Social Media Social media is a necessary component of surgery practice Scott R. Steele, MD,a Seyed Arshad, BS,b Ruth Bush, MD, JD, MPH,b Serena Dasani, BA,c Kyle Cologne, MD,d Joshua I. S. Bleier, MD,c Tal Raphaeli, MD,e and Rachel R. Kelz, MD, MSCE,c for the Society of University Surgeons’ Social and Legislative Committee, Cleveland, OH, College Station and Houston, TX, Philadelphia, PA, and Los Angeles, CA
Social media is a necessary component of the practice of surgery. Each surgeon must embrace the power and potential of social media and serve as a guide or content expert for patients and other health care providers to facilitate and share responsible use of the various media available. Social media facilitates rapid communication of information not only across providers but also between patients and providers. The power of social media has the potential to improve consultation and collaboration, facilitate patient education, and expand research efforts; moreover, by harnessing its potential, the appropriate use of many of the avenues of social media also can be used to disseminate campaigns to increase disease awareness and communicate new research findings and best-practice guidelines. Because its reach is so broad within as well as outside the censorship of medical experts, professional oversight and engagement is required to maximize responsible use. Staying consistent with our history of surgery, rich in innovation and technologic advancement, surgeons must get to the front of this evolving field and direct the path of social media as it applies to the practice of surgery rather than take a passive role. (Surgery 2015;158:857-62.) From the University Hospitals/Case Western Reserve University,a Cleveland, OH; Texas A&M Health Science Center, College of Medicine,b College Station, TX; University of Pennsylvania,c Philadelphia, PA; University of Southern California,d Los Angeles, CA; and Memorial Hermann Healthcare System,e Houston, TX
SOCIAL
MEDIA IS A NECESSARY COMPONENT OF SURGICAL
PRACTICE,
whether we accept it or not. It is the snowball at the top of an emerging avalanche whose spread and use is inevitable. The question for surgeons is not whether to use it, but how to use it. For the naysayers, it is time to turn the page and view social media in the context of what it can and does provide for surgeons and patients alike. Its use in both the private and the world of academics and surgery can be powerful and meaningful; however, each individual surgeon, regardless of his/her personal expertise with social media, must help guide colleagues, staff, and even patients through its implementation. In this work, we will explore briefly the attributes and aspects of the use of social media in medicine as a whole and in the house of surgery.
Accepted for publication June 8, 2015. Reprint requests: Scott R. Steele, MD, 19111 Shelburne Rd, Shaker Heights, OH 44119. E-mail: [email protected]. 0039-6060/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.surg.2015.06.002
CONSULTATION AND COLLABORATION One of the most powerful ways social media has affected the world to date is by creating a real-time community discussion across the globe on any topic at any time. This type of potential global communication, interaction, and coordination can translate directly to medicine and in particular to surgery. As surgeons, our culture is and has been that we do this type of learning, education, and quality improvement frequently: bouncing ideas, treatment plans, and diagnostic dilemmas off others, and even commiserating about cases with our colleagues. We present at weekly morbidity and mortality conferences in front of our associates, who serve as peer-reviewers for those cases that unintentionally and unfortunately do not proceed as planned. Not many other specialties hold as frequent and extensive a morbidity and mortality conference as we do in surgery. Yet, we do not all work in practices with readily available, experienced colleagues to help us out. As a surrogate, surgeons have created online resources, such as the ‘‘listserv’’ of the American SURGERY 857
858 Steele et al
Surgery September 2015
Table. Social media resources for surgeons Site address
Resource
Private site: sign up, admitted after a vetting process, and then participate in an email server exchange http://acscommunities.facs.org/home
American Society of Colon and Rectal Surgeons’ ‘‘listserv’’ American College of Surgeons’ ‘‘Communities’’
www.doc2doc.bmj.com
Doc2Doc
www.sermo.com
Sermo
https://www.facebook.com/ AmCollSurgeons
American College of Surgeons’ Facebook page
Purpose Serves as a HIPPA-compliant ‘‘chat room’’ to discuss cases Serves as a HIPPA-compliant ‘‘chat room’’ to discuss cases, share ideas, and post articles A discussion network for health care professionals created by the British Medical Journal (BMJ) A social network specifically for doctors that advertises the use of ‘‘crowdsourcing’’ medical problems in a ‘‘virtual doctors’ lounge’’ to help solve more difficult cases Daily updates on medical advances, legal changes in the realm of surgery, and news/updates on Fellows of the College
HIPPA, Health Insurance Portability and Accountability Act of 1996.
