#ACR14 Social Media Bootcamp & Tweetup

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“Tell me and I forget, teach me and I may remember, involve me and I learn.” ― Benjamin Franklin

The use of social media in medicine has experienced enormous growth in the past few years, and this short blog post can’t even start to scratch the surface.

A great overview of the importance of social media in the field of rheumatology was recently published earlier in 2014 by Dr. Francis Berenbaum (@Larhumato), rheumatologist from Paris, titled The social (media) side to rheumatology in Nature Reviews Rheumatology. This paper includes discussion of the use of social media in medical education (for providers and patients), how it has affected the doctor-patient relationship (in a great way), and its role in medical research.

Twitter has become the centerpiece of social media in the medical world, and has become an increasingly important part of major medical meetings. The upcoming American College of Rheumatology Annual Meeting in Boston will be using the Twitter hashtag #ACR14.

A great resource if you’re new to using Twitter and hashtags at a medical meeting is Symplur’s Healthcare Hashtag Project, who currently has an #ACR14 Conference Hashtag page, which is helpful in getting an overview of the conference from the perspective of Twitter. In their words:

Our hope is that we can lower the barriers of entry, decrease the learning curve, and enhance the experience of new users.  But we’d also like to introduce experienced healthcare Twitter users to a fresh look, to new information, and to new people who share your passions.

Additional rheumatology hashtags to explore:

With all of this in mind, I’m extremely excited to be part of the following social media events this year in Boston:

Social Media Bootcamp

The goal of the social media bootcamp is to introduce more individuals to the core tools in social media: Twitter and blogging. These sessions are the brainchild of Dr. Ronan Kavanagh (@RonanTKavanagh), and I’m happy to be involved moderating the Sunday session and speaking on the technical aspects of setting up a blog on Monday. Also speaking are Dr. Philip Gardiner (@PhilipGardiner) and Dr. Christopher Collins (@RheumPearls).

More information about the Social Media Bootcamp was discussed in the Preview Issue of the Annual Meeting Daily News and in The Rheumatologist.

Times and descriptions:

  • Sunday, Nov. 16, 9:00–10:00 a.m.: Twitter Basics—The thoughts, opinions and ideas of your rheumatology colleagues, in 140 characters or less, shared in real time for open discussion. Learn how to tweet and engage participants in live tweet forums during the conference!
  • Monday, Nov. 17, 9:00–10:00 a.m.: Blogging for Beginners—Learn the basics of setting up a blog and how to use it effectively to communicate with targeted audiences. Blogging can be a great resource for communicating timely and relevant content in easily digestible quantities. These will include two sessions.

#ACR14 Tweetup

  • When:  Sunday November 16 from 4:30-6:00pm
  • Where: Room 150 of the Boston Convention Center

The yearly gathering of rheumatology Twitter friends from across the globe has gotten to be a bigger and better event each year. Take a look at my post on last years #ACR13 Tweetup and this post that includes links back to every prior rheumatology tweetup that I could find.

Just as last year, this event will again open to anyone who would like to attend. No need to RSVP (although I would appreciate it if you would leave a quick comment to this post if you plan on going, just to get a sense of how many people might attend).

If anyone has questions, feel free to ask me on Twitter (@psufka) or else in the comments below.

I look forward to catching up with everyone again this year.

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Speaking at HealthPartners Primary Care Update Conference

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I’m happy to be invited to speak for the upcoming conference HealthPartners Primary Care Update: Pathways to Knowledge on September 19, 2014.

I’ll be giving a presentation titled Rheumatology Pearls from 11:15-12:00, which will briefly review:

  • Common labs ordered in rheumatology
  • Differentiating inflammatory from non-inflammatory arthritis.
  • Gout: diagnosis, acute and chronic management

Download slides:

Other posts of mine that you may find helpful:

If anyone has questions before or after the conference, feel free to get in touch.

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My WordPress Setup, Plugins and Writing Tools

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“It’s best to have your tools with you. If you don’t, you’re apt to find something you didn’t expect and get discouraged.” ― Stephen King, On Writing: A Memoir of the Craft

The best way for physicians (or anyone) to control their online voice is to create their own content, and the best way for this content to be published is to have their own blog.

I am often surprised at how few physicians have what I would consider a bare minimum online presence: a simple webpage with their name and contact information. At the very least, this is necessary to take your place among the numerous physician rating websites that will show up in a search for your name.

While this may appear at first to be a more technical post, I hope that curating tips I have found helpful on running WordPress will encourage others who may be reluctant to starting their own blog.

