Should residency program directors look at applicants’ social media activity?

Please take a look at my new post on Physician's Weekly: My thoughts on whether residency program directors should review applicants' social media activity.

Social media solves a medical riddle

This foreign body was removed from a non-healing abdominal wall incision in an elderly lady with many comorbidities and previous operations. It was a rigid plastic tube which was 7 cm long and 2-3 mm in diameter. There were four transverse grooves at either end.

Physicians caring for her were unable to identify it. One of them emailed me the photos and asked for help. I didn't know what was, but I knew where to look for the answer.

I tried a Google image search, but the brownish discoloration of the object was interpreted as wood by the algorithm. None of the many images on Google resembled the foreign body.

What has society come to?

A medical student who corresponds with me wrote the following. It has been edited for length.

She was shopping at a mall with her husband and their children.

As I walked underneath the escalators, I heard a horrific sound. I looked up and saw a body cartwheeling down. I ran to front of the escalator to push the stop button. An 80 or 90 year old gentleman was lying partly on and partly under his walker. He seemed unconscious with blood all over the place. I said "Sir, sir," saw his fingers move, and called 911.

A black man from the top of the escalator made eye contact with me and came running down to see how he could help. He hesitated, his face and body language screaming fear, but he came over. He knew he had to once we made eye contact because I was the only one actually doing something.

A security guard who was heading to work arrived. He had no gloves, no radio, nothing. Why wasn't anyone from security coming? What's the point of security cameras? Wasn't there anyone watching? I turned around to see who else could help. About a dozen people were just standing there with their cell phones taking pictures and videos. Not a soul asked me if they could call 911. In fact when I called 911 a second time, the dispatcher asked me if there were more people with me because I had placed the only two calls.

Live tweeting from #ACSCC15

As many of you know, I have not been a fan of live tweeting conferences. I blogged about the issue last year (here and here) and received a lot of feedback about the posts, most of it strongly opposing my views.

Vigorous live tweeting from the American College of Surgeons Clinical Congress (#ACSCC15) in Chicago is underway. Here are a couple of examples of tweets from that meeting. Twitter handles are blocked to protect the innocent (or guilty).

First, the good. Here is a nice montage showing what surgical program directors are looking for in residency applicants.

The photos are in focus and well-positioned. Anyone not in the audience for the talk can get something useful from this tweet. My one complaint -- we do not know who the speaker is. That information may have been provided in an earlier tweet, but this retweet is the only one I saw.

Dr. Topol's bad day

Dr. Eric Topol is a cardiologist, author, editor-in-chief of Medscape, and genomics professor. In 2009, he was named one of the 12 Rock Stars of Science by none other than GQ magazine.

But even rock stars occasionally have a bad day. After blogging for almost 5 years, I sometimes have trouble thinking of things to write about. This apparently happened to Dr. Topol the other day. He published a Medscape article with an accompanying video about how doctors are being squeezed by many outside forces that require them to do things they don't want to do.

It was kind of a rambling discourse in which he suggested that doctors should offload the responsibility to do these "more mundane aspects of care" to the patients. He thinks this would make medicine more exciting "the way it used to be."

Dr. Topol offered this cartoon to illustrate the outside forces that are squeezing doctors.

Genomics is a focus of Dr. Topol's research, but I don't think a lot of doctors are concerned that they lack knowledge about it.

His post created a lot of controversy prompting Medscape to take down all of the comments.

With great foresight, one physician, Dr. Kristin Held, preserved her comment with a screenshot which I have thoughtfully provided for you below.

What do you think she really wanted to say with the start of her second paragraph? Could it have been "How about growing a _ _ _ _ of _ _ _ _s?

Like Dr. Held, I have no idea which of the "mundane aspects of this new world" Dr. Topol had in mind to offload on the patients. Of the 16 forces squeezing doctors that he illustrated, I don't see many of them being taken over by patients. They already control patient satisfaction and what's written on Yelp. Maybe they can cover the lack of genomic knowledge too.

It's sad that an influential doctor like Topol is so lost in the woods. However, the bright side is that gave me something to write about.

Facebook and unprofessional behavior among surgical residents

Have you ever wondered about the behavior of surgical residents on Facebook? I have. A study from the Journal of Surgical Education posted online in June 2014 looked at the issue.