Society of Colon and Rectal Surgeons and the ‘‘Communities’’ of the American College of Surgeons, to name a few examples in which surgeons can interact in a fashion compliant with the Health Insurance Portability and Accountability Act of 1996 to present cases and engage in dialogue about anything from the most complex cases to issues with billing and coding. Even the most remote surgeon who lacks partners needs only an Internet connection to engage easily in a global community that is interactive, readily accessible, and a provides a wealth of experience and expertise. As social media sites have evolved during the last decade, the use of a dedicated social media feed has both easily and seamlessly supplanted many of the more-cumbersome platforms to provide instantaneous mobile access to a community of colleagues available through our smartphones and tablets. Privacy can be ensured by the use of an encrypted or invite-only stream. Physicians also can subscribe to the social media feeds from their professional societies to stay up to date on upcoming events, relevant articles, and news (Table). Depending on the construct and resources available, focused information relevant to one’s surgical practice also can be supplied. PATIENT RESOURCE One of the most powerful aspects of social media is the ability to connect instantly to our patients. The average patient will spend less than 2 hours with a health care provider in a given year, whereas in contrast, they will average more than 5,000 hours
communicating with other people.1 Social media provides an alternative mode of communication that allows sharing of questions and images in a more efficient fashion. In addition, the use of selected forms of social media allows our patients to feel more connected to their physicians in a way that may foster feelings of security and safety. This type of access may also provide another 2-way resource for interaction and exchange of concerns, follow-up, or ideas about their health care. In a study covering 2003–2005, physician use of the Internet to communicate directly with patients increased from 7 to 10%, respectively.2 Not surprisingly, this increase in usage was more common in patients with greater levels of education, patients who lived in cities, and patients with worse overall health or a history of malignancy. During the subsequent decade, this upward trend in the use of social media by both physicians and online patient–physician interaction has evolved slowly; however, this area remains one ripe for growth.3 Furthermore, once a health care provider decides to use social media regularly, the accuracy of the information disseminated to ensure that patients are well informed about all facets of their health and upcoming appointments/procedures improves. Surgeons can take advantage of the increasing popularity and utility of podcasts and videocasts to educate patients about their health status or necessary procedures and to increase patient compliance.4 A recent study asked patients to rate the Web sites of 20 specialty associations from Australia, the United Kingdom, Canada,
Surgery Volume 158, Number 3
Europe, and the United States regarding content, delivery, accessibility, and ease of use.5 Unfortunately, the average patient score per Web site was only 3.2 (scale 1–10; 10 being the best), with the majority failing to meet an ‘‘adequate’’ standard for the basic delivery of information. Social media can counter these low scores and poor patient perspectives by making communication and their online experience much more interactive. In addition, surgeons can use social media as a vehicle to deliver information ranging from preoperative preparatory guidelines and procedural descriptions to sample videos answering frequently asked questions and postprocedure follow-up check lists to ensure that patients adhere to the appropriate expectations and guidelines. For instance, with colonoscopy, social media can enable providers to develop video Web casts that explain the details of the required preprocedural diet when taking a bowel preparation, display a virtual walk-through of the day’s event, and show sample colonoscopic images---all while providing additional information emphasizing why colorectal cancer screening is essential. A 2014 analysis of Youtube videos that addressed specifically bowel preparation for colonoscopy revealed 280 online videos each with >5,000 views, emphasizing the potential reach through this platform.6 Health care professionals also can take advantage of the ‘‘push notifications’’ feature of social media---a way to send alerts directly to a patient’s smart device to remind them of upcoming appointments or preand postoperative guidelines.7 For example, after a thyroidectomy, a patient could subscribe to an application that sends him or her a timed reminder to take the correct medication, as well as instructions on how to take proper care of the incision. Certainly, social media portals would need inherent rules or safeguards, and it must be stated explicitly that this does not represent an avenue for surgeons to address emergent surgical issues. In addition, caution must be exercised to avoid the unrestricted, ‘‘unfiltered’’ ability to post comments, unjust criticisms, or inaccurate or inappropriate material. As a deterrent, the implementation of a gatekeeper or dedicated censor would allow screening of questions as well as avoid posting unsuitable content. Finally, the use of special access feeds that would allow more ‘‘real-time’’ interaction such as a site-protected online chat forum between the surgeon and existing patients may also help mediate this gateway. With the expansion of online communities for various diseases and disorders, we as surgeons not only need to educate our patients on the quality of the available information but also help direct them
Steele et al 859
to access the more appropriate sites. If patients are getting information directly from their physicians, the potential for patients to get inaccurate information remains less of a concern. Indeed, with the increase in online tools and groups such as Mayo’s Symptom Checker (http://www.mayoclinic.org/ symptom-checker/select-symptom/itt-20009075) or ‘‘Ask a Doctor’’ forums (http://www.reddit.com/ r/AskDocs), we are able to guide our patients to trustworthy sites for appropriate information and treatments, as well as limit the reach of armchair physicians or charlatan remedies. In addition, these safeguards allow patients a more direct recommendation toward a vetted source to avoid the ‘‘unfiltered’’ advice they may receive from friends, family members, or other sources that may inadvertently lead to untoward outcomes. For example, it is well known that celebrities have considerable impact and influence for both commercial products as well as functioning as ‘‘medical advisors.’’8 Within this context, it is important that we help patients distinguish between an endorsement of a particular product or