Are Twitter-savvy students “privileged”?

At this week’s AAMC meeting, Alex Djuricich (@MedPedsDoctor), Terry Kind (@Kind4Kids), and I presented a workshop that dealt with using Social Media/Twitter in our roles as medical educators.  During a breakout session within the workshop, I heard an interesting concern that I had not previously considered.

One participant’s administration was concerned that students who are not using Twitter, Facebook, or other social media venues would be excluded from the information provided by the faculty on these sources.  Their concern is that the students who are involved on social media would thus have an advantage over those who do not use the sites.

Although I understand the worry, I am not concerned. Social media is simply a different way that faculty and students can communicate.  After classes, students often come up ask questions or clarify areas of uncertainty with their teachers.  Many professors hold office hours, sometimes even with groups of students.  On a personal note, for years I have been answering students’ emails on a one-to-one basis.

If a significant area of concern arises, it surely is the faculty member’s responsibility to make sure the problem or misunderstanding is not a systemic issue that all students are having.  Social media simply expands the ability for students to communicate efficiently with their faculty.  The faculty members’ responsibilities to clarify information for all their students doesn’t change.  Social media simply helps break the barrier between the two groups, not increase it.

Posted in medical education, Social Media | 2 Comments

My Med 2.0 (#med2) Experience

This weekend I attended my first “med-tech” conference (Medicine 2.0). What an eye-opening experience it was for me!

I got to meet some phenomenal people whom I never would have otherwise met just by staying in my silo of gastroenterology and esophageal diseases over the last decade.  Many of these people I’d previously “met” online through Twitter. For the most part, that was the extent of our relationship. Nonetheless our interactions on Twitter made the real-life meeting seem completely natural, as if we’d known each other for years.

I also got a rejuvenated exhilaration about advancing my work at the intersection of medicine, technology, and the digital space. It has been somewhat difficult as a junior faculty member at a medical school to get the sense that working at this crossroads could be considered “scholarly” and productive by traditional medical academic standards.

At Med 2.0, I encountered a phenomenal group of innovative physicians, nurses, scientists, informational technologists, and communications experts (among others) who have made this field a major part of their life’s work. Creators of digital apps for medical and educational uses have figured out how to get scholarly production our of their work.

Since medical training and research tends to focus on epidemiology, risk factor modification, and patient care interventions like medications and surgery, Medicine 2.0 helped me realize that there is a lot of valuable scholarly work to be done dealing with the intersection of medicine and digital technology. The collaborations that have emerged as a result of Twitter and Medicine 2.0 will be priceless.

Thank you for letting me be a panelist this weekend and asking me to share my experience over the last 2 years. And thank you for welcoming me into this great community.

Posted in medical education, Social Media | Tagged , , , , , , | 7 Comments

The internist as a puzzle solver: my (a)vocation

I’ve been getting GAMES magazine for years. Decades, actually, on and off.  I remember doing logic games way back in elementary school, and I still do them first in my GAMES magazines.  When I was a kid, my grandmother and I would do jigsaw puzzles together, and I now find myself doing them with my own children.
During a lunchtime panel of the Internal Medicine (IM) Interest Group at UNC today, I was drawn to something that one of my colleagues on the panel said. He noted that if you separate the “medical” specialists (internists, pediatricians, etc.) from the “surgical” specialists (orthopedic surgery, urology, etc.), there is often a difference in the type of intellectual arguments the two groups have.  Paraphrasing, he said:
Medical specialists argue more about what diagnosis the patient has over what the treatment of the diagnosis is.
Surgical specialists argue more about what the treatment should be, often whether or not to operate, over what the diagnosis is.
Of course, this is an overly broad generalization.  He did not mean to say that internists don’t argue over treatment plans or that surgeons don’t argue over diagnosis.  Clearly both do.  He pointed out that some medical specialists, like oncologists, tend to keep their discussions more focused on the latter type (e.g. “Should this patient with breast cancer receive chemotherapy?”), and surgeons similarly have to make sure the diagnosis is correct before they operate.
Nonetheless at general internal medicine “morning report”, residents often focus on creating a broad differential diagnosis and then figuring out what data they’d need to get the right answer.  In other words, using their logic to solve the puzzle the patient is presenting to them.
Thinking back now, I find it interesting that I made a conscious decision in the latter half of medical school to change my career path from surgery to medicine. Puzzle solving has occupied a good portion of my recreational time since childhood.  Maybe my choice during medical school to go into IM was my subconscious way of making sure I would enjoy my career.  I’m certainly glad I made that choice!
Posted in medical education | 2 Comments

