By Christina Frangou

imageChicago—Late one night in 2011, University of Buffalo pediatric surgeon Philip Glick, MD, received a call from his resident on call, telling him that a child who had been on extracorporeal membrane oxygenation (ECMO) for several days, now had air tracking back through the venous cannula.

Dr. Glick, a professor of surgery, pediatrics, OB/GYN and management, rushed to the pediatric ICU and his team gathered around the child’s bed. Everyone was baffled; no one, including Dr. Glick, had seen anything like it. The only option he could come up with was to turn off the ventilator, as the child also was on heart-lung bypass support.

“It was 4:30 in the morning,” he said, recounting the story during a session of the 2012 Clinical Congress of the American College of Surgeons (ACS). “The sun was about to come up. I was very tired. I called the ECMO hotline; no explanation. I did a PubMed search; nothing published. Lastly, I sent out a tweet asking if anyone in the universe had had a patient with pertussis on ECMO who had what I was describing as a pulmonary bronchial pulmonary artery fistula.”

When Dr. Glick woke up a few hours later, he’d received an answer from a surgeon from the Karolinska Institute in Sweden. “He had a series of patients, yet to be published, with pertussis who had similar experiences and he said ‘what you may have is a patient with a totally necrotic lung.’”

That is a real-life example of how Twitter can help surgeons access information not readily available from traditional sources, Dr. Glick said. “This surgeon hadn’t even published this information yet. He knew exactly what was wrong, exactly what I should do and I shared it with my patient and [the child’s] family who needed it.”

One doesn’t have to have a Twitter account to know that this social media platform, based on messages sent in a 140-character format, is revolutionizing the way information is spread. By doing so, it is opening up a new style of conversation about health care, one in which every player—patients, physicians and policymakers—can connect summarily, albeit superficially.

Today, more than 200 million Twitter accounts exist and more than 340 million updates are made per day. According to the Pew Internet and American Life Project, 13% of U.S. Internet users have used or currently use Twitter. One-third of U.S. consumers have used social media to find health-related consumer reviews of treatments or doctors; one in three have sought information related to other patients’ experiences with their disease; and one in four have posted comments about their health experience.

As for physicians on Twitter, no one has an exact figure. Studies are currently under way examining physician and subspecialty participation in social media. Not all physicians identify themselves as physicians on Twitter; some use it anonymously, or for strictly personal purposes. Some physicians are represented by their hospital or department tweets. Even self-identified physicians are difficult to track. As of January 2013, nearly 1,200 physicians were registered with the Directory of Twitter Doctors, but it is believed that this number represents only a proportion of the physicians on Twitter.

No studies have looked specifically at the presence of surgeons on Twitter. If their usage is similar to that of oncologists and primary care doctors—the only two groups to have had their social media usage studied in a scientifically rigorous way—one survey suggests about 7% of clinicians use Twitter as part of their lifelong learning, 37% reported that they never plan to use Twitter as part of their lifelong learning and about 50% are on the fence, said Brian McGowan, PhD, a research scientist who specializes in medical education and author of the study (J Med Internet Res 2012;14:e117).

However, the proportion of surgeons who use Twitter is growing, according to a recent report in the Bulletin of the American College of Surgeons. From the 2010 Clinical Congress to the most recent, the number of followers of the American College of Surgeons’ Twitter account increased sevenfold. Tweets from attendees at the meeting increased 800%.

image

When General Surgery News informally asked surgeons about their opinions on Twitter, responses varied widely. Said one: “I had no idea when I started how rewarding my Twitter account would be, both personally and professionally.”

And another: “I don’t tweet as it seems remarkably frivolous and something for people with too much time on their hands to do in order to occupy themselves. I have never met a surgeon who had too much time on their hands.”

How Twitter Can Be Useful

Incredible amounts of general surgery and general health care information is being called out in 140-character bits on Twitter—some of it helpful, some not. For a physician, plucking out the useful information can be difficult but beneficial.

