Social Media is Exploding – But is it Effective?

About a year ago, I posted about accelerating knowledge translation using Twitter, blogs, and other social media. In some respects, the embrace of social media was still in its infancy – originally, #FOAMed, powered by an independent group of individuals passionate about sharing knowledge and teaching Emergency Medicine. The Emergency Medicine Journal, driven in part by Prof. Carley’s efforts, was one of the first journals to add social media, discussion, and dissemination to their official scope and formally appoint Editors in this domain.

Now, to put it mildly, the scene has exploded.

Each of the major Emergency Medicine journals in the U.S. has at least one social media editor (Annals)(AEM), or an entire social media team. The major conferences, in Emergency Medicine and other specialties, have adopted hashtags (e.g., #ACEP14) and live tweeting by meeting participants as part of knowledge dissemination and promotion. Indeed, an upcoming conference in Chicago, USA, specifically addresses Social Media and Critical Care. Finally, even previously small, individual efforts at knowledge translation, like Academic Life in Emergency Medicine, have gathered momentum and become online clearinghouses of peer-reviewed editorial and educational content, along with their own online Journal Clubs.

The Council of Emergency Medicine Residency Directors (CORD) issued a long statement on the professional use of social media in by training programs, including a statement that “social media can be a powerful tool”. The American Congress of Obstetricians and Gynecologists recently issued guidelines on physicians’ use of social media. The United Kingdom Diabetes Professional Conference broadly covered social media use by endocrinologists to learn from and communicate with patients in a new context. Even other health professional disciplines, such as research nurses, have recognized the power of social media for unexpected viral promotion of clinical topics.

However, despite this enthusiasm, it remains a challenge to measure tangible benefits associated with social media use. Anecdotal stories of professional networking via social media abound – but, ultimately, patient-oriented outcomes as result of knowledge translation ought be the true measure of success. A recent study in Circulation randomized newly published articles to traditional knowledge translation or specific social media promotion – and there was no difference in online views between the two cohorts. The lesson, despite the authors’ conclusion, is not that social media is limited – but the content trumps the distribution method. If a social media stream consists of solely unfiltered noise, rather than useful signal, the entire effort will fail.

While increasing numbers of clinicians and patients are accessing information through alternative digital means, and the potential for education and accelerated knowledge translation through social media exists – individuals and organizations should recognize significant challenges remain. No amount of investment or effort into “social media” replaces useful content, and as more sources contribute to the pool of online information, the more difficult it will be to build a following or measure successful effects.

Emergency Medicine for medical students world wide!

ISAEM HR LOGO

A guest blog from Larshan Perinpam (President of ISAEM) and Anh-Nhi Thi Huynh (Vice president of external affairs, ISAEM)

 

ISAEM is an organization established to take Emergency Medicine student Interest groups (EMIGs) extracurricular activities to a whole new level, not only locally or nationally but also worldwide.

ISAEM is the abbreviation of the International Student Association of Emergency Medicine. It is the first international Student organization of it’s kind within Emergency Medicine (EM) and was founded in Denmark in October 2013. ISAEM’s primary aim is to create International relations between EMIGs all over the world.

In the United States, EM was founded more than 40 years ago, and today it is a well-established specialty that occupies the Emergency Department (ED), which in most cases is the front door into the hospital. By having an individual specialty within EM you are able to provide a better and more optimized patient care. In many countries (Norway, Denmark, Brazil, etc.) EM does not exist as an individual specialty. In such countries EDs are occupied by the already established individual specialties (cardiology, general surgery, infectious diseases, primary physicians, orthopedic surgeons etc.) and many EDs does not have its own physician staff.

In order to develop a department the first step is to have its own staff, a staff that is continuous and present in the department on a daily basis. These are just some of the few challenges that are being faced in the EDs worldwide. Some countries already have an established specialty within EM, but it is still under development. Furthermore these countries are also facing recruitment problems due to the rough working conditions.

Larshan1 2

Larshan Perinpam

The members of ISAEM are local and national EMIGs around the world. ISAEM believes that the best possible way to recruit future staff into EM is through the EMIGs that are already established in many medical schools. We need to optimize the extra curricular activities in comparison to all other medical student interest groups, who have their interest within another established specialty.