Introducing #medsm, a new unifying hashtag for the intersection of Medicine & Social Media

As you read this, you might be asking yourself why Twitter needs this new hashtag. The reason is simple: to permit anyone to follow a single unified stream of medical content.

Currently, many people use #hcsm to disseminate medical tweets, but also since it may seem to stand for “healthcare in social media”.  However the actual definition of #hcsm is “healthcare communications and social media,” really meant to discuss the practice of communication of healthcare information, not the actual healthcare information itself.

Even though #hcsm tends to be one of the most widely used healthcare hashtags and subsequently a way to get one’s tweets noticed, it can be quite difficult to filter through the #hcsm stream to find medical information, especially as Twitter grows in popularity.

Therefore, #medsm is being introduced as a new umbrella hashtag for posts related specifically to healthcare and medicine topics.  The #medsm hashtag could be include content with links to studies, stories about patient care, etc.  The more broadly it becomes used, the more likely Twitter users will be able to identify your healthcare-specific content.

Here’s an example of a great use of the #medsm hashtag, by Howard Luks (@hjluks):

I hope you’ll use #medsm and find the new hashtag helpful!

Acknowledgements:  Many thanks to @hjluks, @Doctor_V, @FarrisTimimi, @RichmondDoc, @SeattleMamaDoc, @DoctorNatasha, and @drmikesevilla for their feedback and support of the idea for #medsm!

Posted in Social Media | Tagged , , , , , , , | 21 Comments

Twitter 101 for Docs: Twitter Lingo

At the end of my last post, I said we’d discuss some ways to enhance your professional community on Twitter in an upcoming post.  But first, let’s remain in Twitter 101 so you can understand some of the intricacies of Twitter.

If you’ve been on Twitter for even a few days and you’ve started to follow a few people, you might be confused by some of the codes, words, and symbols you see.  Don’t worry.  Anyone who is on Twitter has had to figure it out at some point.  Fortunately it isn’t too difficult to rapidly understand.  Here are the basics you’ll need to more easily navigate the medical Twitter-sphere:

  • “@” (e.g., @RyanMadanickMD): This is a user’s Twitter handle.  Think of it as their username.  The “@” symbol simply defines to the Twitter server that you are speaking directly to or about a particular user.  This has 2 primary uses: a reply or a mention.
    • Reply (aka an @reply): When you reply to a particular user by clicking the Reply button under the tweet, the user’s @username will automatically appear at the beginning of your tweet, and you can then respond, as @otorhinolarydoc would have done in reply to @pbjpaulito in the conversation below.  When you reply to someone, your tweet will then appear in the user’s Mentions section on the Connect page of Twitter.  Be aware, though, that the @username does indeed count against the 140 characters allowed by Twitter.
    • Mention: If you are not replying to a particular user’s tweet, but you’d like to say something to or about him/her, you “mention” them by first typing the “@” symbol followed by his/her username.  For example, I might tweet: “Thank you @DoctorNatasha for helping with this blog!” Similar to an @reply, a mention will also appear in a user’s Mentions section.  You can mention more than one person, but just as above, each user’s name counts against the 140 character limit.


