Physicians Unite on Twitter, Divide on Practice

She began writing nearly a decade ago, determined to counter the spread of medical misinformation online. Soon, she realized that to be appealing on social media is to be genuine, and her advocacy for women’s health issues along with a generous dose of levity—as in, a photo of her toilet-trained cat—has helped make Gunter the life of the party on Twitter, with nearly 70,000 followers.

The fact that Twitter can be reminiscent of a cocktail party, however, is exactly why some doctors were initially, or remain, reluctant to join. As the healthcare social media consultant Janet M. Kennedy explained, “Doctors thought that what was happening to them at cocktail parties would happen online. They were afraid they were going to run into patients, or somebody would ask them a question that was too personal.” They might also be tempted to lapse in discretion and vent about their workplace or divulge an experience with patients.

Social media can feel like an ethical minefield, and those concerns inspire a variety of approaches. Gunter, for example, tweets with remarkable candor under @DrJenGunter, but avoids discussing anything about her practice.

Nevertheless, social platforms, especially Twitter, have attracted a hyper-engaged community of medical professionals, whether they’re seeking to connect with colleagues, advocate for causes, promote research, share information with the public, or catch the attention of potential patients. And yes, controversially and perhaps even illegally, Twitter can be used to detail bad experiences on the job, though usually behind the veil of anonymity.

I'm going to #gynosplain emergency contraception so there is NO CONFUSION, okay? #emergencycontraceptionisnotabortion

— Jennifer Gunter (@DrJenGunter) February 14, 2018

Plan B works by inhibiting ovulation. THIS IS FACT, It is levonorgestrel and if it caused abortion no one would ever get pregnant on the pill. #emergencycontraceptionisnotabortion

— Jennifer Gunter (@DrJenGunter) February 14, 2018

A decade ago, “People thought that if they ignored the internet, the internet would ignore them,” said Kennedy (@JKennedy93), host of the “Get Social Health” podcast and member of the Mayo Clinic Social Media Network advisory board. “Now, physicians are at least acknowledging that if they don’t control their own reputation, someone will control it for them.”

That insight is shaping industry standards. Two years ago, Mayo Clinic, which has been one of the most enthusiastic adapters of social media, integrated social media performance into its criteria for academic advancement and urged its physicians to include a Twitter handle on their resumes. (A year earlier, the hospital partnered with Hootsuite to develop a 4-hour, $400 online course on social media basics geared toward healthcare professionals nationwide.)

“I never think of social media as a surrogate or substitute for 1-to-1 discussion,” said Farris K. Timimi, MD (@FarrisTimimi), a cardiologist and medical director of Mayo Clinic’s Social Media Network. “If you think about what I tell patients in the exam room, if I could deidentify and amplify that message, it would be foolish not to.”

Toeing the Line

It’s easy to lose sight of the fact that in a different era, it would have been inconceivable for someone like Mike Sevilla, MD, a primary care physician in Salem, Ohio—population 12,000—to achieve a global following. In the mid-2000s, Sevilla became increasingly distressed by the prevalence of material online claiming that vaccines caused autism. Patients would ask him virtually every day about the supposed dangers of vaccination.

He believed medicine as an industry had “underestimated the power of the internet,” and that motivated him to begin blogging, and soon tweeting, under “@DoctorAnonymous.”

(In hindsight, many are convinced that physicians’ reluctance to engage on the internet allowed anti-vaccine hysteria to take hold. By comparison, during the ebola epidemic in 2014, doctors online helped quell undue panic in the United States.)

When Sevilla created Doctor Anonymous, there was a collection of prominent physicians online who posted anonymously and with a striking lack of restraint. “I was venting about bad information out there,” Sevilla says, “but also about the healthcare system, patients, and insurance companies. That was the culture back then.”

It was a matter of time before someone was outed. In 2007, Robert P. Lindeman, MD, a Boston-area pediatrician, was sued for malpractice after the death of a 12-year-old boy. Under the pseudonym “Flea,” Lindeman had used a blog to rant “at length about a trial remarkably similar” to his own, the Boston Globe reported. On the witness stand, Lindeman was forced to admit that he was Flea. The case was settled the following day.

“I work in a small town and didn’t want to get fired,” Sevilla says. “I decided I wasn’t going to write about my patients, and to shift my writing from complaining to being more of an advocate. I wanted to combat the negativity that I saw on the internet.”

In 2011 he wrote a blog post unmasking himself, explaining, “Doctor Anonymous was a gimmick, and now it’s time to be more transparent.” Around that time, people on message boards began wondering why popular anonymous accounts, such as “Panda Bear” and “GutShot,” had suddenly disappeared.

As @DrMikeSevilla, Sevilla has amassed more than 27,000 followers on Twitter, and he’s frequently invited to speak at conferences and on news programs. At times, it’s been overwhelming. Frustrated by accusations that he was “just trying to get attention,” along with the overall trend on Twitter toward negativity, Sevilla took a break from the internet in 2013 in order to do some “social media soul searching.” With encouragement from followers, he decided to recommit.

#HCSM T3: The most significant change I’ve seen in health and social media is empowerment and advocacy.

The next change I hope to see is going back to 2009 where we listened more and yelled less. Finding common ground should be the goal and not pushing one particular POV :)

— Mike Sevilla, MD | DrMikeSevilla.com (@drmikesevilla) January 15, 2018

“I continually try to keep myself centered on why I started this in the first place,” he explained: to champion the importance of family medicine and to combat misinformation.

There is another reason to keep tweeting. “I call them ‘nonbeliever physicians’ who’ve been making fun of me for 10 years,” Sevilla said. “This is marketing. This is business. If you google your specialty in your town and your name doesn’t come up first, patients won’t find you.”