In ISAEM we believe that by connecting every EMIG on a international level we will be able to; exchange ideas, find inspiration in activities created by different EMIGS, be able to further develop the local EMIGs and create a foundation for the next generation of physicians who wishes to pursue a careare in EM

Anh-Nhi Thi Huynh(1)

Anh-Nhi Thi Huynh

Since the establishment of ISAEM we have strived to promote ISAEM in the best way possible by attending international EM meetings (ACEP, EuSEM14, ESEM2014 etc.); finding the right collaboration partners (EMRA, DASEM, EuSEM, ESEM etc.) and focused on creating a stable and strong infrastructure of the organization. Recently ISAEM launched its latest initiative to further develop EM among medical students by creating the ISAEM National Ambassador program. The National Ambassadors will play the part as bridge-builders between the local EMIGS and ISAEM.

The practice of EM is extremely diverse and various internationally and ISAEM wishes to create opportunities in order to expand the experience and understanding for students with an interest in EM. Therefore ISAEM decided to develop an international ED Observership program in order to give medical students the opportunity to see how EM is practiced in different cultures and settings. This will also help to inspire the individual student to further develop Emergency Medicine in their home country.

Currently ISAEM is represented by five countries/members (Denmark, Netherland, Brazil, US and the Netherlands.) These already represent more than 2000 EM interested medical students. In the end of April 2015, ISAEM wish to enroll more EMIGs and by the end of 2015, ISAEM aim to represent more than 20.000 EM interested medical students worldwide! We want to create the biggest international student network within EM.

ISAEM is slowly developing and our current achievements is all because of our members, partners and the medical students who dedicate their free time in order to develop ISAEM. This work is what defines ISAEM and the future of ISAEM. In ISAEM we believe “alone we can go fast but together we will go far”.

 

If you find this interesting, please don’t hesitate to contact us:

Website: www.isaem.net, facebook: https://www.facebook.com/ISAEM13, twitter: https://twitter.com/ISAEM13 or email: Larshan@isaem.net

 

We are looking forward to further develop EM among medical students with you.

More Trouble For tPA at the BMJ

The BMJ recently stirred the pot again on a subject near and dear to our hearts – no, not exit block – but intravenous thrombolysis for acute stroke. For a therapy that’s been approved within 3 hours for nearly two decades, and was extended to 4.5 hours by guidelines in Europe and the United States since 2008, it ought be surprising there is still serious discussion regarding the validity of the results.

Just two years ago, the BMJ allowed members of the Australasian college to debate the risks and benefits for tPA in acute stroke. The accompanying unscientific poll of bmj.com readers came out in favor of skepticism, with 54% of the 612 respondents stating the risks outweighed the benefits. Now, in the context of the UK regulators re-examining the evidence in support of alteplase, the BMJ has published an examination specifically regarding the 3 to 4.5 hour time window.

In contrast to the individual-patient meta-analysis, the Cochrane Review, and many other interpretations of the applicable data, this work is unique in that is led by an outsider – neither a professionally entrenched stroke neurologist or emergency medicine physician. The author, Brian Alper, is a family physician whose professional affiliation is with a knowledge translation medical reference product. Rather than carrying the baggage of twenty years of contentious debate, colored by pharmaceutical sponsorship, his take is of one, colloquially, without a horse in the race.

Dr. Alper et al critques three different interpretations of the evidence regarding the extended time window: The American Heart Association guidelines, the 2014 Cochrane review, and the 2014 individual patient meta-analysis. The crux of each analysis focuses on ECASS III, IST-3, and the integration of such data sources. ECASS III, he points out, enrolled twice as many patients with prior stroke into the control arm – and excluding those with prior stroke from the final analysis diminishes the treatment effect to a 95% CI of 0.89 to 1.59 for mRS 0-1. The 3 to 4.5 hour cohort from IST-3, then, found no benefit to alteplase with a 95% CI of 0.50 to 1.07 for mRS 0-2. These two data sources are then combined to make up the bulk of the individual patient meta-analysis, and despite their seeming contradiction, their synthesis remains strongly positive in favor of thrombolysis.

The critique of the Cochrane review is couched in quite revealing language, noting “Cochrane reviews usually provide the most valid syntheses of evidence of effects of interventions”. As previously critiqued, these authors again take Wardlaw et al to task for discrepancies between their ultimate conclusions and the data presented beyond 3 hours. Dr. Wardlaw has already responded at bmj.com to begin what will hopefully be a provocative and enlightening discussion.

