Thursday, 18 October 2012

Twitter for a/e triage?


  1. Malcolm McKenzie18 October 2012 at 01:27

    Great post. Agree with steristrips, and think there is a lot of value to twitter (or equivalent) for this kind of thing. Risks are non-appreciation of problem (slipped thread etc), non-experts appearing as experts, filtering correct advice and culpability for advice. That said, I'd like to believe crowd-sourcing and 'logic of crowds' would find the solution, but I'd be especially intrigued on the ethics submission for the trial! ;-)

    1. I was asking the question of whether Twitter could do a/e triage slighly tongue in cheek. This is a nice simple example but still raises some interesting issues. How do doctors decide when giving advice via Twitter is appropriate? Alex specifically asked for a medical, not a lay, opinion.

  2. I am not medically qualified (but I've had kids :-) I have a disclaimer on all my blogs that says that I don't give medical advice, consult your doctor. But in this case?
    Although Alex is a good friend of mine, I thought very hard before responding to his tweet. From the picture, I was 99.9% sure that the cut was superficial, clean and had not embedded debris. In this instance, Twitter worked exactly as we would all like, saving the poor kid the misery of a late evening in A&E. The problem would be with more urgent, threatening or complex cases, and the risk of overconfidence.

    1. I had the same reaction. Other doctors asked more probing questions but I presumed in a way that if Alex was asking this question then it was most likely he had evaluated the situation quite well himself.

  3. I really liked this exchange and would do the same if the need arose. Obvious precautions need to be taken (as with any info on the web) but overall a good thing.

    1. This case was simple... although some recognised possible complexity which I assumed wasn't there. That's interesting in itself.

  4. Great post and comments. have limited time right now to engage, so a few ideas and questions. Pardon the brevity/fragmentation.

    I don't know enough about the logistics of health care deliver in the UK (have no idea what A&E is). It appears at first blush that there are a lot of people who could provide advice at the drop of a hat - meaning they have time on their hand.
    Why is it that so many people responded on Twitter but you have to spend a long time to get seen by appropriately trained person?

    Suppose a Twitter-like tool was part of the normal workflow and thus you were getting thousands of these requests for help from all over the country - would all these same people them have the time to respond to this specific query? Would they then have expected to get paid for their opinion? Would all of them get paid or only one rated as the best or most useful response.

    Posting questions like this (dermatology/radiology etc)to a "crowd" of appropriately authenticated qualified providers in a secure manner would potentially help to meet some of the supply and demand problems that might exist. Telemedicine has existed for a long time. The bottleneck at least in the US is legal and financial issues IMHO.

    1. A/e is 'accident and emergency'... the emergency room. Is this where problems like this would go in the US?

      I read this in the evening so I presume that the doctors who responded had time as it they were home from work.

      Could this approach scale? It would be rare to come across many examples as 'cut and dry' as this. (Pun is for Alex's benefit if he gets round to reading this!)

  5. Minor cut in a healthy patient is probably not an issue. However as soon as you have a confounding factor eg dog bite, medical co-morbidity or evidence of other structural damage then formal review required. Also would check what are the local(in this case UK) professional guidelines wrt doctors treating family members

    1. Thanks Deb.... why do you mention docs treating family members? I think doctors only responded on Twitter because they judged that the case was so simple. But I am quite intrigued by those who wanted to seek further information.

  6. Just because a number of regulatory agencies have guidelines, code of conduct, code of practice documents containing explicit statements wrt providing medical care to family members. Something we all need to be cogniscent about in the public domain if there are going to be open discussions held.

    1. As far as I know in the UK at least there is no absolute guidance on treating family members. This was something that was discussed by the GMC in the run up to the update of Good Medical Practice. Surely family members could be given the same advice via social media that could be given to any member of the public. My feeling is that the interactions described in the storify do not constitute a doctor-patient relationship.

      In any case, no family members were involved in this interaction as far as I'm aware.

  7. From Dr Karen Price @brookmanknight Urban GP Melbourne Australia

    Well I am going to be conservative in principle.

    I note that my other colleagues have asked the appropriate surgical questions regarding this apparently superficial laceration. I note too that some of the respondents seemed to indicate that they knew the person/family posting this photo which is context.
    I note that it is a superficial lac on all counts and hardly requires a enquiry, however putting that to one side!!
    Predominantly its the "What if" questions.
    What if as a Dr. I had no context and I do not know the social circumstances of the family?
    What if there are more injuries considered to be insignificant to the Tweeter: Like that haematoma over the territory of the Middle meningeal artery??
    What if this injury was self inflicted?
    What if this injury is the result of abuse?