procedure that can have a substantial positive impact on public health (eg, Katie Couric’s campaign for colorectal cancer screening),9 versus one that may not be rooted in the best medical principles (eg, television pitchman Kevin Trudeau’s weight loss cures).10 To understand social media as a surgeon, it also is important to highlight the wide range of patients who are using various social media platforms. The Pew Research Center conducted an Internet project to identify the demographic profiles of the users of social media Web sites.11 By tracing the usage of social media over time, this study found that Internet usage during the past decade increased in every single age group. For example, between 2005 and 2013, the use of social networking sites by individuals between 18 and 29 years of age increased from 9 to 90%. Similarly, the use of social media amongst people 50–64 years of age also increased from 6 to 65%, perhaps greater than many would have estimated. Hence, social media is not limited to the younger generations; rather, its use has disseminated widely over all ages. In addition, the Pew study documented the role of cell phones and in particular smartphones in expanding the accessibility to social networks in all socioeconomic classes. Not surprising, the percentage of cell phone owners using a social networking site on their phone was 40% for individuals with an annual household income in the range of $30,000–$49,999, 48% for those in the $50,000–$74,999 range, and 45% in those with greater than $75,000 annual income. This trend
860 Steele et al
is shared across other demographics, including race/ethnicity, sex, and education level. Thus, patients from all backgrounds have similar accessibility to social media, and surgeons can use this widespread form of communication as a way to eliminate health disparities by potentially reaching a greater target audience. PATIENT SUPPORT Social media not only provides community forums for health care providers and educators but also allows patients to join online forums, such as group pages on Facebook or community-fostering Web sites like patientslikeme.com and crohnology. com. These platforms of social media allow patients going through similar experiences to communicate with each other to provide support and camaraderie. In addition, hospital systems such as the Mayo Clinic use interactive blogs where health care professionals can participate in the conversation, dispel myths, and answer patient questions directly (http://www. mayoclinic.org/). Furthermore, patients can use the ‘‘sharing’’ feature on the blog to spread their stories. These digital resources provide patients with a safe, efficient way to access support and guidance at any time and place. Moreover, one of the best ways to maximize quality patient care using social media is by disseminating credible ‘‘filtered’’ or ‘‘censored’’ information regarding existing treatments by experts. Consider the case of the growing use of sacral neuromodulation for the treatment of fecal incontinence. Although this treatment has randomized controlled data reporting effectiveness,12 2 major barriers to its widespread use are lack of knowledge of its existence and efficacy, as well as the embarrassment of the problem itself. The use of credible outlets of social media allows for a system of controls on the information stream so that patients with such ‘‘personal’’ disorders can learn about the treatment for this problem in the surgeon’s own words in an anonymous and embarrassment-free manner. This use of one form of social media can provide subsequent direction toward practitioners that offer the therapy. More importantly, patients and health care providers can witness the large number of others that are affected by this condition and begin a dialogue in a support group or relatively discreet fashion. AWARENESS CAMPAIGNS Surgeons also may use social media platforms in creative ways to promote health awareness. For example, the Social Media Lab at the University of
Surgery September 2015
Pennsylvania explored the effectiveness of using crowdsourcing to promote awareness about automated external defibrillators and their locations. The Lab created an online contest (the Defibrillator Design Challenge) that asked the social media public to compose educational designs that promoted AED visibility of automated external defibrillators. The contest engaged successfully a broad audience inclusive of participants and posters, thereby highlighting this platform as a feasible and effective way to improve awareness of a targeted health initiative.13 This model can be extended to other fields of medicine. A general surgeon could promote a design contest centered on various initiatives in cancer screening. Through such an approach, patients can subscribe to various verified sources that will alert them of ongoing health care campaigns, allowing them to receive updates from their physicians and health care systems. Such an approach can be critical in ensuring quality care via the use of credible authors who have been sanctioned. Recently, new Web sites such as FOAMsearch have been launched that serve as custom search engines that pull information exclusively from reputable sources, such as peer-reviewed medical journals and physician blogs. These types of ‘‘verified’’ search engines provide patients with a safe filter that separates the scientifically accurate and medically relevant information from the myriad of Internet sources that vary in credibility.4 The behavioral use of keywords and hashtags on the platforms of social media also allows surgeons insight into their patients’ lives, and most importantly, their patients’ concerns about specific diseases and procedures. Because direct provider–patient interaction time is so limited, further information about patient behavior can be discovered through their social media behavior and postings. Surveillance systems can extract and mine these data to inform surgeons of the high-yield areas of patient concerns to focus efforts on quality initiatives. Surgeons also can then use the insight from this data mining to address these issues in their subsequent inperson visits, or they can release statements via the various platforms of social media to reach a broader audience. The data-mining feature of social media promotes the evolution of interventional health care and allows researchers and health care providers to recognize and specifically target issues affecting large populations of patients.1 ADVERTISEMENT Social media also has become an ideal avenue to advertise all aspects of medicine. What was largely
Steele et al 861
Surgery Volume 158, Number 3
