Transcript

- Colleagues and friends, thank you for joining us for another session of the virtual operating from Neurosurgical Atlas. My name is Aaron Cohen. Today we have an exciting dialogue between Dr. Brian Hoh from University of Florida and Dr. Allan Levi from University of Miami. They're gonna talk about pros and cons of using social media in the neurosurgical practice. As you know, social media has really been an important tool in terms of marketing, exchange of ideas, depending on which platform you're using. However, just like any other tool in neurosurgery in general, comes with its own advantages and disadvantages. So I have asked Dr. Levi to take side of a negative or sort of challenges of being involved with social media, and Dr. Hoh will talk about the blessings of social media in neurosurgery. Brian and Allan, very blessed to have both of you with me. We're very excited to hear both of your sides, and at the end, we'll have a discussion. So with that, Brian, please proceed, and thank you.

- Great, thanks. Thanks, Aaron. So I've taken the side of social media in the world of medicine as a blessing for neurosurgery. These are my disclosures. None of them are relevant. And I just wanted to set the stage for this discussion by creating a scenario for you to think about. So let's say it's the mid-1990s, and you have this idea that you want to create a digital encyclopedia. We're all familiar with "Encyclopedia Britannica," the hardcover, multi-volume encyclopedia that sits on our bookshelf, serving as the ultimate resource guide. But now in the age of technology and the digital age, you have the idea that you wanna create a digital encyclopedia. Well, you're presented with two options of how you're going to go about that. The first option is you could go to Microsoft, the world's largest leader in information technology, pay professionals, experts on the content matter, to write and edit thousands of articles with a team of high level managers to ensure the project's completed on time within budget, and you sell this digital encyclopedia for revenue to consumers. The other option is dramatically different, to create an online resource for anyone, they don't have to be experts, to voluntarily contribute and edit without getting paid and make this available to everyone for free. Well, I think probably most of you know what eventually happened and what went out. So the first option was Microsoft Encarta, which was a digital encyclopedia created by Microsoft, sold to consumers, and came in the form of these CD-ROMs, and ultimately was an abject failure. It was discontinued in 2009, and hardly anyone knows about it or uses it. The other option was Wikipedia, created in 2001, over a billion visitors per month, over 61 million articles in more than 300 languages. And here I've put a snapshot, a screenshot of Wikipedia's entry about Microsoft Encarta. And in there, they indicate in March, 2009, Microsoft discontinued Encarta. And so I just bring this as an example or analogy perhaps of how social media is in the world of neurosurgery. So maybe "Encyclopedia Britannica" or Microsoft Encarta are kind of the traditional, or historical, or conventional ways in which we in neurosurgery have communicated our research, how we've taught trainees, residents, fellows, students, how we connect with each other at meetings and conferences, communicating through journals, hardcover textbooks, teaching in the classroom, et cetera. And perhaps social media is more like Wikipedia. It's free, volunteer, doesn't have to be in person, and is the way that the younger generation communicates, reads journal articles, communicates science, learns, et cetera. So is the intrusion of social media in the world of medicine a blessing or a curse for neurosurgery? Well, in some respects it probably doesn't matter, because social media will continue to play a major role in the medical field. Whether we like it or not, social media is here to stay and will continue to grow and be a major factor in all medical fields, including neurosurgery. In this survey of neurosurgery influencers and people that participate in social media, over 92% agreed or strongly agreed that social media will continue to play a major role in the medical field. It's here to stay. And particularly among the younger generation. It is ubiquitous among trainees. Whether the older generation, and I include myself, you, Aaron, you, Allan, whether we like it or not, our trainees, the younger generation use social media and see it ubiquitous in their use. And although most use social media for personal social communication, they also use it for academic purposes as well. And when you survey younger neurosurgeons, they all indicate that social media is beneficial, and they are more likely to read journal articles if it's on social media or highlighted on social media. So if you are doing research, if you are publishing in the field of neurosurgery, neuroscience, and you want people to read your science, to read your journal articles, then you should post it and announce it on social media, because that is going to be the best way that you can get your science communicated to the younger generation. How did I get involved in social media? Well, my entree into social media was relatively late. It was in 2012. And if you think about that, that's 11 years ago. The reason I got involved in social media is as a member of the executive committee of the Congress of Neurological Surgeons, Ali Rezai at the time was the president or president-elect, and he assigned me the role of working on social media for the Congress of Neurological Surgeons. And so in 2012, the most viewed video on YouTube was "Gangnam Style." The most retweeted tweet on Twitter was Barack Obama, four more years. And here's a list of the top 10 influencers on social media at that time, Lady Gaga, Justin Bieber, Katy Perry, et cetera. And so we've come a long way, but in a relatively short period of time, social