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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On Rounds | 4.26.2015

It’s the weekend after end of block exams, which means it’s time to dig through the 742 links in my Pocket queue. That also means it’s time for another edition of “On Rounds,” bringing you my favorite reads of the week.

On the new MCAT | Forbes
There’s a lot to like about the new Medical College Admission Test; with new content in psychology and sociology, MCAT 2015 acknowledges that there’s more to doctoring than biochemical pathways and physics equations. But are multiple-choice tests the best way to identify humanistic, socially aware aspiring doctors? What more we can do to foster diversity and holistic thinking among medical trainees? Allan Joseph and Karan Chhabra break down the good, the bad, and the path forward.

On quack science and journalistic ethicsVox
When it comes to pseudoscientists and their cults of personality, what’s a better-knowing journalist (or healthcare provider) to do? Speak out, and validate a quack? Or stay silent, and let faulty information rule the airwaves? Julia Belluz is on point with this one, and her insights and advice here ought to be required reading for every journalist, scientist, and clinician with a social media account.

On medical schools as laboratories of health transformationForbes
Esther Dyson once remarked that change in medicine happens one retirement at a time. She’s dead right. If we want our healthcare system to pivot from expensive care and late-stage interventions to systems-based practice, preventive care, and population health, the transition begins with how we train future doctors to think. At UT-Austin, the new Dell Medical School is bringing a ‘re-boot’ to a 100-year old model of medical education. David Shaywitz breaks down their educational approach, and what it could mean for medical schools nationwide.

On the value (or maybe not?) of health apps New York Times
There are two kinds of people. On one hand are those who own wearables and use health applications: the young, the affluent, the health-conscious. On the other hand are those who might often benefit from digital health but can rarely afford it: chronic disease patients, the elderly, and those with limited access to care. Today, the consumer market for health apps and devices is larger than ever. How do we connect tech fads to health outcomes? How do we balance rapid innovation with health equity? This NYT article doesn’t offer all the answers, but it raises many of the right questions.

On restoring the ‘joy of medicine’Medstro
When it comes to physician lifestyle, we keep hearing the same stuff: provider burnout is at a high; satisfaction is at a low; most doctors today wouldn’t recommend the profession to their children. We know all that; now, what are we going to do about it? Medstro and Geneia’s “Joy of Medicine Challenge” invites your ideas to restore joy to the practice of medicine, and they’re offering $1,000 for your thoughts. Instead of talking about how our healthcare system is broken, let’s ideate on how to fix it.

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.