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.”

Saving Urological Face – this has nothing to do with Zachary’s Disease

Urology is a great specialty that provides many opportunities to make a contribution to our field. At times we encounter moments for which we are never prepared; these are not always strictly of a surgical nature but do call upon our skills as surgical leaders.    A recent blog that I read about live surgery, sparked my memory about a personal experience I had with a live surgery demonstration, which in turn reminded me of issues associated with potential loss of face.

A number of years ago I was invited by a national urology association to participate in a live case workshop and to both lecture on and perform photo-selective vaporization of the prostate.  The usual regulatory requirements were appropriated sorted out to enable me to perform surgery in their country.  I first delivered a presentation to an audience of almost two hundred urologists and was then efficiently escorted up to the operating theatres where the readiness of the first case had been timed to perfection.  The urologist at the host hospital had made a late decision regarding who would perform the surgery and he had decided that he would perform the live case while I would provide him guidance as well as commentary to the eagerly attentive audience in the auditorium below.  He commenced with a cystoscopy which was uneventful but once he started the PVP surgery, it was immediately clear to me that his experience was very much in the learning curve and he was clearly not up for performing live surgery.  Soon endoscopic visibility was lost and with irregular vaporization, the anatomy also became difficult to appreciate.  The calls then began to come from the audience for me to take over and fortunately the urologist had good sense to do so in spite of great loss of face amongst his colleagues.  Taking over was certainly challenging but with laser control of the bleeding, visibility suddenly returned and I was then able to create a nice cavity.  I developed a couple of mounds of tissue on the floor of the prostate and then announced that I was handing the surgery back over to the host surgeon.  These mounds of tissue as you could imagine, were in such a configuration where any surgeon with basic PVP skills would have no trouble dealing with.  He did indeed do an excellent job of flattening down these mounds and was done with my verbal encouragement and compliments.  The patient did very well clinically and irrespective of what his colleagues or you as readers might think, the issue second to the welfare of the patient was the fact that he felt a resurrection/preservation of face.  This story might be used as an example as to why live surgery should be banned but I plan to cover my view on ‘not throwing the baby out with the bathwater’ in later blog piece.

In another time and another place, I was invited to operate where very little English was spoken and where we really had to scratch around to find an interpreter. It was however, wonderful how our operative actions enable a transfer of knowledge in spite of the language barriers.  There were no issues with the surgery that was performed but the problems were at the dinner held that evening.  I was taken to a wonderful restaurant where local delicacies were served and as is often the case, substantially more food than any of us could reasonably consume.  Also on the menu was an unlimited supply of spirits.  For my travelling colleague and myself, we were fully cognizant that we were in a very foreign and developing land where little English was spoken, that this was not a place to lose your sensibilities.  We had one interpreter who was actually a medical physician who worked at the hospital that they managed to rustle up at relatively late notice (a useful role for physicians/internists?).  Towards the end of the evening, one of our hosts, who had clearly consumed more than his fill, rose and made an announcement that he would personally drive us to the airport the next morning (our flight was departing early).  It was clear that his blood alcohol levels in 7 hours were still going to be sky high and we politely indicated to him that it would be no trouble for us to proceed with the hotel car booking that had already been made.  He was most insistent and even the interpreter was encouraging us to accept his offer as it was stated to be customary for us as visitors to accept this offer.  Knowing the track record of road deaths in this country, there was no way that I was going to get into a car with him (incidentally he had driven me from the airport to the hotel when I arrived and remembered thinking that he was having trouble seeing the lane markings on the road).  After most of the dinner party had left, he again reiterated his intention to take us to the airport and I am sure that all who were there at the dinner had thought that the matter was all resolved and that this was what was going to be happening. We didn’t push the issue of “no bloody way” as we had not yet come to a stage of “push coming to shove” on the matter.  I had already determined that I was going save making an absolute stand on the matter until when we actually had to leave the hotel for the airport -  essentially, we still had time to resolve the matter.  We were dropped off at the hotel using a sober driver and in the lobby of the hotel, it was now just our host, my travelling companion, myself and a hotel employee as an interpreter.  With him being removed from his colleagues and the dinner party, we gently reinforced our preference to not inconvenience him and to allow us to take the hotel car to the airport.  With this discussion removed from others who were at dinner, he was able to withdraw and say our goodbyes as the best of friends.  As far as the others who were present at dinner were concerned, he was taking us to the airport and that was the end of the matter.  The fact that this did not occur is something only the three of us know.  With this out of the way, I was able to collapse into a great sleep before the journey the following morning.

