Pick the @MedEdChat Logo!

I’d like to thank @thuc for graciously designing some possible logos for our humble account, which until now has just used the famous “Twitter egg”.  Please choose one of the selections.  Results will be announced at the September 29, 2011 #meded chat!

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Posted in Esophagus | 2 Comments

The Internal Medicine Interest Group: a quick story

I just took part in the UNC School of Medicine’s Internal Medicine Interest Group session.   These type of panels were recently discussed in a New England Journal of Medicine Perspective, as well as that week’s #meded Twitter chat (you can read the transcript of that chat here).  Man was I in for a surprise!

With all of the talk about the lack of generalists in medicine and waning interest in Internal Medicine, I only expected about 20 or 30 students to show up.  Instead, I arrived to see about 150 or so students with a nearly-completely filled auditorium.

What should I attribute this to?

I found out later that it was the first of the “Career Opportunity Series” luncheons for the new first year medical students.  That might be a good reason.

I’d like to think that there was some other great reason for so many students showing up.  Maybe they all really want to go into IM (or at least think they do at this juncture). Maybe they heard that I was going to be on the panel (yeah, right!).

Maybe they are truly “undifferentiated” and are taking every opportunity they can to figure out the right career choice for them (the “idealist” viewpoint”)…

Or maybe it was just the free pizza.

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Lessons from My First Six Months at the Crossroads of Healthcare and Social Media

In the very early part of January I made the decision to start blogging.  Little did I know what was in store for me when I did.  Even though I’ve had my own “personal” Facebook account since 2008, it was not until January that I began to experience the “intersection” of Healthcare and Social Media.

With that in mind, here are a few of the things I’ve learned in my first 6 months as a medical professional in Social Media:

  1. Getting involved in Social Media means starting small:  Remember that “a journey of a thousand miles begins with a single step.”  How did I start?  Quite simply by writing a blog post about what I thought the blog would be about.  Although the focus and intent of the blog has changed somewhat, my experience grew out of that first simple piece.  
  2. It is easy to feel overwhelmed in Social Media: Take a look at some of the established blogs and sites.  Depending on where you land, you might see some very advanced networking capabilities, extensive archives, and even advertisements.  But just like your career, if you are trying to build credentials and influence in Social Media, it will take time to grow.  Don’t be afraid of exploring and being led by some of the more seasoned medical bloggers.  You can learn a lot from them, and I continue to be amazed at the complexity of some of their sites.
  3. “If you post it, they will come”: One of the most common things I hear people say (and one of the things that I said before I started blogging and tweeting) is that no one will see their blog, post, tweet, page, etc.  As I quickly learned, it doesn’t matter how many people you know now.  The more you get involved, the more your voice will grow.  We are still early in the intersection of Healthcare and Social Media.  All you really need now is an interest to be involved. When I wrote my second blog post about my friend’s personal experience undergoing endoscopy, I didn’t know who would see it or read it.  So I posted it to my own personal Facebook site.  I’m not even sure if I tweeted it or not, or who saw it the week I originally posted it.  Nonetheless since then my blog has had over 4000 views and my Twitter account has somehow picked up over 1000 followers.  And even though I posted that blog back in January, it became a permanent part of my blog archive, and there have been views of it even this past week.
  4. Both the compliments and the criticisms come more quickly:  Traditional publishing takes months, even years to happen.  Those of us who occasionally or frequently write in medical journals or textbooks often get little public feedback, except for the occasional “Letter to the Editor”.  When criticisms do come in print, they are usually phrased in such a manner that professional relationships and standards can be maintained.  However in Social Media spheres, “peer review” is more like a “public review” of your topic or opinion by anyone who comes across it: peers, patients, or anyone who reads your post. Comments can be supportive, opposing, or even frankly inflammatory.  The ease of posting anonymously makes such opportunities for hateful scorn even simpler.  And for some the negative commentary can be just too overwhelming.
  5. Venturing into Social Media is great way to communicate with a broad audience:  There are so many people with whom we can communicate.  It might be with your colleagues across the country, the general public, even your patients.  For those of my patients who seem interested, I give them the URL of my blog and let them know that I blog about various topics they might find interesting.  In doing so, I hope to become a real person to my patients, seen as someone with whom they can continue a dialog in the office, beyond just being a specialist in a white coat.  But it is important to beware of the risks of having private or semi-private discussions in a public forum, as such inadvertent mistakes can have dramatic consequences, even in “private” media like Facebook.
  6. Don’t enter Social Media expecting to become wildly successful: There are very few prominent bloggers who make their livings (or a second living) by maintaining active blogs.  The experience in Social Media is one of engagement.  The more people you communicate with, the more people you will communicate with, as your voice grows.  Some people are good enough to be able to drum up extra business by posting great content and developing a strong “brand”.  But if your intended audience sees that you are just trying to promote your business or practice, you will lose the interest of many of the people you would hope to become your intended audience.
  7. The proliferation of Social Media is not a passing fad: Whether or not you personally like it, “Social Media” is here to stay.  The popular Social Media sites and types may change from year to year, but this is the new reality.  As our patient bases grow more adept at using Social Media, those who do will expect similarly out of their doctors.  The same goes for the students, the trainees, and eventually our colleagues.  If we do not lead the way, we will trail behind those who do.
  8. Getting involved in Social Media is not for everyone: Well, you probably saw this one coming.  When I originally wrote this piece, this was my #1 thing learned, but I think it works just as well here.  Clearly there are some docs who are drawn to Social Media and some who spurn it.  For the latter group, no explanations will get them to embrace newer methods of mass communication.  There is however another group, a diverse group that contains the majority of docs who are out there (if you are reading this and have not yet tested the waters yourself, this is you).  The group comprises those who are unsure or skeptical about using Social Media as well as those who might be interested but just aren’t sure what to do.  Bryan Vartabedian (33charts.com) asserts that physicians are obligated to participate in Social Media (although this view is not espoused by everyone).  Right now, there is no requirement to be involved in Social Media, but the later a doc gets involved, the farther behind the 8-ball and more antiquated the doc risks becoming.

