Wednesday, June 11, 2014

Guest Post: Twitter and the Physician – On the Etiquette of Trolls

Dino Ramzi, MD, MPH is a family physician who practices in Washington State and blogs at You can follow him on Twitter at @dwramzimdmph.


What is earnest is not always true; on the contrary, error is often more earnest than truth. – Benjamin Disraeli

I was recently called a troll on Twitter by academic physicians at two universities, one to which I was once affiliated. When I looked it up, I found that a troll is “a person who sows discord on the Internet by starting arguments or upsetting people, by posting inflammatory, extraneous, or off-topic messages in an online community, either accidentally or with the deliberate intent of provoking readers into an emotional response.” I wanted to strike back, but with wise counsel and some peace in my heart, I decided not to act like a troll.

The internet is proving no different than other forms of speech; it is fraught with rules of conduct and the opportunity for conflict. State medical boards, the American Medical Association and the Federation of State Medical Boards have written guidelines describing the limits to appropriate social media interactions for physicians. Most of these guidelines understandably focus on interactions with patients, but the FSMB comments on professionalism between physicians, albeit vaguely.

Having been active on social media for over a decade, I have found that the combination of anonymity and the emotions aroused by poor grammar and typos mix poorly with the power to publish at a moment’s notice. It is also difficult not to allow professional and personal unhappiness to seep too deeply into one’s writing. The unhappiness is fleeting, the posts are more permanent.

Some of the conversations I have seen and been involved in would raise the hackles of many a state medical board or academic employer. People do not speak with each other online as we would face-to-face. In academic circles, I would be invited to thoracic surgeons’ homes to dine and occasionally to spar politely with the chief of cardiology. But online, the discussion does not hide professional contempt and degenerates swiftly to the direst rants. I am aware of at least one urologist who lost an academic appointment after “losing it” during an online academic dispute.

Conversational flash points with subspecialists have included PSA screening, mammography, and most recently, CT screening for lung cancer. It is amazing how physicians react when their authority is challenged. There is a lot of shoddy science out there being accepted as fact without good grounding in clinical epidemiology. Physicians who raise doubts about the effectiveness or value of screening are frequently the target of unwarranted online opprobrium.

My primary concern is that screening is a population health measure, and while I want to understand the perspectives of subject experts, they are less qualified than primary care scientists to make decisions regarding screening policy. Make no mistake, I am a family physician and, like most generalists, have been exposed to specialists who belittle my knowledge, skills and credentials; it comes with the territory. Still, it stunning to hear disease experts repudiate the input of their more statistically-inclined colleagues. Screening, properly understood, has nothing to do with expertise in the disease. Surgical expertise and understanding of the biological behavior of various types of cancer cells does not translate into a basic understanding of epidemiology 101.

My second concern is the professionalism of the discourse. The disputes in question are essentially scientific, although the medium is better-suited for marketing than academic discussion. Claims like “you have your study and I have mine,” as I have heard, are not helpful to the integrity of the debate itself. There has to be an approach to dialogue that does not take a page out of the strategic communications handbook. In both the mammography and PSA controversies, urologists and other lobbies applied tremendous pressure on the population health experts to generate recommendations favorable to their cause, a process which undermines the credibility of science itself.

My third concern arises from my reading of the FSMB's guidelines on social media. The FSMB would suggest that physicians should be held to a higher standard of behavior, which means avoiding profanity even if goaded.

Physicians inexperienced in social media may fly off of the cuff, especially given that 140 character messages can lead to misunderstanding. Much better to ask repeated clarification, especially on the part of physicians exercised in the art of nuance, who can frequently take 4 to 5 posts to express themselves properly. When ideas are condensed, it is easy to miss two or three layers of allusion or implication. Better to take it into a medium better suited to lengthier discussions of ideas.

Remember that social media are public media where professional respect and a higher standard of behavior is expected, not for personal reasons or pride, but for the integrity of the scientific debate. We can all learn from each other, in person and online. Think before you post, or consider bouncing words written in anger off a trusted colleague before posting.