media has become a major force in ubiquitous among our society and culture. So I've taken the position, I've been given the position to argue for social media as being a blessing for neurosurgery. And one way that social media has been a blessing is it has really encouraged patient engagement. If you think about it, before social media, what were the avenues or ways in which our patients could become actively engaged and connect with each other? Well, social media really has been a way in which patients could do that. And in this systematic review of social media in neurosurgery, the authors found that the content of posts really reflected patients and caregivers becoming engaged, requesting or providing information about their disease or condition or surgery that they underwent, and seeking or providing emotional support or formal connections to other patients and caregivers going through the same condition, disease, surgery, et cetera. Social media is also a platform for research awareness and patient experiences. In this study of cervical myelopathy and social media, the authors found that tweets most often discuss research, spreading awareness, or informing the public about cervical myelopathy. Tweets describe personal patient perspectives on living with cervical myelopathy. So, again, a way to communicate research and awareness and also a way for patients and caregivers to become engaged. In this study of social media for cerebral aneurysm patients, the authors found that patients often engaged in common themes on Instagram of survival, spreading positivity, and sharing their experiences in recovery and rehabilitation. And not only for patients, social media is a platform to empower caregivers. In this study of patient and family experience after pediatric spine surgery, social media was viewed as a way for patients and caregivers to discuss topics related to pediatric spine surgery, discuss the personal experience, and allow caregivers the empowerment and ability to engage. But I do say that social media is a blessing for neurosurgery if used responsibly. And like many other things, there are ways in which some bad actors are using social media in an irresponsible way. And we've seen examples of irresponsible use of social media in the news and with consequences. And there have been physicians who have lost their medical licenses because of irresponsible use of social media. And this has prompted the AMA to publish Principles of Medical Ethics and ways in which physicians can use social media in a responsible and ethical manner. And perhaps neurosurgery as a field could adopt these same principles or modify them to be specific for our own field. One way in which we need to be responsible as users of social media is to recognize the biases or weaknesses of social media. And just like in our journals, there's publication bias. There is significant publication bias in social media. And this is one study that highlighted this in terms of mechanical thrombectomy cases in social media. And we see this every day, neurosurgeons, neurointerventionalists, other surgeons and procedural physicians like to post their best cases, their best patients, their best outcomes on social media. And very rarely do we ever see a bad outcome or a complication. And this study just highlighted that the cases of mechanical thrombectomy that were posted on social media were by far almost always the best outcomes and did not report any outcomes less than a TICI 2C or 3. There were no reported complications, intercerebral hemorrhages, et cetera. And so we just need to be wary of the publication bias that exists in social media. Why should a neurosurgeon use social media? Well, here are just some possible reasons, and they may not be reasons for you, but this study highlighted that of those neurosurgery departments and neurosurgeons who had social media platforms, they were more likely to have higher ratings of physician review websites. Now, this is a correlation, it doesn't prove causal link, but it tended to find that neurosurgeons and neurosurgery departments that had social media platforms also happened to have greater or higher online physician review website ratings. Again, here's another study that showed that surgeons with a social media presence tended to have higher ratings and comments on physician review websites. And we know that more and more in this day and age, these physician review websites are very important. Patients are looking at these review websites before they come in to see you as their surgeon. It informs the way that they view you and the way that they approach the clinical encounter, and the way that they are referred or seek out neurosurgeons for their condition or diseases. Again, in spine surgeons, social media's presence correlated with higher and better online review scores on physician review websites. And in this study of neurosurgical oncologists, social media increased patient engagement and networking for their patients within that medical community. For those of you who are in academic neurosurgery departments, this study tended to show that the highest reputation rate programs had visible social media presence. And so, again, not a causal link, maybe correlation, but those neurosurgery departments with a strong social media presence happened to also have the highest reputation rankings on Doximity. What do I post on my social media? Well, each of us have different purposes or reasons to use social media. I tend to post things to promote my department, to promote my research, to promote our residency program, to highlight the achievements and accomplishments of our residents. And our department also is actively engaged in community engagement. We do volunteer, community service activities each month, and I use social media as a way to highlight and promote that community engagement. And with that, I now yield the floor to my colleague from South Florida and good friend Allan Levi.