These points really just skim the surface of what is out there to be learned and experienced.  I continue to learn more about Social Media each day.  I remind myself that my own expertise lies in my medical skills and knowledge.  I am not an expert by any means in Journalism, Communication, Marketing, or Education, all of which are aspects of Social Media that I need to learn from experts in these areas so that I can develop my skills more broadly in this arena.

To those who have helped me grow since January, thank you.  I have made some great friends and relationships, and hope to make many many more.

Posted in Social Media | Tagged , , , , , , | 8 Comments

“This is a very pleasant patient…”

As an attending and the program director in a university practice, I have the opportunity to read a lot of notes that other people have written. Many of these notes are written by residents and fellows, often from my own program. In doing so, I often come across a phrase in the opening line of a note that really irritates me, which might go something like this:

“Mrs. Smith is a very pleasant 54-year old woman who…”

Why does this bother me, you might ask?

  1. It immediately imparts a connotation in the note that this patient’s symptoms are to be “believed”, as opposed to other, less “pleasant” patients.  The doc is probably going to be more inclined to help this patient.  I explained to one trainee that I thought it should be changed in her future notes, and I explained why.  Her explanation was that it was a “code” for her to remember that the patient was easier to deal with than many other patients she often sees in her practice.  You can imagine how I took to that explanation…
  2. It implies that other patients are less pleasant.  This same trainee uses “very pleasant” and “pleasant” in various notes.  I sometimes wonder what it means if she doesn’t put either in the note.
  3. A patient’s consultation or progress note, and for that matter, the opening sentence in such a note, is not meant to be where a doctor imparts their values and judgments on the patient.  Pleasantness (or perceived pleasantness) is really the patient’s affect.  Therefore this descriptor really belongs best in the exam, if anywhere at all.

Other words are similarly inappropiate in this context; the word that most frequently comes to mind is “unfortunate”.

“Mrs. Smith is an unfortunate 54-year old woman…”

Although it may seem that you are empathizing with the patient, I doubt that a patient would want to actually see a doctor write in their note that they are “unfortunate”.  The consequence of their problems may be unfortunate, but not the patient him or herself.

By no means do I intend to say that this issue is confined to trainees; I see the same descriptions among seasoned physicians.  My best explanation for this is that no one really ever went over their notes, or that they were just never told to change it.  If you find yourself saying this is your own notes, ask yourself why…and consider omitting it next time.

Posted in patient care | Tagged , , , , | 11 Comments

The Endoscopy: An Original Poem

It just doesn’t look right in the blog format, so click here if you’d like to read my poem.

Below is the brief backstory…if you’re interested in what happened.  Please read the poem first.

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Doc, can I use this natural supplement?

A little while back, I saw a patient in my reflux practice who had recently stopped her PPI and substituted licorice root to help keep her acid reflux symptoms under control. She told me that her symptoms were still under good control with the licorice root, and asked me if I was all right with her staying on it instead.  Since she did not have any mucosal injury (esophagitis) or other complications from GERD, my main question that I had to answer was about the safety of licorice root .

So I looked it up, just to be sure I was doing my due diligence.  If you aren’t aware of the possible side effects of licorice root, the major ones to be aware of are:

  • Edema/fluid retention
  • High blood pressure
  • Potassium loss
  • Headache

Fortunately, these only tend to occur at large doses (> 3 grams per day for several weeks) when the licorice root contains glycyrrhizin. In short, I thought it was fine for her since she was otherwise in good health, and the dose was not that large.

