Will Many Hospital Close Their Doors?

http://www.hospitalimpact.org/index.php/2012/04/24/for_profit_chains_exec_pay_driving_hospi

iMedicine: The Influence of Social Media on Medicine

iMedicine:  The Influence of Social Media on Medicine was the topic of the day-long 27^th Annual Physician Student Awareness Day (SPAD) held on April 24, 2012 on the campus of New York Medical College in Valhalla, New York.  The entire conference was run by medical students from the Class of 2015.

Karl Adler, MD, CEO, welcomed the 200 attendees by recalling his own medical school education in the 1960s. Dr. Adler relied on textbooks, mimeographed handouts, and lecture notes to master both the art and science of medicine.  In his day, students were taught to rely on the history, the physical examination, laboratory tests, radiology studies, and the EKG; his teachers stressed that the history and physical obtained in a face-to-face encounter between the physician and the patient were the keys to successfully caring for the patient.

Ralph A. O’Connell, MD, Provost and Dean, discussed how the party line telephone was the social media of his youth, and he noted that the Council of Deans of the AAMC is holding sessions on social media.  He recommended the social media tool-kit from the CDC as a valuable resource for physicians and medical students (http://www.cdc.gov/healthcommunication/ToolsTemplates/SocialMediaToolkit_BM.pdf).  Dr. O’Connell also discussed The Information:  A History, A Theory, and A Flood by James Gleick (http://www.amazon.com/The-Information-History-Theory-Vintage/dp/1400096235/ref=sr_1_8?s=books&ie=UTF8&qid=1335354272&sr=1-8) and Betsy Sparrow’s article about transactive memory and how Google and smartphones are creating immediately accessible external storage sites for information (http://www.sciencemag.org/content/early/2011/07/13/science.1207745).  After noting that social media is more addictive than cigarettes and alcohol, Dean O’Connell gave the following advice:

·      Balance social media with more traditional forms of communication

·      Some information needed for medical practice needs to be inside your own head

·      Hone your observation skills

·      Make sure you have time for face-to-face encounters with both colleagues and patients

·      Ethical standards are important and patients expect and deserve their physicians to respect confidentiality

·      Medical practice should be evidence-based and we need research on what works and what does not work in social media in medicine.

Paul M. Wallach, MD, Vice Dean for Medical Education, thanked Drs. O’Connell and Adler for their years of service and leadership to the New York Medical College.  He also emphasized how proud he was of the Class of 2015 for putting together such a comprehensive overview of such an important timely topic.

Neil Shah, Chairman of the Class of 2015 SPAD Committee, welcomed the participants and thanked everyone who helped with the planning and logistics of the program.

Howard Luks, MD, a practicing “social orthopedist,” claimed he was not an expert or a key opinion leader.  He noted that the hashtag for the conference was #NYMCSPAD, and he stated that one’s relevance as a physician in the 21^st century will depend on how one uses social media to develop a professional network. After noting that in the past it has taken 17 years for evidence-based medicine practices to make their way into clinical practice, Dr. Luks pleaded with physicians to become more involved in social media.  Patients are taking the lead in using social media for health purposes, and Dr. Luks was disappointed that only 5% of the orthopedic resident applicants he recently interviewed considered social media to be important for health care.  Dr. Luks shared how he uses social media in his practice, and he noted that 17% of his private patients are due to his social media activities.  Perhaps his most inspiring story was how he coached a physician in the mountains of Pakistan through a complicated surgical procedure on a patient who had contacted Dr. Luks through social media.  He ended his talk with the thought that physicians may have a moral obligation to become involved in social media. (http://www.howardluksmd.com/orthopedic-social-media/)

Lawrence Sherman, Senior Vice President, Educational Strategy at Prova Education, polled the audience on their attitudes and practices in social media.  78% of the audience were medical students, 3% attending physicians, and 16% other.  97% of the audience use social media with 91% using it for professional or educational purposes.  67% said they needed a social media 101 lecture, and 79% said they were not confident in their use of social media for education and professional purposes. 

Mr. Sherman then elicited audience responses to six questions.  Who should use social media?  Everyone appropriately.  What should it be used for? Content that is useful to your audience, which might include the entire world. Where should you use it?  The difference between open (twitter) and closed platforms (Doximity) was discussed. When should social media be used? When there is an immediate opportunity to share information, which with the use of smartphones is almost all the time. Why should physicians use social media?  For continuous professional development; for community building and sharing; because it is free. How should one use social media?  The rest of program is structured around how social media can be utilized for treating, teaching, and learning. 

