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mergency Physiciansre Learning to “Tweet”

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his story assesses the various rea-sons why emergency physicians areincreasingly using social media in

eneral, and Twitter in particular.The sentence above measures exactly

40 characters, the maximum length of atweet,” or snippet of communicationent via the rapidly growing social net-orking Web site Twitter.com popular-

zed by the likes of Britney Spears, Ash-on Kutcher, Lance Armstrong and, moreecently, Oprah Winfrey. Anyone who isnyone, it seems, is Twittering. To theninitiated it seems silly. The perceptionf Twitter is that it’s a place for teens toalk about what they had for dinner, orow awesome last night’s All-Americanejects concert was. What possible place

ould there be for serious-minded, hyper-usy emergency physicians to engage inuch folderol? How could Twitter, withts 140-character limit, allow for mean-ngful communication among physi-ians?

Yet despite these perceived limita-ions Twitter seems to be evolving into

social network of choice for oldermericans. According to a January009 survey by The Pew Research Cen-er’s Internet & American Life Project,1

he average age of a Twitter user was 31 l

olume , . : August

ears old, compared to 26 years foracebook, and 27 years for MySpace.n April 2009 survey by Quantcast

ound that 54% of all Twitter usersere 35 or older.2 More than one-fifthf users were over 50.

“Initially I thought it was a timeaster, an attention sink and that itould simply distract me,” said Luis Sal-ana, MD, a practicing emergency phy-ician at Presbyterian Hospital Dallas,nd Medical Director of Clinical Decisionupport at Texas Health Resources. “Af-er trying it, I saw the potential for massollaboration, for rapid diffusion of infor-ation, and I saw it as a connection ofhat I do. This helps me with my job.”

OLLEGIAL TWITTERn addition to individual doctors, dur-ing the first half of 2009, companiesand organizations such as the Ameri-

an College of Emergency PhysiciansACEP) have begun taking a keen inter-st in Twitter. ACEP has a semi-officialresence with its @EmergencyDocs feed,hich is authored by public relationsanager Julie Lloyd. She says she began

sing Twitter in late January out of aecognition that many of ACEP’s newernd younger members were comfortableith social media.

Lloyd uses @EmergencyDocs to callttention to the organization’s news re-

eases, promote new videos and advocate M

ositions in the turbulent realm of healthare reform. A recent tweet from May8, regarding a cut in emergency pre-aredness funding by the US Depart-ent of Health and Human Services,

ighlights the viral nature of Twitternd how organizations can spread theiressage with very little effort. Lloydrote: “In the year of swine flu, HHSecreases hospital emergency prepared-ess funding. Way to go.”

A minute later Saldana “retweeted”he message, meaning he copied it, at-ributing it to @EmergencyDocs, andhen published it to all of 1,294 of hisollowers. A few minutes later one of hisollowers, @StandingFirmCM, a Massa-hussetts-based citizen blogger namedatherine Mitchell who is interested inandemic preparedness, retweeted theame message to her 4,221 followers.

ithin 5 minutes, then, Lloyd’s messagead been spread to more than 6,500 peo-le. It required no phone calls or newseleases.

From this example it’s easy to see hownformation can spread through Twitterike wildfire, especially when it is newsyr gossipy. User-dominated dissemina-ion of information through social mediaas the potential to revolutionize tradi-ional, top-down forms of media.

However, services such as Twitter alsoose challenges because of their immedi-cy. Messages cannot be recalled. Andloyd said she is cognizant that she mustxercise caution as @EmergencyDocs iseen representing a professional organiza-ion in the Wild West of social media.

“Even though it’s an entirely new me-ium I think some of the old rules stillpply,” she said. “If you wouldn’t wantour grandmother to read it, don’t writet. So while we may be tempted, we areot going to make any attacks againstny organization that might cross ourath.”

Lloyd’s boss, Gordon Wheeler, Asso-iate Executive Director of Public Affairsor ACEP, also joined Twitter in late

arch as @ACEPheadlines. Angela

Annals of Emergency Medicine 23A

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ardner, MD, the president-elect ofCEP, joined in April as @ACEPhead-

iner. Other board members have alsooined.

“We recognize that in addition to aurely social aspect, Twitter has the abil-ty to send out relevant and timely infor-ation to physicians,” Wheeler said.

We know from the Obama campaignhat it is a very powerful way to reachell beyond the traditional media to getur message out. We’re still learning ouray as we go, this is still a nascent thing.ut there’s value here. If I go to a meet-

ng on Capitol Hill, for those membersho are interested, I can provide some

mmediate information.”