Nonetheless, there is an important reminder here: just because something is natural, doesn’t mean it is completely without side effects.  Even natural substances are still chemicals.

If you are a patient, please discuss all of your supplements with your physicians.  In this case in particular, extreme use can actually cause rare life threatening problems.  If you are a doctor or other healthcare professional, be sure to ask your patients about any herbs and supplements they might be taking.

Posted in CAM, GERD | Tagged , , , , , , | 6 Comments

A Patient Can Never Be Difficult

“There are no difficult patients; only patients with difficult problems.” I learned this mantra from a colleague and have used it to help shape my practice for quite some time now.

A few recent comments online about “difficult patients” have bothered me. When I tweeted a similar quote the other day, one person on Twitter insinuated that I was naive to say this.  One medical website even has a subsection under “Patient Relations” called “Difficult Patients”. Kevin Pho blogged about a similar issue recently, as has Dr. Maria Yang.  My take is somewhat different, but the basic premise is the same.

This is by no means a naive philosophy.  The simple statement can be applied in every situation.  The concept of a “difficult” patient is, well, difficult to comprehend.  In whose mind is the patient difficult?  Invariably, in the treating physician’s mind, but like many things in medicine, the concept can have different meanings for different observers.

Kevin Pho’s post referred to a study by Hinchey and Jackson published this month in Journal of General Internal Medicine, that explored both patient and physician factors in situations where patients are considered “difficult”.  You may have your own ideas of what makes a patient “difficult” that are not addressed exactly in this article.

Instead of considering the patient “difficult” in the first place, I would suggest another approach when faced with such a patient:

Try to understand what is driving the behavior or the situation that makes the patient seem difficult.

I couldn’t possibly list all of the possible reasons that might make a patient seem difficult, but here are a few options to consider:

  • The behavior that you consider difficult is patterned from early life experiences
  • The patient is worried about a serious problem but hasn’t told you
  • The patient doesn’t feel “listened to” by the healthcare system or other doctors (or you!)

There are innumerable other reasons I’m sure you could come up with. However, ultimately the underlying reasons for the “difficulty” are usually not things that the patient can control without external assistance.  Even in the unusual situation of Munchausen syndrome, in which patients harm themselves for secondary gain, there is a significant underlying disorder that warrants discussion and treatment.

Next time you are faced with a patient you find “difficult”, try considering why you are feeling that way, and explore what the driving force behind the patient’s situation might be.  You will open up the relationship with your patient and hopefully improve your patient’s outcome.

Posted in Esophagus | 12 Comments

Making choices in Social Media

This past week was a pretty exciting, relatively controversial week for people interested in Health Care in Social Media.  If you don’t know what happened, you can listen to Dr. Mike Sevilla’s podcast about it here. Although it is certainly not the end of the discussion, there has been a new flurry of activity today since MommyDoctor (@mommy_doctor) has apparently deleted her Twitter account.

In my opinion, the “system” (i.e., social media and the exuberant discussion that occurred) worked perfectly.  It worked just like it should.  I am not trying to insinuate that I am “pro” Dr. Vartabedian (@Doctor_V) and “anti” MommyDoctor.  On the contrary, I have been listening intently to both sides.

How did the system work perfectly?

  • We the participants (@Doctor_V, @mommy_doctor, and everyone who commented about the debate) were all at liberty to say what was on our minds.
  • We were at liberty to act in a way that best suited their values in response to what was said.  People listened and stayed out, choosing sides or not.  Some took sides, some quite verbally.  Some commented without taking a specific side.
  • In brief, we engaged in a great, open discussion.

Both Dr. V and MommyDoctor chose to enter social media, blog and tweet.  Neither was forced to do so.  They did so in the fashion they felt was appropriate.  Both were at liberty to comment on the other’s posts.  MommyDoctor chose to tweet what she did, Dr. V chose to call her out publicly.  Dr. V took one approach, MommyDoctor took another.

And we chose to comment. Many people chose to use their freedom of expression to lambast him for lambasting her. However, if we don’t think it’s right to call someone out and be the “police” of Social Media, then what makes it right to tell someone else that they were wrong to speak out? It’s sort of contradicting ourselves.

As a result of the brouhaha, Dr. V took one action (remained steadfast in his convictions), and MommyDoctor took another (decided to leave the space). But don’t mistake choice for an obligation.  MommyDoctor was not “forced” to leave.  Was she “bullied” as some would suggest?  If a single blogpost constitutes bullying in your mind then I can see how you’d think that.  Nonetheless, at no point did Dr. V request that MommyDoctor go away.  She listened to the community and took the action that best suited her values.  It was her own choice.

