Medicine has had personal interaction for a long time. You knew your local colleagues, mostly as fellow physicians, sometimes also as friends or other social acquaintances. People you didn't know would post their research at regional or national meetings where anyone could discuss there work face to face. But these are not really friendships. Come the Internet and now an obscure nobody like me who has an MD and sees patients finds himself invited to be a member of the community, be it Physicians Online which became Medscape, Doximity, Sermo, or for less populated but more substantial give and take, KevinMD. Facebook arrived at about the same time, a mixture of people I knew from high school who were dormant but real friends and strangers who had common interests, sharing a hometown, cooking mavens, or bloggers. And let's not forget the predecessor, AOL chat rooms where the 40-somethings were impeccably polite, my fellow Jews less so, and unwelcome troll Abdul with a slur that instead of hitting the ignore button, people would respond back. Abdul succeeded in interrupting pretty much all conversations. I do not know if these chat rooms remain but I've graduated from 40-something.
In person, people are mostly gracious. There are ornery patients but as a professional who has seen this before, I never felt victimized in any way, just fulfilling my duty to these people as best I could. Objectionable members of the public were also expected. The pool of ornery patients is a subset of these people. I've never met an actor who played a TV villain but I'd probably judge him that way if I did. We now have public figures who are cheered on as they become the surrogates for overriding social norms that would violate our Codes of Conduct at work. With few exceptions, they underperform me professionally, educationally, and in all likelihood economically. They may be patients, we may cross each other in the supermarket aisles, but for the most part they live someplace else. Prof. Putnam's more recent work suggests that they and their next couple of generations fulfill the Biblical edict that misconduct perpetuates down generations.
What I did not expect were physicians who when given anonymity would start expressing some pretty vile social ideology that they would not want attached to their office entrance with their name on it, while other similarly anonymous colleagues cheered them on. It's never exactly like Abdul making reference of "Death to the Zionist Swine" on the Jewish discussion sites, but it is the expression of an id that would remain prudently tacit in any on-site medical encounter. My professional colleagues have mostly been personally cordial even when there have been rivalries and once in a while limited respect based on real interaction. And this predates institutional Codes of Conduct and Disruptive Physician edicts though it may be more understandable now why our employers make us sign a statement that we have read them. Committee meetings could have contentious issues but we never called anyone dumb or incompetent or evil, even when it might think that. But once your presence is a keyboard and avatar, in the absence of comment moderation, it did not take long for Medscape to become Mudscape and for the parent company to realize they could not fix a problem that caused some of the most talented contributors to depart, resulting in withdrawal of that part of their service to their participating physicians.
The premier forum, though, has been Sermo, for which I have been a member physician for many years. It has some advantages, not the least is being limited to licensed physicians. One can register in a minute or two. Physicians are asked to choose a screen name. A few keep some abbreviated variant of their own name, but most search the creative portions of their hemispheres for something unique. People are identified by specialty, which is essential in some of the clinical conversations where it becomes clear who does the medical tasks professionally and who dabbles but is opinionated just the same. I started there a number of years ago, I forget how many, flattered that they would have me no questions asked other than my state license number, and immersed among people who I have never met but shared their medical knowledge, often a profound intellect that can tease out the nuances of our professional EHR and insurance challenges, take interesting vacations, and engage in various political discussions in the way that friends would. That was the nascent Sermo. We had conversation makers, a few provocative thinkers, evangelicals and atheists, and most importantly that silent expectation of reciprocity where they could express what they want, I could express what I want and we'd be on the same page with next week's exchange.
That did not last indefinitely, maybe in parallel with larger American trends. Discussions with reasoning underlying what you were writing about devolved into the more crass sloganeering, sometimes targeting people. The Islamists departed first as gratuitous attacks became something of an expectation. The really astute analysts came next as any reasoned mini-essay would find a bunch of trolls making snide remarks about libtards instead of refuting the merits of what was written. Before long there was a Code of Conduct, and a few deactivations of various lengths, usually for clear personal attacks. But it was no longer a discussion forum worthy of people who succeeded personally and professionally by being at the top of their college classes. People whose minds I held in the highest regard started limiting themselves to clinical input, where their expertise could not be reasonably challenged and the rest of us could advance our own knowledge, but the community which started in the right direction had begun to fritter its intellectual capital. At about the same time, there was some awareness of this communal atrophy with a number of frequent posters noting the absence of some of the most revered participants.
About two years ago, I began wondering whether I also needed an absence, starting with two weeks, repeated a few times. Then last year, a month, which turned out to be one of my most personally productive, adding to some of my own professional writing, diverting it from Sermo to KevinMD, which meant selecting a single idea and expanding on it. The downside was that it was limited to medical commentary. I handled it in the manner of a Nazir. If unfamiliar with this, a Nazir is a person in Torah who takes himself voluntarily out of commission for a specified time, does not drink wine, cut hair or come in contact with a corpse. At the completion of this hiatus, he must bring a sin-offering for having voluntarily deprived himself of what the world had to offer. If I said two weeks, it was two weeks, if I determined a month, it was a month.
This time it's different. I specified three months to be concluded at the start of Hanukkah. For a very short while I was itching to type and each Sunday for the next month, the Sermo headquarters would send me an email with how many helpful clicks my comments had accumulated the previous week. It took a month for them to disappear, much like the last time I was away for a month. But this time after a few weeks, I found myself indifferent about returning. Not eager. Not hostile even though I had left partly due to annoyance and partly to protect my own analytical skills by doing other things. Indifferent, that emotion which Elie Wiesel, z"l, repeatedly described as the real opposite of love. I was indifferent and still am as my separation nears the pre-determined return date. I'm not sure I want to re-immerse myself or if I would be more tolerant of the current reality in my previously preferred virtual community, having no realistic expectation that the people who energized my mind but are no longer there would be replaced by new analytical minds. Yet I have that not quite promise to myself to restart at Hanukkah. I always had the option of unsubscribing but never did. The service still sends me emails of weekly highlight postings that I haven't opened and surveys that screen me out as soon as I click retired status. It's not the only medical forum that I have, since KevinMD though smaller, has avoided the sloganeering that turned the best thinkers away from Sermo. And I have started going to Grand Rounds at two medical centers where I see former colleagues who have hands to shake. But Sermo remains a community, or maybe in its current circumstances something of a dysfunctional family. It's not always apparent which ties bind and which ties restrain.
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