Cover Story: Putting the MD in Social Media
By Debra L. Beck (@DebraBeck18, 36 Tweets, 30 followers)
Rick McGuire (@RickMcGuire1, 14.4K Tweets, 3,508 followers)
CardioSource WorldNews | You might not be feeling all that social towards social media. You may find it a giant waste of time and energy. Also, isn’t it a legal minefield? Why in the world should you be interested in this? “Social media is a tool that we can use to transform health care,” said Kevin R. Campbell, MD, FACC, (@DrKevinCampbell; 29.5K Tweets, 99.4K followers), at an ACC.15 session devoted to social media. Dr. Campbell, an electrophysiologist, is from North Carolina Heart and Vascular and a Fox News contributor. On his website (drkevincampbellmd.com) he states it simply: “Social media and cyberspace is where our patients ARE now and where we NEED to be in order to better meet their needs.”
Social media and texting have become the prevailing means of connecting amongst a huge swath of humanity. The numbers are impressive: market leader Facebook averaged 1.04 billion daily active users in Dec. 2015 and 1.59 billion monthly active users. Instagram—that addictive photo-sharing site—boasts 400 million monthly active users and has hosted more than 40 billion photos shared, at an average daily rate of 80 million photos. The messaging app, Whatsapp, speaks for a smooth 900 million monthly active fans.
But what does this mean for the provision of medical services or for physicians trying to better communicate with their patients? How can doctors harness the power of social media to better inform and empower patients? Can these technologies really improve patient adherence and, more importantly, outcomes, or is this all just a ‘flash in the pan’ phenomenon?
Like so much of new technology, social media offers a unique set of opportunities and challenges for the health care world. There is ongoing debate as to whether and how the medical profession should use platforms like Twitter, Facebook, and YouTube to communicate (presumably more effectively) with patients and the public at large.
But given how widely and rapidly these technologies have been adopted, the questions bear answering. Here are some quick stats from the Pew Research Center:
- Nearly two-thirds of Americans own smartphones, putting text messaging, social networking, and apps literally at their fingertips 24 hours a day.
- In a recent survey, 62% report using their phone to access medical information.
- Among all Internet users, a 2014 survey showed that 74% of online adults use social networking sites, the most common by far being Facebook, followed by all the rest (such as Twitter, Instagram, Pinterest, LinkedIn).
Technology has exploded and is not only changing society, according to Peter Papadakos, MD, FACC, from the University of Rochester Medical Center School of Medicine and Dentistry in New York, it is massively changing the individual and his ability to interact with his fellow humans. Disruptive technology is never fun, but usually it does not alter the wiring of our brain. It happens to some degree with most heavy users, but Dr. Papadakos noted that there is also an extreme response called internet addiction disorder, where magnetic resonance imaging reveals hyperstimulation from intensive use that reconfigures the brain.
Twitter may be having a tough time defending its business model lately, but despite stagnant user growth, it remains the “go-to social media channel for physicians, reporters, and many others in the online health ecosystem,” according to Greg Matthews (@chimoose; 21.2K Tweets, 16.2K followers). Mr. Matthews is the founder and managing director of MDigitalLife, a health ecosystem database that has mapped the digital footprint of more than 700,000 people and organizations worldwide who use social media. It is the first database to link physicians’ social properties to an official data source, the National Provider Identifier (NPI)—the 10-digit ID number issued to health care providers by the Centers for Medicare & Medicaid Services (CMS).
Mr. Matthews and MDigitalLife recently published a fascinating series called, “Who doctors ACTUALLY follow, 2016 edition.” They split the series into three parts, one each dedicated to reporters, media outlets, and other physicians. Looking to be “completely objective” they looked at 20,000 Twitter accounts operated by physicians and mapped back to an NPI number from the MDigitalLife Health Ecosystem database. They then charted out all of the accounts those doctors follow (~5 million of them), and created a list of the 1,000 most followed accounts.