I have learned from these episodes that saving face can mean a great deal to some people, and especially in some cultures.  Never assume that issues that you might take in your stride are not those that cause enormous angst for those in other cultures. 

(Definition of Zachary's Disease)

Response From 2GB Advertiser

I have received one response from Harris Partners who were on the list of advertisers with 2GB.  It is pasted here immediately below.

On 30/09/2012, at 17:40, Harris Partners Info <info@harrispartners.com.au> wrote:

Thanks for your email. 

In order to set the record straight, we do not advertise with Alan Jones. I am perplexed as to how or why Harris Partners Real Estate were added to the petition that is now doing the rounds.

Both my wife and I felt Alan Jones' "shame" comments in relation to Prime Minister Julia Gilliard's father John Gilliard passing away, were disgraceful and offensive.

Harris Partners does pay to advertise on Ross Greenwood's 2GB Money News programme from time to time. It is non-political and in line with our target audience.

Any Harris Partners ads that may have run during Alan Jones' programme were unpaid advertisements. Other than the complaint emails I received from telling me that we advertise on Alan Jones' programme, I was totally unaware that we were ever featured on Jones' show.

If you get the chance to forward this email to the person that associated us with Alan Jones and added us to the petition mail-out, I would be grateful.

Best wishes

Peter O'Malley

Principal

Harris Partners Real Estate

404 Darling Street

Balmain NSW 2041

Ph:  (02) 9818 2133

Fax: (02) 9810 6432

Here is my response back to that email:-

On 30/09/2012, at 9:30 PM, "Henry Woo"  wrote:

Thanks for your reply Peter. I am sorry to hear that you are having to respond to so many emails - nevertheless, it is decent and honorable that you do so. I have no idea who complied the list but I imagine that you are on there because of your current association with the 2GB station. Unfortunately, people see 2GB as being complicit to Alan Jones behavior and everybody associated with the station gets caught up in the mess. Your withdrawal of advertising from 2GB would send a strong message of where you stand on the matter and that as an advertiser you are sensitive to public opinion which affect your business. I will however do my bit to propagate your repulsion of his behavior by putting your response below on my blog although actions speak louder than words by your company reconsidering doing any business with 2GB until appropriate action is taken to rein the shock jock in. 

Best regards

Henry

Sent from my iPhone. Apologies for typos and autocorrect functions choosing wrong words. 


Here is the response back from my 2nd email:

From: Harris Partners Info <info@harrispartners.com.au>
Date: Sunday, 30 September 2012 9:35 PM
To: Henry Woo
Subject: Re: Alan Jones 2GB

Thanks Henry.

We have had thousands of emails today.

Unbelievable day, the end is in sight :)

Cheers

Peter

Sometimes It is Okay to Not to be Tolerant

Below is the email sent to the following email addresses. If you wish, you may cut and paste these addresses into your email programme. We cannot touch Alan Jones through the broadcasting regulator (his comments were off air) and his association with 2GB (financially and personally) make it unlikely he will be dismissed or reprimanded for damaging the 2GB brand.

sales@icoolm.com.au; admin@jjmetrowest.com.au; andre@hollywoodbathrooms.com.au; info@harrispartners.com.au; info@grace.com.au; enquiries@harringtonkitchens.com.au; sales@fixatap.com.au; info@waterfordretirementvillage.com.au; info@statecustodians.com.au; sales@renovationboys.com.au; info@parknfly.com.au; info@livenation.com.au; sales@lexusofparramatta.com.au; info@kennedyhealthcare.com.au

Dear Sir/Madam

I am writing to you as a sponsor and supporter of Alan Jones and 2GB. I am hoping that your company is sensitive to the opinion of the wider community beyond 2GB listeners. Over many years, the shock jock comments of Alan Jones have largely been tolerated. I personally have tried to see his positive aspects, particularly in his support of rural and remote communities and non-profit organisations. We have even allowed the issues with the alleged 'cash for comments' affair and his alleged dealings with London police to go to the keeper.

He sailed too close to the wind with his comments about women "destroying the joint" for which any reasonable person would regard as a misogynist comment. If women in leadership roles have been incompetent, it has nothing to do with gender but incompetence in that persons performance. Nothing more and nothing less and to suggest incompetence is gender related is out of step with modern community values. It was not surprising that this became a national trending discussion point on social media.

This latest outburst has taken things too far and confirms that he is out of step with community values. I consider it to have been totally un-Australian. I will not repeat the story behind this matter as you will already be well versed in the course of events as well as the dishonourable attempts to either cover up or massage the truth from what has already been reported in the media. The matter has absolutely nothing to with one's political persuasion and this occasion, the community has had enough and is clearly voicing its displeasure through social media and conventional channels. I believe that your continues support of 2GB implies your continued support of what he stands for. Calls for him to step down or to be censured by 2GB are futile as he is understood to have shareholder of 2GB and enjoys a long close friendship with those who control the station.