Dr. Alper et al make a call for data sharing such that all can examine the individual patient results, similar to the fascinating third-party re-analyses undertaken of the osletamivir data. They also call for additional research to further independently evaluate efficacy. Unfortunately, a paucity of new data is forthcoming. A cursory search of stroke trials indicates a 200 patient trial from China enrolling in the 3 to 4.5 hour time window, with little additional information. Other potentially forthcoming data includes TESPI, an open-label trial from Italy whose recruitment ended last year. The remaining trials, rather than further enlightening us regarding safety under the existing license, aim to expand eligibility by time window or elimination of other exclusions.

Will this most recent dissent produce any meaningful result? It is too early to tell – but, certainly, for our patients’ sake, I hope so.

What Happens When Conflict-of-Interest is Stripped Out of Guidelines?

Nearly 20 years after hitting the prime-time following publication of the findings of the NINDS rt-PA Study Group, tPA use has become widespread.

However, there yet remain many vocal opponents. To say there is sometimes a hearty debate over the use of tPA in acute stroke would be a dramatic understatement. Indeed, even as select groups of stroke neurologists push tPA use beyond the limits of current guidelines, other groups remain steadfast in opposition.

This post is neither pro- nor con- in this ongoing controversy. Rather, this simply draws attention to a relatively interesting development over on the U.S. side of the pond. In 2013, the American College of Emergency Physicians published a new Clinical Policy regarding the use of tPA in acute ischemic stroke – giving tPA under 3 hours a “Level A” recommendation, and 3-4.5 hours a “Level B” recommendation. The uproar that ensued, however, was not entirely based on clinical grounds – it was regarding the composition of the guideline panel, co-written with the American Academy of Neurology, and stacked with experts with professional and financial conflicts-of-interest with the manufacturer of tPA. This gave rise to a BMJ investigative report, delving into the corrupting effect of COI on guideline writing. This further spun off another BMJ consensus publication regarding the evaluation of “red flags” for guidelines, dovetailing nicely with previously published Institute of Medicine recommendations.

The story, however, does not end there. ACEP’s council voted to reconsider the tPA guideline and implement a due, COI-free process, with a focus on methodology rather than content expertise, and an open review policy. The product of the revised process recently became available in draft format – and the difference is striking. The administration of tPA is no longer a “Level A” recommendation – both time windows are “Level B” in the current revision. However, there is a new “Level A” – a mandate to discuss the 7% average observed incidence of harmful intracranial hemorrhage prior to administration of tPA. Finally, a new “Level C” recommendation states, as consensus, to involve patients in shared decision-making during the process.

Whether one agrees with such changes is almost certainly tied to their view regarding the benefits and harms of tPA. It is, however, quite interesting to see how attempts to mitigate bias and COI change how the evidence is graded and the ultimate recommendations. Perhaps this demonstrates, at the least, hope is not necessarily lost regarding purifying the practice of medicine – and guidelines may yet regain the trust of physicians and patients.

Primary survey Highlights from the January 2015 issue. Mary Dawood, Editor

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A mask tells us more than a face (Editor’s choice)
As ED clinicians we often pride ourselves on recognising the sickest patients by how they look, this skill is tacit and one that is the result of experience and longevity in emergency care. Our psychiatric colleagues have long accumulated significant research into disturbances in affect recognition in patients with mental illness, so I was intrigued to read in this issue a study by Kline and colleagues from the US which explored the variability of facial expression in patients with serious cardio pulmonary disease in emergency care settings. They found that patients with serious cardio pulmonary disease lacked facial expression variability and surprise affect. They suggest that stimulus evoked facial expressions in ED patients with cardiopulmonary symptoms may be a useful component of gestalt pre-test probability assessment. So, there may be some substance in one of the many satirical remarks made by Oscar Wilde that “A mask tells us more than a face” though I doubt his context was clinical.

It’s not the age that matters
Accurately measuring weight in children presenting to the ED is essential and particularly crucial in resuscitation situations where interventions and drug dosages are calculated by weight. The APLS formula, 2× (age+4) has been widely used in western ED’s, but as obesity in our young people is becoming more common and children are taller than previous generations , this formula may fall short in terms of accuracy and patient safety. An alternative formula (3×age)+7 by Luscombe and Owens (LO) has been suggested as more accurate than the APLS formula. Skrobo and Kelleher in Cork University Hospital Ireland undertook a retrospective study of 3155 children aged 1–15 years comparing both formulas to identify which one best approximates weight in Irish children presenting to the ED. They conclude that the LO is a safe and more accurate age based estimation over a large age range. Maybe it’s time to review our practice but do read this paper and weigh up your own thoughts, no pun intended!

