Surgery – Eric Levi

Social Media: The Force Awakens

14 December 2015

The Center for Disease Control and Prevention defines “Epidemic” as an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area. Whenever there is an epidemic of any disease, Public Health Physicians and doctors in general pay a careful attention to the trend and devote time and effort into studying their progression. Like detectives, doctors assess the triggers and factors influencing the epidemic in the hope of forecasting its future trend and how it will affect the population in general.

There is a digital epidemic happening in the virtual world that doctors have not paid much attention to. There is a major worldwide shift in patient and population behavior in the way a person relate to information, including health information. This change significantly influences the nature of the therapeutic relationship between health care providers and patients.

I call this a Social Media Epidemic. You can call it anything else. Many health providers think that this is a passing trend; that social media is for teenagers doing “#selfies” and new parents posting endless baby photos on the internet. Some think that social media is an infinite repository of cat videos. Others think that social media is a place for trolls venting out their issues with society.

Social media, like the ubiquitous personal phone, is here to stay and it will change the way a patient meanders through their health journey.

Last year, Pew Research Center reports that 86% of all adults use the internet, and 59% (and increasing) of those above 65 go online. These are the big health consumers. There is a Social Media Epidemic in all age groups in general including the elderly population.

What is social media? Traditional media is a one-way information delivery, while social media is a two-way engagement. The key word here is engagement. In essence, social media allows the average person to engage with news, information and health data. They curate their own personalized news, share, like, retweet, comment and disseminate to their own social networks through Facebook, Twitter, Instagram, Pinterest, YouTube and other platforms. What is significant here is that the common person is no longer a passive receiver of information, but an active ‘engager’ of it.

This is a significant shift. This is good. The Age of Authority is out, The Age of Authenticity is in. The Age of Control is out, The Age of Collaboration is in. We can now engage a patient beyond the walls of the consultation room. Power on the road to health is back in the hands of the patient. The commercial world and other industries have caught this early. The health industry is, unfortunately, a step behind. We have yet to reach our “Tipping Point”. There are still many health care workers who have yet to embrace Social Media, which is rapidly becoming Normal Media.

The power of social media to enhance the clinician-patient relationship is waiting to be tapped. There is a disturbance in the force. We can add great health information on social media to overcome misinformation. We can enhance a face-to-face consultation with great pre-consult introduction and post-consult recommendation through social media. We can reduce patient anxieties by adding valuable videos on conditions and treatments. We can design health Apps that would augment recovery. Patients can find confidential support groups through Facebook. Social Media is a ubiquitous, free, accessible health tool that is waiting to be used for patients’ benefit. It’s a force waiting to be awakened.

And what if a clinician says to me “I don’t need Social Media in my practice.” I shall say, “That’s ok. I just need to let you know that your patients have moved.” Geographically, they have moved from the physical to the virtual. Many health care engagements are now occurring in the virtual world through social media. Patients engaging health information through social media is only going to get more common, more acceptable, and more normal.

Someone else may say, “I find your lack of faith in Social Media disturbing.”

Do you think this social media epidemic is here to stay? How does that change the way we work as clinicians?

Why I love my job

27 November 2015

Today is Thanksgiving Day in the US. Between this morning’s cases I had some moments to ponder on a consultation I had with a patient a few days ago. One of those conversations that is like a glitch in the matrix, seared into my conscience.

Here I am In Canada, far away on the other side of the hemisphere from where I used to be in Australia. I sat with a patient in clinic. People were speaking French behind the door and there was snow falling outside. The view through the window is magical. This gentleman in his 70s sitting in front of me is 5 years away from his treatment of mucosal melanoma of the oral cavity. For a head and neck surgeon, that is significant. Mucosal melanoma is an invariably fatal disease. It’s rare and it gets less media attention compared to its deadly cousin, skin melanoma. The survival statistics is bad. The five year survival rate is about 20%, that is, four in five patients will not be alive 5 years from diagnosis. After his diagnosis, he underwent a major head and neck resection. This was a major deforming surgery that often last 6-10 hours. Some doctors call operations like these ‘horrendoplasties”. Often the question is asked if the treatment is worse than the disease. With such a poor outlook, why, bring someone through such a massive surgery? He has a bigger chance of being dead than alive in a few months.

Because this week he sat in front of me and said, “I am thankful to be alive.”

Like a ton of bricks, it hit me again. This is why I do what I do. This is why I love my job. This is why I devote so much of my time learning to treat head and neck cancer. This is why I train so long and hard. This is why I do the late nights, the incessant oncalls, the long trips to conferences. This is why I stand for 6-10 hours sometimes to finish the job in the operating room. This is why I rely on a team of head and neck cancer nurses, radiation oncologists, medical oncologists, anaesthetists, speech pathologists, dietitians, etc.

It is an incredibly awesome privilege to hear my patients say, “I am thankful to be alive.”

Happy Thanksgiving Day.

Be thankful.

Christmas Wish For My Patients

21 November 2015

Here’s what I’m wishing for my patients:

Ear

Waterproof hearing aids that do not rely on batteries.

A tablet taken in the first trimester that would eliminate the development of congenital ear malformation.

