My Tweet went viral, now for the Mea culpa

On the afternoon of Tuesday, 11 November 2014, a small part of the twitterverse exploded.  Dr. Oz of America's Doctor fame asked for questions via Twitter using the hashtag #OzsInBox.  The adage of be careful what you wish for came true, and numerous physicians whom I follow tore into him, quickly making it a trending topic.  Mixed in with 95% tweets meant to tweak his nose and make fun of him where about 5% serious questions.  The majority of tweets were quite hilarious.

Seeing all the fun they were having, I decided to give it a try, and asked a semi serious question after midnight:

I have always wondered why Dr. Oz has not been censured or disciplined for his lack of scientific and medical morality on his TV show by his colleagues at the medical school where he holds the position of Vice Chair of Surgery.  I would like to think that if my institution had a MD that was spouting nonsense about miracle cures and melting fat away, they would be soundly denounced by their colleagues, privately and publicly.  Even if his speech is protected by the Columbia University Faculty Free Speech policy, he has an obligation, as a physician, not to mislead his viewers.

I forgot about it on Wednesday morning and went about my normal duties, occasionally checking twitter to see if someone had posted something funny.

On Thursday morning, my twitter inbox was getting busy.  Several people questioned my professionalism.  They stated that Twitter was not the appropriate platform for calling for a a fellow physician's firing;  especially since I had linked to the Columbia Department of Surgery's twitter account.  Being a relative twitter neophyte, I started answering some of the questions and tweets personally, not realizing that I was being baited by twitter trolls and others. 

Later that morning, my twitter inbox exploded.  The apparent cause was a USA Today article that featured my tweet.  My tweet was later picked up by Salon.com also

My tweet has become the subject of several mini debates about professionalism, and I have decided not to take any further part in them, and hoping it will die a natural death. As of this writing, I am the 4th top ranked mention in regards to this topic.

My Mea Culpa...

 

In hindsight, my tweet probably should have never went out.  In the twitterverse, I have been accused of being mean, unprofessional, greedy, and not being a gentleman etc...

Gentleman

Gentleman is defined by Merriam Webster as: c (1) :  a man who combines gentle birth or rank with chivalrous qualities (2) :  a man whose conduct conforms to a high standard of propriety or correct behavior. 

While I have never met the man personally, I cannot make a judgement of his personal conduct.  A such, I should not have accused him of conduct unbecoming a gentleman.  I was trying to make a humorous play on the phrase "conduct unbecoming of an officer and gentleman."  I certainly think his public conduct leaves much to be desired, but in a polite and civil society, it was low blow, and for that I am sorry.   Like others, I should have mocked the behavior, not the man.

@ColumbiaSurgery

Tagging the Columbia Med Department Surgery's twitter account also was a mistake. I should have used the hashtag #ColumbiaMed or #ColumbiaSurgery or something similar, not their actual twitter handle.  With all the retweets and mentions, I probably inundated their twitter feed and made their social media team have a heart attack.  The @ColumbiaSurgery twitter tag is designed to present the best of what they have to offer, not a platform for ridicule.  In an attempt to make things right, I did post the following apologies earlier on Thursday AM:

For the record, I do apologize to the professionals at Columbia Department of Surgery for involving them.

Unprofessional

This accusation actually bothers me the most. I have always tried to be a professional and collegial with my colleagues.  I am still struggling with the issues raised about physicians criticizing other physicians, privately and publicly.  Many medical blogs refer to not publicly criticizing another physician because it undermines the confidence of our patients.  I certainly don't do that in person, so why would I do it on twitter? My approach in person is to talk to them one on one, and it is usually about a mistake, or something missed that caused an error.  Universally, all physicians take that kind of critique at heart, and vow to do better next time. I certainly do.  One of my favorite phrases is that when it comes to patient safety, I have no ego.  I have called out MDs who I think are gaming the system, but do so in a much more professional way.