The paper, "An Assessment of Unprofessional Behavior among Surgical Residents on Facebook: A Warning of the Dangers of Social Media," identified 996 surgical residents from 57 surgical residency programs in the Midwest and found that 319 (32%) had Facebook profiles.

Most (73.7%) displayed no unprofessional content, but 45 (14.1%) exhibited possibly unprofessional material. Clearly unprofessional behaviors were noted in 39 (12.2%) resident profiles. The paper said, "binge drinking, sexually suggestive photos, and Health Insurance Portability and Accountability Act (HIPAA) violations were the most commonly found variables."

There were no differences in the rates of unprofessional behavior between male and female residents or by postgraduate year.

I have blogged previously about the ill-defined nature of professionalism, and the papers' authors acknowledged that it can be subjective. Some of the behaviors they felt were potentially unprofessional such as photos of residents holding an alcoholic drink, holding a gun while hunting, or making political or religious comments are debatable.

They referenced another paper that found similar rates of unprofessional behavior (16%) on Facebook among applicants to an orthopedic surgery residency program.

A 2005 New England Journal of Medicine case-control study found that practicing physicians disciplined by state medical boards were significantly more likely to have had documentation of unprofessional behavior in medical school as well as lower Medical College Admission Test scores and poorer grades in the first two years of medical school.

Unprofessional behaviors listed in the New England Journal paper were irresponsibility, diminished capacity for self-improvement, immaturity, poor initiative, impaired relationships with students, residents, nurses, or faculty, impaired relationships with patients and families, and unprofessional behavior associated with anxiety, insecurity, or nervousness.

Some of those \ seem a bit vague. Are diminished capacity for self-improvement and poor initiative really unprofessional behaviors?

Facebook unprofessional behavior and the unprofessional behavior documented in the NEJM paper which pre-dated the widespread use of Facebook may not be comparable.

But I suppose one could say that some of the Facebook behaviors could be categorized as immature or irresponsible.

Until stories about residents being rejected for jobs after training start emerging, there probably won't be a change in the way they use Facebook or other social media.

Or maybe society will change.

In 1987, politician Gary Hart had to withdraw as a candidate for the Democratic Party's presidential nomination because he had an extramarital affair, and just a few years later, the president himself had a dalliance with an intern in the White House and survived.

Who thought marijuana use would ever be legalized?

Reaction to post on academia and social media

"Should social media accomplishments be recognized by academia?" a post of mine from October 4th, generated some lively discussion on Twitter.

Here are a few of the more interesting responses:

@ashishkjha Important question from @Skepticscalpel Should academia value impact on social media? Yes. And it's coming. Slowly.

@MartinSGaynor Science comes 1st, 2nd, 3rd.. MT @ashishkjha Important Q: @Skepticscalpel Shld academia value impact on social media?

@ashishkjha agree how to measure impact a key question. Eye balls can't be enough. But too important a question to ignore.

‏@DoctorTennyson Yes-I think social media has a role for #publichealth, #education, and fosters collaboration. More than obscure journals

@NirajGusani still you add value to your dept -how do/should they measure it?

‏@gorskon Heck, at @ScienceBasedMed, we get 1M page views a month, but I get no credit.

@gorskon I agree though. For the most part, social media harms, not helps, academic career.

Should social media accomplishments be recognized by academia?

In August, I posted this: "A paper of mine was published. Did anyone read it?"

A recent comment on it raised an interesting point. Dr. Christian Sinclair [@ctsinclair] said that a website he is helping to run called "Pallimed" has received almost 2 million views since 2005.

He then made the following calculation:

Two million views with an average of 1:30 minutes on a page = 3 million minutes = 50,000 hours = 2,083 days = 5.7 years of 24/7/365 informal learning on hospice and palliative care topics.

He said that this type of communication counts for nothing regarding academic advancement and added that writing another paper and having it published in a journal no one reads or a chapter in an expensive book no one will buy is considered worthwhile.

This reminded me of something I have talked about in recent presentations. The first laparoscopic cholecystectomy done in the United States took place in 1988. The procedure rapidly became popular due to its obvious benefits over traditional open surgery—smaller scars, shorter hospitalizations, quicker returns to normal activity.

Does anyone really read anything online?

Not long ago, I tweeted a link to a very long story. Within 60 seconds, it received three retweets. Since the article would have taken at least 10 minutes to read, it is highly likely that those who retweeted it did not read it.