From the cardiology world, the top 10 list includes Eric Topol, MD, FACC, (@EricTopol, 8,460 Tweets, 82.6K followers), and C. Michael Gibson, MD, FACC, (@CMichaelGibson; 27K Tweets, 210K followers).
Other big names include Sanjay Gupta, MD (@drsanjaygupta, 3,757 Tweets, 2.03M followers), Andrew Weil, MD (@DrWeil, 3,622 Tweets, 642K followers), and Atul Gawande, MD (@Atul_Gawande, 3,197 Tweets, 159K followers).
In announcing the survey results, Greg Matthews noted that among the Top 10 doctors who are followed by doctors there are some clear “no-brainer” choices. However, atop the list is Kevin Pho, MD (@KevinMD, 34.8K Tweets, 138K followers). Dr. Pho is considered “social media’s leading physician voice.”
“I don’t think that any other doctor has done as much as Kevin has to bring the physician’s voice online through his blog (KevinMD.com—one of the most important medical publications in the world, and a home to hundreds of physician authors) and his 2013 book, Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices,” wrote Mr. Matthews.
Much of Dr. Pho’s blogging and tweeting deals with being a physician and effective use of social media. In a Nov. 2015 post, he offered doctors a step-by-step approach to establishing an online presence.
“Ask yourself, ‘What are my goals for social media?’ Is it educating patients? Is it connecting and learning from colleagues? Is it advocating for a cause, or is it debating health care reform?” wrote Dr. Pho. “A next step for some could be just going on Twitter and listening to what people have to say. You don’t have to contribute a thing.”
When you use any form of social media, Dr. Pho recommends asking yourself before you hit the send button: If I were in a crowded hospital elevator and I said aloud what I just wrote for a social media network, would that be okay? If the answer is no, don’t post it!
One reason many physicians sour on social media is the ease that reputations can be attacked in a public square. If you or your practice has not been attacked online, you may not be paying attention. (Setting up a Google alert on your name is recommended by many experts in the field.) However, Dr. Pho adds, “You have no control over what other people say about you, but you have total control of the content you create about yourself and your practice.”
There are other dark sides to social media, or ‘sosh-meed’ in the vernacular or #SoMe—which is the hashtag for social media, not a collection of self-centeredness. “Our trainees are coming to us addicted to technology,” according to Dr. Papadakos. At an ACC.15 session, Dr. Papadakos was charged with arguing against social media. He sums the problem up as “distracted doctoring” and his gut feeling is that lives are in danger. He noted that the American Society of Anesthesiology is going to start asking about technology use at the beginning of residency to identify residents “who may have a problem, because in anesthesia someone who’s not vigilant in the operating room is going to be very dangerous.”
He also told the cautionary tale of a physician who was sued and the attorney got hold of his cellphone records to prove he was distracted. “For $125, your carrier will share a record of every text you sent, every Tweet you did,” he said.
“Social media, electronics, all this stuff is great, but we need to learn how to integrate this technology into our day-to-day practice,” said Dr. Papadakos. One particular concern he holds: younger staff and trainees may feel uncomfortable or even lack appropriate communication skills for patient care having spent their entire lives glued to their electronics.
It has been suggested that since younger physicians and trainees are so comfortable with digital technologies, perhaps even addicted to them, maybe it’s best to consider moving their training online. One study found that a “sandwich e-learning approach” to supplement point-of-care ultrasound courses led to equal rates of knowledge retention compared to classroom lectures and post-course learning. Moreover, students appreciated new media for learning experiences and were happier with their learning activity.1
Social media is already being used for e-learning, particularly when incorporated in medical education and clinical practice. In one systematic review of social media in medical education found that the most commonly reported opportunities related to incorporating social media tools were promoting learner engagement (71% of studies), feedback (57%), and collaboration and professional development (both 36%).2 The most commonly cited challenges were technical issues (43%), variable learner participation (43%), and privacy/security concerns (29%).
