- Email: [email protected]
This Sentence Easily Would Fit on Twitter: Emergency Physicians Are Learning to “Tweet”
This Sentence Easily Would Fit on Twitter: Emergency Physicians Are Learning to “Tweet” by ERIC BERGER Special Contributor to Annals News and Perspective
T
his story assesses the various reasons why emergency physicians are increasingly using social media in general, and Twitter in particular. The sentence above measures exactly 140 characters, the maximum length of a “tweet,” or snippet of communication sent via the rapidly growing social networking Web site Twitter.com popularized by the likes of Britney Spears, Ashton Kutcher, Lance Armstrong and, more recently, Oprah Winfrey. Anyone who is anyone, it seems, is Twittering. To the uninitiated it seems silly. The perception of Twitter is that it’s a place for teens to talk about what they had for dinner, or how awesome last night’s All-American Rejects concert was. What possible place could there be for serious-minded, hyperbusy emergency physicians to engage in such folderol? How could Twitter, with its 140-character limit, allow for meaningful communication among physicians? Yet despite these perceived limitations Twitter seems to be evolving into a social network of choice for older Americans. According to a January 2009 survey by The Pew Research Center’s Internet & American Life Project,1 the average age of a Twitter user was 31 Volume , . : August
years old, compared to 26 years for Facebook, and 27 years for MySpace. An April 2009 survey by Quantcast found that 54% of all Twitter users were 35 or older.2 More than one-fifth of users were over 50. “Initially I thought it was a time waster, an attention sink and that it would simply distract me,” said Luis Saldana, MD, a practicing emergency physician at Presbyterian Hospital Dallas, and Medical Director of Clinical Decision Support at Texas Health Resources. “After trying it, I saw the potential for mass collaboration, for rapid diffusion of information, and I saw it as a connection of what I do. This helps me with my job.”
COLLEGIAL TWITTER
I
n addition to individual doctors, during the first half of 2009, companies and organizations such as the American College of Emergency Physicians (ACEP) have begun taking a keen interest in Twitter. ACEP has a semi-official presence with its @EmergencyDocs feed, which is authored by public relations manager Julie Lloyd. She says she began using Twitter in late January out of a recognition that many of ACEP’s newer and younger members were comfortable with social media. Lloyd uses @EmergencyDocs to call attention to the organization’s news releases, promote new videos and advocate
positions in the turbulent realm of health care reform. A recent tweet from May 28, regarding a cut in emergency preparedness funding by the US Department of Health and Human Services, highlights the viral nature of Twitter and how organizations can spread their message with very little effort. Lloyd wrote: “In the year of swine flu, HHS decreases hospital emergency preparedness funding. Way to go.” A minute later Saldana “retweeted” the message, meaning he copied it, attributing it to @EmergencyDocs, and then published it to all of 1,294 of his followers. A few minutes later one of his followers, @StandingFirmCM, a Massachussetts-based citizen blogger named Catherine Mitchell who is interested in pandemic preparedness, retweeted the same message to her 4,221 followers. Within 5 minutes, then, Lloyd’s message had been spread to more than 6,500 people. It required no phone calls or news releases. From this example it’s easy to see how information can spread through Twitter like wildfire, especially when it is newsy or gossipy. User-dominated dissemination of information through social media has the potential to revolutionize traditional, top-down forms of media. However, services such as Twitter also pose challenges because of their immediacy. Messages cannot be recalled. And Lloyd said she is cognizant that she must exercise caution as @EmergencyDocs is seen representing a professional organization in the Wild West of social media. “Even though it’s an entirely new medium I think some of the old rules still apply,” she said. “If you wouldn’t want your grandmother to read it, don’t write it. So while we may be tempted, we are not going to make any attacks against any organization that might cross our path.” Lloyd’s boss, Gordon Wheeler, Associate Executive Director of Public Affairs for ACEP, also joined Twitter in late March as @ACEPheadlines. Angela Annals of Emergency Medicine 23A
Gardner, MD, the president-elect of ACEP, joined in April as @ACEPheadliner. Other board members have also joined. “We recognize that in addition to a purely social aspect, Twitter has the ability to send out relevant and timely information to physicians,” Wheeler said. “We know from the Obama campaign that it is a very powerful way to reach well beyond the traditional media to get our message out. We’re still learning our way as we go, this is still a nascent thing. But there’s value here. If I go to a meeting on Capitol Hill, for those members who are interested, I can provide some immediate information.”