Brian McGowan, PhD, author of the book #SocialQI:  Simple Solutions for Improving Healthcare, provided a succinct and accurate history of communication that emphasized the flow of information between actors; he noted that the intention of the speaker can be quite different than the impact on the receiver of the information.  Starting 32,000 years ago with cave paintings that communicated messages that were limited by time and space, Dr. McGowan described how dancing developed about 9,000 years ago into a way that communication could occur wherever the dancers traveled.  The development of language 5,000 years ago enabled leaders to control the message that town criers spread in the town square, and Gutenberg’s movable type printing process created fidelity in communicating the message.  Dr. McGowan characterized today’s communication as digital, networked, and open with the widespread use of computers and smartphones.  In the last 10 years everyone has the ability to “flip production on its head” by using technology to develop “good enough” podcasts, videos, blog postings to share with their global network that becomes a community of practice.   Dr. McGowan ended his talk by discussing the dancer/film maker Jonathan Chu who states “Dancers have created a whole global laboratory online. Kids in Japan are taking moves from a YouTube video created in Detroit, building on it within days and releasing a new video, while teenagers in California are taking the Japanese video and remixing it to create a whole new dance style.” (http://www.ted.com/talks/the_lxd_in_the_internet_age_dance_evolves.html) Dr. Magowan thinks that since crowd-sourcing dance creates innovative art, maybe crowd-sourcing will transform health care.  

Starting with the famous Marcus Welby, MD photo where he studies an upside down x-ray (http://ow.ly/avA3V), Mark Ryan, MD, a practicing family medicine physician from Richmond, Virginia who serves on the External Advisory Board for the Mayo Clinic Center on Social Media, described America’s nostalgia for the friendly, patient-centered doctor who connected with his patients and always did the right thing.  Using beautiful Norman Rockwell paintings, Eugene Smith Life photographs, and images from the book A Fortunate Man (http://ow.ly/avzJJ), Dr. Ryan illustrates the available when needed, listening, kind, connected, well-known member of the community caregiver that is so hard to find in today’s world.  He suggests that we use social media to redefine what a community means in today’s world and that we make sure we take time to stop and listen to our patients.

Natasha Burgert, MD who blogs at kckidsdoc.com and practices pediatrics in Kansas City discussed how social media allows her to be the kind of doctor who stays faithful to what she calls “old school medical core values.”  Dr. Burgert believes the ideal physician is personal, accessible, trustworthy, and expert in her field.  After realizing that she was often providing second opinions to her parents who had already consulted with Dr. Google, Dr. Burgert started blogging to counteract the unreliable online sources that were leading her patients to make bad decisions.  When one parent said she had decided against giving her daughter the HPV vaccine because a Facebook page said it was a government plot to create a generation of sterile women, Dr. Burgert decided she had to provide her community with accurate information. 

Loring Day shared her story of knee injuries and five operations that convinced her that she needed to become an active participant in the shared decision making that guides her orthopedic care.  She believes physicians should be active in social media because humanization leads to trust; trust leads to communication; communication leads to information sharing, and information sharing leads to better care.  When she recently was seen in the Emergency Room for an infection, she was able to connect the ER physician with Dr. Luks, her orthopedist, to coordinate her care. 

Bob MacAvoy, a senior leader at Doximity, described how this start-up company provides a secure and effective closed social network for physicians to collaborate with each other via 2000 secure messages a week.  With 15 billion Faxes a year and YouTube tutorials available to build your own pager scanner to hack into medical communications, American medical communication can hardly be considered secure. Mr. MacAvoy showed an example of how a physician asked for advice from his Doximity community of practice about an unusual foot lesion; the possible diagnoses included wart, dermatofibroma, and melanoma.  When the final diagnosis of wart was shared, all learned from the discussion that took place over a few weeks time.  (https://www.doximity.com/index1)

