The 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.

 

During a clinical encounter recently the mother I was visiting with reached down to the phone sitting on her chair and discreetly hit a red record button.

Increasingly, parents are interested in recording their encounters with me.  Sometimes one parent can’t be present for a visit.  Perhaps the mother of an inconsolable 6-week-old wants to remember what her fatigued brain won’t allow.

It got me wondering if my communication is different when I’m on the record?  I think so.  Recording a conversation isn’t necessarily the same as creating a useful piece of media.  When the red light is on, I am more methodical in the way I lay out a sentence.  I try to speak clearly and a little more slowly so that the recording is legible to subsequent listeners.  I compensate with inflection and volume for points that I may make with my hands or facial expression.  While I may be a little less myself with a microphone, I’m probably more precise and intentional in the way my words are delivered.  What I create hopefully has more practical use once the appointment is over.

Ambient documentation will likely become more prevalent with the popularization of devices such as Google Glass.  Providers have to be prepared that nearly everything we say and do in the clinical setting could be on the record.  But depending on the intent of the recording, it may behoove the recorder to disclose that the red button has been pushed.

 

As you may or may not know, I am responsible for fashioning a new curriculum in digital literacy and professionalism at Baylor College of Medicine.  I’ll offer more details over the coming weeks.  Until then, I need your help.

Concerning digital communication tools and the growing public space for dialog, what the things that you believe a graduating physician should know or be able to do?  We have this well-detailed but I realized that there are people who read this blog who may be able to make some amazing contributions.  And it seems that the more I think about this, the scope of competency, and potential objectives, creep wider.

Just as examples, we want our students to…

• Discriminate appropriate and inappropriate types of public disclosure concerning clinical experiences.
• Understand how to handle (or not handle) patient-specific queries on public platforms.
• Recognize the importance of the digital footprint in their personal professional development.

What do you think students should know, understand or be able to do?  I can’t give you a free t-shirt or mug, but I will respond to your suggestions/comments on a level consistent with my excitement.

What have you got?  Or, more importantly, what do you think the next generation of doctors should have?

If you’d like to comment in private, email fox42 at me dot com.

[Addendum: To clarify, I'm interested in what doctors need to know about networked comms to function on graduation, not how we can use social media to teach.  That's important, but a different question.]

 

This week marked the departure of blogger Mike Sevilla from public view.  Operating as Doctor Anonymous in the earlier years of medical blogging, his colorful contributions to the big conversation will be missed.  The thinking surrounding his decision is here.

I have a couple of thoughts about Mike’s silence and how the world turns.

Things aren’t like they used to be.   The early days of blogging were magical in many respects, but they’re gone.  And while we may romanticize the small world feel of the early years, there’s just as much about the mid-2000′s worth leaving behind.

Social media is less relevant.  One element of our world that has changed since then is the fact that we are less preoccupied with the medium.  Social tools have achieved a level of baseline adoption making them less novel.  Medical blogs are a dime a dozen, most doctors use Facebook (at least personally) and it has become practically impossible to track the numbers of doctors now using Twitter.

It’s not the tools but what you do with them.  More important than our preoccupation with the applications themselves is what we do with them.  The near future will be owned not by doctors who ‘do social media’ but those who apply these tools to move the chains forward.  Mike was spot-on with Family Medicine Rocks, a much needed platform for dialog around family medicine.

Noise.  Noise was apparently one element of the social environment that might have pushed Mike into the dark.  Understood.  As the audience grows and doctors and patients all talk at once, some shout in order to be heard.  For many, volume and frequency is the way to be heard.

But we let in the noise.  We facilitate the noise in our environment.  I work to create the right signal for myself.  I don’t tolerate shouting, politics, vitriol, anger, grandstanding, off-topic verbosity, pontificating and other nonsense that steals my soul and eats my emotional bandwidth.   Maintaining that signal requires constant attention.  I work to shape this input with an eye for smart, measured contributors and liberal use of the unfollow button.  In the old days it was cool to think that you could listen to everyone.  If you listen to everyone, you ultimately hear nothing.

The cocktail party’s over.  Those who have been here for a while must think about how the public part of medicine is changing and evolving.  We have to move beyond social tools as cocktail party to the public conversation as mechanism to redefine and shape our profession.

Pictured in orange is Mike Sevilla participating on a panel in San Francisco.  Mike was known for his colorful shirts.

 

It’s June first.  Cue up the pool safety blog posts.  It’s a predictable part of every hospital’s editorial calendar and a rite of summer in the health infosphere.

We want desperately to be timely and seasonal.  But the end result is the same: Year after year, post after post, empty copy that fills space but falls flat.  Content farming masquerading as stuff that anyone actually cares about has become the new norm for health communication.  We fool ourselves into thinking that another search optimized, sterile, cookie cutter list of vapid, predicable tips make a difference.

New media, it seems, doesn’t give us anything new.  Just the old voices in a new space.

“But we need more pool safety posts,” they say.  “We can’t be too careful.  And if we save just one life, well we’ve done our job.” Of course.  But can’t we do better than that?  Can’t we take health messaging a little more seriously?

Consider whether what we create really impacts anyone or anything.  Make something with at least a remote chance to stick.  Take a new angle, approach, view, or voice.  Tell a story.  Be unsafe, human and real.  Compel young mothers to stop, look and listen.

Give them something they’ll remember.  It’s summer.  School’s out.  Our kids depend upon it.

 

The Greenville Health System has launched a metablog that aggregates content from blogs within its system.  A blog of blogs.  Despite following a number of large medical institutions, this is something that I haven’t seen executed.   It raises questions about strategy versus function with regard to information.