Twitter has opened up a new paradigm in terms of professional interaction on all sorts of levels.  It's great during medical conferences to discuss breaking news and controversial studies.  But again, this is using twitter to critique the topic, not the person.  Instead of using my "professional and official" twitter account which is @drsunilksahai, perhaps I should have used my personal private citizen account @sunilkumarsahai to post the tweet.  That way, it would have been me, as a private citizen commenting.  I know I am the same guy, but one account is meant for more medical news and professional interactions, than the other.  That way I can use my personal account to tweet about my cable company, airline snafus, and humorous memes that don't have a natural fit on the professional side.  I'm pretty sure my medical followers don't want to hear about my latest interaction with @att.

However, I am not sure the same can be applied in Dr. Oz's case.  He is not making medical mistakes on patients he treats and has a physician-patient relationship with.  He is promoting pseudoscience to his viewers who have put their trust into him.  I think the two are very different matters.  As of this writing, I don't have a good answer to that.  Other physicians and bloggers do a much better job at criticizing Dr. Oz than I did, so I will leave it to them from now on.

The Tweet I Should Have Tweeted: (updated 11/14 AM)

 

Medical Literature Critique:

My letter to the editor was rejected by JAMA, so I am posting it here.  It apparently did not get enough points to qualify.  With the word restrictions they have in place, it's hard to write a cogent critique in the first place.

The Article in Question:

Article at: Effect of a Postdischarge Virtual Ward on Readmission or Death for High-Risk Patients A Randomized Clinical Trial

Conclusion:  In a diverse group of high-risk patients being discharged from the hospital, we found no statistically significant effect of a virtual ward model of care on readmissions or death at either 30 days or 90 days, 6 months, or 1 year after hospital discharge.

My letter to the Editor that was rejected by JAMA editors:

Dear Editor,

I read with interest the research article by Dr. Dhalla and his colleagues (1), including the accompanying editorial by Dr. Boling (2).  The authors noted no reduction in readmissions and death between the two groups.  Dr. Boling contrasts this finding with other studies that cite a reduction in readmissions (3-5).

Several important aspects that might prove insightful were not thoroughly discussed by either author.  First and foremost, the patients were Canadian, the studies cited by Dr. Boling involved patients in the United States.  While there are issues with access to primary physicians in Canada, they are nowhere nearly as bad as the United States, where a virtual ward model may be helpful. Secondly, patients who did not have health insurance and who were discharged outside the local catchment area were excluded.  The patients that were left in the study spoke English, had health insurance, and lived locally.

For this study, the virtual ward model is analogous to having the option of purchasing a platinum service contract when buying a new car. You may either opt for the standard manufacturer’s warranty, or for the fancier service contract with free oil changes, tire rotations, etc... In both groups of warranties (standard discharge verses virtual ward) the same model of cars (patients) will break down at a similar rate, requiring a trip to the mechanic (readmission).

The patient who is discharged from a hospital in Ontario under the standard care model and not feeling well will pick up the phone and call his or her provider. The provider will then act on the patient complaint, virtual ward or not.  In the United States, our patients without insurance or providers have no one to call in the first place.  In this case, the post discharge care (roadside assistance, to continue the analogy) is provided by an intact universal health insurance system; whereas the patients discharged from the hospital in the United Sates are at the mercy of whichever tow truck driver happens to drive by.  The Canadian primary providers may not know what happened in the hospital secondary to issues with communication and electronic health records, but they will act if called by a patient.  In summary, the key difference for the differing outcomes lies in the make and model of the vehicle, not the warranty provided.

Sunil K Sahai, MD, FAAP, FACP

Associate Professor of Medicine

The University of Texas MD Anderson Cancer Center

1.         Dhalla IA, O’Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high-risk patients: A randomized clinical trial. JAMA. 2014;312(13):1305-12.

2.         Boling PA. Managing posthospital care transitions for older adults: Challenges and opportunities. JAMA. 2014;312(13):1303-4.

3.         Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine. 2006;166(17):1822-8.

4.         Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA. 1999;281(7):613-20.

5.         Shaughnessy PW, Hittle DF, Crisler KS, Powell MC, Richard AA, Kramer AM, et al. Improving Patient Outcomes of Home Health Care: Findings from Two Demonstration Trials of Outcome-Based Quality Improvement. Journal of the American Geriatrics Society. 2002;50(8):1354-64.