Not all suffering is pain
Pain is the commonest reason patients attend the ED. Our sometimes lack of appreciation and subsequent under-treatment of pain is often a source of distress and dissatisfaction which can result in uncharacteristic behaviour. However not all suffering is pain and we may find ourselves wanting when the cause of distress is emotional rather than physical. This issue features a prospective cohort study by Body and colleagues in Oxford which sought to describe the burden of suffering in the ED. Of the 125 patients included in the study many reported emotional distress particularly anxiety as well as physical symptoms. Indeed only 37 patients reported that pain was causing their suffering. It should not come as any surprise that being seen, information, reassurance, explanation, care by friendly staff and closure were the key themes reported as relieving suffering. This approach just represents best practice but in the mounting pressures of ED’s worldwide it is all too easy to lose sight of the person and their need for compassion and understanding. Dismissing emotional suffering as perhaps someone else’s problem is detrimental to our patients and ultimately ourselves. Do read this paper; it is a timely and salutary reminder of what we should be about, why we do the job we do and what patients expect of us. There is also a podcast with the Editor in Chief and the author. Find this online alongside this issue.

Best evidence or clinical acumen (Readers’choice)
As demands for emergency care and acuity of patients presenting continues to rise globally, ED clinicians are increasingly faced with making decisions to discharge patients from high acuity areas of the ED. Patient safety and well being should govern any decision to discharge a patient but many cases are complex and weigh heavily on clinicians making such decisions. Calder and colleagues in Canada conducted a real time survey of experienced ED physicians to determine how they perceive their discharge decisions and the impact on adverse events. The authors concluded that ED physicians in their study most often relied on clinical acumen rather than evidence based guidelines and that neither approach was associated with adverse events. They recommend further research which focuses on decision support solutions and feedback interventions.

The greater good
Pulmonary embolism (PE) is a leading cause of death in pregnancy and the post partum period and a devastating event for mother and baby. When accurately diagnosed and treated the risk of an adverse outcome is low. In this paper Goodacre and colleagues explore the options for imaging and discuss the evidence for using clinical features and biomarkers for the selection of women for imaging. Their review of the literature suggests that the harm of investigation with diagnostic imaging may outweigh the benefits but that clinical predictors could be used to identify women at higher risk who could be appropriate for imaging. They also state the need for further research around clinical predictors and particularly the use of D-dimer at a pregnancy—specific threshold.

Pearls of wisdom
There is little doubt that the emergency department is a quite unique environment that offers abundant opportunities for learning. Seizing and exploiting these opportunities is not always as straightforward as we would like it to be. The constant pressure to manage multiple patients and make decisions to refer, admit or discharge against the backdrop of a ticking clock often mitigates against the teachable moment however genuine our desire or commitment to teaching is. It’s easy to feel impatient and exasperated by the seemingly slow pace of some learners when you are trying to maintain safety in a crowded department. On the plus side, however, learning in such an environment can instill a sense of urgency, something that cannot be learnt from a textbook. Nonetheless teaching and learning is integral to all our roles and so it was refreshing to read in this issue “Top 10 ideas to improve bedside teaching in a busy emergency department” by Green & Chen from California. We have probably all used some or all of these methods to teach in different circumstances but the authors imaginative use of a framework, of ‘mnemonics’ and easy to remember names such as “Aunt Minnie” and “Snapps” is amusing and lighthearted. In reading this paper, you may just find that pearl of wisdom for the next teachable moment.

 

Mary Dawood

The view from the F2…..

The view from the F2

As an aspiring emergency physician I have been keeping a close eye on the latest media frenzy regarding the NHS crisis. My own feeling is that from working in the NHS over the Christmas and New Year period is that the hospitals are considerably busier than this time last year.

Headlines such as ”hospital declares ‘major incident’ in NHS A&E crisis”1 have become common place and mutterings from GPs, consultants and juniors alike are saying the NHS is at breaking point.

Is it clear that the A&E departments across the country are facing an unprecedented number of admissions than ever. It is worrying that the strains demonstrated by hospitals declaring themselves as ‘major incidents’ could indicate the demise of the NHS , unable to cope with the extra demand.

Why is this? I wish to explore this topic and discuss some of what I believe to be the most crucial contributing factors to this NHS crisis.

I have asked myself, my colleagues and scoured the reports on this ‘ NHS crisis’. Why has there been such a high demand on the NHS this winter? What can I or my colleagues do to alleviate this?