the realm of pharmaceutical companies in the early days of social media14 has now spread to promoting everything from the solo practice of an individual surgeon up to large health care systems. Using keywords and hashtags, patients can be directed toward credible surgeons and find out more about the practice and the diseases in which the surgeon specializes. In this era of emerging transparency,15 hospitals and systems have started to use their presence in online social media to advertise the unique skills and outcomes of their surgeons, departments of surgery, and hospital as a whole. Currently, most nationally ranked hospitals have their ‘‘top 100 hospital’’ badge featured near their name. They also promote frequently the unique skills of particular physicians or encourage patients to make a consultation appointment for elective operations or other procedures. Importantly, recent studies have identified a disconnect between the understanding of risk-adjusted outcomes by the physician and the public,16 which may lead to inappropriate and inaccurate perception of patients toward an individual surgeon or hospital. Social media may help in bridging this gap. Additionally, the use of ‘‘tweeting’’ and other avenues of social media allow people to share their experiences at various events in real time. For instance, physicians can use this approach to rapidly inform other surgeons (or their followers on Twitter) of new, state-of-the-art information reported at a medical meeting before any formal publication. In this way, many may benefit from others’ experiences, travels, and research, even when they do not have the time or means to investigate or acquire this knowledge themselves. Recently, the Baylor Scott and White Health System live-tweeted a heart transplant at their Baylor University Medical Center in Dallas. (http:// bswhlive.com/hearttxlive-news-release.html) This tweet quickly went ‘‘viral’’ and was caught rapidly in an exponential rise in popularity on social networks literally worldwide. In this light, social media provides a unique application to highlight the abilities and activities either parochially at a particular institution or as a possibility elsewhere. The second- and third-tier effects also may involve a resurgence of awareness for a particular disease process, something that could translate to both increased funding and improved outcomes. In the case of the procedure at the Baylor Scott and White Medical Center, Dr. Gonzalo Gonzalez-Stawinski, Chief of Heart Transplantation, said, ‘‘Our goal is to provide an educational look into what happens during a heart transplant
and encourage others to give the gift of life through organ donation.’’ RESEARCH Finally, as members of our broad surgical community, we strive not only to help the patient in front of us but also to increase the body of knowledge as a whole. Social media provides a powerful tool for patient follow-up and surveys and allows us to remain in contact with patients long after they have left our office by subscribing to keywords, hashtags, and pages that notify them of relevant updates specific to their disease. Subscription to unique, focused streams of media will allow instantaneous ‘‘blasts’’ of information and notifications of updates, and could be used ultimately in the development of research projects. Obviously for research purposes, this form of data-gathering will need to be reviewed and vetted carefully by our institutional review boards with a focus on HIPPAcompliant approaches. CONCLUSION Although social media has many potential pitfalls that need to be safeguarded against nonHIPAA compliant usage and the corruption by non-verified ‘‘experts,’’ the potential positive aspects in our house of surgery outweigh the negatives. We have described only a few of the potential uses of social media in our practices--when in reality, its use is limited only by our imaginations. Going forward, it will be imperative that careful forethought be applied to limit liability and maintain compliance with the Health Insurance Portability and Accountability Act of 1996; however, these issues are technical and achievable. As our potential reach is expanding as quickly as the world is contracting, it is critical that we remain at the forefront of this versatile technology. REFERENCES 1. Hill S, Merchant R, Ungar L. Lessons learned about public health from online crowd surveillance. Big Data 2013;1:160-7. 2. Beckjord EB, Finney Rutten LJ, Squiers L, et al. Use of the internet to communicate with health care providers in the United States: estimates from the 2003 and 2005 Health Information National Trends Surveys (HINTS). J Med Internet Res 2007;12:e20. 3. Brown J, Ryan C, Harris A. How doctors view and use social media: a national survey. J Med Internet Res 2014;16:e267. 4. Scott KR, Hsu CH, Johnson NJ, Mamtani M, Conlon LW, DeRoos FJ. Integration of social media in emergency medicine residency curriculum. Ann Emerg Med 2014;64: 396-404. 5. Ow D, Wetherell D, Papa N, Bolton D, Lawrentschuk N. Patients’ perspective of accessibility and digital delivery of
862 Steele et al
6.
7.
8.
9.
10.
11.
factual content provided by official medical and surgical specialty websites: a qualitative assessment. Interact J Med Res 2015;4:e7. Basch CH, Hillyer GC, Reeves R, Baasch CE. Analysis of YouTubeTM videos related to bowel preparation for colonoscopy. World J Gastrointest Endosc 2014;6:432-5. Saleh J, Robinson BS, Kugler NW, Illingworth KD, Patel P, Saleh KJ. Effect of social media in health care and orthopedic surgery. Orthopedics 2012;35:294-7. Hoffman SJ, Tan C. Biological, psychological and social processes that explain celebrities’ influence on patients’ health-related behaviors. Arch Public Health 2015;73:3. EIF Entertainment Industry FoundationTM. Available from: http://www.eifoundation.org/programs/eifs-nationalcolorectal-cancer-research-alliance/content/katie-couric-coloncancer-awarene. ‘‘TV pitchman Kevin Trudeau gets 10-year sentence.’’ Available from: http://www.usatoday.com/story/news/nation/ 2014/03/17/kevin-trudeau-sentenced/6546433/. ‘‘Social Networking Fact Sheet.’’ Pew Research Centers Internet American Life Project RSS. Pew Research Center.
Surgery September 2015
12.
13.
14.
15.
16.
Available from: http://www.pewinternet.org/fact-sheets/ social-networking-fact-sheet/. Thin NN, Taylor SJ, Bremner SA, et al. Neuromodulation Trial Study Group. Randomized clinical trial of sacral versus percutaneous tibial nerve stimulation in patients with faecal incontinence. Br J Surg 2015;102:349-58. Merchant RM, Griffis HM, Ha YP, et al. Hidden in plain sight: a crowdsourced public art contest to make automated external defibrillators more visible. Am J Public Health 2014;104:2306-12. Buechner B. A comparative legal analysis of social media advertising of drugs in Germany and the United States. Food Drug Law J 2013;68:259-79. Dahlke AR, Chung JW, Holl JL. Evaluation of initial participation in public reporting of American College of Surgeons NSQIP surgical outcomes on Medicare’s hospital compare website. J Am Coll Surg 2014;218:374-80. Bhalla A, Mehrotra P, Amawi F, Lund JN. Surgeon-level reporting presented by funnel plot is understood by doctors but inaccurately interpreted by members of the public. J Surg Educ 2014;72:500-3.