WHAT HATH JACK WROUGHT?
C
reated in 2006 by Jack Dorsey, 32, Twitter has seen phenomenal growth during the last year as other social networking sites such as MySpace have seen their growth ebb. Twitter’s month-to-month growth has been 50 to 100%, and by late May the service had more than 30 million users. When a user creates a new account he or she can immediately post new tweets, such as, “I’m on Twitter. Now what?” The answer, invariably, is to figure out how to use the service. For some people it’s simply a means to keep up with friends and family, so they “follow” these people by subscribing to their updates. For other people it’s a way to access celebrities who would otherwise be unapproachable. Basketball player Shaquille O’Neal (@THE_REAL_SHAQ, 1.1 million followers) is among the favorites, with such tweets as, “Should I challenge tiger woods to a homeboy style putting contest? I kno what you are thinking, I dnt putt like I shoot free throws, lol” But during recent months there’s also been a marked change in the use of the service, especially as companies and organizations such as ACEP have joined the fray. These organizations are using Twitter in a variety of ways to build their brands: reach out to customers, do consumer research, conduct e-commerce and create communities for users. It is this more professional side of Twitter – the users who do not post the details of their breakfast but rather dis24A Annals of Emergency Medicine
cuss issues and disseminate news -- that may be more appealing to emergency physicians. Physicians are joining Twitter and following organizations relevant to them, or other physicians to share information and communicate. This is the easiest way to begin experimenting with Twitter. “If you look at Twitter your whole experience is designed by who you follow,” said Bryan Vartabedian, MD, an attending physician at Texas Children’s Hospital and an Assistant Professor of Pediatrics at Baylor College of Medicine. “You’re only as good as the people you follow, or the friends you hang out with.” Within the continuum of social media, from blogs to wikis to YouTube, Twitter is classified as micro-blogging, because unlike longer blog entries, Twitter requires brevity. Just as physicians lagged behind some other professions in embracing the Internet – as recently as 2003 just one-quarter of physicians felt the Web was “essential” to their practice according to Manhattan Research3 – so, too, have they taken a slow-to-warm attitude toward social media, said Jason Bhan, MD, a family practice physician who launched Ozmosis, a physician-only social networking site, in 2008. However, that’s now changing for a variety of reasons, Dr. Bhan said. One survey earlier this year found that 60 percent of physicians were interested in or already participating in online physician communities.4 Ozmosis and other physician-only social networking sites such as Sermo were created as online communities where doctors can access the collective wisdom of their peers through private and professional discussions, Dr. Bhan said. On Ozmosis each participating doctor is clearly identified, and because everyone knows everyone’s name, this engenders trust, he said. Patients are not allowed in. Dr. Bhan created the Web site after he left medical school. During residency and medical school, he recalled, there was a considerable focus on group learning, sharing information with colleagues, best practices and so forth with group meetings and grand rounds. “We marched through residency with this wonderful focus on person-to-person learning,” Dr. Bhan said. “Then you graduate. You get a kick in the rear, get
told you did great, and then you’re on your own. The concept of Ozmosis came out of several years in private practice, where I felt isolated, and I missed the interaction. I found a core group of physicians who felt the same way, that it would be kind of cool to have a place where we can share information. I feel like it’s a virtual version of the experiences we had of collaborating in medical school.” Initially physicians may feel more comfortable with such sites because they’re not open to the general public. But Dr. Bhan and other physicians who have dipped their toes into broader social media sites such as Twitter and Facebook contend that there’s considerable value in going public, too. Physicians’ lives already are an open book, he said. Type any physician’s name into Google and the first site likely to come up probably will be something akin to www.healthgrades.com, where patients can anonymously grade and comment on a doctor. Such sites will be closely followed by negative press. Physicians need to realize that a significant percentage of patients have become accustomed to turning to the Internet for information about their physicians before they make their first phone call or send an e-mail, Dr. Bhan said. Doctors need to become comfortable interacting in these public, online areas as well, he said. “This is just how today’s patients are interacting with one another, and it’s how many of them are coming to expect to interact with their doctor,” Dr. Vartabedian said. “If you have a practice, or are a physician-executive, it’s almost to the point where you can’t afford to not be involved in some way.”