A percutaneous, image guided insertion of a cochlear implant under local anaesthesia.

A pill to eradicate otosclerosis and acoustic neuroma.

A trans tympanic suction device that would extract cholesteatoma.

A fibreoptic trans tympanic device to microscopically inspect the middle ear.

An ultrasonic lithotripsy device to eliminate otoliths and BPPV.

A once off nasal spray to cure Meniere’s.

Tissue engineered ear drum.

Nose

A once off injection to desensitize the nasal mucosa and ablate polyposis.

A nasal spray that would shrink the inferior turbinate.

A microscopic robotic fibreoptic device for sinus surgery, transsphenoidal pituitary and anterior cranial fossa surgery.

A small cream application to expand and stiffen the nasal aperture and eliminate nasal obstruction.

Throat

A once off inhaled medication to prevent tonsillitis, pharyngitis, laryngitis.

A tablet to reduce the size of tonsils and base of tongue to reduce OSA.

An inhaled medication to eradicate vocal cord polyps.

An antiviral tablet to eradicate laryngeal papilloma.

Stem cell and tissue engineered vocal cords.

Head & Neck

An antiviral medication to eradicate Human Papilloma Virus.

A blood test to screen for and diagnose, thyroid and head and neck cancer.

A stem cell application to re-grow a resected tongue, floor of mouth and palate.

A sculptured implantable larynx, maxilla and mandible.

Endoscopic parotidectomy.

A handheld robotic fibreoptic device for transoral tumour removal.

Injections that would kill malignant cells in the lymph nodes.

A tablet that would kill melanoma cells.

Paediatric ENT

A nasal spray to stiffen the larynx and eliminate laryngomalacia.

A perfectly designed and implantable laryngotracheooesophageal complex to treat airway stenosis, laryngeal clefts and tracheooesophageal fistula.

A cream to eliminate arteriovenous malformation.

An inhaled medication to eradicate upper respiratory tract infection and otitis media.

And many other wishes.

But most of all,

That the whole world would stop smoking.

What are your Christmas wish for your patients?

Why did I choose ENT?

5 November 2015

Easy. It is the most beautiful of all the surgical specialties. I know, I’m biased. Let me tell you why (and I am about to have a word diarrhea here)

It’s true that ENT does not get a lot of fanfare in Medical Schools. Most medical schools may spend 1-2 weeks on ENT teaching. ENT is often out of sight and out of mind in many curricula. That is, until a doctor does a term in Emergency, Family Medicine, general medical ward or critical care. Suddenly ENT problems are appearing everywhere: nosebleeds, headaches, dizziness, tinnitus, ear infection, hearing loss, sore throat, sinusitis, airway emergency, thyroid problems, sleep apnoea, hoarse voice, tongue lesions, parotitis, dry mouth, etc.

In ENT, we get to deal with the most urgent of all conditions (airway emergency), to the least (facial plastics and cosmetics). We deal with the most common of all surgical operations (tonsils, adenoids, middle ear tubes) and the least (open craniofacial resection, orbital exenteration, tracheal reconstruction, brain stem auditory implants). We deal with newborns (EXIT procedure, choanal atresia repair, laryngotracheal reconstructions) and the elderly (skin cancer, etc.) We deal with medical conditions (headaches, dizziness, ear infections) and surgical conditions (facial trauma, head and neck cancer). We have short ops (middle ear tubes, botox injections) and long ones (head and neck reconstruction, acoustic neuroma excision, skull base resection). We do things beyond our traditional territories: CSF leak repair, middle cranial fossa approach, pituitary tumour, orbital decompression, scapula and fibula free flap. We do some really fine procedures (vocal cord laser, stapedectomy) and some big knife ones (maxillectomy, mandibulectomy, facial reconstruction). We cure quickly (Epley’s maneuver, tonsillectomy) or we care slowly (chronic rhinosinusitis, vestibular migraine). We do old procedures (tonsillectomy) and new ones (bionic ear, transoral robotic surgery). In essence, we do way more than most people think.

And we like it that way. The variety is interesting for us, and no one else knows what we do. We keep it kinda like a magician’s secrets.

Let me list some of the exciting things we do to give you a sample:

Otology (Ears)

Otoplasty, exostosis drillout, canal atresia repair, microtia reconstruction, myringoplasty, tympanoplasty, ossicular chain reconstruction, mastoidectomy, stapedectomy, endoscopic ear surgery, facial nerve decompression, semicircular canal plugging, superior canal dehiscence repair, meningioma, CSF leak repair, acoustic neuroma (transmastoid, middle cranial fossa, restrosigmoid), etc.

Rhinology (Nose)

Rhinoplasty, Septoplasty, turbinectomy, sinus surgery, endoscopic maxillectomy, transsphenoidal pituitary resection, endoscopic dacrocystorhinostomy, sphenopalatine artery ligation, orbital decompression, endoscopic craniofacial reconstruction, nasopharyngectomy, oesteoma drillout, meningioma, CSF repair, orbital abscess drainage, etc.