I feel sufficiently strongly about this matter that I write to you to appeal to you distance your company from Alan Jones and 2GB. Your failure to do so makes you complicit to his increasingly unacceptable behaviour. With your continued association with Alan Jones and 2GB, I intend to personally make every effort to use products and services of your competitors and would encourage others to do the same. To under-estimate the opinion and power of social media is at the peril of your organisation's community standing.

I sincerely hope that you will do the right thing.

Henry Woo

Doctors Tweeting for Entertainment at the Expense of Public Confidence?

As health professionals participating in social media, we do come across things that we see as inappropriate for a member of our profession in terms of behaviour or content. The temptation is to leave all alone (and unwittingly be complicit to the bad behaviour) or to participate in the self regulation of the medium. SoMe has got a lot of bad press recently and as usual, it is always the tiny percentage of users who create the problems. Recently, Australian users have been concerned about the draft document of proposed regulation of SoMe amongst health professionals by our regulating body, APHRA. As it is, it is heavy handed and unchallenged into its final version would see a significant number of Australian healthcare professionals in breach of its conditions. This got me thinking about a recent interaction that I had virtually forgotten about. I saw a tweet from a young doctor who has chosen to be anonymous when tweeting to his large audience of followers. The tweet was as follows:-

I personally did not think much of it at first but then I thought that as a public message, it was sending out a very wrong message as to what really goes on in multi disciplinary team (MDT) meetings. The reasons clinicians bring cases for discussion at these meetings is to get the best advice from a wide range of opinions from within their own field and outside the field. Too often at these meetings, I find as a surgeon, that I have not always fully considered some of the surrounding non-surgical issues with the care of my patient and I can leave the meeting with a clearer holistic approach to the care of my patient. Patients are delighted to know that we can take their case for multiple opinions rather than themselves having to cart themselves around to see different doctors to obtain additional opinions. The MDTs also helps streamline the multidisciplinary care with colleagues will look out for special cases that cannot afford to be held up by the system. But MDTs do not always function well. The worst type is when there is the dominant clinician who loves discussion on a case as long as it is his or hers and if the final outcome is according to his or her recommendation. Less dominant or junior participants feel essentially gagged from making a contributing comment. The ideal MDT should run like a real-life in person crowdsourcing exercises. I responded to the MDT comment with

In hindsight, perhaps I was a little too harsh in suggesting that he might be ignorant about the value of MDT meetings but it is people's live that we deal with at these meetings and not something that I thought to be for entertainment purposes amongst his following. (If you follow this user, he does provide a predominantly entertainment series of tweets and thrives on the adulation of his audience). I was also concerned that he may have developed this attitude because his own MDT experience was not associated with appropriate leadership and mentoring in cancer care. I cannot see any reason why he would come up with this thought if there had been anything but a positive experience with MDTs. This tweet did upset him as seen by the next tweet:-

This lead to a series of tweets which are fairly self explanatory

My tweet response below is to a tweet that was subsequently deleted but since I did a quoted retweet to give context to my next statement, you are able to see what was deleted.

I think that his comment about being exposed to bad MDTs (that's the tweet that got deleted) demonstrates a problem of where he has been exposed to poor leadership and mentorship in cancer care. This is sad and senior cancer clinicians should take note.

I thought that things might get a bit heated so I tried to back off and give him an honourable exit by agreeing with him on a point and stating that I did not think that he meant to be flippant. When I thought about it later, I did change my mind and think that to hell yes he was being flippant.

I did not feel like challenging him on the fact that surgery is not the only form of treatment for cancer and opinions of other non-surgeon clinicians can make a difference. MDTs are not about 'personal', they are about the patient whose care we are trying to optimise. I was about to let it go and let him continue his indignation that he had been challenged but this fortunately put out the flames.

I promptly un-followed him. I think it is always a lot easier to say things anonymously but even under such cover, if you declare yourself as being a health professional, the public and your colleagues still have an expectation for a level of professionalism for what you represent. This is of course my humble opinion on the matter.

Addendum 31 March 2013

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 does concern me of possible attitudinal issues about morbidity and mortality meetings.  M & M is an essential form of quality control and good clinical unit governance and must be taken seriously.  Sadly it seems to be consistent with earlier comments about MDT meetings.  Whilst we could be quick to chastise this doctor who tweets anonymously, I would raise concerns about potential mentorship issues - 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.