Social media is a necessary component of the practice of surgery. Each surgeon must embrace the power and potential of social media and serve as a guide or content expert for patients and other health care providers to facilitate and share responsible use of the various media available. Social media facilitates rapid communication of information not only across providers but also between patients and providers. The power of social media has the potential to improve consultation and collaboration, facilitate patient education, and expand research efforts; moreover, by harnessing its potential, the appropriate use of many of the avenues of social media also can be used to disseminate campaigns to increase disease awareness and communicate new research findings and best-practice guidelines. Because its reach is so broad within as well as outside the censorship of medical experts, professional oversight and engagement is required to maximize responsible use. Staying consistent with our history of surgery, rich in innovation and technologic advancement, surgeons must get to the front of this evolving field and direct the path of social media as it applies to the practice of surgery rather than take a passive role. (Surgery 2015;158:857-62.) From the University Hospitals/Case Western Reserve University,a Cleveland, OH; Texas A&M Health Science Center, College of Medicine,b College Station, TX; University of Pennsylvania,c Philadelphia, PA; University of Southern California,d Los Angeles, CA; and Memorial Hermann Healthcare System,e Houston, TX
SOCIAL
MEDIA IS A NECESSARY COMPONENT OF SURGICAL
PRACTICE,
whether we accept it or not. It is the snowball at the top of an emerging avalanche whose spread and use is inevitable. The question for surgeons is not whether to use it, but how to use it. For the naysayers, it is time to turn the page and view social media in the context of what it can and does provide for surgeons and patients alike. Its use in both the private and the world of academics and surgery can be powerful and meaningful; however, each individual surgeon, regardless of his/her personal expertise with social media, must help guide colleagues, staff, and even patients through its implementation. In this work, we will explore briefly the attributes and aspects of the use of social media in medicine as a whole and in the house of surgery.
Accepted for publication June 8, 2015. Reprint requests: Scott R. Steele, MD, 19111 Shelburne Rd, Shaker Heights, OH 44119. E-mail: [email protected]. 0039-6060/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.surg.2015.06.002
CONSULTATION AND COLLABORATION One of the most powerful ways social media has affected the world to date is by creating a real-time community discussion across the globe on any topic at any time. This type of potential global communication, interaction, and coordination can translate directly to medicine and in particular to surgery. As surgeons, our culture is and has been that we do this type of learning, education, and quality improvement frequently: bouncing ideas, treatment plans, and diagnostic dilemmas off others, and even commiserating about cases with our colleagues. We present at weekly morbidity and mortality conferences in front of our associates, who serve as peer-reviewers for those cases that unintentionally and unfortunately do not proceed as planned. Not many other specialties hold as frequent and extensive a morbidity and mortality conference as we do in surgery. Yet, we do not all work in practices with readily available, experienced colleagues to help us out. As a surrogate, surgeons have created online resources, such as the ‘‘listserv’’ of the American SURGERY 857
858 Steele et al
Surgery September 2015
Table. Social media resources for surgeons Site address
Resource
Private site: sign up, admitted after a vetting process, and then participate in an email server exchange http://acscommunities.facs.org/home
American Society of Colon and Rectal Surgeons’ ‘‘listserv’’ American College of Surgeons’ ‘‘Communities’’
www.doc2doc.bmj.com
Doc2Doc
www.sermo.com
Sermo
https://www.facebook.com/ AmCollSurgeons
American College of Surgeons’ Facebook page
Purpose Serves as a HIPPA-compliant ‘‘chat room’’ to discuss cases Serves as a HIPPA-compliant ‘‘chat room’’ to discuss cases, share ideas, and post articles A discussion network for health care professionals created by the British Medical Journal (BMJ) A social network specifically for doctors that advertises the use of ‘‘crowdsourcing’’ medical problems in a ‘‘virtual doctors’ lounge’’ to help solve more difficult cases Daily updates on medical advances, legal changes in the realm of surgery, and news/updates on Fellows of the College
HIPPA, Health Insurance Portability and Accountability Act of 1996.
