The case against live tweeting

“Live tweeting” of conference presentations continues to be popular. The practice is defined as posting one or more tweets attempting to tell the Twitter audience what the presenter has to say. It is touted as a great way to convey information to those who are unable to attend the conference.

I’m not a fan of live tweeting, and here’s why.

The live tweets are also supposedly used as a substitute for notetaking. I have blogged about some of the studies showing retention of information is better when notes are taken on paper.

Many of the tweets are incomplete and/or incomprehensible because the description of them has to fit within 280 characters—at most two or maybe three sentences.

Good speakers will use short bullet points and verbally explain what they mean. This can be difficult to accomplish in a tweet.

Papers presented at meetings have not been peer-reviewed. [Okay, I understand that peer review is not perfect, but it is the current gold standard for evaluating published medical literature.] Some people may not know this, but program committees can only judge what is in an abstract—which can be misleading. The submitted abstract is usually worded to attract the attention of those deciding which papers will be accepted. When the paper is presented at the meeting, it sometimes only faintly resembles what was contained in the submitted abstract.

People who rely on live tweets for medical news assume the live tweeter understands what has been presented and is able to coherently communicate it. I worry that snippets of misinformation may be widely disseminated.

What about impressions. Some organizations brag about their combined meeting tweets having 240 million impressions. That doesn’t mean 75% of citizens in the US have seen a tweet. Impressions are simply an index of how many twitter accounts could possibly have seen a tweet. Most tweets are not at all. I have almost 18,000 Twitter followers. I average about 2000 impressions per tweet. Most of my tweets get fewer than 10% engagements—defined as as clicking on a link, expanding detail, likes, and retweets.

Photographs of PowerPoint slides tend to be from bad angles and are often blurry. Here are some examples. Identifying information has been removed to protect the guilty.

The prosecution rests.

Take lecture notes on a laptop computer or use old fashioned longhand?

A paper published last year in Psychological Science suggests that taking notes in longhand is the better choice.

The authors, from Princeton University and UCLA, performed three studies on college students. They found that even if multitasking and distractions were eliminated, “students who took notes on laptops performed worse on conceptual questions than students who took notes longhand.”

Previous research has shown that note taking enhances learning by both providing external storage of information for later review and “encoding,” that is, processing information and reframing it in one’s own words.

Although significantly more notes were taken by laptop users, they tended to be more like transcriptionists instead of thinking about and summarizing what they heard.

Transgastric appendectomy. Would you have one?

A study in the British Journal of Surgery says that removing an inflamed appendix via the stomach is feasible and "promising." This is what is known as NOTES or natural orifice transluminal endoscopic surgery.

The paper (full text plus videos under "Supporting Information" tab) describes the first 15 cases done at the University of Heidelberg in Germany.

There is so much wrong with this paper and the concept in general that it is hard to know where to start.

During the year from April 2010 to April 2011, 111 patients were offered the chance to have this procedure done and only 15 agreed to do so. It appears that patients have a lot more common sense than some physicians think. The patients were carefully selected. Those with BMIs > 30 and with perforated appendicitis were excluded

The procedure was done by inserting an endoscope through the mouth and then through the stomach wall,  but if you read only the abstract, you would miss the fact that a separate trocar was inserted via the umbilicus to facilitate the operation. Therefore, it is not a pure NOTES procedure. The NOTES crowd would call this a "hybrid" procedure.

Several complications occurred. The first case had to be converted to an open appendectomy because of "severe inflammation." This was not explained in the paper but was revealed in the typically uncritical MedPage Today article about it.

Two patients developed postoperative pelvic abscesses requiring what they called "laparoscopic revision" which is their euphemism for second operations. A second operation is very uncommon in patients without perforated appendicitis.

In one patient, a technical problem necessitated ligation of the stump of the appendix through the umbilical port. Another patient had bleeding which had to be controlled by clips. For an obese patient (curious, as only patients with BMIs < 30 were said to have been included), the appendix had to be cut into two pieces because it would not fit through the opening in the gastric wall.

The median duration of the NOTES cases was 105 minutes with a range of 59 to 150 minutes. The average time for a standard three-port laparoscopic appendectomy is about 25 to 35 minutes which means that the NOTES takes three times as long.

The median hospital stay was 3 days with a range on 1 to 8 days. The usual length of stay for a standard laparoscopic appendectomy in the United States is < 24 hours.

The heavily edited videos are worth a look, especially the fourth one, which shows that it takes at least 10 snips of the tiny endoscopic scissors before the appendix is completely divided.

Because of the two patients in the series who developed abscesses, the authors advise caution for those with purulent appendicitis and suggest doing a standard laparoscopic appendectomy instead. The problem is that the surgeon would not know that a patient has purulent appendicitis until she has looked and made what would then have been an unnecessary hole in the stomach.

Most standard laparoscopic appendectomy scars are invisible anyway. If just one patient suffered a leak of the stomach wall closure which would cause sepsis and other major complications, that would strongly negate the minimal cosmetic gain from the trans-gastric operation.

The study ended two years ago but was just published. I always wonder about that. What took so long? Was it rejected by other journals? You would think the authors would want this sort of breakthrough brought to light as soon as possible. Have they done more cases since then? What were the outcomes?

After reading the paper and seeing the videos, is there a surgeon in the world who would want a trans-gastric appendectomy performed on herself or a loved one? An unscientific Twitter poll indicated they would decline. One surgeon said, "Not sure if I'd answer 'No' or 'Hell No,' and I do NOTES research."

Here's the bottom line. Unless you have promised your patient trouble, only the most ardent proponent of NOTES could call these results "promising".