  • “#”: In Twitter-speak, this is known as a hashtag.  Think of it as a keyword or topic of the tweet. It can be used in the middle of the tweet, like this: or tagged on to the tweet, often at the end, to delineate a particular category, such as #meded for medical education, or a topic, such as a medical conference like Digestive Disease Week (#DDW12).  Several years ago, a group of Twitter users established the Healthcare Hashtag Project to help standardize the use of hashtags for healthcare.  This site is quite useful if you’d like to see if a particular hashtag is already in use in the medical Twittersphere.
  • RT: This means “Retweet”, which simply indicates the reposting of another user’s tweet.  On their website, Twitter makes it easy to retweet a post by simply clicking on the “Retweet” link that appears under the original tweet when you hover over it. However, occasionally you will actually see “RT” appear in the tweet, often followed by an @username.  This isn’t officially recognized as a Retweet by Twitter, but often is done to allow you to add something to the original tweet, like this:In this tweet, the user (@rlbates) retweeted (“RT”) the original tweet by @DrJudyStone (who has mentioned @murzee), and added a small comment at the beginning of the tweet (“+1”).  You might now be wondering what “+1” means.  This is a lexicon that many Twitter users employ to indicate their agreement with the particular tweet (some people use other numbers too, to indicate even greater agreement!).
  • MT: This means “modified tweet”. Usually Twitter users employ “MT” to indicate that they are retweeting someone’s post, but in order to fit their own comment into the 140 character limit, they needed to modify the tweet in some way. In these two tweets, @cmaconthehill essentially retweeted the original tweet by @TonyclementCPC, but modified it so that he could comment on @TonyclementCPC’s original tweet.
  • Shortened links: Take a look back at the tweets above by @BetterHealthGov or @rlbates. At the end you will notice some short URLs (or web page addresses): ““, ““, and ““.  Don’t worry too much about the specifics of these, but you should know what they do.  If you click on one of these links in a tweet, they will take you to a pre-specified web page.  It just has shortened the web page’s address to a manner that will more easily fit into a tweet.  As an example, the first link ( takes you to a page with the following address:’s_and_colitis_dietary_considerations. The web page’s address takes up nearly 100 characters by itself!  There are many ways of creating these shortened links, but if you want to start including links in your tweets, Twitter itself will shorten links you enter into your own tweets.

Let me know if there are other semantics you’re having difficulty understanding!

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OK I’m on Twitter…Now What? A Primer for Physicians (aka Twitter 101 for Docs)

So you’ve decided to take the plunge (or at least, dip your toes) into the Twitterverse.  Congratulations! Welcome to a vibrant interactive community.  You’ll find plenty of different personalities here and lots of opinions.  But if you are like I was back in January 2011, you currently have no idea how to actually use Twitter, let alone how a physician might want to use it.

There are plenty of places to find information about how to start a Twitter account, (for example here), so I am going to take a leap of faith and say that if you are reading this, you have already set one up.  If not, check out some online resources regarding starting your account and come back to this blog so you can figure out what you might want to do after the basic infrastructure is lay down (or, if you are just relatively adventurous, just head to Twitter and start your account without listening to any of the “pundits”).  This post is not meant to give you the ins-and-outs about Twitter.  I think they do a pretty good job explaining the basics on their help center.  There, you’ll find the “how’s” of Twitter, like how to post a tweet or how to follow others.

Instead, this post contains some of my basic recommendations about how you might first want to get involved in Twitter a professional manner.  As I have said before, getting involved means starting small.  I think you will quickly see why many people have stayed involved.