    And additionally my conservatism is spurred onwards by my concern over the slippery slope of patient engagment & consultation via SoMe.
    What if enquiries begin to increase even if they continue to be relatively easy and obvious answers?

    These concerns relate to the real danger that Physician Burnout is at least as dangerous to patient care as is inaccurate diagnosis. Physician burn out can be caused by many things. In Australia we are payed as piece workers that is, according to how many patients we see. If we dont see a patient in our consulting rooms or their home we dont get paid. Now we do value added things although some Drs do not. So I have fielded telephone enquiries from my patients which are easier than managing my colleagues patients by phone who are not well known. I also allow Email exchange for selected patients (generally not the ones with personality disorders) to manage my overburdened appointment book. This I consider to be a part of General Practice. I almost always cut and past the email into the patient file or detail the telephone conversation into the file. So its not the permanancy of the record that bothers me as hopefully I dont often give crap advice ! Its the burden of finishing a busy day to find EVEN MORE telephone messages or Emails to finish off which if we now include SoMe potentially at home is not a good boundary between home and work. Thats my point regarding burn out, as well as the issue of remuneration which is essential to consider.

    I can see though that for rural or remote practitioners/patients this may offer some relief to a worried parent. I note that the BMJ published a record of a USA neurologist using facebook photos of a patient to determine that her ptosis was a new finding. So its an interesting developing world. I can understand patients desire to have 24 hour 7 day access to their own physician, however most Dr's in Australia dont provide that level of service preferring to offer cover for each other or use a deputising/locum arrangement. If they do provide 24/7 in a rural/remote location then they may do so for a very short time or are one of the older generation.

    So conservative in principle I havent yet engaged with patients on SoMe and I generally ignore patients requests via SoMe of which I have only had a few thankfully. I havent needed to confront the patient about my consderation that this is inappropriate.

    1. Thanks Karen,

      You raise some very interesting points which address issues that I think need further discussion although they are not directly related to this story.

      I thought this case was interesting to discuss because it possibly shows the limits of what something like Twitter is useful for. Others may argue that the possibilities of public social media extend beyond this and I'd be interested to see their propositions.

  8. Thanks Anne-Marie for creating such an interesting narrative from the evening - and to all for the commentary after.
    Like many of you have suggested, I wouldn't ask such a question lightly: and had two GPs in mind who I knew followed and knew me when I posted. I was also 95% sure that the injury was superficial but had a slight worry about my judgement.
    I was pleasantly surprised by the responses, which helped to ease my mind about that 5%; both from the medical professionals and from parents (warnings or outrage from either and I'd have been straight down to A&E).
    Given that an England match had just finished, the prospect of A&E then was not a good one to expose a small child to, and when I factored in the knowledge from Twitter that the hospital would probably clean it and use steristrips anyway, I figured it was saving time and hassle all round for the same outcome. I did telephone a GP friend of mine though, just to be extra sure ;)
    I certainly wouldn't use Twitter for anything more serious, or where I really had no clue to begin with; but for minor injuries or issues where both medical and parental advice would come in useful, I think there's a place for Twitter based on the evening's evidence...

    1. Hello Alex,

      Thanks for posting your thoughts and reflections on what happened. You are obviously a well-connected person! Where I work as a GP very few of the patients would know a GP personally to be able to check on something like this. Although I didn't follow you at that time I came across your tweet because I've know Jo for quite a long time through social media. And my retweet brought some of the responses that you received.

      Is this scalable? We were operating here in a very informal way. Many of the people who attend a/e 'inappropriately' don't have access to the networks I am describing here to help them make 'appropriate' use of services.

      Your example was visible to be, but are people asking similar questions to their networks through Facebook and other social media? Should the NHS provide a private channel for quick queries like this? Would it be an efficient way of using resources?

      I certainly have more questions than answers!

      Thanks to everyone for sharing here.

    2. I can see this type of approach working as long as it was set up properly[a system established], including with the appropriate governance and risk management in place. So yes it is scalable. In particular for regions of the world where there is a tyranny of distance eg. in Australia there would be immense benefits.

  9. A fascinating insight into the future of healthcare delivery. This is or should be the remit of the 111 service in UK and GP OOH I think. The role of telemedicine (which this case exemplifies) clearly can be extended.

    Karen Price is correct to be concerned about what we do not see. I hasten to add not in this case! Yet, patients often do not tell the whole truth and more mistakes are made in medicine by not looking than not knowing.

    Ideally, we should have a video link to study patient more closely and interrogate parent/patient in real time.

    In a free at point of delivery system like UK, the approach described for triage and simpel advice is fine.

    In a fee for service system, a system must be in place to pay for the consultation (eg Paypal; Google Wallet).