Despite that advantage, anonymous accounts have persisted. An “emergency physician in Texas,” @GruntDoc, has tweeted since 2007 and explains on his blog, “As for the use of a Pseudonym while blogging: I don’t know why every doctor doesn’t!” He didn’t respond to requests to elaborate.

When new family members would visit and put their hand out to shake mine, I’d say no and dive in for a hug.

Most were taken aback but later said that was the best part of having me as a nurse.

— Wheezy Nurse© BSN RN (@WheezyNurse) January 22, 2018

Five years ago, “Wheezy Nurse” created an anonymous account to vent about the licensure examination for becoming a registered nurse. “With studying tips and new graduate career advice, I was able to influence others by sharing my stories. I struggled, I cried, I laughed, but through it all, I persevered and Twitter helped me to assist others to do so as well,” she wrote in an email to MD Magazine. Her account, @WheezyNurse, which features a photo of her back to the camera, has more than 46,000 followers.

“Posting anonymously was a successful way to keep my views and tweets distinctly separate from my professional role within healthcare institutions,” she explained. “I make a point to never discuss my current employer, where I acquired my education, my current location, identity information, and my personal views on politics and religion. Discretion is key.”

Those compromises reflect the series of conflicting interests facing medical professionals on Twitter: identify yourself in order to build a personal brand, but risk giving the impression that you speak for your company; develop an unfiltered persona in order to seem relatable, but risk saying something that turns off a future employer; take a stand on divisive issues, but risk antagonizing internet trolls. To that last point, many physicians who might normally avoid political controversies on Twitter are now speaking out in favor of gun control. It’s too severe a public-health crisis, evidently, to worry about backlash.

As for anonymity, Farris Timimi believes that it’s “profoundly risky for a variety of reasons.” It can feel like a license to be unprofessional, he said, and profiles might not be as anonymous as one thinks. Sevilla, meanwhile, maintains that anonymous accounts can be useful for highlighting problems in healthcare, but noted advocacy for reform is more compelling coming from people willing to identify themselves.

In late January, a resident physician who blogs anonymously published a post that described feeling exhausted, depressed, and having “thought about ending my life, more than once.” People on Twitter frantically sought to identify the author, studying the blog for any possible clues. Eventually word got out that the author was safe.

“It’s really inspiring to see #medtwitter come together to help an anonymous colleague,” a medical student named Stephanie Zhou posted, adding, “the future of medicine is bright!”

The Clinical Benefits

The American Medical Association (AMA) code of ethics makes clear: “The relationship between patient and physician is based on trust and gives rise to physicians’ ethical obligations to place patients’ welfare above their own self-interest and above obligations to other groups.” In 2010, the AMA published policy guidelines for social media, which noted that while “positive uses of the Internet for clinical purposes abound,” social media presents a range of new ethical obstacles. The report encouraged physicians to separate personal and professional content online. And it stated, explicitly, that physicians “must refrain from posting identifiable patient information online.”

Physicians often go a step further and include in their Twitter bios: “Not medical advice.” It’s a necessary protection from liability, or maybe just unwanted questions, but a puzzling refutation of personal expertise. Some physicians’ blogs also note that the author doesn’t guarantee “the usefulness” of anything they publish (a disclaimer more websites should consider adopting).

Physicians can navigate the maze of communities and conversations on Twitter using Symplur’s Healthcare Hashtag Project, a free service that lists which conferences or diseases, for instance, are being tweeted about the most at that moment. Symplur also sells access to analytics of its enormous database. In 2016, a group of physicians used Symplur to study 300 tweets by medical professionals discussing primary-care issues, and found that the average tweet was written at a reading level between the ninth and tenth grade. The National Institutes of Health recommends that medical literature for patients stay within a seventh or eighth grade reading level, yet material is consistently too complex. It’s a rare case where Twitter’s dumbing-down of discourse appears to be serving the public good.

One of the co-authors of the study, Kim Yu, MD, pointed to several examples that illustrate how Twitter can be much more than a brand-building resource for physicians. In 2015, Columbia University/New York-Presbyterian Hospital announced that it would be closing its family medicine residency program, but an onslaught of tweets with the “#SaveFamilyMedicine” hashtag led the hospital to reverse its decision within 36 hours. The same scenario played out a year later at Detroit Medical Center-Sinai Grace Hospital, where pleas of “#SaveSinaiGraceFM” kept a residency program in place.

“To save a residency program with social media,” Yu reflected, “was mind-blowing.” Earlier this year, however, Twitter activism was unable to stop the closure of a family medicine residency program at ProMedica Health in Toledo, Ohio.

When Hurricane Maria devastated Puerto Rico last year, Yu (@DrKKYU) used Twitter and Facebook to rally a network of family physicians to lend support. They helped raise more than $100,000, which paid for 66 generators to keep hospitals open. They also helped organize the delivery of food, water, and supplies to the island.

FM #Doctors in #PuertoRico helping provide relief via supplies, medicines, water & food, seeing patients & caring for those in need! They need generators to open clinics! Please help at https://t.co/QhCgKK8ly8 #grassrootsmedrelief Thanks @FedEx 4 helping us get supplies there! pic.twitter.com/8sLbCW5bWF

— Kim Yu, MD, FAAFP (@drkkyu) October 1, 2017

As recent political news reflects, social media can be used manipulatively and with malice, and the marketing consultant Janet Kennedy has observed that “physicians who might be reluctant to participate are taking this as their opportunity to bail, unfortunately.”

But as Farris Timimi of Mayo Clinic emphasizes, “Social media is like any other tool in medicine. Any new tool requires training, onboarding, and guidelines.”

Used responsibly by physicians, social media is proving capable of being, as Timimi puts it, “breathtaking.”

Danny Funt is a freelance journalist based in New York. He can be reached on Twitter @DannyFunt.