- Well, thank you, Brian, and I appreciate it. I'm just going to share my screen, and I am going to take the opposite view here. So social media in medicine and neurosurgery, it's a curse. And I'm gonna emphasize this word a couple of times during my talk, a short form of social media, SoMe. And before I get into that, I do wanna thank Benjamin Klein, who's at the University of Toledo College of Medicine, who is one of our diversity scholars last summer, who helped me put some of these slides together. He's currently a MS2 and very interested in neurosurgery, so look out for him. So what is exactly social media? It really encompasses a lot of different things. There are different platforms, and each of those platforms have different ways of engaging you. So Twitter is mostly text and photo. Instagram and YouTube is mostly photo and video content. And LinkedIn and ResearchGate are mostly network sites. So just this concept that not all social media platforms are the same. And they definitely have been around for a long time, 25-plus years. And the purpose of this slide is to show you when some of the major social media platforms started, but is also important when they actually stopped. And this will become relevant in some of my arguments about using social media, that there is some social media site instability out there. It's no doubt it's big and it's growing. That's what this slide shows. But, you know, we only have seven billion people on the earth, and probably close to five billion of them use social media. So I would agree with Dr. Hoh in that, you know, it is here to stay. But it doesn't mean that we shouldn't be wary about it. You know, how did neurosurgeons fit into the social media world? Well, you know, when we compare our usage to other surgical subspecialties, we're about on par. And not surprisingly, our plastic surgery colleagues use social media quite a bit more than us. And this is a paper from JAMA showing the different types of social media usage amongst surgical subspecialties. We gave this talk at our academy meeting not too long ago, and I knew I was gonna have a tough time convincing my colleagues that there's a lot to worry about, especially since this particular paper demonstrated some of the top social media neurosurgeons. And of course my competition in the lecture, Dr. Hoh, is ranked number five here. This is about a year old or two and so things may have changed a little bit. Maybe Dr. Hoh is number one. But that was what it was in 2022. And, you know, it's interesting when you look and take a deeper look as to who in neurosurgery is using social media. Not surprisingly, it's the younger generation, sort of the 35 to 54-year-old age group. And on the right of the screen is what social media platforms are most used is Twitter, followed by LinkedIn, followed by Instagram, and things like TikTok and others are sort of lower down. We did a study about two years ago. It was a tremendous amount of work to put this together, but the specific question that we were asking is, if you look in academic programs and you look at subspecialties, are there certain subspecialties that use social media more? And there was clearly a predilection for vascular and neuro-oncology to be more on social media, and spine and peripheral nerve, me, use social media less. The other correlation was that larger programs were more likely to have social media platforms. Those were the two big conclusions from that paper. So my colleague from University of Florida has told you that, you know, this is good, exchange clinical knowledge, showcase research, connect, educate patients, promote care, promote the department, promote publications. And I would say, yes, you know, these are all good things and that they can benefit your practice as indicated on the right. However, I am going to go through a series of 10 different reasons about why you should be wary, and in fact it could actually ruin your career and/or impact your health. Very important topics and issues. So we're gonna go through trustworthiness, professionalism, privacy, time lost, something that I call scratching the surface, something called FOMO, fear of missing out, hazing and censorship, social media site instability, psychiatric and sleep disturbances, and this concept of Darwinism and the survival of our species. So basically what I'm saying is social media threatens our species, and we'll get into that at the end. And I thank Dr. Hoh for bringing this paper out. I thought it was an incredible paper by Waleed. And, you know, just to get in a little deeper is that he did a survey of Twitter posts by endovascular physicians and showed that the outcomes and reperfusion scores compared to multiple, multiple randomized trials were far in excess in terms of the outcomes, positive outcomes. No complications posted. There's obviously, when you use social media, there is no review process, like when you publish in a journal. So people can put anything that they want out there. And we see it unfortunately in our practice. We'll see physicians post, you know, incredible endovascular results, and then we'll see the patient afterwards who has, you know, who has a neurological deficit, recanalization of whatever artery they were working on, because they only gave you 30-minute outcomes. And you really wanna see, you know, one-year outcomes to make judgment on new procedures. And this misinformation is a real risk. And I think most neurosurgeons understand that. 'Cause in a survey of social media and neurosurgery that 51 or more than half stated that this misinformation is the number one disadvantage. And 62% of neurosurgeons said that they would not be involved in any research that use social media to collect data. 'Cause it's just not, it's not reliable, it's not trustworthy. And in terms of educating patients, this particular study looked at what was out on social media about lumbar disc surgery, and was that YouTube data reliable, and did it help patients understand the procedure and its risks? And most of the stuff that they reviewed was not reliable. This was a study done in England. One of the biggest concerns is professionalism. And this is an example, and I'm not gonna get into the details, but it's a local example, you know, because I wanna protect the individual that was involved, but essentially involved a resident, you know, who had one bad, you know, 92nd period of their lives. It was videoed, it went viral. And I'm sure everybody on this, you know, webinar understands what viral means. It means that it exploded across the world within hours. And I was getting emails and text messages from colleagues in Germany and New Zealand within hours of this being released. And it just goes to show you how unpredictable things can be in your career if you do the wrong thing. And how social media can spread that, just like it said, like I said, like a virus. And so you have to be weary of your own professionalism and how things can get leaked out and can destroy your career.

