Maintaining Composure During A Consultation

Doctors are human.  Some things we see will make us laugh when for the circumstances it is totally inappropriate.  I was recently reminded of an episode when I came close to losing all sense of professionalism during a patient consultation but survived.

A number of years ago, I saw a young man aged in his late twenties with lower urinary tract symptoms.  Although he was young, he looked much older and could easily have passed as a man aged in his mid-40s.  He had immigrated to Australia from a dispute ravaged country and probably had good reason for looking hostile and as if carrying concrete blocks of anger and despair on his shoulders.  He spoke no English and interpreter was at hand.  I think you get the scene – it was serious and we had better get on with the job of sorting him out.  Having asked a number of questions, I then asked as to whether he had any stage seen blood in his urine.  The interpreter then turned to him and spoke in his native language a question to which he gave a moderately long reply and to which followed alternating dialogue that went on for approximately five to ten minutes.  I was sat patiently expecting to hear a complex history of how he had indeed seen blood and the circumstances in which it had been observed and so forth.  The interpreter then turned to me and said “No”.  I dug the heel of my boot onto the top of toes of my other foot as hard as I could as I politely excused myself to go into the next office.  I think it took about 10 minutes to regain my composure before going back into my consulting room to complete the interview.  I think my eye contact with the young man was subsequently kept to an absolutely as needed basis.

At the end of the consultation, I did ask the interpreter about the nature of the discussion following my question about blood in the urine.  He told me that he had essentially given him an earful for not looking after himself since being in the country.  Okay.  Next patient. 

Creating One's Own Luck

I’ve been inspired to write this blog piece after seeing the wonderful Prezi presentation constructed by Dr Marni Basto on Urology Social Media 101.  It really is a fantastic presentation that has gone viral throughout the international urological community.  Although she is yet to commence formal urological training (she deferred commencement by a year to work on her Masters of Surgery), she now has an international reputation for her skill and understanding in the area of social media and associated technology.  When you look at her presentation, it is obvious that she is an individual who has great clarity of thought and able to develop depth of understanding of a given topic – these types of skills are easily translated to any area of medicine.  One can only sense that she has a bright future ahead of her. 

I’ll now move onto what her Prezi has got me thinking about.  Over the years, I have observed a number of young urologists returning to Australia after completing post FRACS (surgical qualification) training.  I commonly see this expression of despair that they cannot find a coveted public teaching hospital position, which is always the best way to kick-start a new practice in surgery.  Here you have access to multidisciplinary care, senior collegial mentorship, teaching of surgical trainees and medical students as well as research opportunities.  These positions are in limited supply and only come about when they are to replace a surgeon who has either resigned or retired or if the waters have parted to create a new position. 

Some of these young surgeons feel a sense of entitlement that they should be able to just walk into such a position.  I recall one surgeon who complained that he was a subspecialized surgeon who had done his special post fellowship training and could not understand why no teaching hospital was making any particular effort to find space for him within their units.  Another said to me that he was technically a much better surgeon than some others who had received teaching hospital appointments. When I thought about their achievements, they had not made a single presentation at a major urological meeting, had not published a single paper whilst away and since returning home, had contributed little to the profession (eg could do volunteer work or perform committee work with the Royal Australasian College of Surgeons or Urological Society of Australian and New Zealand).   

And here lies the point that people can create their own luck.  I can usually make a prediction before one of our trainees goes overseas or interstate for post FRACS training, as to who will literally walk back into a teaching hospital position. When I look at trainees who have done research with me, the ones who reliably kept to deadlines and completed their assignments were the same who did such when abroad and the same ones who eventually found positions in teaching hospitals.  These were individuals prepared to go the extra mile and create their own luck.  The trainees where I had to repeatedly provide gentle reminders to complete tasks to help their own careers have more often struggled.   The ability to create luck had already been defined early in their careers.

Back to Marni.  She has already passed the hurdles to be selected for urological training and is yet to commence whilst she does her Masters of Surgery.  You know that Marni has already begun to create her own luck and I am excited that we will have a future urologist who will be more than just ordinary.

Twitter Wars on Anonymity of Doctors on Public Social Media Networks

The discussion on the GMC-UK guidelines on doctor behavior on social media has proved to be most controversial and divisive.  I think that the vast majority of doctors really could not care less but most of these are those are probably not participating in social media in any form.

I have watched with great interest, the arguments put forward by those who oppose Point 17 in particular.

It is also interesting to see how the debate has those in opposition discussing the policy as if the word “should” is “must”.  There appears to be some paranoia that the ‘should’ could become a ‘must’ over time but my own thoughts are that the GMC are unlikely to be bothered or would have the resources to police such a rule.  If doctors do behave themselves professionally on social media and provided there are no regular reports of unprofessional behaviour on the front pages of newspapers, it is unlikely that the ‘should’ would ever become a ‘must’. 