As Google punishes replicated content – how does this impact search?  And when search brings an interested reader onto the meta site, have you lost the opportunity of having the reader exposed to the focal area of interest served by the primary blog?  Is there a dilution effect that’s unintended?

As fragmented content at medical schools and hospital systems scale up, central aggregation may have a future.  I wonder if there’s merit in exploring the development of a lifestream of sorts that goes beyond blogs?

I’ll leave it for the communication wonks to sort out.

The Greenville Healthcare System metablog is the work of Jason Pleakis and Bobby Rettew.

 

This morning Austin’s WGC released the MDigital Life Social Oncology Project. This report represents the deepest look at cancer conversations done to date.  If you live or work in proximity of cancer, communication or health, you need to stop what you’re doing and read.  The deep dive into #ASCO12 alone is worth the look.

Using cancer as the test case, the MDigital Life Social Oncology Project profiles a new model of scientific exchange emerging around disease states.  It’s a pattern of exchange with little regard for the mainstream media and traditional academic publishing venues.  All of this has me wondering how any physician can ignore the public conversation.

A couple of takeaways:

• Online discussion surrounding cancer is driven by experiences, not data.
• Breast cancer generates more online discussion than the top four causes of cancer death combined.
• As medical information increases, expect growing numbers of smaller communities talking about narrow topics at lower volume.

Beyond the cancer conversation, WCG and the MDigital Life Project are giving us a deeper understanding of what motivates social health dialog.

This project is the work of Brian Reid and his posse at the WCG.

 

There are only two things on the web:

1. Content.  The stuff that we look at.
2. Conversation.  The the dialog that happens around the stuff we look at.

Consequently, there are only two things that you can do online:

1. You make the stuff that people look at.
2. You talk about the stuff that other people make.

I’m working on a big project here.  This seems too simple.  What am I missing?

 

This post on Wing of Zock by Jason Franasiak is worth a peek.

Perspectives of this type make deterministic assumptions about technology:  Technology shapes us and we follow.  This reflects a view among physicians that we’re the victims rather than the beneficiaries of technology.

We cling to the belief that things were better way back when.  We blame technology for what we no longer do.  But in reality, the failure of physicians to keep the exam room clinical encounter centered on the patient is a failure of the physician.  The computer doesn’t know better.  It’s just a computer.

It’s interesting that Dr. Franasiak recalls paper charts staying on the patient’s door.  Perhaps he wasn’t around before The Creative Destruction of Medicine, but as an intern at one of the busiest pediatric residencies in the U.S., I had no choice but write my history at the bedside.  I remember a very clear 2 am lesson from an upper level in how to preformat a piece of paper for history, PMH, development, meds, allergies, etc.  It’s convenient to think that our exam room focus on documentation is somehow a function of the digital age.

While the abysmal design of our current EHR interfaces is a clear elephant in the exam room, it remains our responsibility to keep the clinical encounter as something uniquely focused on the patient.  The second screen is just the beginning.  What lies ahead with regard to bedside diagnostic technology will make the problem of the computer screen a charming vestige of history.

How we manage technology in the presence of a patient is a subject that requires intent.  I like to think of this as medical mindfulness.  Clinical education to date has failed to address the issue.  As long as this remains the case, we will continue create physicians with absence of insight about the patient in the room.

Technology shapes us.  But only as much as we allow.

The above image depicts William Osler at the bedside, c. 1904-1905.  National Library of Medicine

 

In The New Digital Age – Reshaping the Future of People, Nations and Business, Eric Schmidt and Jared Cohen take you though a futuristic view of a hyper-connected planet with all of its promises and challenges.  From the future of war and cyberterrorism to virtual hate crimes, online identity and cyber discrimination, the authors offer a unique and thorough take on what lies ahead for all of us.

For those willing to take the leap into The New Digital Age, take some comfort in knowing that it isn’t another technocornucopian book about widgets and gadgets.  It’s instead concerned with humans and our role in our digital future (‘The importance of a guiding human hand in the new digital age.’)  Schmidt and Cohen remind us that despite what communication technology may allow, what we do with it us up to us.  In an increasingly tech deterministic world, this core message bears repeating (so read this paragraph again).

And now for the big caveat:  A book that portends the coming digital age from two of the world’s most prescient thinkers has relegated dialog about health to just a couple of pages.  Really?  The collision course of health and technology is perhaps modern civilization’s most pressing angle.  This omission represents a lost opportunity for readers.

The authors make several references to the coevolution of two civilizations, one virtual and one physical.  Fascinating.

“These civilizations will coexist in a more or less peaceable manner, with each restraining the negative aspects of the other. The virtual world will enable escape from the repression of state control, offering citizens new opportunities to organize and revolt; other citizens will simply connect, learn and play. The physical world will impose rules and laws that help contain the anarchy of virtual space and that protect people from terrorist hackers, misinformation and even from the digital records of their own youthful misbehavior…”

The concluding thoughts were both powerful and reassuring:

“The case for optimism lies not in sci-fi gadgets or holograms but in the check that technology and connectivity bring against the abuses, suffering and destruction in our world. When exposure meets opportunity, the possibilities are endless. The best thing anyone can do to improve the quality of life around the world is to drive connectivity and technological opportunity. When given the access, the people will do the rest. They already know what they need and what they want to build, and they’ll find ways to innovate with even the meagerest set of tools. Anyone passionate about economic prosperity, human rights, social justice, education or self-determination should consider how connectivity can help us reach these goals and even move beyond them. We cannot eliminate inequality or abuse of power, but through technological inclusion we can help transfer power into the hands of individual people and trust that they will take it from there.”

While a provocative read, I’d recommend a pass on The New Digital Age for my health-focused readers.  A must-read, however, for budding futurists.

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