While there are certainly more simple blogging platforms available, such as Blogger, Tumblr, or Squarespace, I specifically use WordPress given the power and flexibility of the platform, much of which comes from your choice in the additional plugins that are used.

Two ways to run WordPress

  • Free from WordPress.com. There are a number of limitations to this, such as being given a domain name (e.g. yourblog.wordpress.com) and having ads (although you can upgrade to your own domain name and to get rid of ads). The biggest downside in my opinion are the restrictions on plugins.
  • Hosting the free software available at WordPress.org on your own domain. This is the more powerful way to run WordPress, and the one I suggest. The easiest way to do this is to chose a host that supports automatic installation of WordPress (I use Dreamhost, which has been great).

This comparison chart between WordPress.com and a hosted WordPress.org site also helps explain many of the differences. If you’re worried that WordPress can get technical, keep in mind that it is the most used blogging platform, so if questions arise, finding answers is fairly easy, and the documentation is well organized.

WordPress Themes

Your WordPress theme is your template for the overall design of your page. There are a number of free options, or else you can pay for a premium theme, which is typically developed and updated by professional web designers, and will often have additional features. I use The Thesis Theme for WordPress, which has a number of simple tools for editing/managing content, and has built-in options for Google Analytics and SEO. This list of some of the most popular themes (both free and premium) can also provide some ideas.

WordPress Plugins

As mentioned above, plugins are the tools to add various function to your blog, and there are currently thousands available. The plugins that I currently use, broken into various categories are:

Security

Speeding up WordPress

  • WP Super Cache  – Generates static html files that are sent to users, which speeds up loading by reducing load on your host server (otherwise, WordPress generates a new html file each time a user accesses your site, which can be slow). I previously used W3 Total Cache, but it never seemed fast enough and has some occasional problems.
  • WP deferred javaScript – speeds up loading time of your site by deferring loading of javascript.
  • Use Google Libraries – loads any javascript libraries used on your blog from Google’s servers, which tends to be faster than loading from your own host.

SEO

  • WordPress SEO by Yoast – despite some Search engine optimization (SEO) being built into my Thesis Theme, I find that this plugin does a better job at optimizing searches for my name (which as a physician, is the result that I care most about). An alternative to consider (with overall easier setup) is All in One SEO Pack. While I haven’t compared my results with these two plugins directly, Yoast’s package seems to be more successful.
  • Google XML sitemaps – XML sitemaps are files listing your sites URLs with important information about each to search engines. Yoast’s WordPress SEO has this built in, which is likely adequate, but this plugin gives you more control.

Statistics

  • Jetpack – this is a must-have plugin that includes numerous features, but the one that I use most frequently are the site statistics.
  • Google Analytics – though not technically a plugin (Analytics is added by adding a tracking code to your site, which I do through my Thesis Theme, but could also be done through WordPress SEO), Google provides piles of free data about who is accessing your site.

Backup

Other 

  • Contact Form 7 – provides a simple but highly customizable contact form, which I like better than the one included in Jetpack.

It can also be useful to look at what plugins your favorite blogs are using with the WPThemeDetector website (although it cannot detect every plugin), or else browse the most popular plugins in the WordPress directory.

Editing Tools

While you could write blog posts directly in WordPress, it can be a bit clumsy to do so. I use MarsEdit, which connects directly to your blog and allows you to write and upload posts with multiple editing options (it even supports Markdown). By connecting to your site, it actually downloads a copy of all of your posts which acts as an additional backup. Of note, if you use Google Authenticator, you’ll have to use an application specific password, since two-factor authentication is not currently supported.

For longer or more complex writing (such as my post on Decision Fatigue), I first write everything in Markdown using Scrivener, which is an incredibly powerful writing program that local author Patrick Rhone convinced me to purchase after this tweet:

It’s like an operating system for words. Everything one would need to turn words from concept to finished product is there.

Creating content

This is the hard part. I like WordPress founder Matt Mullenweg’s post suggesting that you “write for only two people”: yourself and “a single person who you have in mind as the perfect person to read what you write”. As such, this post was inspired by Dr. Rebecca Grainger looking for tips on starting a blog via Twitter.

My suggestion for writing inspiration would be to read the book quoted at the top of this post, Steven King’s On Writing: A Memoir of the Craft.

Have suggestions regarding your own WordPress setup, especially plugins? Post them in the comments.