  1. Consider starting with a private account. If you are still treading the water about getting involved for one reason or another, remember that you can have a private account.  No one can follow you unless you let them.  This means that your posts (or “tweets”) will be hidden from view of everyone except those whom you permit. I suggest using this feature really only as a place to test the waters to get the hang of writing in 140 characters and see if Twitter is for you. Be aware that with a private account, your voice will not be heard.  You are not really contributing your expertise; you can still listen to and follow anyone with a public account, but you limit your prospective audience.  You can always change from private to public once you’ve established your account, so this is often a good way to test the platform, but I do not recommend maintaining a private account unless you want to remain silent or limited in your interactions.
  2. Start following some accounts. This is the key to finding out the power of Twitter.  The majority of the time, you will end up listening (i.e., reading) more than speaking (i.e., posting). Let me spend a few extra moments answering: Who should I follow and how do I find them?
    • Specialty societies and journals: By now almost all major societies and journals have Twitter accounts.  These are generally staffed by communications professionals who often tweet recent articles or news items you might find of interest.  You can try doing a search on Twitter for their accounts, or go to the societies’/journals’ home pages and find the place on the website where you can “Follow Them”.  If you are logged in to Twitter, you can usually just click that link or icon, and you will be taken right to their Twitter account where you can choose to follow them.  Once you’re there, check out who they are following.  Chances are, they follow accounts or people with whom you may have some common professional interests.
    • Let Twitter suggest some accounts: This tool might not give you the most interactive accounts, but at least you can continue to explore accounts that you may be interested in.
    • Search for accounts with similar interests: Do you have a particular area of interest? Maybe a disease or subspecialty? Do a search on Twitter to find people to see what people are saying about your area of interest.
  3. Listen to what others are saying: Are you surprised I said this before I talked about what to tweet? For everyday folk (and by everyday folk, I mean those of use who aren’t “follower millionaires”), Twitter is often more about listening than anything else.  By listening, you will get the feel of how people tweet, what people tweet, the format of a tweet, etc.  Believe it or not, listening to the voices might lead you to the next step…
  4. Decide what to tweet:  This is probably the most common question I get asked about Twitter. There are lots of people on Twitter saying many, many things all the time, but Twitter is not just about tweeting what you are just about to eat at the local diner.  Being on Twitter in a professional manner means you are starting to define your own digital footprint and your voice. Did you read a tweet that you liked? Retweet it.  That is one easy way to tweet, but that doesn’t create any new content of your own.  Are you an expert in one particular area? Start tweeting about it.  I strongly recommend avoiding tweets relating to patients directly. Use common sense when creating original tweets; remember that patient privacy is paramount.  However, you might find it easier though to get started by another common type of tweet: find an article or a news item about an important health issue or topic in your field and tweet it (or comment on it).  Any webpage can easily be tweeted nowadays with one of a number of tools that will shorten the web address to easily fit into the 140 characters of a tweet, like Tiny or bitly. Once you’ve shortened the link, you can import that into any tweet you’d like.  For an example, see the Twitter stream of Dr. Orlowski (@Myeloma_Doc), who tweets virtually exclusively about multiple myeloma.
  5. Find a hashtag: OK, now we’re starting to get to “Twitter 102 for Docs”. But if you’ve come this far and you’re ready to explore a bit, you might want to head over to’s Healthcare Hashtag Project to see what they’ve created.  Let me give you an example.  In the tweet below, “#GERD” acts as a tag for the tweet.  You can search for tweets by including the hashtag to increase the likelihood you’ll find something directly related to your topic of interest.

Well, I hope these hints help you get started navigating your way through Twitter as a medical professional.  Please feel free to comment and add your own suggestions or feedback.

In an upcoming post, we’ll delve a little bit more into “Twitter 102 for Docs”, where I’ll discuss some ways to enhance your professional community.

Special thanks to Natasha Burgert (@DoctorNatasha) for helpful hints!

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How to Become a Famous Doctor: A 4-Step Primer

After years of languishing and trying to figure out how to become famous in medicine, I have finally realized the key!

How did I finally reach my epiphany?

Well, one particular doctor (who shall remain nameless) has become famous in my field, as well as moderating famous around the country in the lay press, by promulgating a very specific theory for the last 20 years.  Although the theory does have some validity, this doc promotes it as the end-all-be-all of the issue at hand.  So much so that the doc now has published a book directed at patients who need help for their problem.  When I happened upon the book’s website, I noticed a picture of the doc standing together with another physician with a very famous TV show. (I’ll let this doc remain nameless as well, but if you are a wizard you’ll figure it out…)

It was then that the light went off about the key to getting famous…

Promote your agenda by being dogmatic

Here’s how you do that:

  1. Speak in absolutes. Talk in black and white. Never bring up the shades of gray because that might confuse your target audience.  Words to avoid include: may, might, could, and possibly.  Instead choose words like: will, won’t, always, and definitely.
  2. Incite fear in people.  Tell everyone that if they don’t follow your advice something bad will happen to you.  Like inflammation or dysfunction…those are hard to disprove.  Or maybe malaise, fatigue, depression, or other problems that have a hard time getting better.  Then your audience will believe you, because that’s probably why they’re listening to you anyway.
  3. Never rely on science (“evidence-based medicine”), because only your opinion (“media-based medicine” #mbmed) counts. Studies with valid, patient-oriented outcomes are much harder to do and probably won’t prove your point.  So why waste the time and money, when being charming and loud is much easier to make sure people know you’re right?
  4. Never admit that you don’t know. That will just show you are a failure and you will appear less god-like to the people you are trying to reach.