Posted in Social Media | Tagged , , , , | 6 Comments

Announcing the new #meded chat

In the last few weeks, several #meded tweeps have been bouncing the idea around about starting a Twitter chat dedicated to discussing issues related to medical education.  One night, Vinny Arora (@FutureDocs) made the proclamation that she thought we had now reached a “critical mass” of people interested in pursuing a #meded chat…

With that in mind, I decided to just sit down and make it happen.  So here goes the big announcement…

The weekly #meded chat will take place at Thursday nights at 9 pm Eastern time (US).

All of the ins and outs have not been completely worked out, but here are the basics for the time being:

  • For now, suggestions for questions/topics can be submitted by email to mededucchat (at) gmail (dot) com. This will be changing soon, as we work out the specifics of the moderator accounts on Gmail and Twitter.  If you would rather DM me (@RyanMadanickMD) for now, go right ahead.
  • Those interested in posting to or following the chat can simply use the #meded hashtag.

Those of us who were in the discussions about the arrangements realized that it would probably be too difficult to accommodate both the European and North American contingents at an appropriate time (this time slot is 1:00 am GMT).  AnneMarie Cunningham (@amcunningham) is thinking about a second time slot that would suit the European #meded interest group better, but for now we will use the Thursday night time slot as our initial footprint.  If it has to move around a bit, so be it.

We hope that this chat group will advancer collaborative efforts toward and permit rapid exchange of great ideas in medical education.

This is a work in progress, so your feedback is greatly appreciated!

Posted in medical education | Tagged , , , , , , , , | 2 Comments

Anonymity and Professionalism on Twitter: Room to Educate

A well-established medical blogger Dr. Bryan Vartabedian (aka @Doctor_V, a fellow gastroenterologist whom I recently had the pleasure of meeting at DDW 2011 #DDW11) seemed to ignite a firestorm this week amongst #hcsm tweeps with his post about a specific incident he saw on Twitter.  He was (is) of the opinion that:

  1. Physicians who maintain a professional presence in the Social Media space (Twitter, Facebook, blogosphere), should not do so anonymously.
  2. Professionalism and respect for patients should be maintained in this space in a manner similar to the non-internet space.

I read the blog and was sure that most people would be of the same opinion.  With only a few exceptions, most of the doctors I have encountered on Twitter have maintained a professional attitude, with a few notable exceptions, as documented in a recent JAMA Letter to the Editor.  I was definitely not expecting the eruption of sentiment from several others.

What transpired felt like a political debate between conservatives and liberals.  As a moderate I found it intriguing to listen to both sides and take it in, like an argument between the Dems and GOP on the appropriate way to decrease the deficit.  Let’s at least agree that those who have differing opinions are not going to agree, and neither side is truly “correct” or “incorrect”.

To explain the basic themes of those that espouse the opposite view of Dr. Vartabedian:

  1. Physicians do not have a responsibility to maintain an online “level of professionalism” that reflects our profession.
  2. This space is a social, not a professional, space.
  3. Physicians have every right to be anonymous.
  4. Our freedom of expression, even as physicians, is protected, and one person should not be the sole arbiter of morality.
  5. Public condemnation of individual physicians may be just as unprofessional as the actions being condemned.
  6. Since there were no actual HIPAA violations, there was no direct harm.

I am going to limit the remainder of this discussion to Point #1, professionalism. Do we have a responsibility to maintain a certain level of decorum in every aspect of our lives, or just certain aspects?  If just certain aspects, in which ones are we permitted to let loose? Is the Social Media space the appropriate place to drop our guard?

This is a matter of fervent discussion among medical educators and ethicists.  In a recent article in the Annals of Internal Medicine, Drs. Mostaghimi and Crotty said “social networks may be considered the new millenium’s elevator”.  We all know of doctors that do not keep quiet in the elevator no matter how often they are reminded of the issue of patient privacy.  The same can be said for online personae.

I have recently become more interested in the issue of medical professionalism after attending talks at the recent GI Training Directors workshop as well as a seminar series led by Drs. Sylvia and Richard Cruess from McMaster, who are leaders in this area.  They stressed that there is a gradient of professionalism and a learning curve that occurs over the years of education, training, and practice.

Two attributes of professional behavior are are germane to the discussion at hand: Morality/Ethical behavior, and Responsibility to Profession.  The fact that the internet and social media are new does not excuse the behavior, which was clearly less moral or ethical than optimal, nor does the novelty of the space eliminate the Responsibility to Profession that all who are physicians should maintain.  But just like there are some physicians whose medical knowledge, patient care, or interpersonal communication skills are less than optimal, we must realize that there are some doctors whose professionalism is so as well.

For those of us who enjoy educating, it behooves us to try to engender excellence among all of our colleagues.  We have a long way to go, but let’s keep working at it.

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Posted in medical education, patient care | Tagged , , , , , , , , , | 8 Comments