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The Monkeysphere: Dunbar’s Number and How Many People You Should Follow on Twitter

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“More data—such as paying attention to the eye colors of the people around when crossing the street—can make you miss the big truck.” — Nassim Nicholas Taleb, Antifragile

[Update 10/11/2014: Excellent article from The New Yorker on the topic of Dunbar’s nunber: The Limits of Friendship)

Twitter has had global impact in ways that never could have been imagined since the first tweets in March 2006. Now, with hundreds of millions of active Twitter users and tweets numbering over 500 million per day, we easily become tempted to follow so many accounts that it can become too noisy to be useful.

Looking for some guidance on a maximal number of accounts to follow on Twitter, I came across Dunbar’s number. This is a theory by British anthropologist Dr. Robin Dunbar that there is a “cognitive limit to the number of people we can maintain social relationships,” in which brain size “limits the number of relationships that an individual can monitor simultaneously” (PDF). He felt that this number was around 150 relationships in humans, although proposed numbers range anywhere between 100-230. The term Monkeysphere was coined in reference to an experiment confirming this correlation between brain size and social groups in monkeys.

Dunbar looked at whether his proposed cognitive limit also applies to Facebook, and wrote:

Facebook itself did a survey of its accounts about a year ago and found that the average number of friends was between 120 and 130.

The odd reality is that we are actually not capable of managing more friendships than you typically see on Facebook now—or more than people have traditionally maintained.

And concluded that:

If you have more than 150, it is because you are including people who have no meaningful relationship with you.

I don’t think there is a “correct” way to use Twitter, but given it has become my primary source of incoming information, I try to be thoughtful about both who I follow and how many I follow. Looking at an October 2012 study, the average Twitter user follows about 102 accounts, which is well within Dunbar’s observations. I certainly start to feel a bit of cognitive strain when the number I’m following is too high (which is most of the time).

My approach to Twitter is to generally focus on following thought leaders for topics I’m interested in, and have a low threshold to unfollow an account unless I’m finding they consistently add value to my network.

When you first start to filter your network and unfollow accounts on Twitter, you’ll be a bit nervous that you’ll miss something. Trust me, you won’t. If something is important, your well selected network is going to amplify that message and you’ll see it.

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Decision Fatigue in Physicians and Medicine: The Importance of Routines and Habits

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“Everything must be made as simple as possible. But not simpler.” — Albert Einstein

One of the most mentally fatiguing actions that physicians face on a daily basis is the number of decisions we must make. Although we likely only make one or two major decisions for every patient encounter, in total we make hundreds (or maybe thousands) of decisions every day. This includes deciding what labs, imaging, and other studies to order, followed by what those results mean, a diagnosis or list of possible diagnoses, treatments, monitoring, patient follow up, etc.

Unfortunately, it has been shown that the more decisions that we make over the course of a day, the worse we become at it.

The New York Times article Do You Suffer From Decision Fatigue? (highly suggested; approximately 22 minute read) begins by describing the rulings of parole board judges over the course of a year, finding that the pattern of their decisions fluctuated throughout the work day, favoring the prisoners who appeared early in the day.

The more choices you make throughout the day, the harder each one becomes for your brain, and eventually it looks for shortcuts, usually in either of two very different ways. One shortcut is to become reckless: to act impulsively instead of expending the energy to first think through the consequences.

The other shortcut is the ultimate energy saver: do nothing. Instead of agonizing over decisions, avoid any choice.

Decision fatigue was described by Dr. Roy F. Baumeister, who demonstrated that humans have a finite store of mental energy for making decisions, which can be broken down into the Rubicon model of action phases:

  1. Predecisional Phase – assessing wishes and forming intended goal
  2. Preactional Phase / Making a Decision – planning and choosing goal-directed actions
  3. Actional Phase – implementing chosen actions
  4. Postactional Phase – evaluating whether goal was achieved

It turns out that a number of studies have shown that the act of making the decision and committing to action is more mentally demanding than any other phase.

The idea of decision fatigue is explained by Dr. Baumeister through a theory called ego depletion, where decisions are higher level executive functions thought to occur in the prefrontal cortex, and every decision we make, no matter how important or unimportant, expends some of the energy of this system, until our ability to make decisions deteriorates.

Once you’re mentally depleted, you become reluctant to make trade-offs, which involve a particularly advanced and taxing form of decision making. In the rest of the animal kingdom, there aren’t a lot of protracted negotiations between predators and prey. To compromise is a complex human ability and therefore one of the first to decline when willpower is depleted.