HAT HATH JACKROUGHT?

reated in 2006 by Jack Dorsey, 32,Twitter has seen phenomenalgrowth during the last year as other

ocial networking sites such as MySpaceave seen their growth ebb. Twitter’sonth-to-month growth has been 50 to

00%, and by late May the service hadore than 30 million users.When a user creates a new account he

r she can immediately post new tweets,uch as, “I’m on Twitter. Now what?”he answer, invariably, is to figure outow to use the service. For some peoplet’s simply a means to keep up withriends and family, so they “follow” theseeople by subscribing to their updates.or other people it’s a way to access ce-ebrities who would otherwise be unap-roachable. Basketball player Shaquille’Neal (@THE_REAL_SHAQ, 1.1 mil-

ion followers) is among the favorites,ith such tweets as, “Should I challenge

iger woods to a homeboy style puttingontest? I kno what you are thinking, Int putt like I shoot free throws, lol”

But during recent months there’s alsoeen a marked change in the use of theervice, especially as companies and orga-izations such as ACEP have joined theray. These organizations are using Twit-er in a variety of ways to build theirrands: reach out to customers, do con-umer research, conduct e-commerce andreate communities for users.

It is this more professional side ofwitter – the users who do not post the

etails of their breakfast but rather dis- g

4A Annals of Emergency Medicine

uss issues and disseminate news -- thatay be more appealing to emergency

hysicians. Physicians are joining Twit-er and following organizations relevanto them, or other physicians to share in-ormation and communicate. This is theasiest way to begin experimenting withwitter.

“If you look at Twitter your wholexperience is designed by who you fol-ow,” said Bryan Vartabedian, MD, anttending physician at Texas Children’sospital and an Assistant Professor ofediatrics at Baylor College of Medicine.You’re only as good as the people youollow, or the friends you hang out with.”

Within the continuum of social me-ia, from blogs to wikis to YouTube,witter is classified as micro-blogging,ecause unlike longer blog entries, Twit-er requires brevity. Just as physiciansagged behind some other professions inmbracing the Internet – as recently as003 just one-quarter of physicians felthe Web was “essential” to their practiceccording to Manhattan Research3 – so,oo, have they taken a slow-to-warm at-itude toward social media, said Jasonhan, MD, a family practice physicianho launched Ozmosis, a physician-only

ocial networking site, in 2008.However, that’s now changing for a

ariety of reasons, Dr. Bhan said. Oneurvey earlier this year found that 60ercent of physicians were interested inr already participating in online physi-ian communities.4

Ozmosis and other physician-only so-ial networking sites such as Sermo werereated as online communities where doc-ors can access the collective wisdom ofheir peers through private and profes-ional discussions, Dr. Bhan said. Onzmosis each participating doctor is

learly identified, and because everyonenows everyone’s name, this engendersrust, he said. Patients are not allowed in.

Dr. Bhan created the Web site after heeft medical school. During residency andedical school, he recalled, there was a

onsiderable focus on group learning,haring information with colleagues, bestractices and so forth with group meet-ngs and grand rounds.

“We marched through residency withhis wonderful focus on person-to-personearning,” Dr. Bhan said. “Then you

raduate. You get a kick in the rear, get c

old you did great, and then you’re onour own. The concept of Ozmosis cameut of several years in private practice,here I felt isolated, and I missed the

nteraction. I found a core group of phy-icians who felt the same way, that itould be kind of cool to have a placehere we can share information. I feel

ike it’s a virtual version of the experi-nces we had of collaborating in medicalchool.”

Initially physicians may feel moreomfortable with such sites becausehey’re not open to the general public.ut Dr. Bhan and other physicians whoave dipped their toes into broader socialedia sites such as Twitter and Facebook

ontend that there’s considerable value inoing public, too.

Physicians’ lives already are an openook, he said. Type any physician’s namento Google and the first site likely toome up probably will be something akino www.healthgrades.com, where pa-ients can anonymously grade and com-ent on a doctor. Such sites will be

losely followed by negative press.Physicians need to realize that a sig-

ificant percentage of patients have be-ome accustomed to turning to the Inter-et for information about their physiciansefore they make their first phone call orend an e-mail, Dr. Bhan said. Doctorseed to become comfortable interactingn these public, online areas as well, heaid.

“This is just how today’s patients arenteracting with one another, and it’s how

any of them are coming to expect tonteract with their doctor,” Dr. Vartabe-ian said. “If you have a practice, or are ahysician-executive, it’s almost to theoint where you can’t afford to not benvolved in some way.”