Ryan Madanick, MD, an Assistant Professor of Medicine at University of North Carolina School of Medicine, discussed his community of practice called @MedEdChat on twitter.  Medical education leaders like Vinny Arora (@FutureDocs) and Anne Marie Cunningham (@amcunningham) share instant feedback on educational issues by using the hashtag #SMIME to label their posts.  Dr. Madanick delivered shout-outs to Kevin Pho, MD (@kevinmd) and Ves Dimov, MD (@DrVes) as physicians he tries to emulate and Mike Moore (@michaelbmoore) and Danielle Jones (@daniellenjones) as medical students who have actually mentored him in social media.  Dr. Madanick lessons learned include:

·      Start small

·      It is easy to feel overwhelmed but filters can help you stay on top of information overload

·      “If you post it they will come”

·      Compliments and criticisms come quickly on social media

·      Communicate with a broad audience

·      Social media is not a passing fad

·      Do not expect to wildly successful overnight

Mr. Sherman addressed “Pitfalls, Perils, and Potholes” by sharing two cases where a physician shared irreverent tweets that elicited a critical response from another physician active in social media.  In both cases everyone involved came in for criticism. (http://www.dailymail.co.uk/news/article-2038487/Welsh-Gas-Doc-Twitter-Irreverent-tweets-hospital-medic-provokes-angry-backlash.html) (http://wishfulthinkinginmedicaleducation.blogspot.com/2011/09/social-media-black-humour-and.html) (http://33charts.com/2011/05/unprofessional-physician-behavior-twitter.html) Every professional involved in social media can learn some important lessons by studying these two incidents.

Dr. Luks gave a second talk on professional reputation management.  For Dr. Luks reputation management is just as important as educational outreach, personal learning, and inbound marketing.  Because residency directors are looking at the digital footprints of their applicants and Fortune 500 companies are now asking for Facebook passwords from their future employees, Dr. Luks concludes that you cannot hide from Facebook, Google, or Healthgrades.  His simple advice is to “don’t be stupid” on social media. 

Dr. Burgert’s second talk addressed how adding “yourself” to your social media message can make you a more authentic source of trusted information.  She tries to be entertaining and humorous because she believes that style makes her more relevant to the audience of parents and children that she is trying to reach. 

In the last presentation of the morning, I tried to put social media into the overall context of 21^st century American medicine.  The federal budget deficit that requires a combination of raising taxes and cutting spending to the tune of $4 trillion is the major driving force behind the current ongoing transformation of American medicine.  I described the traditional medicine approach that I learned in medical school in the late 1970s.  The ruling paradigm was the biomedical model that reduces every illness to a biological mechanism of cause and effect.  The focus was on acute illness, and specialists replaced generalists.  The goal of medical care was cure, and health was defined as absence of disease. In many ways we ignored the patient story as subjective and untrustworthy, and we concentrated on laboratory results as objective and true.  I became a pathologist because I foolishly believed they were the most important physicians; clinicians merely carried out treatments after receiving the diagnosis from the blood test or tissue biopsy. 

Today the convergence of several developments is changing diagnose and treat to predict and prevent.  Health is now appreciated as a state of complete physical, mental, and social well-being and not merely absence of disease.  The patient story is essential for the development of personal metrics that will be unique for each individual.  Loring Day made it quite clear that she needed to be able to bike and ski because these activities define who she is as a person. Charity Tillemann-Dick underwent a double lung transplant for her pulmonary hypertension because it allowed her to continue singing opera which is her passion (http://www.huffingtonpost.com/2011/01/19/ted-med-2010-double-lung-transplant-saves-opera_n_810442.html) The pathologist sadly becomes less important because the human body and disease is recognized as a complex emergent system that may never be fully understood.  We now concentrate on chronic diseases and recognize that managing diseases is as important as curing disease. 

The convergence of genomics, wireless sensors, imaging, information systems, social networks, smartphones, and unlimited computing power via cloud server farms make a new digital medicine possible.  We have to begin to understand what it means to digitize a human being, and Eric Topol’s The Creative Destruction of Medicine is our best current guide (http://www.amazon.com/The-Creative-Destruction-Medicine-Revolution/dp/0465025501/ref=sr_1_1?s=books&ie=UTF8&qid=1335368798&sr=1-1)

So social media needs to be appreciated as only one of the developments that are converging to make digital medicine possible.  And nobody is smart enough to know how all this will play out.  I projected a copy of the Gartner Hype Cycle because I think social media is a technology trigger that creates the peak of inflated expectations, the trough of disillusionment, and if successful the slope of enlightenment, and the plateau of productivity. (http://ow.ly/avKSV) I do believe that social media will endure and that it is not a fad, but I also believe that none of us are smart enough to predict how it will transform medicine. 