Laryngology (voice)

Vocal cord microsurgery, vocal cord injection, botox, laser vocal cord surgery, papilloma shave, vocal cord medialisation and lateralisation etc.

Head and Neck Cancer

Skin excision, lip reconstruction, glossectomy, pharyngectomy, laryngectomy, laryngopharyngectomy, maxillectomy, mandibulectomy, neck dissection, tracheostomy, craniofacial resection, rhinectomy, microsurgical reconstruction, thyroid, parathyroid, sialendoscopy, parotidectomy, etc.

Paediatric

Tonsils, adenoids, ear tubes, airway reconstruction, choanal atresia repair, microtia repair, mandibular distraction, laryngolamacia supraglottoplasty, vascular malformation, bionic ears, bone anchored hearing aid, drooling surgery, etc

Facial plastics

Rhinoplasty, mentoplasty, facelift, blepharoplasty, brow lifts, fillers, TCA peels, botox, liposuction, implants, fat transfer, etc

Trauma

Head and neck trauma, skull base trauma., etc

And those are the surgical cases. There are plenty more non-surgical fun to be had in ENT.

I love ENT because of the variety that I see everyday. A good mix of acute and chronic, medicine and surgery, kids and adults., rare and common conditions, routine and creative procedures, quick and complex cases, and lots more.

We’ve found gold, and that’s a secret that we hide from the rest of the world. Best of all, we get to help some people! Every specialty within medicine and surgery is fascinating. I happened to have found something I dearly love and enjoy.

Field Notes on Tracheostomy Part 2: The Problems

10 August 2015

So you’ve got a patient with a tracheostomy tube. And Houston, we’ve got a problem. What do we do? Here are some common problems and basic troubleshooting actions:

Tube dislodgment

This is often a problem in the first few days of tracheostomy when the wound is still fresh and the tracheostomy tract is still not mature or patent. Risk factors: thick neck, big neck, no neck, short tube, insecure tube (not in a sense of low self esteem, but tubes which are not well stitched to skin or well tied), emergency insertion (higher chance of poor technique), patient movement (frequent rolling or bed transfers for procedures, delirium, etc), high ventilation pressures (higher chance of tube migration), frequent coughing. It is always better to watch out for these red flags and do all you can to prevent tube dislodgement. Stitching in and tying down the tube may look uncomfortable but your patient will thank you for preventing an accidental decannulation. What happens if the tube gets dislodged though? Either a complete decannulation or creation of a false passage with the tip of the tracheostomy sitting in the soft tissues of the neck. If the patient is still machine-ventilated, you’ll get the immediate and obvious subcutaneous emphysema from the creation of the false passage. Pull the tube out altogether. Do not attempt to blindly reinsert as further false passage may be created. We’ve lost the airway.

So relax. Take a deep breath. You have some time.

Call for help.

Gently open up the wound or tracheostoma with your thumb and index finger. This is often enough to create a patent passage all the way into the trachea where you can pass a sucker or feed an oxygen cannula. You will need a light to be able to see down the hole, though.

With a tracheal dilator (or a pair of haemostat, artery, mosquito, scissors, nasal speculum, anything available in the trach tray which should be next to the patient), insert the tip into the trachea between the tracheal rings which had been previously cut and open the instrument up to open the airway.

Take another breath.

Suction the area around it and the track into the trachea.

Re-insert a new tracheostomy tube, or insert a flexible sucker or flexible scope into the airway and use it as a guidewire to insert the new tracheostomy tube.

Confirm the position visually with a scope, or with capnography.

If all the above maneuvers fail, and in a true airway emergency, simply put your index finger down the stoma hole until you can feel tracheal rings. Put the tip of your finger into the lumen of the trachea. Then either feed a tracheal dilator by feel into the airway, or feed the new tracheostomy into the airway alongside your finger. That’s the quickest way of re-establishing the airway.

If the tracheostomy tract is old (more than 2 weeks) and mature, usually the stoma is patent and you can reinsert a new tracheostomy tube under direct vision without much trouble.

Tube occlusion

This is probably the most common problem. Tracheostomy tubes can be occluded by blood, or frequently dried mucous and sputum. The use of humidification will reduce the chances. Regular cleaning of inner cannula helps. Regular suctioning with a flexible suction catheter down the lumen of the tube into the trachea also helps to prevent and relieve the tube of obstruction. A small amount of normal saline can be put down the tube to dislodge these crusts. In some cases, granulation tissue may be the obstructing lesion. This can be identified with the use of a flexible scope. Repositioning of the tube and some systemic steroids may help reduce the granulation tissue. Sometimes surgical removal of the offending tissue may be required.

Bleeding

The most fearsome complication is a fistula between the trachea and the innominate artery or any of the great vessels in the superior mediastinum. Note that a tracheostomy tube is only centimetres away from the arch of aorta, brachiocephalic and carotid arteries. Pathologies, surgical interventions, and radiation therapy may distort the anatomy and increase the chance of a fistula. If this was to occur, it could be fatal, and an emergency surgical intervention by ENT, vascular and/or thoracic surgeons is necessary. Tamponading the bleed by inflating the tracheostomy cuff and putting pressure around the stoma is the only temporizing method. The definitive treatment is by surgical exploration, ligation or endoluminal stenting of the artery.