    Including telemedicine and social media in the medical school curriculum must be a priority to better prepare tomorrow's doctors for the new technology.

    Why are so few medical students using mobile tools, including social media to aid learning?


  10. Comment from Simon Carly via Google +
    Hi Anne Marie,

    Thanks again for asking the question in an area that is evolving at a speed that is a real challenge both to doctors and the regulator. It's a really interesting area to think about.

    +Damian Roland asked me to comment probably because I am an ED consultant in an inner city teaching hospital working in both adult and paediatric practice.

    I am therefore interested in this from two perspectives. Firstly, I quite like the idea of community based care, the extended family advice, that not EVERYTHING has to come to the ED (I had a very busy weekend). However, as an active blogger I'm also really interested in how we use social media to help learning without ending up in front of the regulator! At the moment we are trying to be really, really careful, but as the rules of the game are not always clear it can be tricky.

    1. Crowd sourcing is an attractive option, but for medical advice? I'm not so sure. Like many EM cases this is low risk for harm - but it is possible (retained foreign body, neurovascular deficit etc.). This injury and many others can be assessed using telemedicine principles, but that's rather difficult to do in 140 characters.

    2. If a doc does comment on this does that constitute a professional relationship with the patient? Arguably (and there probably is an argument to be had) it does and therefore there is a responsibility in ensuring that a 'good' consultation takes place. Can a 'good' consultation be achieved - I'm not so sure. Personally, I would probably not have commented on this case as although the risks of getting it wrong are really small they are not zero and I'm not sure how much I could reassure myself using just twitter.

    3. The Emergency Department is usually deadly quiet when England (or any other major team) are playing - don't tell anyone but that IS the time to come down - but shhhh, it's a secret between me and the rest of the blogosphere! Having said that a trip to the ED is not the only option here. Out of hours care anyone? Minor injuries unit? The GP practice? Just a thought, but we should not always be the default provider. Also, not all trips to the ED are dreadful. We do try and do a good job sometimes ;-)

    4. Confidentiality is potentially an issue. As an EM physician I am frequently amazed at patients/relatives/friends penchant for taking pictures of various bits of the injured/ill/sore bits and then uploading them to their twitter/facebook accounts in real time with clear personal identification (think embarrassing bodies live and you get the idea). This is not always done with the patient's consent I might add (e.g. teenage boys taking pictures of a friends dislocated finger and uploading live from the ED to facebook). Similarly at the scene of accidents I regularly see people taking photos and video, with rapid upload to the web. The standards that the public are applying are considerably less stringent than those expected of us (which is right and proper, but whilst in the past there was a gap between lay and the profession, it is rather more of a 'gulf' these days). Would this have been different if the patient's friend had taken the picture and asked for an opinion? Probably yes. Would it have been different if a doc had tweeted this for advice - absolutely yes (many would be up in arms if it was the doc without consent), but such differences do give us reason to stop and think about whether the advent of social media in healthcare might really challenge the current guidance around what is and what is not acceptable (my advice is to err on the side of caution at the moment).

    Similarly consider the copyright of the images originally taken and which are now rebroadcast over a variety of media. Copyright for the image probably remains with the person who took it and technically I suspect you need permission to re-use it (very unlikely to be an issue here - but just a thought).

    1. Thanks Simon. I'll address your points as you raise them.

      1. You may not be sure about crowd-sourcing for medical advice but as you point out and as this evidences it is happening. What is our responsibility as healthcare professionals? Should we be trying to increase the digital health literacy of the public? I raised related issues a few years ago in this post on patient organisations and Facebook.

      2. I think that if a doctor offers similar advice and in a similar style to a member of the public then it is not constituting a professional relationship. It is possible that when the doctors asked further questions about nerve damage etc then this is entering into a professional relationship. I'm hoping that the GMC is going to feed back on this soon and will pass this post onto them.

      3. In my area Minor injuries is referred to as 'minor a/e' I presume that Alex was considering a similar unit but I don't know about configuration of services in his area.

      4. In your opinion, how you would respond depends on who you think is asking for advice. But you have no way of knowing if the person asking for advice is really the patient or a parent or other relative or a friend. So how you this affect how you would respond?

      With respect to copyright, it remains with Alex. However by uploading to Lockerz he has granted them an irrevocable royalty-free license to distribute this image. It is added to the Storify from Twitter under the terms of that license.

  11. Rest of comment form Simon Carly via Google +

    5. If you want examples of crowd sourced advice in health care then I am sure that you can find some fantastic examples of poor advice, just as you can find good. As a cyclist I occasionally delve into some of the message boards for cyclists and read information posted on there about training, supplements, drugs, diet that is just dreadful, and in some cases potentially harmful. I can see similar things happening on twitter and I am not sure that the wisdom of crowds can be relied upon to be particularly wise.