One of the great advantages of Twitter is that it’s a very targeted way to get up-to-the-minute news about things that affect your practice and patients. For instance, organizations like the Centers for Disease Control and Prevention (CDC) and the FDA use their Twitter feeds to send out real-time updates on things like pandemics, emergencies and drug approvals. All of the major surgical professional societies also are on Twitter, tweeting about things like annual meetings, publication of major studies and member-related news. Additionally, every major general surgery and medical journal has a Twitter presence. When used in this way, Twitter can serve as a highly personalized, continuously updating news feed.

“Many doctors think of Twitter just as a gab site and certainly it can be that. But one of the reasons that I’m attracted to it is it’s a way to screen for information in a very efficient way,” said Marty Makary, MD, associate professor of surgery, Johns Hopkins School of Medicine, Baltimore.

For instance, he said, he can track information coming from the CDC and can monitor the response to CDC reports. Moreover, he receives direct feedback from patients and other health care providers about his own research.

“I learn from Twitter. I learn from putting ideas out there. And it’s a chance for me to promote articles and issues that I think are relevant to practicing surgeons like myself.”

Bryan Vartabedian, MD, a pediatric gastroenterologist at Texas Children’s Hospital, Baylor College of Medicine, in Houston, who tweets about the intersection of medicine, social media and technology on his blog, 33charts.com, said that physicians can tailor how they use Twitter to get the results they want.

For example, if a physician is interested in only one type of information—say, updates on new drugs or devices—he or she can follow only users who send out information relevant to that topic.

“If you follow 20 to 30 really smart people—people who are part of a conversation that you are interested in, be it endoscopy, interventional endoscopy, whatever—you can get a really great signal or feed that will provide you with remarkable information.”

Dr. Vartabedian stressed that physicians can control what they want to say, if indeed they want to say anything at all.

“I use Twitter more for listening than for speaking, for following than for driving the conversation,” he said.

For individuals who want to use Twitter without being “seen,” that’s also possible. They simply lock the account so that only their “Tweeps” (i.e., Twitter followers who they have approved) can see the account.

On the other end, Twitter can be a great way to network. It’s a way to meet other researchers, advertise upcoming events, improve resident education, drive traffic to a blog or discuss issues in patient care, said Sani Z. Yamout, MD, a pediatric surgery trainee in Buffalo, speaking during an ACS session on social media.

Some surgeons are using Twitter to improve doctor–patient communication, although they are careful to avoid providing specific medical advice.

Deanna Attai, MD, is a private practice breast surgeon in Los Angeles and now one of the most prolific surgeons on Twitter. When she first signed up, she simply followed news and breast cancer organizations without sending out tweets of her own. Surprised by the number of patients turning to Twitter to gain answers to questions that should have been answered by their physicians, Dr. Attai started to engage with patients on Twitter. “I don’t provide specific medical advice, of course, but there is plenty of opportunity to share knowledge and provide support.”

Last fall, she became a co-moderator of a weekly breast cancer support community that meets online once a week. She says this relationship gives her new insight into the patients she sees in her office.

“While I think as physicians we have a good idea of how our patients are tolerating treatments, I quickly realized that our patients hide a lot from us. They don’t always let us in on all of the pain and suffering they go through.

“Twitter has given me an idea of how our treatments and conversations affect all aspects of their lives. It’s also given me a new appreciation for just how important our words are as physicians, and just how precious the few minutes of an office visit can be to a patient and her family.”

And one more way Twitter is reshaping public knowledge of surgery: Surgeons and hospitals have used Twitter to “live-tweet” operations, giving an online play-by-play as the procedures were under way. It’s a way of informing the public about a procedure or a condition, and a way to advertise a hospital's or surgeon’s services.

Houston’s Memorial Hermann Hospital first live-tweeted a heart surgery in February 2012, followed by a brain surgery that spring. For the latter, as neurosurgeon Dong Kim, MD, removed a cavernous angioma from the side of a woman’s brain, colleague Scott Shepard updated the hospital’s Twitter feed and answered questions about the procedure. Their tweets included video, pictures and commentary.

In explaining the decision to live-tweet the surgery, Dr. Kim said he hoped that Twitter could help to demystify the process of brain surgery.