This reluctancy to make trade-offs explains why the parole judges were reluctant to decide to give prisoners parole at the end of the day. As physicians, we need to be aware of the tendency for decision fatigue to occur during our long days. Unfortunately, there is no telltale symptom of when willpower to make decisions is low, and the best method to avoid decision fatigue is planning routines to avoid it:

“Good decision making is not a trait of the person, in the sense that it’s always there,” Baumeister says. “It’s a state that fluctuates.” His studies show that people with the best self-control are the ones who structure their lives so as to conserve willpower. They don’t schedule endless back-to-back meetings. They avoid temptations like all-you-can-eat buffets, and they establish habits that eliminate the mental effort of making choices. Instead of deciding every morning whether or not to force themselves to exercise, they set up regular appointments to work out with a friend. Instead of counting on willpower to remain robust all day, they conserve it so that it’s available for emergencies and important decisions.

Any opportunity to learn from extreme cases can offer incredible insight, and an extraordinary example of a decision maker to study is President Obama in Michael Lewis’ article, Obama’s Way, where he discusses routines with the President, who is well aware of the effects of decision fatigue:

You also need to remove from your life the day-to-day problems that absorb most people for meaningful parts of their day. “You’ll see I wear only gray or blue suits,” he said. “I’m trying to pare down decisions. I don’t want to make decisions about what I’m eating or wearing. Because I have too many other decisions to make.” He mentioned research that shows the simple act of making decisions degrades one’s ability to make further decisions. It’s why shopping is so exhausting. “You need to focus your decision-making energy. You need to routinize yourself. You can’t be going through the day distracted by trivia.” [Emphasis added]

An article from EMSWorld, When Thinking is Hard: Managing Decision Fatigue, discussed the implications of decision fatigue for EMTs and paramedics and agreed that trying to reduce overall decision load was the best way to manage this problem, and noted that individuals who were able to do this had routines and habits that included thoughtful planning, which reserved willpower for when it was needed most. As healthcare professionals, they noted the importance of having these planned routines:

We tell ourselves it’s how we perform under pressure that counts most, but the sum of who we are as professionals is just as much determined by the everyday habits which make up our work.

The idea that having specific routines to improve productivity is not new. The American philosopher and physician William James (1842-1910) wrote in detail about the importance of forming regular routines and the subsequent effect of allowing our brains to remain productive in his book Habit (open domain; review on Brain Pickings).

The book, Daily Rituals: A Guided Tour of Writers’ and Artists’ Creative Habits, which describes the routines of 161 famous and inspired minds (also reviewed on Brain Pickings), is another opportunity to learn from extreme thinkers, and also quotes one of William James’ 1892 lectures from the book Habit:

The great thing, then, in all education, is to make our nervous system our ally instead of our enemy. It is to fund and capitalize our acquisitions, and live at ease upon the interest of the fund. For this we must make automatic and habitual, as early as possible, as many useful actions as we can, and guard against the growing into ways that are likely to be disadvantageous to us, as we should guard against the plague. The more of the details of our daily life we can hand over to the effortless custody of automatism, the more our higher powers of mind will be set free for their own proper work. [Emphasis added]

At this point, the effect of decision fatigue in medicine needs further research for both physicians and patients. The University of Pennsylvania currently has two studies ongoing on this topic, one looking at its role in the ICU and another looking at its role in patients’ and patient surrogates’ end-of-life choices. The Journal of Palliative Medicine has written about the problem of decision fatigue for patients who are already exhausted from severe illness, acting as a reminder to give patients and their families a chance to regroup before making important decisions.

As MDs, we will always be required to make numerous daily decisions, so we need to do what we can try reduce our own decision fatigue, which might actually improve our work as a physicians and lives in general:

  • Spend some time thinking about your routines at home and at work to avoid making additional decisions. Many of the routines described in Daily Rituals included repeating meals, dressing/grooming habits, and setups for getting work done.
  • Make important or difficult decisions first in the morning. Many of us have a habit of checking email first thing in the morning, which is often filled with a number of unimportant decisions that can wear us down. Instead, save this time of day for the tough ones.
  • When possible, put off difficult decisions that come up at the end of the day until the next morning. In the field of rheumatology, we are often faced with complex decisions, but luckily, the majority of them are not extremely time sensitive, allowing us time to research and discuss with collagues.
  • I find it difficult to say anything to the effect of “workup every case of x with tests a, b, and c”, but I do think that as physicians, we do need to have a good understanding of the workup and management for the common conditions in our fields, such that we are able to reserve decision making energy throughout the day.

Any suggestions on routines or other habits that you have found helpful? Mention them in the comments.

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