This phenomenon is not limited to Twitter. A couple of recent articles revealed some interesting data about what people really do online.

From Time magazine in early March: "A stunning 55% [of those who clicked into an article] spent fewer than 15 seconds actively on a page. [emphasis theirs] The stats get a little better if you filter purely for article pages, but even then one in every three visitors spend [sic] less than 15 seconds reading articles they land on."

Analysis of 10,000 articles shared on social media "found that there is no relationship whatsoever between the amount a piece of content is shared and the amount of attention an average reader will give that content."

A Slate article noted that about 5% to 10% of those who open an article leave it immediately and 38% of people who click on it "bounce" [leave it] before the end of the first paragraph.

At a few hundred words into the article, about half of the remaining readers have left, and very few of the rest make it through to the end.

The amount of scrolling can also be tracked. "There’s a very weak relationship between scroll depth and sharing. Both at Slate and across the Web, articles that get a lot of tweets don’t necessarily get read very deeply. Articles that get read deeply aren’t necessarily generating a lot of tweets."

On April Fools' Day, NPR published a story called "Why Doesn't America Read Anymore?" There was no article [emphasis mine]—only the headline and an explanation of the fact that they wanted to see if people would comment anyway. They were not disappointed as many brainless comments rolled in. This Gawker post has the best of them.  

The Washington Post noted that in addition to diminishing attention spans, we are developing into a nation of superficial readers. “It’s like your eyes are passing over the words but you’re not taking in what they say,” said a graduate student in creative writing.

Attempting to stay with the trend, last week both the Associated Press and Reuters directed their reporters to limit stories to fewer than 500 words.

If anyone is still reading this, what it means is that I should not feel slighted that people are retweeting me without necessarily reading what I so carefully and lovingly select for dissemination. 

It's not me. It's you.

PS: I am aware that some people retweet things and plan to read them later. But how do they know that what they have retweeted is worthy? Or does it matter?

Who would ask an anonymous blogger for medical advice?

I'm often asked why I use a pseudonym. When I first started blogging almost 4 years ago, I was still in practice. Some of my posts are a little edgy and my sense of humor is not for everyone. I didn't want patients to google me and have my blog come up on the first page of hits.

Now that I've been retired for over a year, I still have not revealed my true identity. You may ask, "Why not?"

I like being anonymous. I feel that I can be more honest because I am not worrying about what someone is going to think. A quote from Oscar Wilde says it all: "Man is least himself when he talks in his own person. Give him a mask, and he will tell you the truth."

Some people have questioned my credibility. They say how can anyone believe what you write when they don't know who you are? I've been referred to the UK General Medical Council's rule #17, which states "If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely."

Regarding the previous sentence, I agree with the first part about trust and strongly disagree with the second part. How could anyone think that what a single doctor writes is representative of the profession more widely? I am reasonably certain that is not the case in my situation.

You want credibility?

A single post of mine called "Appendicitis: Diagnosis,CT Scans and Reality," which I wrote about three weeks into my blogging career, has received almost 14,000 page views.

In the comments section of that post or via email, more than 50 people have asked me questions about their own or a family member's abdominal pain. I've had to add numerous disclaimers over the years reminding readers that I could not give medical advice without examining the patient.

Despite the disclaimers, the questions keep coming with the most recent one submitted two days ago. I can only guess that they are either reluctant to ask questions in person or not getting satisfactory answers from the doctors they are seeing.

Premed and medical students and residents frequently look to me for career counseling. Last week I even got a question from a high school student who was thinking about becoming a doctor. The students and residents occasionally preface their questions by saying that they didn't want to ask someone from their school or residency program for fear it would reflect poorly on them.

I have been amazed at how many readers seem to trust me enough to ask personal questions about their health or their career. To be able to connect with so many people despite my use of a pseudonym is rewarding.

Patients and aspiring doctors—that's who would ask an anonymous blogger for advice.

