Welcome to the Digital World

Over the past two decades, social media has become an integral part of everyday lives, with millions of people using it as an avenue for keeping in touch with family and friends, receiving news and product recommendations, and – with varying outcomes – asking questions about health conditions. Doctors aren’t any different: More than 75,000 health-care professionals are on Twitter, posting an average of 152,000 tweets per day.1

But investigators, basic scientists, and clinicians are using social media for much different purposes than the general public. Some may consult with a colleague about a perplexing pathology image or case or providing a 280-character-or-less summary of a newly published peer-reviewed journal article. For many doctors, social media has also become another tool to reach for in the clinic, thanks to the ubiquity of mobile devices: According to a 2017 study, 88 percent of doctors report using a smartphone or tablet in the clinical setting, typically to access information for patient care.2

So, everyone and his or her doctor is on social media – now what? ASH Clinical News spoke with clinicians and investigators about how hematologists are using social media, its benefits and limitations, and how it affects their practice and patient relationships.

Endless Applications

During the first week of December, more than 25,000 hematologists convened in San Diego for the 2018 American Society of Hematology (ASH) Annual Meeting, and many more could check in virtually by following the more than 29,000 tweets tagged #ASH18 on social media. The growing use of social media was the focus of a special-interest session at the meeting.

As session chair and chair of the ASH Committee on Communications Aaron Gerds, MD, MS (@AaronGerds), from the Leukemia Program at Cleveland Clinic, said, “Whatever you want social media to do for you, it can do.” For the speakers at this session, that includes patient interaction, medical education, networking, and even career advancement.

For example, in the past decade, the U.S. has seen a resurgence of diseases once thought to be nearly or completely eradicated, due largely in part to the anti-vaccination movement. While the controversy over vaccinations has existed as long as the vaccines themselves, the campaign escalated and spread worldwide in recent years – largely through misinformation shared on social media outlets.

An analysis from 2018 showed that 60 percent of the information about influenza vaccines shared on social networks such as Facebook, Twitter, and YouTube promoted anti-vaccination sentiments.3 Moreover, 45 percent of consumers claim information on social media would affect the likelihood that they’d seek second opinions, while 40 percent said it would influence the way they manage chronic conditions or diet and exercise.4

Through Facebook groups and hashtags, patients have formed groups to seek advice and support from other people living with the same condition. For social media–savvy doctors, it also is an opportunity to learn more about how their patients experience the diseases they treat.

“As more people get into [the social media–engagement] game, I think we’re going to see a call to arms to not only adjust the quality of it, but also to start rewarding it.”

—Teresa Chan, MD

Jerad Gardner, MD (@JMGardnerMD), from the University of Arkansas for Medical Sciences and chair of Social Media Subcommittees for the United States and Canadian Academy of Pathology, told ASH Clinical News that, in his experience, patients often appreciate having a doctor’s perspective in these groups.

The first Facebook group Dr. Gardner joined was for people diagnosed with a tumor called dermatofibrosarcoma protuberans. When he answered a question a group member posted, he also acknowledged that he “wasn’t sure if [he] should be in the group, since [he] is not a patient.” His concerns were allayed when the group’s founder responded gratefully, telling him that, in the six years of the group’s existence, he was the only medical professional to join and offer information or ask patients about living with the disease.

“That blew me away,” Dr. Gardner said. “I realized that [engaging with patients through] social media is a way that we can help people – especially those with rare diseases – feel more empowered about their disease. Many doctors still don’t even know that these groups are out there, which is kind of sad, because I think it is a way for us to help patients, as well as a huge resource for us.”

He has expanded his social media reach to about 17,000 followers on Twitter by joining groups formed around the diseases he studies. In his spare time, he’ll respond to questions users have posted in the forums. However, he recommended that clinicians set careful boundaries and manage expectations about how much help they can offer. General questions are OK, he said, but doctors need to be clear that they cannot offer medical advice without actually seeing a patient. Instead, these interactions should help patients have more informed, empowered discussions with their personal doctors.

When using Facebook, Ruben Mesa, MD (@mpdrc), a panelist at the session and director of the UT Health San Antonio MD Anderson Cancer Center, also urged practitioners to join these types of groups – rather than creating new ones – for another reason. “It’s always important that these groups are created and stewarded by patients themselves so that there is no perceived conflict of interest that we are creating something just for our professional benefit.”

Leveraging Social Media

Patients in these groups derive benefit from sharing their experiences with each other, but their reach can extend beyond closed Facebook groups, according to Dr. Mesa, because these groups are “natural reservoirs” for patients who may be interested in participating in clinical trials.

“Rather than waiting for [potential study participants] to show up to my clinic,” he said, “I can put the word out there.” That includes sharing patient recruitment materials and information about a trial in “patient-friendly” terms. Sharing videos about the trial, its purpose, and how it works through social media “makes it much more ‘real’ for people and is more powerful than [showing patients] a website with enrollment criteria,” he said.

He referenced a recent study in which his center participated that evaluated the benefits of online yoga for symptom management for patients with myeloproliferative neoplasms.5 Within one week of posting the opportunity on social media channels, more than 400 people tried to register for the interventional, Institutional Review Board–approved study.

