This Just In: Patients Can Use the Internet Now.

Sometimes, the future arrives so swiftly that we don’t even notice the subtle revolutions unfolding before our eyes.

For years, the notion of patients searching for health information online was anathema to physicians. The slightest mention of patients as engaged consumers of health information would cue a noxious reflex from most providers, fueled, no doubt, by stereotypes of patients like these:

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As recently as 2013, when I interviewed for medical school, stated interests and curiosities in healthcare social media, e-health, and participatory medicine were best, bold propositions, and at worst, toxic taboos.

“Do me a favor,” one dean of admissions quipped, “When you’re a third-year on clerkships, you’ll meet the man who’s been convinced by a WebMD search that his toe pain is diagnostic for brain cancer. Spend 15 minutes with that guy, then come find me and let me know if you’re still an optimist about online resources as tools for patient empowerment and engagement.”

Fast forward to 2015, where I’m now a clinical-phase student on an outpatient pediatrics rotation, and I finally have an answer for that dean–though it’s probably not the one he expected. I’m still an optimist in the power of online communities and digital content to equip patients with the information they need to engage in their clinical-decision making, as equals, with their providers.

Actually, after the conversations and clinical interactions I’ve witnessed these past weeks on pediatrics, that optimism has never held more firm.

Figure 1. An adolescent seen one week earlier for an acute infection and prescribed antibiotics returns with unresolved infection. The physician makes a diagnosis of antibiotic treatment failure. As she studies the literature for an appropriate second-line treatment, the patient’s mother does a Google search on her phone–and suggests a finding of her own. The physician reviews it, confirms it, prescribes it. Snap.

Figure 2. A child who is seen frequently for recurrent febrile illnesses presents for a well-child visit. The child’s parent mentions having searched online and identified a periodic fever syndrome consistent with the child’s clinical history. The parent shares printouts of relevant patient education materials, academic review articles, and diagnostic manuals with the physician. The physician agrees with the parent’s impression, and makes the diagnosis. Snap, crackle.

Figure 3. A neonate with a congenital condition arrives for a new-patient evaluation. The patient’s mother admits she selected this physician based upon reviews and recommendations from a local online patient community for disease-specific support. At the visit’s conclusion, the mother impresses the physician when she suggests a prescription for ondansetron–a tip she found through, yes, an online patient community. Snap, crackle, and pop.

As a health technologies optimist and medical futurist, it’s evident I’ve been so focused looking ahead to the future that I’ve missed the simple reality: in subtle ways, it’s already arrived.

We used to see e-health as synonymous with WebMD, the digital quack doc where all differential diagnoses lead to cancer. We used to think too much information would break the patient, break the doctor-patient relationship, or worst of all, break the monopoly on expertise that gave our profession relevance. We were, clearly, misguided.

The patient’s access to communities and open-access platforms for online health information is breaking healthcare–but not as doctors once thought it would. Instead, it’s breaking hierarchies, allowing patients to contribute to differentials and suggest treatments as engaged participants on their care team. It’s breaking barriers, connecting patients to insights and innovations previously sealed beyond paywalls and subscriptions. And it’s breaking the metaphorical walls of isolation, bringing patients in touch with others who understand the experience of living with illness and navigating a complex health system.

And every evening, as I drive home from another day in medical school, I’m inspired by the resilience of children, the resourcefulness of their caregivers, and the realization that I’m blessed to be entering medicine at a time of profound transformation, revolution, and creative destruction.

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MedX|Ed: Fast Four

Medicine X is an event that’s one part performance art, two parts academic conference, and three parts social movement. The last 24 hours have been a whirlwind of awe and inspiration that’s left me speechless—sorry, tweet-less.

First and foremost, I have to applaud Medicine X for its unique approach to medical education. Traditionally, medical education meetings are where deans, program directors, and educators meet to prescribe a top-down vision of what’s best for medical learners. MedX|Ed—and naturally, MedX is anything but traditional—takes the opposite approach. It begins with the end users, learners and patients. Next, it identifies these users’ needs in an evolving healthcare system and dynamic social-technological climate, and imagines how academic medical ecosystems might be re-engineered to better support them.

What a wild idea: that medical students might actually have a vested interest in crafting their ideal learning modalities, and that patients might actually have a vested interest in shaping their ideal provider’s skill set. Imagine that.

As the MedX webcast and tweet-stream illustrate, when students, patients, providers, and educators converge, the discussions are delightful, and the ideas are incredible. If you’re not keen on combing through 6,500+ tweets of lofty ideation, raw emotion, and heated disruption, here’s a “fast four” of take-always to ponder.

Reimagining pre-med. Creative destruction of medical practice starts with creative destruction of medical training, which starts with creative destruction of medical admissions and selection. If we want scholars, innovators, and humanists, why do we, as Nisha Pradhan critiqued, put physician-hopefuls through a meat grinder of memorization and multiple-choice assessments? As a medical student, I never solve Diels-Alder reactions or draw Krebs cycle intermediates. I frequently search for the subtexts in dialogues and make perceptual assessments of subjective situations—you know, fluencies I built from my humanities coursework. How might we rethink pre-medical prerequisites to actually hold relevance to the practice of medicine?