Thankfully however, such a massive bleeding complication is rare. The more common is a small to moderate amount of bleeding that is non life-threatening. Most common cause of bleeding is at the subcutaneous level. Small vessels around the wound site may bleed. With a light source, suction and a little skin retraction, most clinicians will be able to identify a bleeding spot under the flange around the stoma. Several options: inject with local (eg xylocaine) and adrenaline which vasoconstricts the vessels, cauterize with bipolar or silver nitrate sticks, pack with surgicell or kaltostat. Another possible source of bleeding is the thyroid gland a little deeper. Injections don’t work too well here, but cauterization and packing still works.

Cuff leak

Not too uncommonly, the cuff pressure may be difficult to maintain. This can be due to a perforation in the cuff or the inflation line. If this is the problem, then unfortunately the cuff will always leak and a tracheostomy tube change is warranted in a safe elective setting. However, I have found many occasions when the one-way valve of the pilot balloon is faulty. Placing an IV bung on the end of that valve seem to sort that problem quite easily.

Tracheostomy tube change

Often done about day 7 and every few weeks after that as necessary. You will need 3 essential things: a light source (head light or procedural light), aflexible & rigid sucker, and a trache dilator. The older the tracheostomy tract is, the easier the tube change will be, as the tract is often mature, patent and epithelialized. In new tracheostomies, the tissue layers are still soft and may slide and herniate into the tract easily. The bigger the neck, the longer is the distance between skin and trachea, and therefore the more challenging it would be. Always have on standby an oxymetry, an airway exchange catheter (or a flexible suction catheter to guidewire slide tube in and out if necessary), a new stitch and stitch cutter, a trache tape, a new trache tube of the same size and one size smaller (in case there’s significant resistance putting in the same size, put a smaller one in).

Suction the airway, pull out the tube, retract the skin, suck around the stoma, inspect the track, put another one in with an introducer.

Bedside tray

Tracheostomy tube care is reliant on specific instruments. On the trache patient’s bedside there should be a box of tools that would help in routine management and the emergency care should an urgent problem arise. This should include: trache dilators, flexible and rigid suckers, torchlight, new trache tubes of same size or smaller, inner cannulas, gauze, normal saline, pickup forceps, tapes, stitch cutter, scissors.

Tracheostomy patients

Our beloved patients need to be empowered through education. The tracheostomy tube is a marker of severe life threatening illness. The tracheostomy tube is a safe airway but the only airway that the patient has. This is often in the context of patients who need multi-systemic and multi-disciplinary care. Meticulous care is required. Educating the patient in aspects of tracheostomy tube care will go a long way in alleviating their anxieties.

Thank you for looking after the patient with tracheostomy tube.

Field Notes on Tracheostomy Part 1: The Basics

10 August 2015

Hello! This is not a comprehensive textbook on how to manage patients with tracheostomies. This is a humble collection of practical brief notes, as requested by a twitter friend. This is a primer. For more extensive information, feel free to consult the big texts.

Tracheostomy

Someone once said that a tracheostomy tube is a piece of plastic that sits between 12 specialties. I can only count 9 (ENT, ICU, Anaesthesiology, Respirology, Thoracic, Nursing, Speech Pathology, Physiotherapy, Emergency), but I get the drift. Many of us will manage patients with tracheostomy tubes and find it a little uncomfortable. I hope to give you some practical basics to hang on to. There would certainly be tracheostomy protocols in most of the hospital you work with. Do read them.

Tracheostomy is a tracheo-cutaneous airway fistula surgically created to provide direct cannulation of the trachea and therefore direct ventilation of the lower airway. The opening on the skin is called a tracheostoma. (I know, some purists would say that tracheostoma refers only to the permanent stomal opening of the trachea after a laryngectomy- removal of the larynx and separation of the digestive and upper airway tracts – another topic altogether.)

How is it inserted?

Two main ways. Open surgical tracheostomy via skin incision and dissection of anterior neck tissues down to tracheal cartilages. Secondly, percutaneously through needle insertion and guidewire directed dilatation. This is usually assisted by a flexible scope to confirm position intraluminally. There are many percutaneous tracheostomy kits available. As you can imagine, there are advantages and disadvantages to both methods and complications associated with them.

Why tracheostomies?

In the emergency situation: to secure the airway in the context of upper airway pathology (eg. Laryngeal tumours, epiglottitis, Ludwig’s angina, base of tongue cancer, facial fractures, etc.)

In the elective situation: for prolonged intubation and ventilation (ICU patients, long term ventilation and toileting in neuromuscular disorders, etc), as adjunct to other procedures (eg. Major head and neck maxillofacial resection and reconstruction), and congenital airway pathologies (vocal fold palsies, craniofacial syndromes, etc.)

Tube choices

This can be quite confusing, but it’s actually quite logical. There are many options available, and we choose them on the basis of the indications.

First, choose the size in the same way you would choose an endotracheal tube size. Therefore most adult would be a size 7 or 8.

