Intimacy, Mission and a Physician’s Public Role

This weekend at Stanford Medicine XiStock_000018781954XSmall I’m co-teaching with Wendy Swanson a Master Class on physician online identity.  As I was working through some of my thoughts on the plane, I settled into the idea that being public with our thinking is a pretty big deal for providers.

Being out and open in the virtual space carries with it a whole new set of preoccupations.  Physicians traditionally only had to worry about their IRL (in real life) presence.  We walked around, we touched people, we talked to them.  All of our interactions were in person.  Eye-to-eye and hands-on defined everything about us.

We still do that, but now we’re faced with the new challenge of managing a presence in the virtual space.  But…

  1. We don’t know what the rules are.
  2. Many of us don’t know what the tools are.
  3. A lot of us don’t know what we want there.

This last reality become obvious when I talk to physicians about blogs.  A relevant blog, of course, requires some degree of focus or direction.  You need to create and share around something that drives or inspires you.  But when you get down to it with them, many don’t know what turns them on.  They have no idea what they could even create a blog post about.  Many don’t even know why they’d want to make or share anything.  So beyond even having a mission, there’s no understanding of why it would want to be shared.  It’s striking, really.  It’s like they’ve never been forced to declare themselves in any meaningful way.

The capacity to be public really amplifies the fact that we all have passions, missions and roles in the world.  Being front and center with a footprint and identity forces us to think about where we fit in the world.  It was easy to be elusive when the world was private and our existence was restricted to an exam room.  But now we’re part of a wide-open, networked world.  This capacity to share and create exposes us for who we are and what we believe in.  Being here is an act of intimacy.  Participation is something that many of us just aren’t prepared for.

Often times I position the discussion of our ‘obligation to be public and present’ as so easy and obvious.  But it’s a big step for the provider trained to contain his life within a silo.

More on this later.

The Branded Doctor

Every doctor has a brand.  But when I mention this, people throw things at me.  Because everybody knows a brand is for potato chips and toilet paper.

This has nothing do with promotion or commercials.

Your brand is what people think about you.  It’s what comes to mind when your name is mentioned.  It’s a tattoo on the brain that’s been created by your clinical deeds and actions.

  • He’s the surgeon who answers within 30 seconds of being paged.
  • She’s the ID doctor who’s dress is as impeccable as her penmanship.
  • He’s the vascular surgeon known for his rough bedside manner and compulsive attention to operative detail.
  • She’s the softspoken pediatrician who takes lots of time no matter how far behind she is.

Even that quirky anatomy professor with the 7 dry erase markers has a brand.

Now enter the age of democratized media where every doctor with a smart phone is a publisher.  Our public persona reinforces, or even shapes, our identity.  Tell me that Wendy Swanson, ZDoggMD don’t have brands.  Wendy is defined by her passion, energy, voice and transparency.  ZDoggMD is defined by his unique delivery of health information.

Sure you can portray yourself in any way you like.  But doctors don’t need to sell or pitch anything to have a brand.  All they have to do is show up.  Their patients and peers watching will do the rest.

One Physician and His Paid Twitter Promotion

gossip_birdsPhysician executive and coach Richard Winters recently paid to promote his work on Twitter.  It created a small kerfuffle.  Not surprising, really.  We get wiggy when doctors do something different.  Hats off for poking the box.

But it’s really not surprising that promoted tweets ‘worked.’  Google adwords, banner ads and sponsored tweets will get you eyeballs, short-term traffic and the unexpected phone call.  But while paid media has a place and time, value and trust are required for integration into a community.  These take years of work and consistency.  It’s hard to buy.

Nonetheless it’s interesting to think about and fun to watch.  Winters’ demo also showcases how self-experimentation and narration can be an effective way to engage folks.

He finishes his post with a tease suggesting that he’ll disclose the results of his next Twitter promotion self-trial.  But with one small catch: you can see it if you leave him your email.  Love it.

I’ll leave my email when he offers a free set of steak knives.

Twitter birds from here.

The First Mover Advantage

iStock_000012150861XSmallIn social networks there’s a phenomenon called the first mover advantage.  The first person who shows up gets some advantage.  This happens in business as well.  The first person to create a commodity always has the upper hand over the next guy who replicates it.

I showed up early to Twitter as a physician.  I was a unicorn and people followed me to see what I’d do.  Then I wound up on lists and more people followed me.  And when people make new lists, they just take the names from the old list.  That’s what we’ve come to expect.

The unfortunate thing is that influence is determined by Klout scores rather than looking at what an individual curates, collects, creates and says.  Of course I’m thankful for those who have nice things to say about me.  But we need to find a new way to make lists.