- You are a beautiful person, but one day, you have a bad day.

- I'm gonna repeat that, 'cause I think it's so important, and it could affect any and all of us.

- But sometimes, you are a beautiful person, but one day, you have a bad day.

- Right, and social media can proliferate that in hours. And, you know, if you're looking for a job or if you're looking for a residency position, don't think that your employers won't look at your social media presence and make judgements about you. So it's something that's out there, and you have to exercise sound judgment for anything that you post. How about time? Time is certainly precious. So why waste it on social media? And when we look at some of the published data on social media use, and again, this was social media use amongst the top hundred users. When a survey was done by Dr. Jabbour and colleagues, they found that, you know, most were spending about an hour a day on social media, and a certain percentage, a quarter, was spending one to three hours a day on social media. That's a lot of time. It takes away from your family, from your practice, reduces clinical efficiencies. So if you don't think this is you, and I'm just making this stuff up, you know, you can do your own self-test of how much time you spend on social media. Because if you look at your iPhone and you swipe right, you can see how much time you're spending on Twitter and Instagram and all these other things. So it's a way to check, an internal check of how much time you're spending doing this as opposed to other tasks. Dr. Hoh again helped me out in my argument here, giving examples of surgeons who have lost their license because of things that they posted on social media platforms. And, you know, I think this person may have had all the good intentions in the world, but because they didn't go about it in the right way, they lost their license. And it has a lot to do with privacy and how you get consent to post pictures and videos on social media platforms. And all I can tell you is that institutionally, every single institution has different rules and encourage you to look at your own institution, ask your people what are the rules and regulations about posting medical information, and what kind of consent do I need to post this. You don't wanna be left like this plastic surgeon. And we have, again, some local examples, they're in the news, I don't mind repeating them, but early on, this is now 2012, so over 10 years ago, there were pictures that were leaked from the trauma center on this sort, again, famous face-eating attack by a person that was felt to be due to bath salts. It's just a very bad, unprofessional thing to do to leak an emergency photo like that on social media. And there was consequences. These are lawsuits that have happened again similarly of people leaking photos in the hospital without permission. And some thought, well, you know, it was okay because there was no identifying information. Well, that, and it's not necessarily a protection for people using pictures and posting it on social media, and again, encourage you to look at your individual institutional policy. The next reason is something I call scratching the surface. And I'll give you an example of what I mean. And without using a social media example, but it's like, you know, if you spent, you know, three weeks reading "War and Peace," and you said, "I read the book," that has a different meaning than spending two or three hours going to a movie and saying, "I saw the movie," you know? So did you read the book? No, no, but I saw the movie. Well, the movie is gonna give you a different flavor than the book. And then to take it to the extreme, you know, I didn't read the book, I didn't see the movie, but I did see the social media post on it. It just, it means you've gotten a different level of understanding of what Tolstoy meant when he wrote "War and Peace." Well, the same could