Society of Colon and Rectal Surgeons and the ‘‘Communities’’ of the American College of Surgeons, to name a few examples in which surgeons can interact in a fashion compliant with the Health Insurance Portability and Accountability Act of 1996 to present cases and engage in dialogue about anything from the most complex cases to issues with billing and coding. Even the most remote surgeon who lacks partners needs only an Internet connection to engage easily in a global community that is interactive, readily accessible, and a provides a wealth of experience and expertise. As social media sites have evolved during the last decade, the use of a dedicated social media feed has both easily and seamlessly supplanted many of the more-cumbersome platforms to provide instantaneous mobile access to a community of colleagues available through our smartphones and tablets. Privacy can be ensured by the use of an encrypted or invite-only stream. Physicians also can subscribe to the social media feeds from their professional societies to stay up to date on upcoming events, relevant articles, and news (Table). Depending on the construct and resources available, focused information relevant to one’s surgical practice also can be supplied. PATIENT RESOURCE One of the most powerful aspects of social media is the ability to connect instantly to our patients. The average patient will spend less than 2 hours with a health care provider in a given year, whereas in contrast, they will average more than 5,000 hours
communicating with other people.1 Social media provides an alternative mode of communication that allows sharing of questions and images in a more efficient fashion. In addition, the use of selected forms of social media allows our patients to feel more connected to their physicians in a way that may foster feelings of security and safety. This type of access may also provide another 2-way resource for interaction and exchange of concerns, follow-up, or ideas about their health care. In a study covering 2003–2005, physician use of the Internet to communicate directly with patients increased from 7 to 10%, respectively.2 Not surprisingly, this increase in usage was more common in patients with greater levels of education, patients who lived in cities, and patients with worse overall health or a history of malignancy. During the subsequent decade, this upward trend in the use of social media by both physicians and online patient–physician interaction has evolved slowly; however, this area remains one ripe for growth.3 Furthermore, once a health care provider decides to use social media regularly, the accuracy of the information disseminated to ensure that patients are well informed about all facets of their health and upcoming appointments/procedures improves. Surgeons can take advantage of the increasing popularity and utility of podcasts and videocasts to educate patients about their health status or necessary procedures and to increase patient compliance.4 A recent study asked patients to rate the Web sites of 20 specialty associations from Australia, the United Kingdom, Canada,
Surgery Volume 158, Number 3
Europe, and the United States regarding content, delivery, accessibility, and ease of use.5 Unfortunately, the average patient score per Web site was only 3.2 (scale 1–10; 10 being the best), with the majority failing to meet an ‘‘adequate’’ standard for the basic delivery of information. Social media can counter these low scores and poor patient perspectives by making communication and their online experience much more interactive. In addition, surgeons can use social media as a vehicle to deliver information ranging from preoperative preparatory guidelines and procedural descriptions to sample videos answering frequently asked questions and postprocedure follow-up check lists to ensure that patients adhere to the appropriate expectations and guidelines. For instance, with colonoscopy, social media can enable providers to develop video Web casts that explain the details of the required preprocedural diet when taking a bowel preparation, display a virtual walk-through of the day’s event, and show sample colonoscopic images---all while providing additional information emphasizing why colorectal cancer screening is essential. A 2014 analysis of Youtube videos that addressed specifically bowel preparation for colonoscopy revealed 280 online videos each with >5,000 views, emphasizing the potential reach through this platform.6 Health care professionals also can take advantage of the ‘‘push notifications’’ feature of social media---a way to send alerts directly to a patient’s smart device to remind them of upcoming appointments or preand postoperative guidelines.7 For example, after a thyroidectomy, a patient could subscribe to an application that sends him or her a timed reminder to take the correct medication, as well as instructions on how to take proper care of the incision. Certainly, social media portals would need inherent rules or safeguards, and it must be stated explicitly that this does not represent an avenue for surgeons to address emergent surgical issues. In addition, caution must be exercised to avoid the unrestricted, ‘‘unfiltered’’ ability to post comments, unjust criticisms, or inaccurate or inappropriate material. As a deterrent, the implementation of a gatekeeper or dedicated censor would allow screening of questions as well as avoid posting unsuitable content. Finally, the use of special access feeds that would allow more ‘‘real-time’’ interaction such as a site-protected online chat forum between the surgeon and existing patients may also help mediate this gateway. With the expansion of online communities for various diseases and disorders, we as surgeons not only need to educate our patients on the quality of the available information but also help direct them
Steele et al 859
to access the more appropriate sites. If patients are getting information directly from their physicians, the potential for patients to get inaccurate information remains less of a concern. Indeed, with the increase in online tools and groups such as Mayo’s Symptom Checker (http://www.mayoclinic.org/ symptom-checker/select-symptom/itt-20009075) or ‘‘Ask a Doctor’’ forums (http://www.reddit.com/ r/AskDocs), we are able to guide our patients to trustworthy sites for appropriate information and treatments, as well as limit the reach of armchair physicians or charlatan remedies. In addition, these safeguards allow patients a more direct recommendation toward a vetted source to avoid the ‘‘unfiltered’’ advice they may receive from friends, family members, or other sources that may inadvertently lead to untoward outcomes. For example, it is well known that celebrities have considerable impact and influence for both commercial products as well as functioning as ‘‘medical advisors.’’8 Within this context, it is important that we help patients distinguish between an endorsement of a particular product or