Reimagining med ed. Anki, Picmonic, Firecracker, Pathoma, Goljean, DIT, UWorld: the last decade has seen an explosion of digital study tools, tutorials, and Q-banks in medical education, and it’s all driven by the increasing centrality of standardized testing in residency selection. Have dreams of derm? Better splurge for that $500 test prep resource. Now consider that this ‘Step 1 economy’ exists in addition to a medical education that costs $30-60,000 per year. Medical students today are dually enrolled in the study of patient care and the study of Step 1. Why is that? If our tests are so detached from the curricula they evaluate, shouldn’t we aim to close the gap? How might we redesign assessments to capture a holistic excellence in clinical practice, rather than an acute ability in factual recall?

Reimagining patient ed. It’s no coincidence that the word ‘doctor’ derives from the Latin word ‘docere’: to teach. At its core, to be a physician is to be an educator. In today’s volume-driven healthcare system, though, that teaching interaction is often confined to a brief moment at the close of a patient visit. As more physicians become content creators and digital connectivity becomes ubiquitous, might we extend patient education beyond the clinic? It’s easy to imagine a near future where a patient’s ‘presenting complaint’ triggers an email with curated educational content, like an Evans Health Lab video, ahead of a visit. Such ‘flips’ would allow more time for the clinic visit to focus on hands-on teaching or addressing questions. How might we use digital media, informatics, and educational theory to inform a ‘flipped classroom’ for tomorrow’s patients?

Reimagining educators. Traditionally, teaching moves down the hierarchy: attending physicians teach residents and fellows, who teach medical students, who sit at the bottom of the totem pole and try not to mess up. As we continually extend the competencies and fluencies expected of providers in an age of accountable care and networked medicine, perhaps the best educators aren’t solely physicians. Maybe the best educator on empathy, bedside dialogue, and the patient experience is, as Dave DeBronkart and Emily Kramer Golinkoff proposed, a patient. And maybe not even just learning from a patient lecturer, but from a patient’s chronological illness narrative on social media,or from a patient who brings their ‘Google biopsy’ results to an appointment. How might we create structure opportunities for trainees to connect to and learn from non-conventional teachers?

Clearly, we have much to think about, and even more to still accomplish. Again, a huge kudos to MedX for extending the vision of ‘nothing about me, without me’ from the clinic to the classroom. And a final note for healthcare students: now that we’ve been given the opportunity to participate and speak, we’re charged with the responsibility to co-lead and actively shape our learning ecosystems. Let’s get to work.

Closing question: what are your “how might we’s” from MedX|Ed, and how do you envision implementing them by MedX|Ed 2016?

Medicine, Live-Streamed?

MeerkatAs a health tech optimist, I’m constantly fascinated—and completely stumped—by the science of ‘viral’ ideas. What is it that makes some innovations emerge, ignite, and transform, while others stumble, sputter, and fade?

Take live-streaming, for example. The concept of broadcasting one’s first-person perspective in real-time isn’t a novel notion. It’s existed since the early 1990s, when tech pioneers like Steve Mann strapped on cameras and webcast their lives to the world. And, if you’re a millennial in medicine, it’s how you attended medical school.

So what makes Meerkat, the latest ‘app of the moment,’ matter? The short answer: simplicity.

Until now, live-streaming has been done by big institutions for big events: the State of the Union, Apple product reveals, March Madness games. Sure, casual users have YouTube or Vine, but the real-time element of a live-stream takes engagement a step further.

Meerkat now empowers you, the viewer, to become the broadcaster. Open the app, click ‘stream,’ and cast via a link that’s available on your Twitter feed. It’s intuitive, instant, and inexpensive—it’s Meerkat.

How might we leverage this real-time capacity to share our perspectives to enrich medicine?

To transfer knowledge. Take it from a medical student: conferences cost. A lot. An academic conference is a buffet of food for thought, but learners and patients are often left to catch the leftovers through tweets and news releases. Now imagine a future where every presentation, pitch, and panel is immediately available. Imagine a future where your audience isn’t just a room of conference-goers, but the global Twitterati. And imagine the impact that will have on the time to translate insights from bench to bedside.

To foster empathy. Too often, the communication gaps and patient-provider tensions in healthcare are rooted in a failure to understand the other’s experience. Live-streamers invite their audience to watch the world through their eyes, to witness the challenges they face daily, and to respond accordingly. What if providers could observe the barriers that prevent their patients from adhering to treatments? What if patients could see why their doctor seems distracted, or doesn’t have an answer to every question? With Meerkat, it’s possible, quite literally, to walk a mile in someone’s shoes.

To promote accountability. When the world’s watching, we sit up straight and put on our best behavior. The ability to (broad)cast public scrutiny on any individual is powerful—perhaps, too powerful. Whether or not we should put others under this spotlight, the indisputable truth is that we can. That alone should make hospitals and providers pay attention.