I’m glad that I figured that out. Now I don’t have to spend my time trying to understand and study complicated medical issues when I can just make everything fit my agenda. Whew, that’s a relief!

Oh, and this is a pretty good way to get elected to political office too.

Posted in Media-Based Medicine | Tagged , , , , , , , , , , | 7 Comments

Your Job Interview Begins Now

A few days ago I was sitting in the endoscopy unit working on some notes, when one of my fellows walked into the physician’s room to speak to one of her patients over the phone.  The patient evidently had a lot of complex questions about her condition that she didn’t quite comprehend.  The fellow took her time to respond calmly and in straightforward language.  She didn’t rush and never became flustered or frustrated.  After about 15 minutes or so, their discussion ended and the fellow left the room.

Why am I telling you this story?  To illustrate an important point. 

I was all the way on the opposite side of the room, and the fellow probably didn’t consciously notice me.  While I was sitting there, I was not intending to judge her on her patient interaction.  While she was talking to her patient, she didn’t necessarily think (or care) that she might be getting “graded” on her conversation.  Nonetheless as I was working I was quietly taking in my surroundings and her conversation happened to catch my ear.  Without even realizing it, I was making an informal mini-assessment of her knowledge, skills, attitudes, and behaviors.

Why is this example critical? 

The interaction registered in my perception of her overall ability to be a gastroenterologist.  And maybe, one of my future colleagues.  I am pretty sure that she wasn’t thinking that the phone call would make or break her ability to be get hired.  Most people wouldn’t.  But add up lots of mini-assessments, outside of the context of a formal job interview, and an opinion about you has been formed.  For all intents and purposes, everything you do that someone else could perceive (see, hear, or read), could be used as a mini-assessment, and you might not even have realized it.  And that time you flippantly yelled at a nurse and then laughed about it later with your colleagues might come back to haunt you.

How has Social Media changed this paradigm?

Social media such as Facebook and Twitter provide a means for rapid communication with virtually anyone, anywhere, at any time. Such platforms have changed the model for the expectation of privacy. The younger generation will grow up with Social Media so entrenched in their lives that they may not recognize all the ramifications of a single reckless post. Information can now become disseminated faster and more broadly, sometimes even ruining people’s lives with just a single action, post, or tweet.

The topic of professionalism has been receiving more and more importance within medicine and medical training.  For those who have a hard time understanding its importance, I would tell you this:

Professionalism is the 24-hour-a-day job interview

And now that social media has entered the mainstream, we (as parents, teachers, doctors, etc.) need to educate everyone about its potential.  Medical students, college students…even high school students.  Certainly, actions in childhood have little effect on one’s professional life as an adult.  However a professional and courteous attitude toward others does not begin overnight.

If you care about young people, whether your own children, students you are mentoring, or trainees, take the time to remind them that their actions, both in the real world and the virtual world, have the potential for consequences.  Let them know their job interview doesn’t just begin when they walk through the door of a potential employer…it begins right now.

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6 Things to Be Thankful For in Modern Medicine

Public sentiment about our healthcare system has certainly seen better days.  In the spirit of Thanksgiving, let’s take just a few minutes to reflect on what we can be thankful for in the current state of medicine:

  1. Informed consent: The concept of informed consent has its roots in multiple fields, but in medicine, informed consent was not a formal concept until the middle of the 20th century.  Respect for the values of others’ is paramount in patient care, and informed concept is at the heart of ensuring free will in medicine.
  2. Randomized controlled trials (RCTs):  Although clinical trials themselves date back to the 1700’s with a trial of citrus fruits for scurvy, the specifics of RCTs as we know them today developed much more recently.  Concepts such as randomization, masking (better known as blinding), and concealed allocation are important elements of controlled trials that all had to be introduced into clinical research in the last few decades.  Before RCTs, clinical research was based on case reports of physicians’ experiences in managing certain diseases.  RCTs are now the mainstay of establishing best practice and treatments in medicine.
  3. Intensive Care Units (ICUs): Bjorn Ibsen established the first ICU in Copenhagen in 1953.  The first ICU in the US was established at Dartmouth two years later.  Technological advances in medicine have often stemmed from ICU care, such as automated monitoring of vital signs and heart rhythms.  We can thank such advances for significantly contributing to improving mortality in critically ill patients.
  4. Electronic charting: Yes, there are problems with electronic medical records. Yes, the “copy-and-paste” phenomenon is unbearable.  But as we incorporate more and more digital record keeping, order entry, and prescription writing into our daily lives, the less likely patients are to suffer because of the illegible handwriting that physicians have been famous for.
  5. Specialty service and ancillary support teams: Teams comprising nurses, social workers, speech therapists, etc., are taking exponentially greater roles in providing excellence in patient care across the spectrum of healthcare settings.  Teams such as Wound, Ostomy, and Continence Nurse teams help ensure that patients receive consistent, reliable expert care and teaching when they require it.
  6. The ACGME competencies: Last but not least, I thought I would mention a recent change in medical education.  The competencies have been developed in an attempt to standardize the outcomes in our education and training of medical students and trainees.  One long-term goal of the competencies is to ensure that physicians can do more than just take care of diseases; we need to be able to take care of patients in complex health-care systems with a patient-centric approach, and prove to our patients and payers that we do it well.

I am not saying that the current healthcare system is perfect.  It has a lot of pieces that need smart people to work together to fix.  But let’s at least be thankful for what we have.  What else are you thankful for in modern medicine?

Posted in patient care | Tagged , , , , | 6 Comments

“Thank you for your consult…”

Until recently, there was a financial difference between performing a “Consultation” and a “New Patient Visit” for office visits (Medicare stopped paying for Consultations at a higher rate than New Patient Visits in 2010).  I won’t get into the ins-and-outs of what the criteria for a consultation were, why payment for the codes were eliminated for Medicare patients, etc… (If you want to read more about the difference, click here). The long and short is: in specialists’ offices, patients often get/got billed for the more expensive “consults” when in fact the visit was not a consultation at all.  Let’s just use this understanding as the brief background for what I’m about to say…

I work at an academic medical center.  My patient base is quite different from that of a typical gastroenterologist in that I often get asked to consult on (i.e. render an opinion about treatment for) patients by other gastroenterologists.  Because I see patients from all over the state, patients often come from several hours away and do not expect to get their routine GI care where I work.  Patients frequently return to their referring gastroenterologist for their care after I have rendered my opinion or helped them through their situations.  This is the way tertiary care medicine is supposed to be.  When a patient returns to their gastroenterologist, they are closing the circle of the consultation.

How then should I feel when a referring physician sends me a note on a patient, originally sent to me by him, that says something to the effect of:

“John Doe is being seen in consultation at the request of Dr. Ryan Madanick for a history of colon polyps.” ?

Here are my issues with this:

  1. I didn’t send the patient to him in consultation. I know how to take care of patients with a history of colon polyps. As a matter of fact, I DO perform colonoscopy. The patient returned to his care because he was the patient’s referring doctor in the first place, not because I wasn’t certain about the best option for this patient’s care.
  2. The patient is returning to the original referring physician.  The visit shouldn’t even be billed as a New Patient Visit.  It is an Established Patient Visit (which pays a lot less).
  3. If the patient’s insurance covers Consultation codes at a higher billing level, we are all losing (well, except for the payee). The patient probably wouldn’t see any difference. However, if this happens time and time again, the payment system would break down (or wait, maybe it already did…)

Let’s get this straight.  I know the referring doctor well, and I think he practices good medicine.  Still, we know why the note was documented this way.  And this is exactly the type of fraudulent billing practice that got the Consultation codes removed by Medicare.

I’ll end by making a plea:  Please don’t bill a patient and their insurance for a consultation when it is just a visit.

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