procedure that can have a substantial positive impact on public health (eg, Katie Couric’s campaign for colorectal cancer screening),9 versus one that may not be rooted in the best medical principles (eg, television pitchman Kevin Trudeau’s weight loss cures).10 To understand social media as a surgeon, it also is important to highlight the wide range of patients who are using various social media platforms. The Pew Research Center conducted an Internet project to identify the demographic profiles of the users of social media Web sites.11 By tracing the usage of social media over time, this study found that Internet usage during the past decade increased in every single age group. For example, between 2005 and 2013, the use of social networking sites by individuals between 18 and 29 years of age increased from 9 to 90%. Similarly, the use of social media amongst people 50–64 years of age also increased from 6 to 65%, perhaps greater than many would have estimated. Hence, social media is not limited to the younger generations; rather, its use has disseminated widely over all ages. In addition, the Pew study documented the role of cell phones and in particular smartphones in expanding the accessibility to social networks in all socioeconomic classes. Not surprising, the percentage of cell phone owners using a social networking site on their phone was 40% for individuals with an annual household income in the range of $30,000–$49,999, 48% for those in the $50,000–$74,999 range, and 45% in those with greater than $75,000 annual income. This trend
860 Steele et al
is shared across other demographics, including race/ethnicity, sex, and education level. Thus, patients from all backgrounds have similar accessibility to social media, and surgeons can use this widespread form of communication as a way to eliminate health disparities by potentially reaching a greater target audience. PATIENT SUPPORT Social media not only provides community forums for health care providers and educators but also allows patients to join online forums, such as group pages on Facebook or community-fostering Web sites like patientslikeme.com and crohnology. com. These platforms of social media allow patients going through similar experiences to communicate with each other to provide support and camaraderie. In addition, hospital systems such as the Mayo Clinic use interactive blogs where health care professionals can participate in the conversation, dispel myths, and answer patient questions directly (http://www. mayoclinic.org/). Furthermore, patients can use the ‘‘sharing’’ feature on the blog to spread their stories. These digital resources provide patients with a safe, efficient way to access support and guidance at any time and place. Moreover, one of the best ways to maximize quality patient care using social media is by disseminating credible ‘‘filtered’’ or ‘‘censored’’ information regarding existing treatments by experts. Consider the case of the growing use of sacral neuromodulation for the treatment of fecal incontinence. Although this treatment has randomized controlled data reporting effectiveness,12 2 major barriers to its widespread use are lack of knowledge of its existence and efficacy, as well as the embarrassment of the problem itself. The use of credible outlets of social media allows for a system of controls on the information stream so that patients with such ‘‘personal’’ disorders can learn about the treatment for this problem in the surgeon’s own words in an anonymous and embarrassment-free manner. This use of one form of social media can provide subsequent direction toward practitioners that offer the therapy. More importantly, patients and health care providers can witness the large number of others that are affected by this condition and begin a dialogue in a support group or relatively discreet fashion. AWARENESS CAMPAIGNS Surgeons also may use social media platforms in creative ways to promote health awareness. For example, the Social Media Lab at the University of
Surgery September 2015
Pennsylvania explored the effectiveness of using crowdsourcing to promote awareness about automated external defibrillators and their locations. The Lab created an online contest (the Defibrillator Design Challenge) that asked the social media public to compose educational designs that promoted AED visibility of automated external defibrillators. The contest engaged successfully a broad audience inclusive of participants and posters, thereby highlighting this platform as a feasible and effective way to improve awareness of a targeted health initiative.13 This model can be extended to other fields of medicine. A general surgeon could promote a design contest centered on various initiatives in cancer screening. Through such an approach, patients can subscribe to various verified sources that will alert them of ongoing health care campaigns, allowing them to receive updates from their physicians and health care systems. Such an approach can be critical in ensuring quality care via the use of credible authors who have been sanctioned. Recently, new Web sites such as FOAMsearch have been launched that serve as custom search engines that pull information exclusively from reputable sources, such as peer-reviewed medical journals and physician blogs. These types of ‘‘verified’’ search engines provide patients with a safe filter that separates the scientifically accurate and medically relevant information from the myriad of Internet sources that vary in credibility.4 The behavioral use of keywords and hashtags on the platforms of social media also allows surgeons insight into their patients’ lives, and most importantly, their patients’ concerns about specific diseases and procedures. Because direct provider–patient interaction time is so limited, further information about patient behavior can be discovered through their social media behavior and postings. Surveillance systems can extract and mine these data to inform surgeons of the high-yield areas of patient concerns to focus efforts on quality initiatives. Surgeons also can then use the insight from this data mining to address these issues in their subsequent inperson visits, or they can release statements via the various platforms of social media to reach a broader audience. The data-mining feature of social media promotes the evolution of interventional health care and allows researchers and health care providers to recognize and specifically target issues affecting large populations of patients.1 ADVERTISEMENT Social media also has become an ideal avenue to advertise all aspects of medicine. What was largely
Steele et al 861
Surgery Volume 158, Number 3