WHAT’S UP, DOC?
S
o how are physicians using Twitter? Dr. Saldana said he uses it primarily to share information about emergency medicine and health information technology. He says in his medical group it’s a useful way to share information in bite-size packets. For example, he said, if a trusted colleague passed along a link to a new medical study, Dr. Saldana said he would be much more inclined to review the article than he otherwise would have. Volume , . : August
“It’s almost like we act as a group filter to find the most relevant stuff,” he said. Other emergency physicians use Twitter because they are early adopters and like to tinker with new technologies. An emergency physician from Northern California, Tim Sturgill, MD, has blogged for more than 5 years and says he uses Twitter to communicate not only with other doctors but to have conversations with those who, like him, are exploring the potential of social media. Dr. Sturgill conversed with the author on Twitter (see a snippet below) while he was having 4 other conversations on Twitter.
A REAL TWEET @chronsciguy: Does Twitter help or impact your practice of medicine in any way? @symtym: it does ”impact” in terms of med literature injected into the twittersphere for discussion @symtym: probably more ”weighty” discussions on LinkedIn, Ning, FB, Friendfeed, etc. b/c of the 140 character limitation @chronsciguy: What’s the primary benefit of such communications for EPs? Aid in diagnoses? Identifying disease outbreaks or trends? @symtym: ”primary benefit” I don’t think its there yet, albeit the H1N1 tracking was impressive; the potential is great -- but diffuse @symtym: by diffuse, I mean you have to work it to get a good picture, so many users, so much dialog, you have 2b actively filtering @chronsciguy: Do you feel this is something useful for a lot of docs, or just those who like to tinker with new technologies?
Volume , . : August
@symtym The value of Twitter is not actuality, but potentiality, where universal messaging and social applications/ awareness is going @symtym: it is a technology that is not ripe for usage yet, but may in retrospect 5-10 years from now be indispensable Other physicians have gotten into Twitter and other social media simply because they believe it will play a big role in the future delivery of medicine, and want to understand the digital landscape. Dr. Vartabedian says he first got into blogging as a means to promote his popular books, such as Colic Solved, and has stuck with it because he sees the potential for communication with patients. At some point doctors will regularly converse with their patients over the Internet using new media tools. The major unsolved question at this time, he said, is reimbursement for physicians when a patient doesn’t visit the doctor’s office. Already some doctors such as Natalie Hodge, MD, are experimenting with the practice of iPhone medicine. For doctors reticent to take the plunge, physicians who use Twitter say it’s easy to join. After joining, they say, a new user need not write anything, but rather search out a few relevant users to follow. From there the growth happens naturally. “Soon you may need to watch how much time you’re spending on Twitter,” Dr. Vartabedian said. “It can be habitforming.”
APPENDIX Most people named in this story have active Twitter accounts. Here are their user names along with the number of followers they have accrued.
Bryan Vartabedian, MD, @Doctor_V, 1,393 followers Luis Saldana, MD, @lsaldanamd, 1,353 followers Tim Sturgill, MD, @symtym, 1,053 followers Jason Bhan, MD, @jmbhan, 492 followers Julie Lloyd, @EmergencyDocs, 175 followers Angela Gardner, MD, @ACEPheadliner, 51 followers Gordon Wheeler, @ACEPheadlines, 43 followers Twitter statistics as of June 1, 2009. Section editor Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. doi:10.1016/j.annemergmed.2009.06.002
REFERENCES 1. Lenhart A. Adults and Social Network Websites, Pew Internet & American Life Project, Available at: http://www.pewinternet. org/Reports/2009/Adults-and-Social-NetworkWebsites.aspx. Accessed June 13, 2009. 2. Quantcast survey. Available at: http:// www.quantcast.com/twitter.com, Accessed April 30, 2009. 3. Manhattan Research. Taking the Pulse v6.0. New York: Manhattan Research; 2006. 4. Manhattan Research. Taking the Pulse v8.0. New York: Manhattan Research; 2008.