Clinical trial accrual is incredibly important, he said. “It helps [researchers’] careers, it helps the center, and it helps to meet the goals of those studies to identify whether a drug is active.” Leveraging social media for research makes sense, he continued, especially for communities of people with rare diseases.

Digital Scholarship

Doctors also form their own groups on social media, for professional and personal support and to discuss the unique experiences of being a practitioner. “We’re seeing more and more activity in closed groups,” Teresa Chan, MD (@TChanMD), an assistant professor in emergency medicine at McMaster University who also spoke at the ASH annual meeting session, told ASH Clinical News.

For example, Dr. Chan is a member of the “Physician Moms” group, which has tens of thousands of members. As one user wrote, the group is “a main source of support for being a doctor and mother,” while another praised the group for sharing continuing medical education opportunities.

“Social media is revolutionizing the way we are educating and reaching people,” Dr. Chan noted. During her talk at the ASH annual meeting, she discussed “digital scholarship,” and the growing use of social media in medical education. “For a long time, independent practice was seen as a solo enterprise, [but now] we see physicians wanting to engage with the world and talk about the exploding amount of research,” she explained.

“ [Social media] allows doctors to meet patients where they are. … We need to provide patient forums where patients are talking to each other.”

—Amber Yates, MD

Researchers, clinicians, and investigators use Twitter hashtags to discuss new research in their fields of interest or to live-tweet scientific meetings to a global audience. With this type of curation, conversations can continue long after the meeting has ended. (Alternatively, introductions on Twitter can turn into real-life meetings that may never have happened due to scheduling conflicts or geographic constraints. Search any meeting hashtag and you’re sure to also see photos tagged with #TweetUp (or “a meetup for Tweeters”) or #mottirl (or “Met on Twitter Then in Real Life”).

“Just as the basic scientists are doing really cool discovery work, so too can we advance the cause in linking people to that knowledge,” Dr. Chan said. “As medical educators, we need more people who are interested in advocating and sharing their knowledge online.” She urged attendees to engage with digital scholarship, building their academic portfolios and amplifying their message by sharing workshops and lectures on sites like MedEdPORTAL, an open-access clearinghouse of peer-reviewed teaching and learning resources published by the Association of American Medical Colleges.

The proliferation of health-care related blogs, podcasts, and online communities sends a clear message that doctors have carved out a space for themselves in the social media landscape, and now is the time to start critically appraising that material, Dr. Chan said. Several tools have emerged in recent years designed to evaluate how doctors are using nontraditional online education resources (like social media groups, podcasts, and journal clubs) – and how successful they are.

As part of the METRIQ podcast study, for example, Dr. Chan and other medical educators developed a quality-assessment tool to help trainees evaluate these types of resources.6 In another project, they evaluated the reliability and validity of the Academic Life in Emergency Medicine’s Approved Instructional Resources score, finding that the five-question tool gave medical educators an easy way to critically appraise online content.7

Through this research, Dr. Chan and colleagues developed general criteria for evaluating nontraditional educational material: “It must be original, advance the field by building, be archived, and include a method for the community to share transparent feedback.”

Point-of-Care Apps

While social media offers broad access to communities of patients, caregivers, and colleagues to help doctors facilitate discussions, many doctors have also begun using applications built for more specialized purposes. According to a 2014 report, doctors spend an average of three hours each week watching continuing medical education videos, and 85 percent reported using their phones at least once a day for clinical purposes.8

The same study showed that 38 percent of the time that doctors spent on their smartphones was using professional apps, such as the physicians-only site Doximity. However, in her experience, Dr. Chan said, when doctors reach for their mobile devices in the clinic, “it’s usually to look at quick reference guides, or information that they can use to teach patients or trainees.”

A scan of the iTunes Store charts bears this out: The most popular point-of-care apps are reference apps, like the ASH Pocket Guides on specific diseases. Dr. Yates said these types of apps are helpful because she doesn’t always know which patients will be in the clinic each day. “If I see a patient with von Willebrand disease – which is not my specialty – I will pull up the ASH Pocket Guide for von Willebrand Disease on my phone,” she explained.

Dr. Yates found one of her other favorite reference apps, the Kettering Cancer Center’s About Herbs app, through a Facebook patient group. “So many families are starting to ask about herbs and supplements and I never had a great resource that I felt confident in,” she said. Before discovering the app, a patient would ask about an herb or supplement and she would have to conduct her own research and then get back to the patient at the next visit. Now, she can address the question as soon as it comes up.

But patients don’t always present just like the cases in the textbooks or reference apps. That’s where apps like Figure 1 come in. The photo- and knowledge-sharing app, sometimes referred to as “Instagram for doctors,” allows health-care professionals to upload photos and information about certain cases; other users can comment and discuss possible diagnoses or treatment options.

Josh Landy, MD (@joshualandy), a critical care specialist and founder of Figure 1, told ASH Clinical News that the idea for the app came from his experiences during training. “I realized that the clinical discussions of patients being seen by med students or residents that were just happening over email and text could be amazing teaching resources,” he said. The app has become a go-to resource for challenging cases, he noted. “If I have a case that is not in the textbooks, I use Figure 1.”