the realm of pharmaceutical companies in the early days of social media14 has now spread to promoting everything from the solo practice of an individual surgeon up to large health care systems. Using keywords and hashtags, patients can be directed toward credible surgeons and find out more about the practice and the diseases in which the surgeon specializes. In this era of emerging transparency,15 hospitals and systems have started to use their presence in online social media to advertise the unique skills and outcomes of their surgeons, departments of surgery, and hospital as a whole. Currently, most nationally ranked hospitals have their ‘‘top 100 hospital’’ badge featured near their name. They also promote frequently the unique skills of particular physicians or encourage patients to make a consultation appointment for elective operations or other procedures. Importantly, recent studies have identified a disconnect between the understanding of risk-adjusted outcomes by the physician and the public,16 which may lead to inappropriate and inaccurate perception of patients toward an individual surgeon or hospital. Social media may help in bridging this gap. Additionally, the use of ‘‘tweeting’’ and other avenues of social media allow people to share their experiences at various events in real time. For instance, physicians can use this approach to rapidly inform other surgeons (or their followers on Twitter) of new, state-of-the-art information reported at a medical meeting before any formal publication. In this way, many may benefit from others’ experiences, travels, and research, even when they do not have the time or means to investigate or acquire this knowledge themselves. Recently, the Baylor Scott and White Health System live-tweeted a heart transplant at their Baylor University Medical Center in Dallas. (http:// bswhlive.com/hearttxlive-news-release.html) This tweet quickly went ‘‘viral’’ and was caught rapidly in an exponential rise in popularity on social networks literally worldwide. In this light, social media provides a unique application to highlight the abilities and activities either parochially at a particular institution or as a possibility elsewhere. The second- and third-tier effects also may involve a resurgence of awareness for a particular disease process, something that could translate to both increased funding and improved outcomes. In the case of the procedure at the Baylor Scott and White Medical Center, Dr. Gonzalo Gonzalez-Stawinski, Chief of Heart Transplantation, said, ‘‘Our goal is to provide an educational look into what happens during a heart transplant
and encourage others to give the gift of life through organ donation.’’ RESEARCH Finally, as members of our broad surgical community, we strive not only to help the patient in front of us but also to increase the body of knowledge as a whole. Social media provides a powerful tool for patient follow-up and surveys and allows us to remain in contact with patients long after they have left our office by subscribing to keywords, hashtags, and pages that notify them of relevant updates specific to their disease. Subscription to unique, focused streams of media will allow instantaneous ‘‘blasts’’ of information and notifications of updates, and could be used ultimately in the development of research projects. Obviously for research purposes, this form of data-gathering will need to be reviewed and vetted carefully by our institutional review boards with a focus on HIPPAcompliant approaches. CONCLUSION Although social media has many potential pitfalls that need to be safeguarded against nonHIPAA compliant usage and the corruption by non-verified ‘‘experts,’’ the potential positive aspects in our house of surgery outweigh the negatives. We have described only a few of the potential uses of social media in our practices--when in reality, its use is limited only by our imaginations. Going forward, it will be imperative that careful forethought be applied to limit liability and maintain compliance with the Health Insurance Portability and Accountability Act of 1996; however, these issues are technical and achievable. As our potential reach is expanding as quickly as the world is contracting, it is critical that we remain at the forefront of this versatile technology. REFERENCES 1. Hill S, Merchant R, Ungar L. Lessons learned about public health from online crowd surveillance. Big Data 2013;1:160-7. 2. Beckjord EB, Finney Rutten LJ, Squiers L, et al. Use of the internet to communicate with health care providers in the United States: estimates from the 2003 and 2005 Health Information National Trends Surveys (HINTS). J Med Internet Res 2007;12:e20. 3. Brown J, Ryan C, Harris A. How doctors view and use social media: a national survey. J Med Internet Res 2014;16:e267. 4. Scott KR, Hsu CH, Johnson NJ, Mamtani M, Conlon LW, DeRoos FJ. Integration of social media in emergency medicine residency curriculum. Ann Emerg Med 2014;64: 396-404. 5. Ow D, Wetherell D, Papa N, Bolton D, Lawrentschuk N. Patients’ perspective of accessibility and digital delivery of
862 Steele et al
6.
7.
8.
9.
10.
11.
factual content provided by official medical and surgical specialty websites: a qualitative assessment. Interact J Med Res 2015;4:e7. Basch CH, Hillyer GC, Reeves R, Baasch CE. Analysis of YouTubeTM videos related to bowel preparation for colonoscopy. World J Gastrointest Endosc 2014;6:432-5. Saleh J, Robinson BS, Kugler NW, Illingworth KD, Patel P, Saleh KJ. Effect of social media in health care and orthopedic surgery. Orthopedics 2012;35:294-7. Hoffman SJ, Tan C. Biological, psychological and social processes that explain celebrities’ influence on patients’ health-related behaviors. Arch Public Health 2015;73:3. EIF Entertainment Industry FoundationTM. Available from: http://www.eifoundation.org/programs/eifs-nationalcolorectal-cancer-research-alliance/content/katie-couric-coloncancer-awarene. ‘‘TV pitchman Kevin Trudeau gets 10-year sentence.’’ Available from: http://www.usatoday.com/story/news/nation/ 2014/03/17/kevin-trudeau-sentenced/6546433/. ‘‘Social Networking Fact Sheet.’’ Pew Research Centers Internet American Life Project RSS. Pew Research Center.
Surgery September 2015
12.
13.
14.
15.
16.
Available from: http://www.pewinternet.org/fact-sheets/ social-networking-fact-sheet/. Thin NN, Taylor SJ, Bremner SA, et al. Neuromodulation Trial Study Group. Randomized clinical trial of sacral versus percutaneous tibial nerve stimulation in patients with faecal incontinence. Br J Surg 2015;102:349-58. Merchant RM, Griffis HM, Ha YP, et al. Hidden in plain sight: a crowdsourced public art contest to make automated external defibrillators more visible. Am J Public Health 2014;104:2306-12. Buechner B. A comparative legal analysis of social media advertising of drugs in Germany and the United States. Food Drug Law J 2013;68:259-79. Dahlke AR, Chung JW, Holl JL. Evaluation of initial participation in public reporting of American College of Surgeons NSQIP surgical outcomes on Medicare’s hospital compare website. J Am Coll Surg 2014;218:374-80. Bhalla A, Mehrotra P, Amawi F, Lund JN. Surgeon-level reporting presented by funnel plot is understood by doctors but inaccurately interpreted by members of the public. J Surg Educ 2014;72:500-3.