HAT’S UP, DOC?o how are physicians using Twit-ter? Dr. Saldana said he uses itprimarily to share information

bout emergency medicine and healthnformation technology. He says in hisedical group it’s a useful way to share

nformation in bite-size packets. Forxample, he said, if a trusted colleagueassed along a link to a new medicaltudy, Dr. Saldana said he would beuch more inclined to review the arti-

le than he otherwise would have.

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“It’s almost like we act as a grouplter to find the most relevant stuff,” heaid.

Other emergency physicians use Twit-er because they are early adopters andike to tinker with new technologies. Anmergency physician from Northern Cal-fornia, Tim Sturgill, MD, has bloggedor more than 5 years and says he useswitter to communicate not only withther doctors but to have conversationsith those who, like him, are exploring

he potential of social media. Dr. Sturgillonversed with the author on Twitter (seesnippet below) while he was having 4

ther conversations on Twitter.

REAL TWEETchronsciguy: Does Twitter help or im-

act your practice of medicine in anyay?

@symtym: it does ”impact” in termsf med literature injected into the twit-ersphere for discussion

@symtym: probably more ”weighty”iscussions on LinkedIn, Ning, FB,riendfeed, etc. b/c of the 140 characterimitation

@chronsciguy: What’s the primaryenefit of such communications for EPs?id in diagnoses? Identifying diseaseutbreaks or trends?

@symtym: ”primary benefit” I don’think its there yet, albeit the H1N1racking was impressive; the potential isreat -- but diffuse

@symtym: by diffuse, I mean youave to work it to get a good picture, soany users, so much dialog, you have 2b

ctively filtering@chronsciguy: Do you feel this is

omething useful for a lot of docs, or justhose who like to tinker with new tech-

ologies? l

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@symtym The value of Twitter is notctuality, but potentiality, where univer-al messaging and social applications/wareness is going

@symtym: it is a technology that isot ripe for usage yet, but may in retro-pect 5-10 years from now be indispens-ble

Other physicians have gotten intowitter and other social media simplyecause they believe it will play a big rolen the future delivery of medicine, andant to understand the digital landscape.r. Vartabedian says he first got intologging as a means to promote his pop-lar books, such as Colic Solved, and hastuck with it because he sees the potentialor communication with patients. Atome point doctors will regularly con-erse with their patients over the Internetsing new media tools. The major un-olved question at this time, he said, iseimbursement for physicians when a pa-ient doesn’t visit the doctor’s office. Al-eady some doctors such as Natalieodge, MD, are experimenting with the

ractice of iPhone medicine.For doctors reticent to take the

lunge, physicians who use Twitter sayt’s easy to join. After joining, they say, aew user need not write anything, butather search out a few relevant users toollow. From there the growth happensaturally.

“Soon you may need to watch howuch time you’re spending on Twitter,”r. Vartabedian said. “It can be habit-

orming.”

PPENDIXMost people named in this story have

ctive Twitter accounts. Here are theirser names along with the number of fol-

owers they have accrued.

Bryan Vartabedian, MD, @Doctor_V,,393 followersLuis Saldana, MD, @lsaldanamd,

,353 followersTim Sturgill, MD, @symtym, 1,053

ollowersJason Bhan, MD, @jmbhan, 492 fol-

owersJulie Lloyd, @EmergencyDocs, 175

ollowersAngela Gardner, MD, @ACEPhead-

iner, 51 followersGordon Wheeler, @ACEPheadlines,

3 followersTwitter statistics as of June 1, 2009.

ection editor Truman J. Milling, Jr, MD

unding and support: By Annals policy, alluthors are required to disclose any and allommercial, financial, and other relation-hips in any way related to the subject ofhis article that might create any potentialonflict of interest. The author has statedhat no such relationships exist. See the

anuscript Submission Agreement inhis issue for examples of specific conflictsovered by this statement.

oi:10.1016/j.annemergmed.2009.06.002

EFERENCES. Lenhart A. Adults and Social Network

Websites, Pew Internet & American LifeProject, Available at: http://www.pewinternet.org/Reports/2009/Adults-and-Social-Network-Websites.aspx. Accessed June 13, 2009.

. Quantcast survey. Available at: http://www.quantcast.com/twitter.com,Accessed April 30, 2009.

. Manhattan Research. Taking the Pulsev6.0. New York: Manhattan Research;2006.

. Manhattan Research. Taking the Pulsev8.0. New York: Manhattan Research;

2008.

Annals of Emergency Medicine 25A