On the flip side, if doctors are going to further their reach with online teaching tools, they really better know what they are doing! When researchers in Turkey assessed chest tube insertion techniques illustrated on YouTube videos with current practice guidelines, they were unimpressed with many.2 The median total score (on a scale of 0 to 10) for videos originating from authorized foundations was 9 compared to a score of just 4 for those from “health care professionals” (physicians, emergency medical technicians, nurses, etc.). Accuracy did not correlate with the number of views per video.
The researchers suggested that while medical training can be improved by watching video clips, mistakes and misunderstandings can be made if the videos are missing important information or are simply incorrect. A peer review process is needed, they concluded.
Twitter, Instagram, Facebook, and LinkedIn may be great for patient education and engagement, networking, etc., but they can also get physicians in trouble, if misused. One challenge posed by social media is separating one’s personal and professional lives. This separation can be quickly blurred when doctors enter the social networking realm.
Recently, a certain celebrity who seems incapable of staying off social media (who will remain unnamed to prevent additional publicity) was “diagnosed” by a TV psychologist with “oversharing.” It makes one wonder if oversharing will be appearing sometime soon in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Already there is talk of including nomophobia—the fear of having no mobile phone handy—in the next version of DSM.
Certainly, many who participate regularly on social media sites find it hard to resist the urge to share, but a policy statement from the Canadian Medical Association notes that physicians should retain the same boundaries and professionalism that would apply to face-to-face communication when interacting electronically. The statement warns about patient confidentiality issues but clearly suggests several benefits from social media involvement, including more frequent communication with patients, quick access to medical expertise, and the dissemination of evidence-based medical information on social media sites that can improve the quality of the information made available to the public.
Beyond issues of privacy and professionalism, physicians might also get in trouble with the Health Insurance Portability and Accountability Act (HIPAA), not to mention state privacy laws and state medical laws. The issue is not TMI (#TooMuchInformation) but PHI—protected health information, defined under HIPAA as health information that relates to:
- the individual’s past, present, or future physical or mental health or condition;
- the provision of health care to the individual; or
- the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe can be used to identify the individual. PHI includes many common identifiers (e.g., name, address, birth date, Social Security Number) when they can be associated with the health information listed above.
“HIPAA does allow us to exchange privileged health care information with another doctor for treatment purposes, but you have to keep it quiet, it can’t be broadcast mainline,” explained Dr. Campbell at last year’s ACC meeting.
note: doximity.com is a private network for physicians and medical students. It is convenient and HIPAA-compliant.
Don’t think the Food and Drug Administration (@US_FDA) doesn’t approve of social media use. In fact, their policy “encourages employees to use social media to share information that may benefit the public health.” Even for industry, the FDA has acknowledged the usefulness of social media as a means of rapidly communicating information about medical products to consumers.
To assist the process, the FDA has issued specific recommendations for how to present risk-benefit information using social media sites with character limitations, such as Twitter and paid search results on Google and Yahoo.
“We understand that communicating on electronic Internet sites with character space limitations can be challenging,” wrote Thomas Abrams, MBA (@fdacder, 0 Tweets, 31 followers), the director of FDA’s Office of Prescription Drug Promotion in the Agency’s Center for Drug Evaluation and Research (CDER). “But, no matter the Internet source used, benefit claims in product promotions should be balanced with risk information.”
The FDA has also issued guidance on how industry entities should go about correcting misinformation related to their drugs or products found on third-party Internet and social media sites.
“In health care, we have issues, we have recalls. The ubiquity of social media gives us the chance to spread the word and save lives instantaneously,” said David E. Albert, MD (@DrDave01, 42.4K Tweets, 10.5K followers), chief medical officer at AliveCor in San Francisco and inventor of the AliveCor ECG. “But we have to be responsible in its application. Obey the rules, but take advantage of its power.”