Secondly, do you need a cuff (balloon)? Usually the answer is yes. Having a cuff would provide a seal around the tube for ventilation, and prevent secretions or blood from going down into the lower airway. When would you choose an uncuffed tube? When the patient is able to breathe on their own and maintain their own secretions by swallowing. This is usually when the patient is expected to be tracheostomy tube dependent for a prolonged period.

Thirdly, do you need longer tubes? Depending on the anatomy of the neck, sometimes you need to choose a longer tube. The extension can be on the proximal or distal segment. In an obese neck, we need a proximal extension. In a long thin neck and high tracheostomy, we need distal extension. Some tubes have a flange that can be moved so the proximal extension length can be modified to the patient’s neck thickness.

Easy enough?

Other special features:

Inner cannula: an inner tube or cannula allows the lumen to be easily cleaned regularly. This is important as blood, mucous, and sputum can occlude the lumen easily. Pull it out, wash it out, put it back in. Easy. Note also though that an inner cannula narrows the internal diameter of the tube. The smaller you go, the harder the airflow.

Suction: Some tubes have suction-aid: a small suction hole just above the cuff so that secretions above the cuff can be suctioned. Very useful.

Fenestration: some uncuffed tube provide fenestration opening on the superior surface of the tube. This is useful for vocalization in patients who are tracheostomy dependent. Patients can breathe around and through the tube fenestration to project air into the larynx and oral cavity, and therefore speak.

Materials: most tubes are made of hard plastic. Some are made of flexible silicone to reduce pressure around the neck and trachea. There are even those made of metal for long term tracheostomy dependent patients. Note that different materials will result in different sizes of internal and external diameter of the tube. So a size 8 tube may have different outer diameters based on the materials, which means it may be a little wider and harder to insert.

Tracheostomy care in the first few days

I tell my residents that there are 3 significant potential complications within the first few days of tracheostomy: tube dislodgement, tube occlusion and bleeding. Tracheostomy tube care is critical in the first few days. Positioning of the neck and the tube is important, particularly as patients are being rolled or moved in bed. If the tube is not stitched to skin, a firm tape around the neck is essential. Sometimes firm padding around the flange is helpful. Humidification is important as the humidifying properties of the nose is bypassed in patients with tracheostomy. Humidification prevents dried mucous to become an obstructing plug in and around the tube. The use of inner cannula is recommended and the inner cannula should be washed and cleaned several times a day to prevent crusting and occlusion. Regular suctioning transorally above the cuff and through the tube under the cuff is necessary to prevent excessive secretions from seeping down into the lower airway and interfering with ventilation. Most newly tracheostomised patients are not able to swallow well or clear secretions with the tube in situ. Remember that patients are not able to produce an effective cough with tracheostomy tube in situ. Suctioning takes over the toileting properties of a cough. It is normal for small amounts of blood and mucous to be expressed around the stoma and during suctioning. Simple packing with gauze and suctioning usually resolve most problems.

What about tube dislodgement or excessive bleeding? What about change of tracheostomies? We’ll talk about that in Part 2: Problems.

Five People You Will Meet on Social Media

28 June 2015

Twitter is a communication platform, and therefore, it is a neutral medium. It’s not the medium itself, but how you use the medium that makes Twitter ‘good’ or ‘bad’. In my 5 years of being an anonymous and 5 months of being a named individual on Twitter, I have come to realise that different people use Twitter for different purposes. In general, these are the 5 people (or doctors) I have met on Twitter. They have enriched my experience on Social Media and taught me much about life and doctoring.

The Knowledge Distributor

These are the ones who frequently tweet and retweet various information, news, latest studies, guidelines and opinions. Following a few of these people will add to your knowledge base. They often have tens of thousands of followers and they usually have tens of thousands of tweets. They are good at disseminating information. Their timeline is full of information. The downside? They read like a newsfeed and therefore often lack the personal and social engagement that is an enjoyable part of Twitter. But they serve their purpose well. I learn lots of new things from them.

The Court Jester

The Court Jester is the one who entertains, enlightens and yet educates at the same time. They’re the ones who put up a mirror to our faces. They poke fun at important issues, sometimes even taboos, and bring up a very important message. They are often the ones behind the mask who would tell the truth when no one else would. They provide the behind-the-scenes look at the medical industry (or any industry) and challenge the status quo. As you can guess, they’re often anonymous. They’re the ones the lawyers and administrators warn you about. But I see great value in following them. Because they tell the truth behind their masks, I reckon every industry needs some of these, with respect of course. I can think of a few doctors who are anonymous who make a massive impact through their Tweets and blogs.

The Social Collaborator

They are fun to hang out with. They are one of the main reasons for joining social media. It is social after all. There are lots of conversations about life. Lots of food photos and baby photos. And cat photos, of course. One must never forget the abundance of cat photos on Twitter. Sometimes, in their eminently sociable space, the line between public and personal lives get crisscrossed. Raw emotions, anger, bitterness and hurts make their way into their tweets. It can be painful to watch. Sometimes downright unprofessional. But I love following them, because at the end of the day, we’re human. I need to always be in touch with the raw and unpredictable nature of human emotions and relationships.