    6. What about credibility? Some of the people in the timeline are ED docs, surgeons and a plastic surgeon......, but are they? We don't know this for sure and it is very simple indeed to set oneself up as something we are not. As a user of any advice given how can a patient be sure that the person is who they say they are?

    7. Lastly, we have the problem of porosity. Social media is easy to transmit on to other circumstances, people and situations. In this case we might get great advice for THIS laceration BUT it might be entirely inappropriate for another similar looking injury just 3cm away over a knuckle (when I would really want to know about tendon injury). Patients seeing this answer might then do the same for something that looks the same but isn't. You could see the scenario 'Oh I saw something like that on twitter and it just needs steristrips'.

    So, having been asked to comment I still think it's been a really interesting question and perhaps I have been a bit negative but I really do get the feeling that the rules of engagement are still out there to be defined. I am not entirely convinced that we have robust and reliable advice as professionals and I'm not sure that patients have access to the best advice.

    Anne Marie, I do enjoy your blog and I'm glad that there are people in the profession asking the difficult questions. Hopefully we can carry on rocking the boat of social media - but I just hope that it does not end up sinking.



    1. 5 and 6. These two points are related. I think that Alex has explained how he regarded the advice given. By the way, I have been on Twitter for years and spent a lot of time here. This kind of crowd-sourcing is a very rare event in my timeline. That's why I decided to share this story. I don't think we yet have evidence that the wider public does not help in developing digital health literacy, as described above, but perhaps the need for this will become more apparent.

      7. People are making many decisions about their health based on what they have heard and learnt about through friends and family. I'm not sure that this is any different. It may be seen by more people, but we don't know if it is likely to be taken more or less seriously than advice that is passed on offline.

      I don't think you have been negative at all. This looks a very simple case. if it didn't raise any issues then there would have been no point in me posting it here! I deliberately tried not to direct the conversation in particular directions when I first shared this.

  12. And further comment from Simon Carly via Google +

    Chatting with colleagues.

    You could test the ability of crowd sourcing to give advice by posting fictitious cases on twitter, facebook,.....and then reviewing and classifying responses (safe/unsafe etc.). Obviously would need to be seeded from non-medical twitter accounts. Anonymous cases etc.

    Clearly would need ethical approval (just in case anyone thinks they might try it this afternoon - would suggest not), but might be interesting to test the hypothesis.

    I'm sure someone will do this at some point (nice project really), but it's unlikely to be me.



    1. Interesting proposition! Let's see if anyone takes it up!

    2. Comment from Damian Roland
      Why do we need ethics?

      If I choose to post something about a blog I have written for instance? I can look at who favourites and re-tweets and I can record comments via twitter which have been made on the blog

      If I choose I can post a picture of my thumb - I can look at who favourites and re-tweets and I can record comments via twitter on the picture

      If I choose I can post a de-anonimysed CXR of a right lower lobe pneumonia - again I can look at who favourites and re-tweets and I can record comments via twitter on the X-ray

      So If I have a consented picture of a cut finger and choose to put this on twitter why can I not look at who favourites and re-tweets and I can record comments via twitter on the picture

      Twitter is the biggest collaborative networking experiment ever. You implicitly consent to analysis of your tweets by the very nature of tweeting.

      The only ethical dilemma is whether the very action of deciding this is research means the public have a right to know it is research...

  13. I think for your proposed experiment, I would create a new twitter account with the protocol clearly written up and on a link in the profile of the account. That would get around the potential problem of people not having fair warning that this is research. Then get local IRB approval - probably would get an exemption. Then start posting cases. Ethically, what is posted on Twitter is public record, and is research-able, I believe. I suppose you could put up a disclaimer tweet occasionally as well to let those who respond know that this is an ongoing research project. Sound cool. If you want to proceed, put the protocol on Google docs, and we can crowdsource the protocol and cases to present.

    1. I feel that as well as just sending public messages on Twitter we are also building a community. It is for that reason that I feel it is important that any research is done with the awareness of participants. But in any case I think that IRB approval should be sought. We've tried to make that clear on this google document about the #ukmeded chat sessions which we restarted last week.

  14. Thanks Anne Marie, I really enjoyed reading this and the associated comments. In terms of your question about how NHS Direct would respond, this would most likely have resulted in self-care advice from either a self-assessment using our website or mobile App or by calling the telephone service after certain risk factors were eliminated, e.g. potential for foreign bodies, depth and exact location of wound.


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