The debate has become quite emotive.  It was implied to me that I was being hypocritical in my views and sending mixed messages on the basis that my avatar on twitter has an image of me wearing loupes and a headlight and therefore obscuring my face.  I totally disagreed in that the picture perfectly reflects what I do in my work and that my name and details in my bio are totally unambiguous as to who I am and what I do and where my interests lie.  Additionally, pictures of me without the ‘theatre armour’ are easily found on a simple Google image search. 

Some of the arguments I have seen include:-

Doctors will disappear off Twitter and interaction will be lost

One argument put forward is that without the anonymity option, doctors will disappear off social media and interaction will be lost. I disagree totally.  We only have to look at conference tweeting – at the recent 2013 Social Media and Acute Care Conference (SMACC), over 1200 users contributed to the hashtag for the meeting and the substantial majority were using their real name or at least had a link that would identify who they were.  The interaction was outstanding and the comraderie associated with knowing with whom individuals were interacting and the excitement with tweetups was palpable for anybody following the hashtag.  This data does not suggest that doctors on twitter are going to disappear.

Tweet Metrics from Symplur of the 2013 SMACC Conference

A similar interactivity was seen with the 2013 European Association of Urology Congress – again, almost all users being identifiable.   Additionally, we only have to look at weekly twitter discussions where doctors are significantly involved and again the substantial majority are using real names – good examples are #hcsm, #hcsmanz, #meded. More recently, a highly interactive twitter journal club has been in operation and this has been a perfect example of doctors interacting and again, this is not likely to go away - incidentally, all doctors involved in the #urojc are using real names. What about doctors interacting with patients and other health professionals? this will continue and a great example of this is with #hcsmanz and #healthychat

Can doctors be trusted to exercise professionalism online?

Largely yes.  Sadly, we need regulations to ensure that doctors understand what constitutes unprofessional behavior.  Doctors could easily argue that we do not need to have a regulatory body to tell them not to have a sexual relationship with their patients – whilst having such regulations does not always work, I have little doubt it has made many doctors think twice before embarking upon such a path.  Doctors can be trusted but a guidance on appropriate behavior can make a difference to those wavering on taking a wrong path.  That said, remember that the guidance says ‘should’ and not ‘must’.

That doctor anonymity will help protect identification of patient cases being discussed.

What the ...?  Patient histories should not be discussed in a public forum FULLSTOP.  There are plenty of other avenues (including online) to discuss patient histories amongst colleagues and twitter and facebook are in my opinion inappropriate. 

Suggestions have been made to run two accounts - If one account is anonymous and the other under a real name, then the user is bound to get them mixed up

This is the user's problem.  Many of us have a private and work email.  Many of us have a work and private mobile phone number.  This is an irrelevant argument.

Why, when patient safety is not an issue?

As recently as last week, I have seen anonymous doctors on twitter giving personal medical advice without so much of a less than 140 character history and without even cursory view of imaging.  The lowest common denominator factors into why there is a need for professional guidance documents.

That doctors should have the right to be anonymous in their social media activities just like any other profession.

Doctors are NOT just like any other profession.  There is a level of personal trust and privilege and power imbalance in the relationships that doctors have with their patients that is consistently there like no other profession.  Doctors CAN engage on social media anonymously – this right is NOT being taken away.  It is however, stated that doctors who want to say that they are doctors SHOULD (not MUST) identify themselves.  Doctors can therefore continue to tweet and blog anonymously but should not make representation to themselves being a doctor.   In my earlier blog piece on this matter, there may be exceptions as to why a doctor needs to be anonymous and these could be stated in the bio or a link to explain why a nom de plume is being used - I think that this would be the fair and transparent thing to do.  I think that the public have a right to know why a doctor feels the need to be anonymous given the special status that the profession holds within the community.

Doctors will feel unable to comment on medicine and medical politics

Anybody is free to comment on medicine and medical politics.  If they do not include that they are a doctor in their bio or links on the bio, there is no reason why they cannot continue.  It is not essential to be a doctor to comment on medicine or medical politics. Other professionals such as biochemists, scientists, those in the pharmaceutical or medical device industry often know a great deal about medicine without having to be doctors.  If one feels a need to state that they are doctor because they want the credibility that comes with that, then they 'should' use their real name.

There are valid reasons to be anonymous

This is something I do agree with.  Particularly with whistle blowing and for doctors working in small communities.  Additionally, if you want to actively debate controversial emotive topics that can truly put ones safety in danger such as abortion issues, this is also a valid reason.  These doctors have good reason to not comply with 'should' and could make good argument to the case.  To quote the GMC guidance:-

'You should’ is used when we are providing an explanation of how you will meet the overriding duty. ‘You should’ is also used where the duty or principle will not apply in all situations or circumstances, or where there are factors outside your control that affect whether or how you can follow the guidance.