Two recent studies document how difficult it is to predict how any disruptive technology will evolve.  In the brilliant Steve Jobs biography, Walter Isaacson describes how Jobs was one of the first twenty people in the world to have his pancreatic neuroendocrine tumor genotyped so that therapy could be tailored to the specific biochemical pathway affected by his tumor’s genetic mutation. Jobs even is quoted as saying he will be among the first to be cured by this approach or one of the last to die before it is perfected.  A recent New England Journal of Medicine article found that only one third of the 128 tumor mutations identified were present in all sites sampled of the four patients with renal cell carcinoma.  The tumor’s genetic makeup varies significantly within the same tumor sample, and this development complicates the personalized medicine strategy.  (http://www.nejm.org/doi/full/10.1056/NEJMoa1113205?query=featured_home#.T1jNegH6pWY)

Bert Vogelstein recently published a study of 53,666 identical twins looking at 24 diseases and asking the question, if every aspect of a person’s DNA is known can we predict that person’s future diseases?  The disappointing answer was no because behavior, environment, random events, and genetics all play a role in the development of disease. (http://www.nytimes.com/2012/04/03/health/research/dnas-power-to-predict-is-limited-study-finds.html?ref=science)

I discussed the difference between evidence based medicine and patient-centered choice.  Two important points were emphasized.  Much of what we do in medicine has not been verified scientifically by randomized controlled clinical trials.  Some estimate that only about 25% of current clinical practice is truly evidence-based.  The other point is Karl Popper’s famous declaration that there only two kinds of scientific theories:  those that have been proven to be wrong and those that are yet to be proven wrong.

Artificial intelligence and sociable humanoid robots is another disruptive technology that will affect medicine in ways that are hard to predict.  Farhad Manjoo believes robots will replace specialists but not primary care physicians (http://www.slate.com/articles/technology/robot_invasion/2011/09/will_robots_steal_your_job_3.single.htm). Ezra Klein argues that primary care providers are most at risk because IBM’s Watson has proven that it is possible to scan the entire medical literature in order to come up with a correct diagnosis. (http://www.washingtonpost.com/blogs/ezra-klein/post/how-robots-will-replace-doctors/2011/08/25/gIQASA17AL_blog.html)

I ended the talk with a slide of the Hype Cycle 2012 which attempts to predict where various technologies are in their evolution.  (http://www.motiviti.com/blog/gartner-hype-cycle-for-2012-and-beyond/)

Neil Mehta, MD of the Cleveland Clinic moderated a break-out session on social media and life-long learning.  Here is a link to a previous presentation on the same subject that took place in Cleveland (http://www.clevelandclinicmeded.com/online/webcasts/medtoday/social-media-and-lifelong-learning/)

Davidoff Education Day Video Interview

http://ein.st/I60EzA This link goes to a video interview of me at Einstein College of Medicine where I gave a keynote on social media and medical education during the Davidoff Education Day.

Is Your Hospital Culture Ready for Radical Transparency?

http://www.hospitalimpact.org/index.php/2012/04/04/is_your_hospital_ready_for_radical_trans

Will the Quantified Self Movement Take Off in Health Care?

“If you cannot measure it, you cannot improve it.” Lord Kelvin

“Asking science to explain life and vital matters is equivalent to asking a grammarian to explain poetry.” Nassim Nicholas Taleb

Of course the quantified self movement with its self-tracking, body hacking, and data-driven life started in San Francisco when Gary Wolf started the “Quantified Self” blog in 2007 (http://quantifiedself.com/). By 2012, there were regular meetings in 50 cities and a European and American conference. Most of us do not keep track of our moods, our blood pressure, how many drinks we have, or our sleep patterns every day. Most of us probably prefer the Taleb to the Lord Kelvin quotation when it comes to living our daily lives. And yet there are an increasing number of early adopters who are dedicated members of the quantified self movement.

“They are an eclectic mix of early adopters, fitness freaks, technology evangelists, personal-development junkies, hackers, and patients suffering from a wide variety of health problems. What they share is a belief that gathering and analysing data about their everyday activities can help them improve their lives.”

