Web 2.0 in Emergency Medicine: Specialty Embracing the Future of Medical Communication

Abstract

Scott Weingart, MD, woke up to the power of Web 2.0 after tiring of pouring 15 hours of work into preparing lectures for a few dozen emergency medicine residents. “It was an insane amount of work, and it had a limited effect,” he said. “When they walked out the door, it was over.” Then, in 2009, he had an epiphany. Dr. Weingart, an attending physician in the Department of Emergency Medicine at the Elmhurst Hospital Center and an associate professor and the director of emergency department (ED) Critical Care at the Mount Sinai School of Medicine, decided to convert his resident lectures into podcasts. Now he's reaching a much larger audience: his bimonthly podcasts on anesthesia, critical care, and emergency medicine have totaled 1.5 million downloads and average 100,000 a month. “When I start converting those lectures into podcasts, a lot more people can learn from it,” Dr. Weingart said. “It's convenient. It's asynchronous; you can listen to it when your time allows, on the subway or in your car or on the train.” But taking his lectures digital and sharing them on the Internet isn't the Web 2.0 part. People have been podcasting for more than a decade, although the spread of iPods in the middle of the last decade popularized the digitally recorded lectures and talk shows. Web 2.0 comes in through the feedback the podcast generates. Through his Twitter account (@emcrit), Dr. Weingart tweets to his followers when a new podcast is available, and the feedback from other Twitter users is nearly instantaneous. He also receives feedback by Facebook pages and other social media Web sites. “I also get a few e-mails,” he said. “I guess those are from the Web 1.0 generation.” Physicians who still communicate primarily through e-mail may be surprised to learn they are already a generation behind, yet the Web is evolving away from such linear communication. The emerging Internet has been dubbed Web 2.0, which essentially is defined as collaborative and the sharing of information. Instead of just reading information, Web users both read and write in the new paradigm. In a post on his blog, Life in the Fast Lane, emergency physician Chris Nickson, BSc(Hons), BHB, MBCh, B DipPaeds, DTM&H, recently summarized some of the defining characteristics of how information is shared by Web 2.0: •rapidly accessible anytime, from anywhere with an Internet connection•current and continuously updated•dynamic and interactive•created collaboratively•easily stored, shared, and modified Some components of Web 2.0 have been around for the better part of a decade. Blogs, which foster a 2-way dialogue, were an early example of Web 2.0's participatory publishing process. Other examples of the new, interactive Web versus the old paradigm include Google documents, which allow other users to collaborate on documents over the Web, in contrast to Microsoft Word; and Wikipedia, the encyclopedia written by multiple users, in contrast to Britannica Online. Although these trends have been playing out for years, Dr. Nickson, a Perth, Australia–based physician, said they have accelerated during the last year. “Generally, this stuff is getting gradually more and more mainstream,” Dr. Nickson said. “It's really gotten a lot bigger in the last year, with new stuff appearing all the time.” That “new stuff” represents a virtual fire hose of information to emergency physicians just dabbling in the brave new world of Web 2.0. There are thousands of blogs about kinds of medicine, communities of physicians on Twitter who share thoughts and information in 140-character tweets, social networks such as Facebook, news aggregators such as RSS feeds, and medical wikis. That may sound overwhelming, like an information overload, but it need not be, argues Clay Shirky, a prominent Internet consultant and new media expert. Shirky says the problem of “information overload” dates at least to the 1500s, with the dawn of the publishing industry, when people began to have access to more information than they could read in their lifetimes. But people accustomed to the printed word don't feel overloaded because they have learned to use filters. In an interview with Columbia Journalism Review, Shirky explained his line of reasoning: “If you took the contents of an average Barnes and Noble, and you dumped it into the streets and said to someone, ‘You know what’s in there? There's some works of Auden in there, there's some Plato in there. Wade on in and you'll find what you like.' And if you wade on in, you know what you'd get? You'd get Chicken Soup for the Soul. Or you'd get Love's Tender Fear. You'd get all this junk. The reason we think that there's not an information overload problem in a Barnes and Noble or a library is that we're actually used to the cataloging system.” On the Web, there's more information than in a Barnes and Noble library, but those who feel overwhelmed by it simply haven't harnessed filters, which sort useful information from junk, in an effective way, Shirky said. “You never hear 20-year-olds talking about information overload because they understand the filters they're given,” he said in the interview. “You only hear, you know, 40- and 50-year-olds talking about it, 60-year-olds talking about it, because we grew up in the world of card catalogs and TV Guide. And now, all the filters we're used to are broken and we'd like to blame it on the environment instead of admitting that we're just, you know, we just don't understand what's going on.” A “filter” on the Web can be something as simple as choosing to read only news on The New York Times or Wall Street Journal Web site. But increasingly, Web surfers are migrating toward more social filters such as Digg, del.icio.us or Google Reader, in which users rate content and the highest ranked becomes the most widely read and shared. Similar filters exist for emergency physicians browsing for pertinent medical information. Life in the Fast Lane, which Dr. Nickson coedits with Mike Cadogan, MD, serves as such a filter by surveying the greater landscape of emergency medicine and summarizing the best of Web 2.0 in concise blog posts. This can take the form of news in emergency medicine or identifying and highlighting new journal articles that might otherwise be missed. “It's very difficult to obviously hunt through PubMed or journals to keep up with the flow of information,” Dr. Nickson said. “Podcasts and blogs are very useful for finding the most useful stuff, and oftentimes you'll get some expert