The following are some of contributing factors which I believe have placed the NHS under more strain than ever. I have also discussed action plans that we as physicians could implement to try to alleviate some of these pressures.

 

  1. Ageing population: Medical advances have allowed an extended life expectancy for our population. 30 years ago a myocardial infarction carried a mortality rate of over 40%, now with advances such as PCI, time limits of 60mins from onset of chest pain to catheter table , cardiac rehabilitation & medications the mortality rates have significantly improved. This has consequences for the health service in other ways – people are living longer in the community with now more chronic illness. Our population is also living for longer , there are over ten million adults aged over 65 years living in the UK currently and this is projected to increase by an additional 5.5 million in twenty years time.2 We are now experiencing the conse of this situation with more patients with chronic illnesses unable to cope in the community and requiring hospital admission.
  2. Four hour target in the A&E department – The government and media have publicised the 4 hour target in the Emergency department. This is a potentially lucrative enticement to a patient who cannot get an immediate appointment from their GP in that they can be seen / investigate / treated / admitted or discharged within 4 hours from the emergency department. Should this target be abolished? – there does not appear to be much evidence that it improves healthcare and it seems that it in fact has created additional waiting / clinical assessment unit type wards in the hospital. If the targets were dropped and patients were seen purely on clinical need, perhaps not so urgent / acutely unwell patients would attend and instead try and attend their GP.
  3. GP out of hour’s service access – Since the GP contract changed in 2004, it has placed an extra strain on access of healthcare ‘out of hours’. Patients often think that after 6pm there are no GP services available and therefore present directly to the emergency department as they know its open 24/7. Some patients are unaware that a GP out of hour’s services exist. Is there an opportunity to educate patients in the community about accessing healthcare out-of-hours?
  4. NHS budget – in the financial climate, austere measures have been placed upon all public services. The NHS has also been affected by this. The NHS budget has been frozen for around 5 years, more productivity has been demanded from it and as the population has risen demand upon it has increased. The NHS is paid for by the taxpayer, and it is difficult to ask more from the taxpayer to contribute to the NHS. This calls into question privatisation of the NHS (I do apologise if this word causes offence to anyone reading). Should some fees be introduced to the NHS? e.g. fines for those who continually fail to attend appointments , recurrent drunks in the ED , a small fee for calling upon ambulance services and attending the ED?? Imposing fees could have major consequences. It is known that those who are in the lowest socio economic state have the poorest health. If fees were placed would we be neglecting those who could not afford a small payment towards their health? What do we do if patients refuse to pay? Do we set litigation against them? Would fee for service environment result in a more litigious society?
  5. Societal attitudes to illness and health – With the advent of social media , constant and instant information is available from Twitter , Facebook and Google. Society has become more risk averse. People are generally unwilling to accept any health risks (and why should they accept risk?). Therefore attending the hospital /emergency department whereby health can be assessed quickly with bloods & imaging and quick decisions can be made is now an expectation. It is not uncommon to hear colleagues complain that more patients are attending the emergency department for non emergency ailments such as simple coughs and sore throats. I don’t think there is any solution to this rather than acceptance of society’s shift in their health beliefs and health seeking behaviours. Perhaps its time we roll with this change and consider making healthcare more accessible to people’s lifestyles e.g. running more evening clinics in general practice when people can attend after work.

 

Rant over, I feel like a weight has been lifted off me however the gravidity of this situation is bearing down on the NHS and it appears to be unravelling before our eyes (maybe I am being a tad dramatic here but it is a pressing issue all the same).

I realise that this is a complex issue that will require time, money and patient education. What can we do as physicians? What can I do as a budding emergency medicine doctor? I suppose for now its patient education. Information empowers our patients and perhaps the next time we encounter a patient in the emergency room who you felt may have benefited from a visit to their general practitioner rather than the emergency room, inform them of this. There is no need to chastise patients but pointing out the resources available such as walk-in centres and out of hours GP services towards the end of the consultation may be worthwhile.

So from a foundation doctors perspective the above factor are what I belief are contributing to the current crisis however , what do you think? Are there other factors I have not considered? Does anyone have any remedies for this NHS ailment?

Yours comments and opinions are greatly appreciated.

Thanks for reading.

Aine Keating

 

References:

  1. BBC news article Nick Triggle (06/01/2015). A&E waiting is worst for a decade. UK
  2. Government document. (2007). Ageing population. Available: http://www.parliament.uk/documents/commons/lib/research/key_issues/Key-Issues-The-ageing-population2007.pdf. Last accessed 06/01/15.