CONCLUSIONS

In conclusion, I think that for most this will end up being just a storm in a teacup.  Several commentators are propagating the argument that 1+1=3.  The suggestion that doctors who say that they are doctors 'should' (not MUST) use their real name is my opinion perfectly reasonable. As per point 17, "Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonable be taken to represent the views of the profession more widely."


Update
The following piece has been published on Croakey on crikey.com.au - strong recommend that you have a look at this as well
http://blogs.crikey.com.au/croakey/2013/04/05/its-all-just-a-social-media-and-medicine-storm-in-a-teacup-says-one-surgical-tweeter/

Addendum for Blog Post September 2012

Addendum 31 March 2013 to September 2012 Blog Piece


The main reason I have decided to put this up on my blog is that the issue of anonymous tweeting is running riot in doctor circles over recent GMC-UK recommendations. Rather considering this a new piece in isolation, I regard it more as an addendum to my blog post from September 2012.  If you read the earlier blog, this will make a lot more sense.


A doctor on twitter who had read this blog piece recently, sent me the following cropped mobile phone screenshot by email (easy to track down via either one of my publications or through the University of Sydney website - you see, I don't try to hide) that was taken of a tweet made about 10 days ago - comment was made that it was seen from a re-tweet as this person like myself, does not follow @otorhinolarydoc.  It wasn't sent to me anonymously but there is nothing to be gained by mentioning who that person was.  Interestingly, it is noted that he has since changed his user name and from this I gather that he is perhaps no longer a trainee and now a qualified ENT surgeon.  Whilst we can say it is a bit of harmless banter, it is essential that readers understand that M & M are an essential form of quality control and good clinical unit governance that must be taken seriously.  The purpose is not to chastise this tweeter but raise the question as to whether anonymous tweeting for entertainment purposes potentially undermines public confidence in the medical profession.  Whilst it might seem minor, you can give an inch and before you know it, you have a mile.  Once we lose public opinion, it is something unlikely to be regained.  Another issue is that of mentorship - registrars often copy the behaviour of their mentors - perhaps there is some shared responsibility between himself and his former mentors if these are the attitudes with which he has been raised as an ENT surgeon.  Let you be the judge on this.  

Doctors on Twitter

This blog piece is on my thoughts about Australian doctors on Twitter using their real names or pseudonyms. Those of you who follow me on twitter may have observed how I rant and rave on this issue.  I have had this blog piece on the subject sitting incomplete for a number of months, mainly for the reason that I have not had time to finish it.  The impetus to get on and finish this blog piece came about when one of my favourite twitter colleagues, Dr Gerry Considine, tweeted me to inform me that the General Medical Council in the UK has formulated recommendations on this very matter.  He was well aware of my views on the matter and I appreciate being given the heads up. It is always good to hear that a well respected professional body is aligned with your own thoughts on a matter.

What we say on Twitter as doctors, particularly with medically related topics, carries a lot more weight than might always be recognized.  By saying we are doctors gives our tweets a greater level of authenticity that is not commonly afforded to other users. By virtue of what we do and who we are, we enjoy a level of respect, trust and admiration that is not generally held for many of the other professions. 

All of this stems from the fact that medical practitioners have a privileged position in society.  Not only do we hold power with knowledge, we are respected for the judicious use of our knowledge which has been painstakingly acquired over many years and enhanced by a responsibility for life long learning. 

It is incumbent upon us to not abuse this privilege and for this reason, professional organisations such as the Australian Medical Association has a Code of Ethics . Whilst this Code expresses how we should behave in the interests of the public, I see it as a manner by which we as doctors should expect of ourselves.    The Australian Health PractitionersRegulation Agency (APHRA)  also maintains a Code of Conduct for Doctors in Australia

More recently APHRA has moved to develop a policy on Social Media behavior for health professionals. I do not wish to get into a discussion on the deficiencies of the draft documents that have been publically available but it does provide a timely reminder that there is increasing interest on how we as doctors behave on Social Media.

In my personal experience, the vast majority of doctors who declare themselves as such, will either use their real name or have reference to easily attribute their real name to what is written on their tweets.  Personally, I make the choice to use my real name “Henry Woo” as my Twitter Name and for my Twitter User Name, a short form of my name “@DrHWoo”.  My bio indicates that I am a doctor.  My website link would give reference to my real name even if my Twitter Name and Twitter @ User Name did not have such information.  I don’t think it really matters if it is your user name or bio or link that has your real name as a doctor, as long as what you say is easily attributable to you as a real person.