But I take nothing for granted and I work hard.  I write early in the morning and late at night.  I try to make and shape ideas that you won’t find in other places.  I hope to make the right lists for the right reasons.

It’s a noisy world.  You need to work hard to be heard.  Just doing what I do isn’t enough to establish a workable public presence.

Because I’ve got the first mover advantage.

Figure 1 – A Safe App for Medical Images?

CameraThe latest mobile app for doctors is Figure 1, which has been touted as ‘instragram for doctors.’  Figure 1 is a crowdsourced medical library that allows individuals to post clinical images from their mobile devices.

The concept makes sense.  Images in medicine represent a great way to teach and tell a story.  But I’m bearish on Figure 1.  Here’s why:

Low barrier to post.  Figure 1 facilitates ease of posting.  Low barrier to entry is good when sharing pictures of you and your buds on the strip in Vegas.  Immediacy and nowness isn’t so good when what we’re sharing requires intent and mindfulness.

Absence of clinical context.  Images offer the best bang for the buck when delivered with some element of history.  Medical images shared in the absence of context run the risk of serving as entertainment.  While it would appear that users can add as much history as they would like, the nature of the application doesn’t lend to this kind of detail.  The platform would create a stronger offering through the encouragement of more background from users.

Risk for sensationalism.  When we share clinical images or stories there’s lots to think about.  Among other things, we need to consider our intent.  Are we sharing to shock, amuse or teach?  I’m concerned that the absence of context coupled with the point-and-shoot functionality creates the potential for shock-and-awe to overshadow show-and-tell.

The world is watching.  While agreeing to the terms of service serves as an acknowledgment that you are a health professional, the system allows you to register as non-professional.  Under that circumstance, you are apparently unable to post or comment to Figure 1.  Makes sense.  But if you try to post as a non-professional, you are prompted to submit for verification as a physician.

I registered and declared myself as a physician and was able to post and comment without ever being verified.  After declaring that you are a physician, there is an option within your profile to become a ‘verified’ physician.  Verified physicians apparently rank higher within the database.

Absence of identification.  Names and institutional affiliations are not part of the registration process and so you can be who you want to be.  Users are identified by user name only.  So while anyone can sign up and call themselves a doctor, it’s practically irrelevant since no one knows who you are.  It should be clear to most who spend time in physician social spaces, anonymity went out of style back in the days of Sermo.

Study the TOS.  The appearance of a walled-off doctor-only community in Figure 1 may lead some to believe that this is a place where we can safely post and share without concern.  But you might make a pot of coffee and hunker down with the terms of service.  The platform is indemnified with dense, eye-opening legalease.  None of this is surprising, really.  But studying the TOS should emphasize how personally accountable and liable physicians really are when they share clinical images.

De-identification is tricky business.  There’s a difference between de-identification of images on a level that’s compliant with health privacy law and de-identification that respects a patient’s wishes.  I operate within the understanding that if a patient can individually identify their own leg, finger, laceration within an image, they should understand very clearly that the image is headed for the very public domain.  Figure 1 recognizes faces and offers tools to erase uniquely identifying characteristics.  The application does take effort to warn users at points along the way.  However, understanding how to de-identify isn’t as straight forward as the application may lead less experienced doctors and trainees to believe.

While there is an in-app consent form that a patient can sign with their finger, I find it hard to believe that any institution, or court for that matter, would recognize such a consent as appropriate or adequate.  And I wonder if that patient in the hospital bed understands that when they consent to the sharing of their image, they “hereby grant to Movable Science, in perpetuity, a non-exclusive, fully paid and royalty-free, transferable, sub-licensable, worldwide license to use the Content that you post on or through the Service, subject to the Service’s Privacy Policy.

Of course, all of this used to be easy.  In the old days medical images never left the medical library or the glossy paper on which they were printed.  But times have changed, technology is advancing faster than the discussion surrounding its use, and we have to think carefully about how we repurpose and share the images of those under our care.

My criticism has to be tempered with the fact that this concept of photo sharing is ripe for development.  A properly developed tool that cultivates community and thoughtful dialog around medical images has real potential.  I’m afraid that Figure 1 isn’t there with this first iteration.

If I were Figure 1, here’s what I’d do:

  • Partner with someone like Doximity to verify physicians.
  • Eliminate anonymity.
  • Pivot the away from a tool that allows on the fly posting to something that requires more contextual info and forces users to think about why they might be sharing a medical image.
  • Tighten the consent requirement in a way that better protects patients.

We’ll follow this to see where it goes.

See also Figure 1 reviews in The Atlantic and MedGadget.

Why IBM Watson is Important

watson_avatar2_140x140First he won at Jeopardy.  Now he’s helping treat cancer.