The Relentless Commentator

The devil’s advocate. They seem to have an opinion on and a comment for anything and everything. Some of them good, some of them very critical and negative. They always provide a contrasting view and they’re happy to let loose with their opinions. You’ll find them debating certain issues with passion and their timeline reads like an angry verbal joust. It’s good to follow them because there are always many sides to any story and you get to learn from them. However the line between respectful difference versus discourteous disagreement can be very thin at times. First rule of Twitter: be respectful of others.

The Thought Leader

Here’s the one everyone wants to be. The person who leads the world with contemporary ideas and tweets their sophisticated perspective to everyone. Twitter truly adds to their impact and in some immeasurable ways, they are truly changing the world. They are examples of what’s good on Twitter. The synthesis and harnessing of people and expertise. There are not too many of them around, true thought leaders. When you’ve found them, they’re a treasure to follow as they enrich your days with colourful thoughts and perspectives. I’m certain that they would be as amazing in real life as they are on Twitter.

It would be great to follow a few of these different kinds of tweeps to challenge your thinking and enhance your perspective. What about yourself? What kind of a twitter person are you? My guess is that most of us would be a bit of all of them. Who we are on Twitter is probably defined by who we are in real life and what our purposes are in joining social media.

My Twitter Experiment: From Anonymity to Community

12 June 2015

I was once Australia’s most followed surgeon on Twitter, according to dear wife. She was probably right, as always. I had more than 3700 followers on my account, but very few people knew who I was behind that necktie avi. You see, I was an anonymous, or more correctly, a pseudonymous. There were 3 reasons why I chose to start off life on Twitter as an anonymous surgeon:

Who wanted to hear my voice anyway? I was a young trainee surgeon at the time. There were more important people and celebrities to follow. Who wants to follow me? Well apparently, as this twitter experiment rolled out, quite a few.

Is it really safe to be a doctor on Twitter? Australia was grappling with the legalities of doctoring and tweeting. No one was sure if it was safe to be a doctor on social media. I think we’re a little wiser now.

How do you use this Twitter thing? Twitter was new. It didn’t come with a manual. I haven’t found my voice. I didn’t know what works and what doesn’t.

So, over 5 years and more than 22000 tweets, I learned a few things from Twitter:

People are inherently interested in other people’s lives. So somehow, as I shared my victories and struggles through my surgical training, people listened and friendships were built.
Twitter is the great equalizer and collaborator. On twitter I can speak to a Professor, Astronaut and Miss Universe at the same time. We’re each individuals with a voice and the chance to collaborate on multiple issues affecting individuals and the great public.
The rules of real life applied to Twitter. Respect, kindness and authenticity are valued as much on Twitter as in real life. If you’re not a likeable person in real life, chances are, you won’t be likeable on Twitter.

After having found my voice and learned the good and bad of Twitter, I decided to lock the account, come out and start afresh with a new personal account. I’ve learned now the difference between the effectiveness of an anonymous, and that of a named account. I learned that these are the strengths of an anonymous:

People were happy to treat the anonymous as a sounding board of their issues. I had lots of DMs and private conversations with people from around the world. I suppose, it’s like talking to a bartender or cab driver. People were happy to spill out their guts to someone they don’t really know by name.
As an anonymous, I was the court jester or stand-up comedian who could point out issues in real life and poke fun at it with the hope of bringing a serious message. There are many effective anonymous accounts that do this very well. As a named person, however, I tend to be a lot more careful with my words as it can now be contextualized and locked to a person, time and place. The generality of the issues discussed suddenly become specifics.
Being an anonymous was for me a safe way to learn, observe and discover what twitter was all about. I learned the strengths and limitations of twitter. I have regretted a handful of tweets. Who wouldn’t? I have learned some good lessons.

Twitter is a powerful medium of communication and collaboration. I would encourage all physicians and surgeons to consider being on Twitter to extend your reach and impact. If however, you are concerned and hesitant about it, I would suggest a gentle progression from Twitter anonymity to community.

Why I love twitter but need to let it go.

2 June 2015

I wrote this on 27th December 2013 on my ‘anonymous’ blog. Interesting reading one and a half years later.

I joined twitter 3 years and 4 months ago. I did it twice. The first time as an observer-explorer, but gave up on it. The second time, with a friend’s encouragement I tried it again. Like any new technology, medium of expression, or tools, there were trials and errors. I didn’t know how to use twitter at first, but well, none of us did. People got into trouble for their tweets, and I did too. There have been doctors out there ready to crucify me and my tweets as it did not fit their brand of professionalism. The legal boundaries formed around tweeting doctors were blurred and there was a period when we doctors were forced to ‘come out’. All these anonymous witch-doctors were being pulled kicking and screaming out into the open.

Why did I join twitter?

Enjoyment (Social)

It’s social media after all. Twitter is mostly fun, encouraging and funny. There are a few out there for negative reasons, but it’s a mostly safe social arena. I have met many wonderful, interesting, fascinating people who are now dear friends to me. These are not friends I’d ever meet through ‘traditional’ social methods, frankly because I have no time to socialize in parties or pubs anymore. Remember that for every tweet, there are plenty of personal DMs not seen by the public. Some of those DMs from close twitter friends have pulled me together during difficult times. Hey, I even got Canadian socks from an awesome Twitter friend who I’ve never met before. It’s like pen pals in the past. The sharing of words and lives is an inherently human experience.