Annals of Emergency Medicine 25A
T
his story assesses the various reasons why emergency physicians are increasingly using social media in general, and Twitter in particular. The sentence above measures exactly 140 characters, the maximum length of a “tweet,” or snippet of communication sent via the rapidly growing social networking Web site Twitter.com popularized by the likes of Britney Spears, Ashton Kutcher, Lance Armstrong and, more recently, Oprah Winfrey. Anyone who is anyone, it seems, is Twittering. To the uninitiated it seems silly. The perception of Twitter is that it’s a place for teens to talk about what they had for dinner, or how awesome last night’s All-American Rejects concert was. What possible place could there be for serious-minded, hyperbusy emergency physicians to engage in such folderol? How could Twitter, with its 140-character limit, allow for meaningful communication among physicians? Yet despite these perceived limitations Twitter seems to be evolving into a social network of choice for older Americans. According to a January 2009 survey by The Pew Research Center’s Internet & American Life Project,1 the average age of a Twitter user was 31 Volume , . : August
years old, compared to 26 years for Facebook, and 27 years for MySpace. An April 2009 survey by Quantcast found that 54% of all Twitter users were 35 or older.2 More than one-fifth of users were over 50. “Initially I thought it was a time waster, an attention sink and that it would simply distract me,” said Luis Saldana, MD, a practicing emergency physician at Presbyterian Hospital Dallas, and Medical Director of Clinical Decision Support at Texas Health Resources. “After trying it, I saw the potential for mass collaboration, for rapid diffusion of information, and I saw it as a connection of what I do. This helps me with my job.”
COLLEGIAL TWITTER
I
n addition to individual doctors, during the first half of 2009, companies and organizations such as the American College of Emergency Physicians (ACEP) have begun taking a keen interest in Twitter. ACEP has a semi-official presence with its @EmergencyDocs feed, which is authored by public relations manager Julie Lloyd. She says she began using Twitter in late January out of a recognition that many of ACEP’s newer and younger members were comfortable with social media. Lloyd uses @EmergencyDocs to call attention to the organization’s news releases, promote new videos and advocate
positions in the turbulent realm of health care reform. A recent tweet from May 28, regarding a cut in emergency preparedness funding by the US Department of Health and Human Services, highlights the viral nature of Twitter and how organizations can spread their message with very little effort. Lloyd wrote: “In the year of swine flu, HHS decreases hospital emergency preparedness funding. Way to go.” A minute later Saldana “retweeted” the message, meaning he copied it, attributing it to @EmergencyDocs, and then published it to all of 1,294 of his followers. A few minutes later one of his followers, @StandingFirmCM, a Massachussetts-based citizen blogger named Catherine Mitchell who is interested in pandemic preparedness, retweeted the same message to her 4,221 followers. Within 5 minutes, then, Lloyd’s message had been spread to more than 6,500 people. It required no phone calls or news releases. From this example it’s easy to see how information can spread through Twitter like wildfire, especially when it is newsy or gossipy. User-dominated dissemination of information through social media has the potential to revolutionize traditional, top-down forms of media. However, services such as Twitter also pose challenges because of their immediacy. Messages cannot be recalled. And Lloyd said she is cognizant that she must exercise caution as @EmergencyDocs is seen representing a professional organization in the Wild West of social media. “Even though it’s an entirely new medium I think some of the old rules still apply,” she said. “If you wouldn’t want your grandmother to read it, don’t write it. So while we may be tempted, we are not going to make any attacks against any organization that might cross our path.” Lloyd’s boss, Gordon Wheeler, Associate Executive Director of Public Affairs for ACEP, also joined Twitter in late March as @ACEPheadlines. Angela Annals of Emergency Medicine 23A
Gardner, MD, the president-elect of ACEP, joined in April as @ACEPheadliner. Other board members have also joined. “We recognize that in addition to a purely social aspect, Twitter has the ability to send out relevant and timely information to physicians,” Wheeler said. “We know from the Obama campaign that it is a very powerful way to reach well beyond the traditional media to get our message out. We’re still learning our way as we go, this is still a nascent thing. But there’s value here. If I go to a meeting on Capitol Hill, for those members who are interested, I can provide some immediate information.”