If you are a doctor hiding under a pseudonym, why is it that you need to hide your real identity?   If there is a specific issue that you wish to remain anonymous for, why not create a separate identity and state that this is the case.  If you really wish to remain anonymous on Twitter, then may I suggest that you do not say that you do not mention that you are a doctor in your bio – the only reason we mention that we are a doctor in our bio because we know it adds to the authenticity and respectability of what we tweet on medical matters, so do not abuse this privilege.  I know of a number of doctors who tweet but do not make any mention that they are doctors - I have no concerns about this – in fact I respect these doctors for not abusing the privilege of what the title doctor means. 

What is rather interesting is that the pseudonym doctors tend to gravitate to each other and engage each other moreso than those of us who use our real names – take a closer look at this next time you look at pseudonym doctors.

In a free and open society, there is should only be very exceptional circumstances in which doctors in Australia should feel the need to use a pseudonym – this might include whistleblowing, a commercially sensitive employer, risk of identifying healthcare workers and patients with uncommon diseases/conditions and there may be others.  But to hide because the individual wishes to publish inappropriate or controversial medical tweets indicates a lack of courage or conviction in their thoughts to use their real name.

One example of inappropriate behavior is here where a user made a comment that undermines what we are trying to achieve in improving cancer care and this is not the type of cynicism about medicine that should be promoted -  the vast majority of us take cancer care very seriously since lives are at stake.  Some have an agenda to undermine the profession by pointing out our mistakes with references to already published news articles – as they are not the authors, there should be nothing at stake by using their real names.  Just today, I saw one of our pseudonym doctors giving personal medical advice on an ultrasound result without having taken a full history or even having seen ultrasound images (allowing for the fact that real time ultrasound visualization is the optimal approach).

To conclude, I confirm that I do not have a problem with doctors being on Twitter nor do I have a problem with any individuals using pseudonyms on this public medium.  I do have concerns when a doctor declares themselves as such and then tweets on medical issues or topics and then hides under a pseudonym.  

OMICS Publishing - pseudo-academia? predatory?

Is the Hyderabad based OMICS publishing group a pseudo-academic and predatory organisation?  I have done a little bit of digging around and have made up my own mind. I am interested to know what you think.


The Spam into my inbox from the OMICS publishing group seems to becoming a tidal wave.  So far I have had 5 emails this month about some conference or journal associated with OMICS and we are barely half way through the month - I have heard of some academics who are getting them on a daily basis so I count myself lucky.  I had not placed emails from the automatic send to junk email because they actually did have one, yes just one, journal that might be of interest but now I do not care, it is all going to go the junk folder.  That journal is called Medical and Surgical Urology and having looked at what they have published, I would never have given them a recommendation for publication if I was the manuscript reviewer - if you are a urologist, have a look for yourself and you can see why publication there would not be positive for your cv - well that's my opinion on it!

The company creates a front of respectability and sends you a ‘personalised’ email with your name cut and pasted in the appropriate sections and starts with a sweetener as to how you are an eminent person in your field.  You are then invited to submit a paper to one of their many junk journals or to submit an abstract for consideration at one of their conferences.  Of course you have to pay to have this privilege.  Apart from repeatedly sending you emails, the problem is that almost all of these conferences have absolutely nothing to do with your field of interest.

The only problem is that they are getting smart and now sending many of these requests using gmail accounts to avoid them going straight to spam folders - some of the emails have no reference to OMICS until you check out the links.

Problem is that as a urologist, I have no expertise in immunology as per request above and below, I have nothing to do with analytical pharmacy.  These are a few examples of numerous such requests all received just recently.

The company OMICS is a professionally run predatory publishing company from India.  Often addresses and telephone number contacts are in the USA to hide this fact.  Often, but not always, the names of academics they use to be the face of their conference or journals are those who have little if at all any academic presence in their fields.  The more you dig, the more that you find that you do not like about OMICS. The most comprehensive discussion on OMICS is on Richard Poynder's blog site  – it describes many of the frustrations contributors have had with the company.

Another interesting article on predatory publishing by OMICS is at the following link and is worth a read.

OMICS will continue to 'prosper' because unwitting researchers continue to respond to their email spam and they must be making money.  If you email enough people, somebody is going to contribute to their income stream whether it be by manuscript publication fees or conference attendance (your paper or abstract will be accepted - if anybody has ever had one rejected, now that would be too embarrassing to admit)

My personal thoughts on this company are

1. do not fall for the opening 'pick up lines' of how are eminent you are in your field
2. do not submit a manuscript to any of their journals
3. do not accept an editorial board position - you are giving them credibility and put your reputation on the line
4. do not submit an abstract to attend their conferences
5. do not perform peer review of articles for them
6. direct their emails to your junk folder

I am not against open access publishing and in fact support it.  I have in fact published in two manuscripts in open access pubmed indexed journals by choice.

On a moderated forum specifically discussing OMICS, it is interesting to see that the reputation of this publishing machine is under question with comments such as :-

"I'd trash the cv of anyone who had an OMICS publication”
“The only thing to do with OMICS is avoid, avoid, avoid.”