Education (Learning)

I’m on twitter to learn a bit of medicine, surgery and life skills in general. Some of the studies that have changed the way I practice surgery I first read on twitter. Some life wisdom that has encouraged me to live a better life I first read on twitter. Funny one liners, trivia, awesome pictures, random information, latest news and all sorts of beautiful things that colour my day all gets delivered through twitter. I have learned much through twitter. I’m usually the first on my unit to hear about a breaking news, new ideas, interesting studies, etc. Twitter adds colour to my days.

Engagement (Teaching)

Yes, if you haven’t figured that out already, I’m an ENT surgeon in training. It means that one aspect of my calling as a doctor is to teach others how to live better lives and help them through their ENT problems. I also freely give out life advice that I’ve found helpful. Take it or leave it. More importantly, I want people to laugh or smile when they read my tweet. I want people to enjoy my tweet, not get a PhD in ENT.

What else have I learned through twitter?

Twitter is here to stay.

Just like moving from snail mail to e-mail, from phone landlines to mobile phones, from desktop computer to portable personal computing, Twitter is a new medium of communication that is here to stay. When I’m looking up another doctor, I not only look up their addresses, emails or phone numbers up, I also look up their twitter handle. Twitter is a new address, a new email, a new phone number, a new contact point in this increasingly interconnected society we live in. It almost does not matter if we live on different continents, as long as you’ve got twitter, you can contact/DM/interrupt my day any time, as if you’re a colleague working in the next operating theatre.

Twitter helps me express my thoughts.

I used to journal my thoughts. I still do. The word is my medium of self-expression. I find that I feel better if I can articulate my convoluted mind using a few well-chosen words. Not that I’m a poet or anything. Twitter is like a toothbrush. It keeps my brains clean and free from thought sediments. My wife knows this and although she hates me for spending too much time on twitter, she also knows that it is my medium of expression. It’s a way of me clearing up my thoughts as I go through my stressful surgical days. That’s why I hope to continue tweeting to keep my mind active.

Get a shorter twitter handle next time.
3,700 followers mean nothing if you’ve added nothing into their lives.

There are celebrities with millions of followers. I don’t want to be that. But I do want to be an inspiration to a few. I want to help if I can. Twitter is a unique method of getting into people’s lives. When I’m followed, it means that I’ve been invited to enter into the lives and thoughts of someone, and I need to respect that. I cannot be putting up garbage on their timeline. I want people to laugh, or be inspired, or learn something from my tweets because they have allowed me the privilege of allowing my words to enter into their conscious minds.

The timeline is the appetizer. The DMs is where the public becomes personal.

I’ve seen your hurts on your DMs (Direct Messages). I want to reach out and help. Words, even mere words, can be an incredible powerful agent of change. Tell me your pain, and I will do what I can to share in your struggles. It’s like being in a busy train, sometimes you strike up a good conversation and tell your story to a total stranger who can share your pain even if only briefly.

People are inherently interested in other people’s lives.

The common bond amongst us all: life. We have lives to live, stories to tell. I’m interested in your life and thoughts. And I know that many people are interested in what it’s like to be training as a surgeon. I tell you my story. I allow you to see the raw emotions I feel when I’ve been on call non-stop for 10days. I tell you my struggles with family, work, dying patients, etc. And I’m interested in your stories too. It’s like sitting around a campfire, trading stories, enriching lives.

Don’t judge a tweep by a single tweet. See the whole timeline.

Lots of bad twitter fights happen because of this error in misinterpreting a single tweet. In life as in twitter, there is no point winning an argument but losing the friendship.

Everyone is equal and accessible on Twitter.

I can speak to a professor, an astronaut and a Miss Universe contestant on Twitter. And I get to discover that they are all down to earth people, happy to live out their ordinary lives. It’s inspiring like that. Similarly, I hope people can just tweet me up and I can help them in whatever way I can.

There are different uses for twitter.

Some are on twitter for commercial reasons. Some for clinical reasons. Some for political reasons. Others like me, are here for fun. Just like in any social gathering, don’t assume that everyone is here for serious purposes. For example, my lighthearted comments about medicine and surgery have been mistaken for serious criticisms. The funny thing is I never meant for any of my tweets to be a serious opinion. I liken myself some times to the court jester who performs and cracks jokes to provide a lighthearted alternative at looking at this serous business of life and surgery. The Surgical News, which is the monthly magazine of The Royal Australasian College of Surgeons, read by thousands of Aussie and New Zealand surgeons routinely include several articles written by anonymous Prof R U Kidding, Dr BB Gloved and Dr IMA Trainee. They are anonymous articles meant to poke fun at the serious business of surgery. Sometimes being told directly about an issue has a negative effect compared to being told a funny story by an anonymous. The effect is the same though: laughter, enlightenment and behavior change. I hope my tweets do that. If you’re looking for medical information, there are plenty of doctors on twitter who do that better than me.