WHAT HATH JACK WROUGHT?
C
reated in 2006 by Jack Dorsey, 32, Twitter has seen phenomenal growth during the last year as other social networking sites such as MySpace have seen their growth ebb. Twitter’s month-to-month growth has been 50 to 100%, and by late May the service had more than 30 million users. When a user creates a new account he or she can immediately post new tweets, such as, “I’m on Twitter. Now what?” The answer, invariably, is to figure out how to use the service. For some people it’s simply a means to keep up with friends and family, so they “follow” these people by subscribing to their updates. For other people it’s a way to access celebrities who would otherwise be unapproachable. Basketball player Shaquille O’Neal (@THE_REAL_SHAQ, 1.1 million followers) is among the favorites, with such tweets as, “Should I challenge tiger woods to a homeboy style putting contest? I kno what you are thinking, I dnt putt like I shoot free throws, lol” But during recent months there’s also been a marked change in the use of the service, especially as companies and organizations such as ACEP have joined the fray. These organizations are using Twitter in a variety of ways to build their brands: reach out to customers, do consumer research, conduct e-commerce and create communities for users. It is this more professional side of Twitter – the users who do not post the details of their breakfast but rather dis24A Annals of Emergency Medicine
cuss issues and disseminate news -- that may be more appealing to emergency physicians. Physicians are joining Twitter and following organizations relevant to them, or other physicians to share information and communicate. This is the easiest way to begin experimenting with Twitter. “If you look at Twitter your whole experience is designed by who you follow,” said Bryan Vartabedian, MD, an attending physician at Texas Children’s Hospital and an Assistant Professor of Pediatrics at Baylor College of Medicine. “You’re only as good as the people you follow, or the friends you hang out with.” Within the continuum of social media, from blogs to wikis to YouTube, Twitter is classified as micro-blogging, because unlike longer blog entries, Twitter requires brevity. Just as physicians lagged behind some other professions in embracing the Internet – as recently as 2003 just one-quarter of physicians felt the Web was “essential” to their practice according to Manhattan Research3 – so, too, have they taken a slow-to-warm attitude toward social media, said Jason Bhan, MD, a family practice physician who launched Ozmosis, a physician-only social networking site, in 2008. However, that’s now changing for a variety of reasons, Dr. Bhan said. One survey earlier this year found that 60 percent of physicians were interested in or already participating in online physician communities.4 Ozmosis and other physician-only social networking sites such as Sermo were created as online communities where doctors can access the collective wisdom of their peers through private and professional discussions, Dr. Bhan said. On Ozmosis each participating doctor is clearly identified, and because everyone knows everyone’s name, this engenders trust, he said. Patients are not allowed in. Dr. Bhan created the Web site after he left medical school. During residency and medical school, he recalled, there was a considerable focus on group learning, sharing information with colleagues, best practices and so forth with group meetings and grand rounds. “We marched through residency with this wonderful focus on person-to-person learning,” Dr. Bhan said. “Then you graduate. You get a kick in the rear, get
told you did great, and then you’re on your own. The concept of Ozmosis came out of several years in private practice, where I felt isolated, and I missed the interaction. I found a core group of physicians who felt the same way, that it would be kind of cool to have a place where we can share information. I feel like it’s a virtual version of the experiences we had of collaborating in medical school.” Initially physicians may feel more comfortable with such sites because they’re not open to the general public. But Dr. Bhan and other physicians who have dipped their toes into broader social media sites such as Twitter and Facebook contend that there’s considerable value in going public, too. Physicians’ lives already are an open book, he said. Type any physician’s name into Google and the first site likely to come up probably will be something akin to www.healthgrades.com, where patients can anonymously grade and comment on a doctor. Such sites will be closely followed by negative press. Physicians need to realize that a significant percentage of patients have become accustomed to turning to the Internet for information about their physicians before they make their first phone call or send an e-mail, Dr. Bhan said. Doctors need to become comfortable interacting in these public, online areas as well, he said. “This is just how today’s patients are interacting with one another, and it’s how many of them are coming to expect to interact with their doctor,” Dr. Vartabedian said. “If you have a practice, or are a physician-executive, it’s almost to the point where you can’t afford to not be involved in some way.”