Let’s be realistic: Meerkat isn’t likely to be the next Twitter or Facebook; it’s too ephemeral, too public, and too inconspicuous to replace more established forms of public dialogue. But it does open opportunities to communicate visually and to communicate live. And in a discipline where many of our biggest problems are communication problems, that’s worth thinking about.

A Digital Native’s Open Letter to the Academic Journal

Many of my grayer-haired relatives have recently made the leap to digital. The transition isn’t always smooth. There are the charming, all-CAPS lock emails; the Facebook posts to me … on their own wall; and even the occasional phone call about which app to use for playing a video with a .pdf extension. After the laughs and the face-palms, I remind myself that these fumbles are understandable. To transition from an analog lifestyle to a connected one is no easy task, and on some level, it’s important to respect and appreciate the effort itself.

It’s a similar philosophy that we should apply to the academic medical journal’s search for its place in an information economy centered on social media. In a distant era before I was born, medical journals produced content that was aggregated, validated, and current. Now, content aggregation is as affordable and simple as a well-curated Twitter feed or Flipboard Journal. Validation comes in the forms of shares, RTs, and up-votes by the trusted voices of one’s network. And as for current … don’t even ask me how many blog entries, Facebook posts, and tweets I penned in the nine months that this paper was under review, revision, re-review, final edits, and scheduling for publication. These factors all converge upon the question: how do medical journals ‘do digital’ and stay relevant in the time of social media?

If this week’s “Intention to Tweet” study in Circulation is any indication, the jury’s still out on that one. From Dr. John Gordon Harold at the “ACC in Touch” blog:

The trial, “Intention-to-Tweet,” randomized 243 articles published in Circulation to either receive social media or not and found no difference in median 30-day page views (409 [social media] versus 392 [control], P=0.80). There were also no differences observed by article type (clinical, population, or basic science; P=0.19), whether an article had an editorial (P=0.87), or whether the corresponding author was from the U.S. (P=0.73).

The trial authors noted that these findings suggest “a social media intervention in a traditional cardiovascular journal setting may not increase the number of times that an article is accessed and viewed in the first 30-days after publication.”

In brief: “We’re posting links to our articles, but readers aren’t clicking.” Despite the journal’s efforts, social media did little to boost article traffic. . What’s a journal to conclude—and how is it to respond—after that? If I’m the social media editor for a medical publication (oh wait!) here’s what’s on my mind:

Right message? If there was an antithesis to Buzzfeed or Upworthy’s trademark brand of clickbait, it’s something like this:

I’ve spent the last five weeks of my life living, breathing, and dreaming the cardiovascular system (which is a less hyperbolic system than I’m proud to admit), and I understand about 25% of this tweet. Understandably, the academic’s journal’s charge isn’t to make headlines, but to faithfully report the science. But if I’m allowed to be naive for a second and idealize research as an enterprise that creates knowledge, informs public opinion, and affects institutional decision-making … isn’t step 1 to make sure that research is seen? And isn’t a pre-requisite to being seen to be interesting, or curious, or evocative? When communication happens 140 characters at a time, even the best content may fall flat without a compelling ‘hook.’

Right medium? 75% of Twitter’s users are primarily mobile; for Facebook, it’s 78%. Let’s put the Circulation study’s findings into perspective, for a moment. Realistically, how often do you read any article—much less a full-length academic publication—from start to finish on a mobile interface? Also realistically, how often do you actually get back to the articles saved to Pocket, Readability, Instapaper, etc.? Now think about the last time you struggled with reading a PDF on a smart-phone (as if academic journals use large, easily-readable fonts to begin with …) and it’s entirely logical why social media hasn’t translated to page views for Circulation.

As mobile becomes the new default in how we access and interact with content, academic journals should reimagine how they present content to a society on the move. Podcasts? Short-form news updates? Info-graphics or tweet-embedded media? Perhaps it’s time to repackage the academic paper into formats that fit daily function.

Right audience? Beyond the Circulation study, here’s a real question for journals’ social media editors … who’s the [intended] audience? For most journals, it seems platforms like Facebook and Twitter are another channel for dialogue with providers [Exhibit A: the language of the above tweet]. That’s undeniably valuable; amid busy workflows, clinicians need filters to locate and organize the latest data, and social media is integral to that process.

Still, there’s a deeper conversation here about how academic medical journals can use their social media presence to connect with the real stakeholders: the patients. Patients are not only the key backers of research (read: taxpayers), but its core beneficiaries. A public presence offers an opportunity, perhaps even the obligation, to bring research findings out of the ivory tower and into a broader, community-wide dialogue.

In closing, I’m not too optimistic that social media will disrupt the academic journal enterprise anytime soon. Hands down, a well-curated Twitter feed offers more agile and accessible (not to mention affordable) content, any day. But for now, peer review outweighs social network curation; impact factor supersedes RTs or up-votes; and publication volume, not blog traffic, drives tenure decisions. In the meantime, academic journals would be well-served to think more deeply about how to craft their message and hone their medium for an ever-evolving, digitally-focused audience.