“So our goal of performing this surgery live via Twitter is to educate the general public about brain tumors and take them into the OR [operating room] to see what happens during a brain surgery. Someone may have a loved one who is considering a similar procedure and perhaps they can glean some information from this Twittercast that may help them make a decision about whether surgery is the right choice for them,” said Dr. Kim in a statement.

A Twitter Primer

What is Twitter? It’s a free social networking site. Users post a message, with a 140-character maximum, called 'tweets' to their followers.

How To Get Started?

Sign up at www.twitter.com. Set up your username and password. You can choose to add a photo and choose to protect your tweets so only approved followers can read your posts. Select the Twitter accounts you want to follow (see “Who To Follow” on page 30 for some surgery-friendly suggestions). In turn, you’ll be able to track who is following your tweets. You also can block specific individuals from following you.

Twitter has a help site to assist new users in setting up their account and finding followers.

Learn the Lingo

Retweet: Reposting another person’s tweet

Tweeps: Twitter followers

@: The ampersat is used to call out user names in tweets. For instance, to address General Surgery News, you’d start the message with @gensurgnews.

#: The hashtag is used to mark keywords or topics in a tweet. A few that are often used by physicians: #hcsm (health care social media) and #meded (medical education).

Direct messages: Private tweets between the sender and recipient.

Lists: Curated groups of other Twitter users. (Lists are a good way to find physicians.)

Twitter Faux Pas

Physicians generally are able to maintain a high degree of professionalism and steer clear of privacy violations on Twitter. This has been shown in a small study published last year in which a group of physicians from the VA Medical Center in Washington, D.C., studied 260 self-identified physicians with 500 or more Twitter followers (JAMA 2011;305:566-568). The investigators tracked physician tweets over a one-month period and coded the results, looking for potentially unprofessional tweets. Of 5,5156 tweets analyzed, 49% were health- or medical-related, 21% were personal communications, 14% were retweets and 58% contained hyperlinks. Of the tweets, 3% (144 of 5,5156) were categorized as unprofessional: 0.7% of tweets represented potential patient privacy violations, 0.6% contained profanity, 0.3% included sexually explicit material and 0.1% included discriminatory statements. Nine of 10 physicians who sent tweets that included potential privacy violations were identifiable by a full listed name on their profile, profile photograph or full listed name on a linked website.

The investigators concluded that Twitter might be enormously beneficial, but that health professionals could benefit from education and guidelines about use of social media.

Self-identified physicians on Twitter share medical information with the public, with the potential to positively affect health, wrote Katherine C. Chretien, MD, and her colleagues. “Accountability for health professionals, in addition to greater education and guidelines, may be needed to maximize potential societal and professional benefit through engagement with social media.”

Medical schools are getting on board with the idea that educating physicians and aspiring physicians about social media is critical. This year, four medical schools were awarded two-year grants to help educate faculty members and medical students on the use of social media. The project aims to teach faculty, who can then instruct students, on how to use social media sites like Twitter and Facebook to benefit patient care while maintaining professional standards.

“The next generation of doctors needs to understand how social media can be a double-edged sword,” said principal investigator Elizabeth Kitsis, MD, director of bioethics education and assistant professor of epidemiology, population health and medicine at Albert Einstein College of Medicine in New York City, in a statement. “It can be a great way to provide personalized medical education for patients. However, great attention must be paid to maintaining the principles of professionalism, such as privacy and confidentiality of the physician–patient relationship.”

In 2010, the American Medical Association issued a policy statement to help physicians keep their online experiences positive and preserve the integrity of the patient–physician relationship, including the following recommendations:

  • Use privacy settings to safeguard personal information.
  • Routinely monitor your own Internet presence to ensure that online personal and professional information is accurate and that content posted by others is accurate and appropriate.
  • Maintain appropriate boundaries of the patient–physician relationship online and ensure patient privacy and confidentiality is maintained.
  • Consider separating personal and professional content online by opening two separate Twitter accounts.
  • Recognize that actions online can negatively affect your reputation among patients and colleagues.