It’s ok to be an anonymous doctor.

I know some would not agree with that. This is how I see it: being a doctor is who I am. I cannot separate who I am in real life and who I am on twitter. But I’m not here on twitter as your doctor, so I’m not going to offer you personal medical advice. Also, I’m not here as a professional entity, although I will remain professional and courteous. I’m not here marketing my surgical practice. I’m here as me, myself and I, who happened to be a doctor and tweet doctorish thoughts. If I can help you in any way, does it matter if you don’t know my full name? I’m not endorsing any special treatment, surgery or thoughts. You don’t really need my name.

Sometimes I share the raw emotions, the confusions, the frustrations, the anger, the uncertainties, the inexactness of the science and practice of surgery. All those things are real. Real patients and real doctors know that. Medicine is not a sterile, perfect, exacting practice. I don’t think I’m painting a bad picture of medicine and surgery when I share some of those raw experiences. I don’t think I’m being unprofessional when I’m questioning my own and my hospital practice. I don’t think I’m being unprofessional when I’m sharing the human side of medicine and surgery – the blame game, the politics, the money, the administration, the ego clashes. And I don’t think that I’m hiding behind my anonymity when I do that. I’m sharing the real story behind doctoring that does not need to be hidden. One day I will come out. But at the moment I still feel that I am effective being an anonymous. And yes, I am accountable for every tweet I have tweeted. I’m fine with that.

Twitter has become a routine part of my daily life. I’ve had so much fun with it. I’ve learned much, and I love it. It has given me so much needed support during odd hours of my nights. It has been a real enjoyment, education and engagement tool. I hope to have inspired some lives out there during the process.

But I need to let it go.

Why? Because it has taken up so much of my thoughts and my time. I need to focus on something else of immense importance in the next 3 months, and I need to be single-mindedly preparing for this and this alone: FRACS Fellowship Exam. It’s like taking a sabbatical. I need to focus on studying and training myself up to be the best I can be, so that hopefully I can return as a fully trained surgeon and be even more helpful for the people around me and my friends on twitter.

So farewell, my friends. While I fall in love with ENT, will you keep a space for me when I return.

5 Reasons Why Surgeons are better at Tweeting

8 May 2015

I wrote this on 20th November 2011 on my previous anonymous blog. This was meant to poke fun at surgeons and Twitter. what do you think today?

A/Prof Katherine Chretien and team has recently published a landmark study on Twitter Physicians. It was aptly titled “Physicians on Twitter”, published in The Journal of The American Medical Association, February 9, 2011—Vol 305, No. 6, pg 566-568. There are some very interesting statistics there. Definitely an article worth a read particularly if you’re interested in the use of Social Media in Health Care.

There have been many correspondences and blog posts written in response to the article. Most of them have indicated the good progress that doctors and medical professionals are making in utilising tools such as Twitter, Facebook and the like.

When the article detailed the profile of doctors on Twitter, there were a few surprises.

Guess which group of medical specialists Twitter the most?

Surgeons.

That’s right! There are more Tweeting Surgeons than other specialties. (Read the article for the rest of the specialties and see how your specialty ranks.) I found this a little interesting because we surgeons often work longer hours and are usually stuck in theatre doing stuff. When do we find the time to Twitter?

So I started to analyse my own tweeting habits, and asked myself why Surgeons tweet more than other specialties.

I think I’ve found 5 reasons why Surgeons are Superior at Tweeting. Here are the reasons:

5. We are always waiting for theatre.

I don’t know how it works in your corner of the world, but here in Australia, taking someone to theatre is like getting a bride to the church altar. We have to book the church, get the certificates signed, get all the equipments, romance the anaesthetists (who are usually the atheists who do not believe the surgery need to happen and withhold their blessings), bla.. bla.. bla… After all the hard work of organising theatre, we wait till the cows come home or pigs fly. So we surgeons end up having lots of times twiddling our thumbs waiting. We wait, therefore we tweet.

4. We are brief, succinct, and to the point.

We are simple people. We’re not multifactorial. We can’t compute the cosmological reasons why someone should be on omeprazole instead of esomeprazole in some situations. Hence, our simplicity limits our thought processes to 140 characters only. Perfect for twitter.

3. We’re more comfortable speaking out when no one talks back.

The beauty of twitter is that there are so many conversations going on at any one time. It’s like a college party. So many tangential conversations, and in the morning you can’t remember who you’ve talked to last night. Surgeons, being surgeons, love to impress people, and perhaps we like to impress but not really want to be spoken back to. Perfect communication style for twitter. Follow me, and I might follow back, maybe.

2. We are not comfortable socializing with real people.

We like our consults brief, our operations long, our patients asleep, and our anaesthetists asleep as well. Just like twitter.

And the top reason why Surgeons are More Superior at Tweeting:

1. We have the most outstanding, intelligent and witty one liners.

Perfect for twitter. Some call it sarcasm, others call it irony. We say, witty.

Now if you are a surgeon, any other reasons you are better at Twitter compared to your non-surgical colleagues? If you’re not a surgeon, aren’t we right?