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.

White Coats for Black Lives? Prove It.

When it comes to advocacy on matters of race and social justice, medicine’s C.V. is, at best, mediocre. 19th century medical students learned their craft by dissecting the grave-robbed cadavers of African Americans, immigrants, and the poor—the bodies that wouldn’t be missed or spark protest. Decades of translational research relies on an immortal cell line extracted, without consent, from African-American Henrietta Lacks in the 1950s. And, of course, there was that clinical experiment for “bad blood.”

Which makes it all the more fascinating, then, how medical students nationwide responded to the recent controversies surrounding the deaths of Michael Brown and Eric Garner:

On one level, it’s incredible to see medical students taking a stand, making ripples nationwide, and letting all our patients know that we stand with them. The white coat—even a short one—lends reputation and gravitas, and #WhiteCoats4BlackLives proves that if we stand (or die-in) together, people listen. As tomorrow’s doctors, we should be inspired from these events to capture that attention and guide public discourse on society’s leading issues: access to care, women’s health, medical errors, gun control … the opportunities are immense.

And yet, on another level, it feels somewhat hollow to die-in together, to call our campuses to attention with powerful gestures, to feel the pride of a national movement … only to return to clinic or class an hour later, ready to resume our usual routines. We have the public’s attention, but now I’m tempted to follow up with a question I encountered too often as an Indian-American liberal arts major: “What are you going to do with that?” If social media is any indication, we grabbed the microphone for a moment, dropped it, and walked off the stage. That’s not social advocacy; it’s feel-good activism.

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In the days to come, we have to remember that raising awareness is a means to an end, but not an end in itself. It’s imperative that our objective is continuity, not complacency. We’re entering a discipline where our black and white patients’ life expectancies differ by five years. Where blacks have the highest rates of cancer, but the lowest rates of clinical trial enrollment. Where six percent of our colleagues are black. Where 70% of the applicants for NIH funding are white, and 1.4% are black. If we want to take action—to not just “raise awareness” of problems, but solve them—the social agenda practically writes itself.

As medical students, we chose this profession to help others—to make a difference. So let’s challenge ourselves to go beyond the “social activism” of fighting a disease by wearing pink, pouring ice water on ourselves, or sprawling out on a sidewalk. Let’s challenge ourselves to identify matters of race and social inequality within our communities, in our medical institutions, and at the bedside of each patient we meet. Let’s challenge ourselves to not simply “raise awareness” of the issues that are already trending in the media, but to take real, directly measurable actions to make these social inequalities artifacts of history.

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.

Searching Under the Streetlights

Walking home the other night, I walked upon a man knelt on the ground, searching for something under the streetlight. He told me he was searching for his wallet, and I, too, got on all fours to help.

After some time, I asked, “Are you sure you dropped it here?” The man laughed, “No, of course not! I lost it a few blocks over that way, but the lighting is much better here.”

As a child, I found this often-recited parable silly; what sort of nut does that? In these first months of medical school, I found my answer: we do.

Despite medicine’s obsession with data, evidence, and validity, when it comes to education and assessment, we search under the streetlights. Time and time again, we look not for the metrics that are important, or the outcomes that matter most, but those that are easiest to obtain.

Exhibit A: the way medical students are evaluated. Some time ago, Ashish Jha asked Twitter, “What makes a good doctor?” The results don’t have NEJM- or JAMA-caliber rigor, but they’re telling; ‘Competent/effective’ ranks fifth, after ’empathetic,’ ‘good listener,’ ‘compassionate,’ and ‘humble’ … even ‘intelligence’ is eighth. And yet, I’d challenge any medical student to tell me, with confidence and candor, that their medical curriculum values those traits above clinical knowledge. I don’t blame my school, but the system; there’s a reason that, of the 759 pages in my First Aid for the USMLE Step 1 book, the social sciences are a succinct 13.

The conversation about post-Flexnerian medicine, competency-based assessment, and holistic evaluation is refreshing. But there are buzzwords thrown around at conferences, and then there are the day-to-day realities—where a clean divide exists between the things that really matter, and the things that are easy to measure. In medical school, clinical knowledge comes before empathy, listening, or compassion, because clinical knowledge is a number. A discrete, objective data point that fits nicely on a bell curve.

Even as I complain about the system, I absolutely understand it. Last block, I scored a 91% in the Medical Knowledge competency. A good, clean, objectively quantifiable 91%. Meanwhile, my peer reviews ranged from ‘sub-optimal’ to ‘above average’ in Integration of Knowledge, and ‘entry-level’ to ‘aspirational’ in Professionalism. The result: I passed Microbes & Immunity, even though I might be terrible (or wonderful) at putting ideas together and working with others.

Perhaps the reality of medical education today is that we simply don’t yet have the tools and evidence to align what matters in learning to what matters in clinical practice. Maybe the informatics platforms aren’t refined enough to reliably identify the ‘well-rounded physician.’ But if that’s the case, then let’s take a moment to erase the buzzwords, look past the illusion, and admit to ourselves what’s really going on: that we’re searching under the streetlights.