Figure 1 is available in 19 countries and boasts millions of users. Next year, developers will be adding new features that allow doctors to answer multiple choice questions to prepare for board exams in hematology and hematology/oncology. Doctors will also be able to receive continuing medical education credit for completing questions.

Of course, with any social media or application where sharing clinical cases occurs, the number-one concern among the community is compliance with HIPAA regulations. “The best way to keep a secret is not to know it,” Dr. Landy said, noting that “absolutely no identifying information can be found on Figure 1.”

These are valid concerns, Dr. Gardner agreed, but they should not prevent wary doctors from participating in social media. In an article called “Keep Calm and Tweet On,” Dr. Gardner investigated such concerns among pathologists by searching for records of individuals being sued for sharing medical images on social media. The authors failed to find a single record of a user being sued for sharing images, as long as the images were de-identified and shared for educational purposes.

“If you use a little common sense, I think most doctors can stay out of trouble,” Dr. Gardner said, but, for the risk-averse who are still concerned, he and Eve Crane, MD, PhD (@evemariecrane), a hematopathologist at Weill Cornell Medicine who posts slide images for her Twitter followers to discuss, published guidelines for pathology image-sharing in the American Journal of Ethics.9

“More Than Likes and Tweets”

Social media has played a large role in expanding doctors’ knowledge, and, as nontraditional educational resources are being accepted as valid tools alongside traditional peer-reviewed publications, some doctors are finding that participation in social media also is expanding their careers.

In his presentation at the ASH annual meeting, Dr. Mesa posed the question many doctors may be asking themselves: “Why does my boss want me to get on social media?” The answer? Impact.

“What your bosses and chairs are looking for is impact,” he said, and social media is the perfect opportunity to demonstrate that you are reaching patients. As an example, Dr. Mesa discussed a patient-directed video that he produced with highlights from the 2017 ASH Annual Meeting. “This video was seen by more than 4,000 individuals,” he said. “Indeed, I rarely see a patient who doesn’t say, ‘I saw your videos, and that’s part of the reason why I came to see you – you seemed like you cared about my disease.”

Dr. Chan agreed, noting that “as more people get into this game, I think we’re going to see a call to arms to not only adjust the quality of it, but also to start rewarding it,” just as people would be rewarded for successful publishing or funding track records.

“What your bosses and chairs are looking for is impact. … I rarely see a patient who doesn’t say, ‘I saw your videos, and that’s part of the reason why I came to see you.’”

—Ruben Mesa, MD

This is a relatively new idea, but one that is being explored among graduate medical education researchers. For example, researchers from the Mayo Clinic in Rochester recently published a “social media promotion grading scale,” which provides definitions of high-, medium-, and low-impact content (determined by numbers of views or downloads).10

As more health-care providers flock to apps and social media for learning, teaching, and networking, Dr. Chan said, it will be crucial to “think about how we can engage in social media to up our game [and] to value people who can translate scientific knowledge and broadly disseminate it.”

When asked about how social media has changed her practice, Dr. Yates cited a different type of reward. “I’m standing here because of social media,” she said at the ASH annual meeting.

“I’m a clinician educator; I don’t do research and I don’t run a lab,” she said, which is how most doctors find recognition. “I’m speaking at the annual meeting, and I never thought I would have that opportunity in my career. I took a chance [in joining social media], and it has changed my career for the better.”—By Emma Yasinski

References

  1. Creation Health, “New study reveals explosion of doctors on Twitter.” Accessed December 10, 2018.
  2. Nerminathan A, Harrison A, Phelps M, et al. Doctors’ use of mobile devices in the clinical setting: a mixed methods study. Int Med J. 2017;47:291-8.
  3. Hussain A, Ali S, Ahmed M, Hussain S. The anti-vaccination movement: a regression in modern medicine. Cureus. 2018;10:e2919.
  4. Pricewaterhouse Coopers. Social media “likes” healthcare: from marketing to social business. Accessed December 10, 2018.
  5. Huberty J, Eckert R, Gowin K, et al. Feasibility study of online yoga for symptom management in patients with myeloproliferative neoplasms. Haematologica. 2017;102:e384-8.
  6. Chan TM, Thoma B, Krishnan K, et al. Derivation of two critical appraisal scores for trainees to evaluate online educational resources: a METRIQ study. West J Emerg Med. 2016;17:574-84.
  7. Chan TM, Grock A, Paddock M, et al. Examining reliability and validity of an online score (ALiEM AIR) for rating free open access medical education resources. Ann Emerg Med. 2016;68:729-35.
  8. Ventola CL. Mobile devices and apps for health care professionals: uses and benefits. P T. 2014;39:356-64.
  9. Crane GM, Gardner JM. Pathology image-sharing on social media: recommendations for protecting privacy while motivating education. AMA J Ethics. 2016;18:817-25.
  10. Cabrera D, Vartabedian BS, Spinner RJ, et al. More than likes and tweets: creating social media portfolios for academic promotion and tenure. J Grad Med Ed. 2017;9:421-5.