be said about the journals, and I'm sure Dr. Cohen will have some comments about this later on, but my concern is that many people bypass the actual original article. So instead of what we did in the old days, when you read the article, looked at the figures, looked at everything, the conclusions, you know, read some of the references that were posted about the paper, a lot of time people are sort of taking the shortcut and just reading the title and the abstract, conclusion, and maybe not really understanding, you know, the problems of the original paper. And again, my biggest fear is that our new generation and even some of the older generation are bypassing both of those things, looking at the social media post about the paper, and that's it. And saying, okay, now I get it. I can use minimally invasive spine surgery to fix all my CSF leaks. The next concern that I have, and this has been published a lot about, maybe not so much in neurosurgery, but amongst our, you know, teenagers, is this thing called FOMO, which means fear of missing out. And there are other terms, FOMOMO, and ROMO, but they all mean the same thing is that most people, you know, post the great things that they're doing, the great surgeries, fantastic reunions, and fantastic publications in nature medicine. And then you could be looking at this and, you know, going through your screen and seeing everybody doing amazing. And then you're looking at yourself. You just had your 10th grant rejected, you know, your boss is yelling at you, you're up at 12 o'clock at night doing charts and signing charts. And so automatically this can create anxiety, because what you're seeing and what you're experiencing in yourself is not the same. But of course the people who are posting it are only posting the greatest stuff. And again, this can cause anxiety, sleep disturbances, and it's been well, well documented. There's also this component of censorship and hazing issues when, certainly when physicians have posted advocacy, sometimes political views, it can be very nasty what people will say back to you in social media. And there's this whole element of censorship by social media sites on things that can be posted. So another concern about social media. Another thing that concerns me is social media site instability. And I've given you three examples of social media sites, Vine, Friendster, and Six Degrees, who have sort of come and gone. So it's a question of investment. If you invested a lot of time building your social media presence in a platform and all of a sudden it goes away, that can be a lot of wasted time. And I think people are, you know, develop followers. And if, for example, Twitter goes away one day for whatever reason, that's a potential harm, I would say, to people who've posted a lot of time there. We've already talked about sleep and psychological disturbances, low self-esteem, boredom, could impact your mood and life satisfaction, and affect mindfulness. So another negativity about social media. And this is my last point, maybe taking it a little bit to the extreme, but this concept of digital Darwinism. And there is a book written by Andrew Keen, now quite a few years ago, but talking about internet and social media. And he wrote in this book, again, "Out of this anarchy, it suddenly became clear that what was governing the infinite monkeys now inputting away on social media was the law of digital Darwinism, the survival of the loudest and the most opinionated. Under these rules, the only way to prevail is by infinite filibustering. So with that, I leave you with this conclusion.

- Social media, it can be overwhelming.

- It is a world that is becoming ever more reliant on social media and technology. It is important to recognize the risks and potential harms that come with being a neurosurgeon who is active on social media. And again, thank you for your attention. And Dr. Gadol, take it away.