commentary along with it.” Among the medical specialties, emergency physician bloggers are the most active, said Michelle Lin, MD, an associate professor of emergency medicine at the University of California, San Francisco, and a practicing physician at San Francisco General Hospital. Dr. Lin, editor in chief of the Academic Life in Emergency Medicine blog, said she has also seen a tremendous amount of growth in both publishing and readership of emergency medicine information online. This has led medical organizations and some journal publishers to move into Web 2.0 as well. “People are hungry for information that's hot off the presses,” she said. “Journals aren't quite as timely. Journals are moving toward social media, social media is moving clearly toward journals. I think they will meet in a happy medium.” The American College of Emergency Physicians (ACEP) has embraced the Web 2.0 movement, beginning its Central Line blog in May 2008 and maintaining active Twitter accounts and Facebook pages. David C. Seaberg, MD, the 2011 to 2012 president of ACEP, tweets with the @ACEPpresident account. But for now individual physicians and not organizations are leading the charge into Web 2.0, especially younger emergency physicians. “It's here to stay, and it's not going away,” Dr. Lin said. “I find that students and residents are much more willing to engage in these new tools. Unfortunately, it is very generational. There are very few older doctors using Twitter, for example.” Dr. Lin has advice for physicians new to the new Internet: start small. Forget the term “Web 2.0,” she said, which can seem a little daunting. “Start out by just sticking one toe in the pool. Sign up for Twitter and follow 5 people, and let it organically grow from there. Find a few more friends and follow them. Step by step, you realize you're not in a pool but a big ocean.” In the ocean there are all sorts of resources. Residents of the Temple University Hospital Emergency Medicine program, for example, have created the Web site Free Emergency Medicine Talks to help distribute the emergency medicine lecture library of Joe Lex, MD, a professor of emergency medicine at the university. At last count, there were more than 1,600 recorded lectures from conferences around the world, ranging from Alon Duby's “Is ATLS Obsolete?” to Ziad Kazzi's “The Public Health Impacts of a Nuclear Plant Crisis in Your Backyard.” There are also blogs that dig into a specialty, such as Cliff Reid's ResusMe site, in which he blogs about choice items from several dozen journals related to the topic of resuscitation. “I look for little bits of resuscitation magic,” said Reid, MD, an emergency physician in New South Wales. “I keep a spreadsheet of the journals I look at. To be honest, there are some gaps, some months I won't have a chance to go through all of them. So it's not a very rigorous or objective way of documenting the literature, but it's the kind of thing where I'm looking for something new, something that will help other physicians improve their practice. The mission is if I see something that I think will help someone else save a life, I will blog it.” But it's not a job, so there's room for some fun. At the end of December, because he liked it, Dr. Reid blogged a video from New Scientist magazine about a water-propelled jetpack. Like most other bloggers interviewed for this article, Dr. Reid does not publish information on the Web for financial gain, but rather to improve his own knowledge of medicine by joining the conversation. For now at least, that conversation is held primarily among physicians, with patients left outside of the loop. There's virtually no medical care being provided through the Web in the open platforms of Web 2.0. The primary reason for these restrictions, of course, is patient confidentiality. “I think there are hurdles, and there's very little historical precedent for this kind of thing,” Dr. Reid said. “Some of the juicy stuff I see on my job, the pictures, patient case information, would certainly make for interesting blog entries. But that's not an option. One sloppy move on my part could, at worst, terminate my employment. I'm not sure where it's headed; things could change, but for now I think the dividing line between the two is probably a healthy one.” In addition to blogs, Twitter, and other mediums, physicians are also getting together on their own social networks. Doximity, a social network that claims 30,000 physicians as members, says it has a Health Insurance Portability and Accountability Act-secure communication platform for physicians to connect and collaborate with their peers. Unlike LinkedIn and Facebook, Doximity membership is reserved for the medical community. “Doximity is filling a real void in medicine by enabling physicians to connect with colleagues, specialists, and former classmates and coresidents to expand their network, grow their practice, and consult with one another about patient cases,” said Jeff Tangney, the company's founder and chief executive. There are other sites as well for physicians, such as Sermo, which recently launched a mobile application that the company says allows users to have real-time consultations. According to the company, with 3 touches of the screen, physicians can take or add a photograph of a physical finding, radiograph, or laboratory result; choose a suitable question from the list available; and then immediately send it to relevant specialists in the Sermo network. Members can view and respond in real time. “This technology allows physicians to immediately impact patient care,” said Daniel Palestrant, MD, founder and chief executive of the company. Experts interviewed for this article agree the future is uncertain, but they agree that the increasing digitalization and collaborative nature are trends that will continue. Some of this is already in evidence with Dr. Weingart's podcast. He is one of the few emergency medicine Web 2.0 gurus who is turning a hobby into a part-time job and in doing so may be providing a glimpse of the future crossover between traditional medicine and the Internet. In the next few months, listeners of his podcast will be able to, for a fee, take a test afterward and earn CME credit. The podcasts themselves will remain free. He also sees a day soon when medical residents can do an hour or two of their 5 hours of weekly conference time at home, reading blogs or listening to podcasts. “That's the kind of thing that should count in the eyes of a residency review committee,” Dr. Weingart said. “It's time to embrace the future.”