At the 2014 ACC meeting, Dr. Albert related his personal experience with social media when he first invented the AliveCor ECG and his 4-minute video, meant for his 4 Twitter followers went viral, unleashing “a global #SoMe viral epidemic.” Within days he was asked to appear on ABC, CNN, Fox, and NBC and received calls from the likes of Eric Topol, Sanjay Gupta, and Leslie Saxon, and…the FDA. The latter weren’t too happy about a viral video promoting an unapproved product.
In SoMe parlance, he was #clueless. He admitted, “What I did was ‘inappropriate’ promotion of a non-cleared medical device, but it was an unintentional accident and I did not further ‘PROMOTE’ the commercialization of the product until I had FDA clearance.”
Not afraid to act against bad Tweeting, in August 2015 the FDA ordered the maker of a morning sickness pill to remove a post by Kim Kardashian because it was “false or misleading” in that it presented efficacy claims but failed to communicate any risk information or state clearly the approved indication for the drug, specifically that it has not been tested in women with hyperemesis gravidarum.
At the time, Ms. Kardashian had more than 34 million Twitter followers and 42 million Instagram followers. Yet, proving again the adage that there is no such thing as bad publicity, she now has 41.8 million Twitter followers and 63.6 million Instagram followers. One might imagine, that includes some poor soul at the FDA, charged with following Ms. Kardashian.
As impersonal as social media can seem, many of those who accept its limitations find it can allow for and enhance relationships in a whole new way.
At ACC.15, Dr. Campbell told the story of an internist with limited resources who treats patients outside of Manila in the Philippines. She and Dr. Campbell connected in a response to a Tweet of his and they became “dear friends.” When her father developed atrial fibrillation, Dr. Campbell was able to steer them towards the proper care, at one point troubleshooting with her and Medtronic about a problem with his implantable cardioverter-defibrillator.
“I was able to connect with my friend who happens to be a physician and help her in Manila from North Carolina, literally, while lying in my bed…” said Dr. Campbell. “The bottom line is connectivity through social media shrinks the size of our world, it shrinks the Earth and brings us closer together,” he said. “The time is now to get involved. Social media is one way, along with mobile devices, along with electronic patients, along with mobile health, that we can affect the way we engage and treat and assist those in our world.”
New technology will always present both opportunities and problems. It can only be hoped that with the massive potential in mobile technology and social media to inform, educate, and augment patient care, that sufficient effort will be made to combat the issues and enhance the possibilities.
Christian Gardner (@ChristianGrdnr, 898 Tweets, 473 followers), the director of media services at Pharmaphorum media in London, was asked in an April 2016 ACCEL interview what he thought the impact of social media on cardiovascular medicine might look like in 5 years. His response focused on two areas: patient and professional.
For patients, Mr. Gardner expects greater access to “more sound, credible, and accurate information via social media.” It might be coming from other patients or from health care professionals. In the professional realm, he expects that major cardiology meetings will increasingly be virtual.
Interviewed during ACC.15, he said, “The people who are lucky enough to be here almost have a role to share the data, discussion, and findings to everyone else that isn’t able to make it.” To some degree, it’s already happening. A huge amount of information has been shared from recent meetings, with a four-fold increase, for example, in the number of Tweets sent during the 2014 European Society of Cardiology meeting compared to the year before.
Mr. Gardner added, “In 5 years, you can guarantee that that trend will continue and the virtual following of these cardiovascular meetings will outweigh the number of physical attendees.”
- Hempel D, Haunhorst S, Sinnathurai S, et al. Crit Ultrasound J. 2016;8:3.
- Cheston CC, Flickinger TE, Chisolm MS. Acad Med. 2013;88:893-901.
- Yıldırım B, Basaran O, Alatas OD, et al. Am J Emerg Med. 2015;33:1709-10.
|Read the full April issue of CardioSource WorldNews at ACC.org/CSWN|
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