WHAT’S UP, DOC?
S
o how are physicians using Twitter? Dr. Saldana said he uses it primarily to share information about emergency medicine and health information technology. He says in his medical group it’s a useful way to share information in bite-size packets. For example, he said, if a trusted colleague passed along a link to a new medical study, Dr. Saldana said he would be much more inclined to review the article than he otherwise would have. Volume , . : August
“It’s almost like we act as a group filter to find the most relevant stuff,” he said. Other emergency physicians use Twitter because they are early adopters and like to tinker with new technologies. An emergency physician from Northern California, Tim Sturgill, MD, has blogged for more than 5 years and says he uses Twitter to communicate not only with other doctors but to have conversations with those who, like him, are exploring the potential of social media. Dr. Sturgill conversed with the author on Twitter (see a snippet below) while he was having 4 other conversations on Twitter.
A REAL TWEET @chronsciguy: Does Twitter help or impact your practice of medicine in any way? @symtym: it does ”impact” in terms of med literature injected into the twittersphere for discussion @symtym: probably more ”weighty” discussions on LinkedIn, Ning, FB, Friendfeed, etc. b/c of the 140 character limitation @chronsciguy: What’s the primary benefit of such communications for EPs? Aid in diagnoses? Identifying disease outbreaks or trends? @symtym: ”primary benefit” I don’t think its there yet, albeit the H1N1 tracking was impressive; the potential is great -- but diffuse @symtym: by diffuse, I mean you have to work it to get a good picture, so many users, so much dialog, you have 2b actively filtering @chronsciguy: Do you feel this is something useful for a lot of docs, or just those who like to tinker with new technologies?
Volume , . : August
@symtym The value of Twitter is not actuality, but potentiality, where universal messaging and social applications/ awareness is going @symtym: it is a technology that is not ripe for usage yet, but may in retrospect 5-10 years from now be indispensable Other physicians have gotten into Twitter and other social media simply because they believe it will play a big role in the future delivery of medicine, and want to understand the digital landscape. Dr. Vartabedian says he first got into blogging as a means to promote his popular books, such as Colic Solved, and has stuck with it because he sees the potential for communication with patients. At some point doctors will regularly converse with their patients over the Internet using new media tools. The major unsolved question at this time, he said, is reimbursement for physicians when a patient doesn’t visit the doctor’s office. Already some doctors such as Natalie Hodge, MD, are experimenting with the practice of iPhone medicine. For doctors reticent to take the plunge, physicians who use Twitter say it’s easy to join. After joining, they say, a new user need not write anything, but rather search out a few relevant users to follow. From there the growth happens naturally. “Soon you may need to watch how much time you’re spending on Twitter,” Dr. Vartabedian said. “It can be habitforming.”
APPENDIX Most people named in this story have active Twitter accounts. Here are their user names along with the number of followers they have accrued.
Bryan Vartabedian, MD, @Doctor_V, 1,393 followers Luis Saldana, MD, @lsaldanamd, 1,353 followers Tim Sturgill, MD, @symtym, 1,053 followers Jason Bhan, MD, @jmbhan, 492 followers Julie Lloyd, @EmergencyDocs, 175 followers Angela Gardner, MD, @ACEPheadliner, 51 followers Gordon Wheeler, @ACEPheadlines, 43 followers Twitter statistics as of June 1, 2009. Section editor Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. doi:10.1016/j.annemergmed.2009.06.002
REFERENCES 1. Lenhart A. Adults and Social Network Websites, Pew Internet & American Life Project, Available at: http://www.pewinternet. org/Reports/2009/Adults-and-Social-NetworkWebsites.aspx. Accessed June 13, 2009. 2. Quantcast survey. Available at: http:// www.quantcast.com/twitter.com, Accessed April 30, 2009. 3. Manhattan Research. Taking the Pulse v6.0. New York: Manhattan Research; 2006. 4. Manhattan Research. Taking the Pulse v8.0. New York: Manhattan Research; 2008.
Annals of Emergency Medicine 25A