A study says you can trust online physician ratings

This abstract comes from the Social Science Research Network:

Despite heated debate about the pros and cons of online physician ratings, very little systematic work examines the correlation between physicians’ online ratings and their actual medical performance. Using patients’ ratings of physicians at RateMDs website and the Florida Hospital Discharge data, we investigate whether online ratings reflect physicians’ medical skill by means of a two-stage model that takes into account patients’ ratings-based selection of cardiac surgeons. Estimation results suggest that five-star surgeons perform significantly better and are more likely to be selected by sicker patients than lower-rated surgeons. Our findings suggest that we can trust online physician reviews, at least of cardiac surgeons.

You won't be surprised to learn that I don't believe it. As is my custom, I decided to read the entire paper the full text of which can be found here. At 37 pages, the raw manuscript is rather lengthy. As a public service, I waded through it.

The authors, non-MD faculty from the William E. Simon Graduate School of Business Administration at the University of Rochester, in New York, combed the ratings for Florida cardiac surgeons on the website RateMDs.com and classified surgeons into three categories—five-star surgeons, non-five-star surgeons, and those with no ratings at all.

They looked at 799 quarterly opportunities for ratings over a 9-year period and found that 21% of surgeons had an average of 1.9 online ratings. The 79% of surgeons who did not have an online rating performed 79% of the total surgeries in 2012, the year that the authors analyzed for patient results.

The five-star surgeons had a mean of 1.8 reviews each, and only 10% had more than 2 reviews.

The average mortality rate for coronary artery bypass grafting (CABG) among the Florida cardiac surgeons was 1.8% in 2012. The five-star surgeons with multiple reviews had the highest mortality rates at 3.3%.

I could find no evidence that patient mortality rates were adjusted for risk. But a lot of statistical manipulations took place. It's all explained by this simple equation—one of many.

 The authors say, "For a representative patient who is severely ill, being treated by a five-star surgeon can reduce the in-hospital mortality by 55% compared with being treated by a non-five-star surgeon. [I have no idea how they determined that figure.] Moreover, the negative and significant coefficient of no-ratings suggests that patients treated by surgeons without ratings also have a lower mortality rate than those treated by non-five-star surgeons, all else being equal." Huh?

And this, "Patients with private insurance are less likely to select the surgeons without ratings than patients with Medicare. We suspect that patients with private insurance have to use search engines to figure out whether a surgeon is within the network that an insurance plan covers, while government patients enjoy a large physician network." I question that assumption. My experience is that patients with Medicare sometimes have problems finding anyone to care for them, let alone the best surgeons.

It turns out that half of the five-star surgeons had only one review. In one iteration of the study model, five-star surgeons with multiple reviews had higher mortality rates than those with only one review, but then they also say, "One surprising finding is that five-star surgeons with a single review show no statistical difference in performance from those with multiple reviews."

Are you as confused as I?

The paper makes no mention of the possibility that some of the online ratings could be fake. Recent articles [here and here] suggest that one-fifth to one-third of such reviews are phony.

You can manipulate the statistics all you want, but you won't convince me that one or two or even 20 online ratings are valid or useful in choosing a surgeon.

Is it a blog or a post?

Sometimes in the throes of temporary insanity, I call a blog "post" a "blog."

Luckily I have Twitter followers to set me straight. They have called me to task on several occasions for this linguistic gaffe. 

You see, calling a post a blog is like calling an article a  magazine. And it tends to upset people who are the arbiters of what is right and wrong on line (or is it online?).

For example, Paul Hutchinson, who posts blogs at the cleverly titled "Paul Hutchinson's Blog," says he is "getting very annoyed" at what he sees as a redefinition of the venerable (since 1999 when it was coined from "weblog") word "blog".

There's Kristen Havens, who wrote an interesting blog on semantics, at her "Writing and Editing" site. Using just 485 words, Kristen mentions different ways to use post and blog correctly and incorrectly. This particular blog of hers originally appeared on a site called MySpace, whatever that is.

But the real winner is Forrest Wickman writing in Slate's Culture blog. In a blog entitled "This is a blog post, not a 'blog,'" he excoriates people like Arianna Huffington and late Roger Ebert for using "blog" when they should have said "post."

Wickman says, "I hit my breaking point a few weeks back with—who else?—Amanda Palmer."

Who else indeed? I will save you the trouble of googling her name. She is some kind of singer and performer who gave a TED Talk, which actually is pretty interesting. She drove Wickman to the breaking point by calling a post of hers a blog! Can you imagine?

Suitably censured, she now calls her blogs posts as you can see on her website. 

I hope you enjoyed this blog post.