IBM, WellPoint, and Memorial Sloan-Kettering Cancer Center today unveiled the first commercially developed Watson-based cognitive computing breakthroughs.  This is transformative stuff.  IBM Watson is using evidence-based treatment models to individualize care and improve the speed and quality of treatment.  Doctors from Memorial Sloan-Kettering have spent thousands of hours “teaching” Watson how to process analyze and interpret the meaning of complex clinical information using natural language processing.

IBM Watson videos to see how it all works.  Essentially, Watson takes data from the EHR and analyses it against published data to offer confidence-scored suggestions for treatment.  Physicians can drill as deep as they want with Watson.

Here’s why this is important:

There’s too much to know.  Information and knowledge are exploding at a rate that humans can no longer follow.  Watson offers machine-based relief delivered in the context of a patient’s specific situation.

This is what an EHR should do.  Watson offers what I’ve always pictured an EHR should do: provide a two-way dialog with evidence-based suggestions for treatment.  This represents the first practical, and perhaps the most impressive, application of AI in a clinical setting.  Think of Watson as that friendly nurse who asks, “have you thought about this?

Watson redefines the physician.  This demonstrates how the role of the physician is evolving.  Physicians will not be replaced, but rather radically redefined by machine-based intelligence.  We are moving from learning what we need to know to learning how to access what we need to know.

There’s lots to consider here and I’ll post more as ideas arise.  Let me know what you think

Doctors, Patients, Old and New

There’s this tension that I pick up on when I talk with patients.  It’s the fantasy of the new and the old.

It’s the fantasy of the physician encounter where a doctor will look at us and never to a screen.  We insist on all of the affordances of the digital age with the human connection of a time gone by.  We want an intensely human connection but we want everything flawlessly documented, reviewed, flagged and cross-checked in the EHR.  We want to spend lots of time with the doctor but we also want to send an unlimited supply of emails (2,000 words, one paragraph).   We want desperately to be human but we glorify transhumanism.  We want to know that we have the ability to make decisions while at times we want our doctors to make the decisions.

We talk endlessly about the power of the story and the importance of patient narrative but we want desperately to be recorded, uploaded, graphed, and analyzed.  We don’t want to be seen as a number but we demand that our numbers are seen.  We insist on laws to protect our privacy yet we yearn to have our stories heard.  We worry lots about data and less about wisdom.  We want doctors who will stare, touch, talk, laugh and connect while at the same time remaining glued to a screen and available 24/7 in 140 characters.  We criticize those docs who refuse to accept the independent e-patient but we swoon when Abraham Verghese paints a romantic picture of 19th century paternalism.

We want the best of the analog and digital all rolled up into one.

Is There a Physician Mandate to Connect?

The more popular Twitter becomes, the more we hear about the mandate to participate.  Those of us who’ve made the step feel like we’ve discovered something that everyone should do.  We want our friends and coworkers to jump in with us.  In the corporate communications world there’s a shortsighted trend to ‘make CEO’s use Twitter.’  The same pressure can be seen among medical professionals.

The decision to tweet, blog or record should be made on value.  Those of us trained to think in the analog era have a hard time seeing the value of networked knowledge and communication.  The physician’s comfort zone is the silo of the clinic.  Our understanding of professional connection is limited to the doctor’s lounge, hospital hallway or, at best a listserve.  Our understanding of health teaching is limited to the 7 minute face-to-face encounter delivered under the harsh glare of UV lights.

But there are 50 ways to use something like Twitter to make your world, or the world of those around you, a better place.  YouTube’s potential application in health care is limited only by the imagination.  While no one has to use any of these tools, believing that Twitter is only a place to share what you’re eating for breakfast is to live with your head in the sand.

We can’t value what we don’t understand.  And we’ll only understand what something can offer by poking at it and trying it in different ways. The world is increasingly networked.  And when you find the right place to connect, share and create, you’re likely to find value.

When Few Doctors Ruled the Media Landscape

I remember as a college student I had access to only a few newspapers.  There was a Boston Children’s Hospital pediatrician named Perri Klass whose essays I used to read in the New York Times.  She had an amazing voice.  My inspiration to be a pediatrician was drawn from her.  I wanted to have her experiences and I wanted to react and think like her.  I wanted to handle vulnerable parents with the poise and fluency that she seemed to convey.  Because she was effectively all I could see, I thought all pediatricians were like Perri Klass.

Since that time I became a pediatrician and the internet appeared.

And with respect to physician voices, things have changed.  There are now countless physicians being heard.  There’s no longer one fortified newspaper with one doctor’s isolated perspective.  And any medical student or doctor with a keyboard, an internet connection and a good idea has a shot at developing a global platform.   We’re seeing wild opinions, crazy ideas, and brilliance that reflect all the things about doctors once hidden by editors.  Sure, there’s rubbish.  But the good stuff survives and flourishes in a system of sharing and social reinforcement.  As it has been said, editorial selection happens after publication.

