dr. Danielle Ofri, the discussion on YouTube was titled “Covid Writing Goes Viral: How Literary & Social Media Writing Became a Lifeline during the Pandemic.”

The discussion actually split into two distinct threads – one steeped in literature and works such as Albert Camus’ The Plague (which I re-read in the bathtub over several sessions last summer) that dealt with great writing about pandemics – the other discussing the value social media and especially Twitter has brought to helping people deal with the pandemic.

The latter focused predominately on Dr. Topol and his work on Twitter. As editor-in-chief of Medscape, founder and director of the Scripps Research Translational Institute, and successful author of several books on new trends in medicine, Topol has been one of the most credible U.S. physician voices on Twitter since the pandemic began.

I first heard Dr. Topol live in an address to the Health Information Management Systems Society (HIMSS) meeting in New Orleans in 2013 when he effectively stated “I’m on Twitter and you should be to.” In the year of the pandemic, Dr. Topol has doubled-down on his commitment to the platform and with more than 400,000 followers he has a large audience.

“Back in late February or March (2020), I made a conscious decision that I was going to get deep into this,” Dr. Topol said, adding that he wanted to serve as navigational guide for those in the scientific or medical community.

“I started to double or triple the number of posts I would do in a day and that’s been maintained for the year and sort of took over my life.” Dr.Topol added that he has also come to appreciate the educational value of social media in linking him with other experts around the globe and across disciplines.

“Twitter has introduced me to scientists I am not sure I would have ever known but they have emerged on Twitter as reliable sources of information.”

Dr. Verghese acknowledged the importance of what Dr. Topol was doing in noting the sources of information he had traditionally used to keep track of events were insufficient to keep him informed about the fast-moving events of pandemic.

“The sources that I might go to were already old by the time I saw them compared to Twitter.” Dr. Verghese said his views on Twitter shifted from seeing it as “cute and fluffy” to an essential lifeline in keeping informed.”

However, he also sounded a cautionary note but talking about the need to filter all of the information coming through on Twitter so as to only deal with credible information.

While the COVID-19 pandemic has provided a basis for many people to tell their own narratives and raise awareness within medicine of the important roles played by others in the health care system, Dr. Topol acknowledged Twitter was not the best place to find these stories.

He talked about the inability of Twitter to reflect nuances concerning ambiguity or vulnerability in tweets.

“There’s no storytelling on Twitter or any social media.”

Social Media and Healthcare 2021: The #hcldr view

Where better to find a predominately positive overview of the current impact of social media on healthcare than during a  #hcldr tweetchat?

Launched in 2012 and masterfully moderated by co-hosts Colin Hung (@colin_hung) and Joe Babaian (@JoeBabaian), #hcldr is one of the only remaining regular weekly tweet chats that deals with a broad range of healthcare topics.

Earlier this week, they hosted a chat on the current state of social media and healthcare that drew almost 200 participants including physicians, other health care providers, digital health specialists, patients and patient advocates predominately from the US but also from Canada, the Philippines and other countries.

From among the usual rapid-fire exchange of greetings and subchats emerged a strongly positive overview (with caveats) of the role of social media in healthcare. It also revealed interesting insights into the continuing evolution of how informed individuals are utilizing these platforms.

Most of those contributing to the chat indicated their use of social media has changed over the years.

Some  talked about switching their emphasis from Facebook to Twitter and LinkedIn and from using social media for social interactions to taking a more professional approach and becoming more engaged. While definitely an older cohort of social media users, some participants talked about productively having used Snapchat and now TikTok.

However, Dr. Nick Van Terheyden (@drnic1), a digital healthcare innovator and former chief medical officer for Dell, noted his use of social media has decreased significantly because the platforms have been “weaponized” to promote dissinformation. Ziva Mann (@MannZiva) agreed, adding that now without careful facilitation “venom” often seeps into social media discussions.

For the vast majority of participants, social media today seems to be used primarily for engagement and networking and for information gathering or curation. As Ottawa child psychiatrist Dr. Gail Beck (@gailyentabeck) tweeted: “I access some of the best information on many subjects from social media. I’ve ‘met’ some inspiring people and groups like #hcldr.”

Dr. Rashu Shrestha (@RashuShrestha), chief strategy officer at Atrium Heath, noted “social media has always been about connecting at an exponential scale. The value of @Twitter has evolved from basic information sharing to meaningful engagement, and much deeper dialogue.”

“Every generation will have education and information gaps and “discover” social media as a tool to learn and share more among themselves,” tweeted Dr. Meredith Gould (@meredithgould), an author and digital activist. However she later added “I believe at least one and maybe two generations of physicians and allied health workers need to depart this mortal coil before social media is fully appreciated. Young hc pros on TikTok are delivering essential info with delightful edge.”

In response to one of the tweet chat questions, participants seemed in strong agreement that social media has a role in healthcare today, particularly as a means of patient empowerment.

As Annie-Danielle Grenier (@AdanGrenier), a patient partner in Quebec tweeted, social media can help patients obtain information as well as being a place for support groups. Social media, she said, can also help healthcare professionals get their message out and learn from patients.

“I often tell patients about hashtags or social media groups that I think are good for their specific medical experiences or diagnoses,” confirmed Dr. Latita Abhyankar (@L_Abhyankar), a US family physician, in her tweet.

“While the way we use social media may evolve, it is still a valuable outlet for education, collaboration, and information. It allows us to challenge healthcare norms, advocate for patients, and support our peers,” tweeted Shereese Maynard (@ShereeseMayMba), a digital strategist.