- Great discussion, great discussion. Really enjoyed it. You know, it all goes back to saying that a fool with a tool is still a fool. And it's about how you use the tool to be able to do it and how to use it effectively. I think the challenge with social media is that it's a great tool if it's used effectively, just like the scissor in the operating room or the kerosine or anything else we use can be extremely dangerous, but at the same time can heal. So how you use that and how we have social responsibility and accountability really defines the best of us in social media. So who is the most accountable, who is most responsible would win and in fact would gain a lot more in social media than others. There's no question there is this topic of addiction to social media. FOMO, you mentioned, can be prevalent. There's many challenges with social media because it's so uncontrolled, it is so sort of free. And the fact that people just wanna know how everybody else's business. And how much of your business do you wanna hang out there and for everybody to know? Really if you look at people's social media platforms, you can really easily find out who they are. There are people who get extremely, I would say, radical and have pictures in the operating room with their operating staff. Really some challenging pictures we should not promote. At the same time, there are people like Journal of Neurosurgery that use it very effectively to promote good science, as well as Operative Neurosurgery or the Red Journal or World Neurosurgery, all the journals in particular. So I think it's a great tool, but it's how you use it. It always defines the performance of the tool. Just based on the discussion we had today, we at the Neurosurgical Atlas is creating a very unique platform called Atlas Link, that it would be by invitation, or you can ask to be added, but we'll verify you as a person who wants to join to be truly who you are, and it will be well moderated to make sure that the information is correct. We think the Atlas link would be extremely powerful, because it would improve communication in a network of, exclusive network of neurosurgeons. So please watch for that. We have already created profiles for 11,000 neurosurgeons there, so you'll get your profile. You don't even have to create one. And we look forward to seeing that, because there will be an opportunity for live surgery where you get a, you know, a notification on your iPhone, and the moment you open the app, you'll be in the operating room of the other neurosurgeon watching the surgery. And this can be extremely powerful. When the residents are rounding on the floor, they wanna just sort of go in and out of a case and be able to see how the other surgeon in another institution is doing. We're also gonna use artificial intelligence to be able to provide very powerful information published in literature. The big question is how does the AI work, because as you know, ChatGPT, BART, and all these guys crawl what's available in the internet. Much of the information unfortunately is misinformation. So the Neurosurgical Atlas has taken another role that we're creating the AtlasGPT. AtlasGPT will provide information that is behind the paywall with permission of peer-reviewed publications. Therefore, when you go and use GPT or generative data, you'll be only looking at data that has been previously reviewed and previously vetted. And that really creates incredible reliability. So we're creating two roles, Atlas Link, exclusive, verified, well moderated, without any political orientation or any individual agenda. It's not from NNS, it's not from CNS, it's not from any organization or any academy. It's gonna be very much a Switzerland. And then we're gonna use the generative data from what is previously reviewed to make sure the data is very accurate. We feel like these two roles would be critical. I appreciate your comments on that or any other comments you have.

- No, it sounds like a terrific, you know, a terrific idea, and I look forward to seeing it, I would tell you. And I'm glad that you mentioned the issue of things like being pre-screened and having people with authority to look at things. But, again, and I think we both emphasized it in our talks is that, you know, what we see on social media in neurosurgery may not represent reality. And I think that you've got to be aware of it and take everything a little bit with a grain of salt.

- I could not agree with you more. What we see in social media is an extremely edited version of the real humans. Believe me, I've been in the operating room of those people who have advertised their surgical MRIs, post-op, and surgical videos. And what I see on social media is extremely different than what I have heard from their fellows. So no question. As you well mentioned, what you see on social media is like a movie. It's not reality always. Any other comments? Brian, please?

- No, this is great. Thank you for inviting Allan and me to participate in this discussion. I think ultimately in the end, even though it was meant to be a type of a debate, Allan and I, I think, are basically giving the same message and you're giving the same message as well, Aaron. Social media is here to stay. You have to be involved, but it needs to be used responsibly. There are ways in which it can be used irresponsibly and in a negative fashion, but as with many things, we have to be responsible in its use. And it sounds like this new initiative you're launching will be one step forward in advancing the responsible use of a tool like social media.

- Thank you. Thank you for your kind comments, Brian. Thanks very much, Allan. Very appreciative of both of your comments. Look forward to having you with us in the future.

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