Now without anyone’s editorial consent I maintain a regular voice online and people can hear what I have to say.  Some of it’s rubbish but the good stuff survives.  One story that stuck found its way into the The Real Life of a Pediatrician.  Check it out.  It’s a great collection with a great editor.

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Physician Thought Leaders in the Digital Age

I was on a panel recently where it was asked, ‘What will become of the medical thought leader in the digital age.’  It’s an interesting question because it draws on what constitutes influence in the modern medical world.  How do we determine who we listen to and how will digital communication change that?

It used to be that influence in medicine was determined by traditional, industrial-age measures: publication in medical journals, institutional affiliation and influence within the guild.  The density of ivy outside one’s office window correlated with one’s smarts.  Rank on the academic ladder conferred who had the podium at The National Meeting.

While those who create new information in the lab will always be recognized for their contributions, this is no longer be the only variable determining influence in medicine.  As doctors collect in new spaces, new rules of influence will apply.  The digital age will deliver a new type of thought leader.

A few ideas on the future of physician thought leaders:

The physician audience now has a voice.  In medicine it used to be that few physicians spoke and the rest listened.  But ability of the physician audience to have the mike allows those previously shut out to become influential.  Solid thinking no longer needs permission to be shared. Expect to see regular doctors emerge as influential not based on their connections within ‘the society,’ but on the strength and novelty of their ideas.  Old world connections within dated institutions will hold weight only with those desperately banding together, unwilling to do anything different.

New channels make new leaders.  As the numbers of doctors consuming information and conversing in the online space increases, there will be new places for delivering information.  The journals and outlets of news and information for physicians will create new places for doctors to develop visibility.  Anyone with expertise can share that know how and create an audience.  New physician influencers will emerge from new these channels of publication.

Kevin Pho of KevinMD has fashioned himself as one of the more influential physicians online.  As it turns out, his platform is evolving as a place for doctors to showcase their expertise and opinions.  A KOL who has fashioned a place to launch other KOLs.  Academic affiliation or not, Kevin’s success is not a function of his position in an institution or society, but rather initiative and opportunity.

Home-made KOLs.  As a means of proactively playing to the new market, institutions will look to cultivate their own dedicated physician influencers.  These will be influencers not by the traditional measure, but social rainmakers with an eye for content, an ear for conversation and the smarts of a new age.  Writing, recording and connecting as a physician representing an organization will fashion itself as a new position.  Competitive institutions will create the conversation, not just respond to it.

Paid influence – then and now.  Kevin Kelly has suggested that where there’s attention there’s money.  And, of course, where there’s money, there’s influence.  Just as pharma has co-opted physician KOLs for speaking, the new influencers will have new avenues of conflict. Personal technology, products, services for other doctor’s or patients will represent the parties looking for attention.  There are lots of places to share information and exert influence.  This will require special attention both from those who create media to those who consume it.

What do you think the digital physician KOL will look like?

3 Great Links for the Week of March 26, 2012

Here are 3 links that I stumbled on this week that I think are worth a peek.  I’ve not been one to curate links, but I see so much great stuff.  I thought that I should share some of what I find.  Tell me what you think.

Telemedicine predicted in 1925

This post from Paleofuture, the retro futuristic Smithsonian blog, shows how one 1925 radio enthusiast predicted the future of telemedicine.  Publisher and entrepreneur Hugo Gernsback envisioned the use of remote robotic arms (teledactyls) that could sense resistance and feed information back to an ‘examining physician.’  While his precise vision never came to be, the operating physician in this picture does resemble an early 21st century surgeon operating a DaVinci robot.  This is one to keep. (image via

First Person Sick

This post by New Jersey oncologist Jim Salwitz questions if it’s possible for us to see the world from beyond our personal lens view.  Using various narrative methods as a jumping off point, Salwitz and leaves us with the challenge of working harder to feel and understand beyond ourselves.  This is serious stuff.  His clear writing is surpassed only by his thinking.  I can’t remember the last time I read something four times.

Lego Anesthesia machine

And this is just silly.  It’s an anesthesia machine built to scale from Lego pieces.  It’s the work of Eric Harshbarger and it seems he was commissioned by GE Healthcare to put the project together.  You can see images at various stages of development here.  This story was bouncing crazy on Twitter and it supports my assertion that there’s a role for rejuvenalia in medicine.

I’m now inspired to recreate a full-scale endoscopy unit.  I wonder if Olympus will sponsor me.