(http://www.economist.com/node/21548493/print)

According to Wolf four technologic advances made the quantified self movement possible:

“First, electronic sensors got smaller and better. Second, people started carrying powerful computing devices, typically disguised as mobile phones. Third, social media made it seem normal to share everything. And fourth, we began to get an inkling of the rise of a global superintelligence known as the cloud.”

(http://www.nytimes.com/2010/05/02/magazine/02self-measurement-t.html?pagewanted=all)

An investment banker who had trouble falling asleep worried that his concentration level at work was suffering. Using a headband manufactured by Zeo, he monitored his sleep quantity and quality, and he also recorded data about his diet, supplements, exercise, and alcohol consumption. By adjusting his alcohol intake and taking magnesium supplements, he has increased his sleeping by an hour and a half from the start of the experiment. (http://www.economist.com/node/21548493/print)

A California teacher used CureTogether, an online health website, to study her insomnia and found that tryptophan improved both her sleep and concentration. As an experiment, she stopped the tryptophan and continued to sleep well, but her ability to concentrate suffered. The teacher discovered a way to increase her concentration while curing her insomnia. Her experience illustrates a phenomenon that Wolf has noticed: “For many self-trackers, the goal is unknown…they believe their numbers hold secrets that they can’t afford to ignore, including answers to questions they have not yet thought to ask.” (http://www.nytimes.com/2010/05/02/magazine/02self-measurement-t.html?pagewanted=all)

Employers are becoming interested in this approach in connection with their company sponsored wellness programs. Suggested experiments include using the Jawbone UP wristband to see if different amounts of sleep affect work performance such as sales or using the HeartMath emWave2 to monitor pulse rates for determining what parts of the workday are most stressful.

(http://online.wsj.com/article/SB10001424052970204520204577249691204802060.html?mod=googlenews_wsj)

Stephen Wolfram recently wrote a blog illustrating just how extensive these personal analytics experiments in self-awareness could become when coupled with sophisticated technologies. Wolfram shares graphs of his “third of a million emails I’ve sent since 1989” and his more than 100 million keystrokes he has typed. (http://blog.stephenwolfram.com/2012/03/the-personal-analytics-of-my-life/)

Anyone interested in understanding just how far reaching this approach may become in the future should examine the 23 pages of projects being conducted by the MIT Media Center (http://affect.media.mit.edu/projects.php) My favorites from this fascinating list include automatic stress recognition in real-life settings where call center employees were monitored for one week of their regular work; an emotional-social intelligence toolkit to help autism patients learn about nonverbal communication in a natural, social context by wearing affective technologies; and mobile health interventions for drug addiction and PTSD where wearable, wireless biosensors detect specific physiological states and then perform automatic interventions in the form of text/images plus sound files and social networking elements.

It is easy to get caught up in the excitement of all this new technology and to start crafting sentences about how the quantified self movement will “transform” and “revolutionize” health care and spawn wildly successful new technology companies.

Jackie Fenn's "hype cycle" concept has identified the common pattern of enthusiasm for a new technology that leads to the Peak of Inflated Expectations, disappointment that results in the Trough of Disillusionment and gradual success over time that concludes in the Slope of Enlightenment and the Plateau of Productivity. Fenn's book, Mastering the Hype Cycle: How to Choose the Right Innovation at the Right Time can help all of us realize that not all new technologies becomes killer applications.

Jay Parkinson, MD has also written a blog that made me pause before rushing out to invest in quantified self companies or predict the widespread adoption of this approach by all patients. Parkinson divides patients into three groups. The first group is the young, active person who defines health as “not having to think about it until they get sick or hurt themselves.” The second group is the newly diagnosed patient with a chronic illness that will affect the rest of their lives. After a six month period of time coming to terms with their illness, Parkinson believes this group moves closer and closer to group one who do not have to think about their disease. The third group are the chronically ill who have to think about their disability every day. Parkinson concludes that “it’s almost impossible to build a viable social media business that focuses on health. It’s the wrong tool for the problem at hand.” (http://blog.jayparkinsonmd.com/post/19238089868/why-health-and-social-media-dont-mix).

The quantified self movement should be closely monitored by all interested in the future of the American health care delivery system. The potential to improve the life of patients with chronic diseases is clearly apparent; whether most people will use the increasingly sophisticated tools being developed is open to debate.