Dr. Vartabedian said that adhering to professional standards and preventing privacy violations comes down to two simple rules: 1) Never post anything online that you wouldn’t want disseminated among your colleagues, and 2) avoid any mention of specific patient information.

Zack Glick, a web developer and specialist in cyber security who spoke at the ACS session on Twitter, warned physicians to take precautions to keep their Twitter and other social media accounts protected. He recommends using “https” to sign onto Twitter and using a long, complicated password.

Surgeons who do not plan to use Twitter should still sign up and register their name, he said. “That way, no one else can pretend to be you. You want to make sure your credentials are safe.”

Who To Follow

Compiled by Christina Frangou

Surgeons

@Atul_Gawande, Atul Gawande, MD: surgeon and writer

@bnwomeh, Benedict C. Nwomeh, MD: pediatric surgeon

@DrAttai, Deanna Attai, MD: breast surgeon in Los Angeles; moderates a weekly Twitter discussion on breast cancer

@DrMartyMD, Martin Makary, MD: surgeon and researcher at Johns Hopkins, Baltimore; author of Unaccountable

@drmlb, Mary L. Brandt, MD: professor of surgery, pediatrics and medical ethics at Baylor College of Medicine, Houston; blogger at www.wellnessrounds.org

@glicklab, Philip Glick, MD, MBA: professor of surgery, University of Buffalo, N.Y.

@globalsurgeon, Adam L. Kushner, MD: surgeon and founder of Surgeons SOS

@HeatherLogghe, Heather Logghe, MD: general surgery resident

@hjluks, Howard Luks, MD: orthopedic surgeon, blogger at www.howardluksmd.com and advocate for patient-centered care

@Melanoma_doctor, Eric D. Whitman, MD: surgical oncologist and melanoma specialist

@NirajGusani, Niraj J. Gusani, MD: surgical oncologist

@PedSurgZn, Sani Z. Yamout, MD: pediatric surgeon at Kaiser Permanente Oakland Medical Center

@SkepticalScalpel: surgeon who tweets and blogs about medicine at www.skepticalscalpel.blogspot.com

@UCD_ChestHealth, David Tom Cooke, MD: thoracic surgeon

@UtahBurnDoc, Amalia Cochran, MD: burn and critical care surgeon in Salt Lake City

Other Physicians

@Doctor_V, Bryan Vartabedian, MD: pediatric gastroenterologist and blogger (www.33charts.com) at Texas Children’s Hospital, Baylor College of Medicine, Houston; leader in the health care/social media space

@GlassHospital, John Schumann, MD: general internist and medical educator at the University of Oklahoma School of Community Medicine, Tulsa; blogs about the workings of medical practice and how to improve the health care experience for patients (www.glasshospital.com)

@kevinmd, Kevin Pho, MD: writer (www.kevinmd.com) and internal medicine physician; leader in health care social media

@NightShiftMD, Brian Goldman, MD: ER physician at Mount Sinai Hospital, Toronto; host of CBC’s radio show and podcast White Coat, Black Art; author of The Night Shift

Professional Societies

@AmCollSurgeons: American College of Surgeons

@AmericanCancer: American Cancer Society

@AmerMedicalAssn: American Medical Association

@ASBrS: American Society of Breast Surgeons

@ASCO: American Society of Clinical Oncology

@ASGEendoscopy: American Society for Gastro intestinal Endoscopy

@ASMBS: American Society for Metabolic and Bariatric Surgery

@AssocAcademicSurgery: Association of Academic Surgery

@CDC_Cancer: Centers for Disease Control and Prevention’s Division of Cancer Prevention and Control

@FDARecalls: FDA

@RCofSurgeons: Royal College of Surgeons of England

@SAGES_Updates: Society of American Gastro intestinal and Endoscopic Surgeons

@SocSurgOnc: Society of Surgical Oncology

@WHO: World Health Organization

@WomenSurgeons: Association of Women Surgeons

Publications

@Annals of Surgery

@BJSurgery: British Journal of Surgery

@GenSurgNews: General Surgery News

@JAMASurgery: Archives of Surgery

@NEJM: New England Journal of Medicine