Visiting Command Central

Sometimes to my credit, sometimes to my detriment, I've never been timid about expressing my thoughts when I've done enough homework to surpass any threshold of expected knowledge.  Not at committee meetings, not on Social Media, and in recent years not in writing.  There is no shortage of medical and science schmutz getting generated for the susceptible readers who have their own agendas.  Anybody, including me, can bypass an editor via the blog option where all but the most venal commercial deception gets free speech protection.  We lack appropriate filters, sometimes restraints, sometimes learned rebuttals.  Everyone who knows the letters on a keyboard can pretend expertise, reinforced by spell-check to add the illusion of education.

My good friend and his daughter, accomplished authors and scientists in their own right, established an organization which they named Critica to intercept some of the scientific drek, whether well intentioned or malignant, that finds its way to people's minds via the screens that we now all have.  As he seeks associates, he connected with the operator of a kindred mind and soul who created Retraction Watch to organize science reports that are mostly intentionally flawed, or at least fall far enough below honest errors to arrive at public journals prematurely.  Since this might be a good shidduch for his project, he set up a meeting and invited me along.

Retraction Watch might be the baby of this rising star of medical journalism, but his day job is VP of Medscape.  We met at his headquarters.  While I have been submitting monthly essays to Medscape for my Hormone Happenings series, I had never been to headquarters.  Impressive place and impressive person.  Being a subsidiary of WebMD, the business occupies two floors of a Lower West Side building in Manhattan in a neighborhood that has a gentrified look.  Major security at the front door where they took our pictures and gave us badges.  On to the 3rd floor.  Figuring this was a NYC business, I carried a tie in my jacket pocket but my friend advised me no ties.  It really was no ties.  The reception area appeared plush.  They had a snack bar right out front where employees would saunter by and take what they want.  Nobody wore a tie.  Some did not even have a collar to be kept open.  No shorts, though.  And everyone looked young, most in a hurry to get their soda from the fountain and move to their next place.  An escort took us to our meeting place, the office of the VP.  Ultra sleek, along a side wall of a big space with computer flat screens lined up cheek to jowl.  Surprisingly few people sitting at the screens.  Walls were white, art sparse but colorful.  Our host did not wear a tie either but he had a dress shirt with buttons.

Our meeting proceeded for its allotted time, then we were given a shortcut back to the lobby.  En route, we stopped at one of the many white circular tables to plan our next step, again a modern, tasteful space undoubtedly created to float important ideas.

I've always like the places I worked as a physician.  They have a certain formality, whether office, exam room, conference room, or hospital.  But even at a university, I've not worked at a place designed for collaboration.  Increasingly medical work, or the patient care element, is formally defined by appointments per hour, a fixed conference schedule, an administrative half-day.  The more free-wheeling environment of Medscape, and I understand other creative enterprises that depend on savvy young people hired to generate and implement ideas, is something I might have found very alluring in my younger years, maybe now.  As physicians burn out more largely by the restricted working conditions with their unwelcome impositions, perhaps some of the senior policy makers of the medical world should schedule their own meetings with places like Medscape for better options to keep a young work force more enthused about what they do.

Medscape's Best and Worst

As each calendar year reaches its conclusion, many organizations attempt to compile best and worst lists, be it TV shows, movies, cars, people of prominence or infamy that bring character and maybe immortality to the year that will soon fade into history

Medicine like any other pursuit has its heroes and its scoundrels.  I would take a safe guess that all physicians can name in an instant the five teachers who shaped them and the five guys they thought should be reported to the state board, if not the FBI.   For the bad apples, we contented ourselves as residents to mostly scoring them with a lot of zeroes on our attending physician evaluation form but never pursued anything seriously punitive.  For the benefactors, we not only gave them higher scores but assimilated some elements of their revered practices into what became of us professionally forever.  We know who they are and what they did on our behalf, even if nobody else does.

We also come across medical colleagues who we do not know but find their way into the medical and secular news for their exceptional deeds that reach beyond our personal experience.  Some win Nobel Prizes, some swindle Medicare.  In recent years we have passively received enough lurid news in print or electronically that it registers as our daily expected dose of world affairs.  Some respond, most don't but file some imprint deep into the cerebrum where it might be retrieved if ever needed but does not stay with our awareness for very long.  At the other pole, when we attend our annual meetings, some physicians get awards while we sit in the audience and clap.  Professional achievement always gets our admiration.  We see the news of physicians gunned down, including a personal college friend killed in the Pittsburgh synagogue massacre or by a disgruntled patient, usually not the superstars of medicine but professional colleagues who get some combination of sympathy and honor for the dignity that their abruptly halted careers brought to the medical profession.

While our recognition of these physicians tends to have the trajectory of a funnel where stuff goes in the big end, gets concentrated and disappears in a moment out the small end, we are fortunate to have an organization like Medscape that identifies, catalogs, and retains these positive and negative outliers each year in an easily searchable way.  The list comes out in mid-December and is traceable at least back to 2011.  Being something of a news voyeur, I scrolled through the current roster as it came passively to my email inbox.  What makes physicians, and sometimes scientists, heroes or villains can be hard to tease out on one year's list, but by searching back about five years, laudatory and despicable themes emerge with some consistency, which may not be all that different than how we each individually assigned the best and worst physicians who we personally encountered between medical school and retirement.

The rascals have a lot more consistency, and most years larger numbers, than the exemplars.  With rare exceptions they have traded in their white coats for orange jumpsuits.  Some are outright predators, engaging in assaults on mostly female or pediatric patients.  Others engage in various forms of lucrative unconscionable care.  The scientists among us might call them errors of the First Kind, assigning significance to diseases that were not present.  The intent takes it outside the realm of error.  Patients without cancer received chemotherapy, normal coronary arteries got stented, inappropriate but systematic retinal photocoagulation, and any variety of excessive bodily invasions from sinus surgeries to repetitive skin biopsies.  While these docs seem more profiteers than predators, there is something inherently evil about intentional unneeded care.  Over the few years of my review, there were few overtly incompentents, other than a few surgeons functioning above their level of training, but generally medical schools and residencies produce capable people, though not always ethical people.  The next common category are the profiteers.  There are a lot of these.  They probably caused little bodily harm to vulnerable people so, in my mind at least, would fall one level less on my personal evil-meter.  They are more financial cheats than medical ones, though a few cut corners by obtaining less expensive medicines from authorized sources then billing for the real thing.  But mostly these doctors arranged for others to due financial processing of bogus services for financial gain but not medical harm.  There were a lot of these on each annual list.  And finally we have a handful of unfortunate people who offered suitable care but got videotaped engaging in mockery of patient or staff or fulfilling a dream of being a rapper while removing a body part.  Poor judgment probably, worthy of a worst of doctors list, probably not.

Medscape's best of doctors each year fall into more categories with too few to make generalizations of how the majority of practitioners can upgrade themselves to be more like them.  One common category of people worthy of admiring though not emulating are those whose recognition that year was brought about by their untimely death.  They did good work, for sure, but it was the car accident or plane crash while on a mercy mission that caused Medscape to include those physicians that year.  About an equal number also arrived on the annual recognition list by appearing in obituaries first.  These people had lifetime achievements, mostly in advancing the science of medicine.  Their CV's no doubt had a few awards while still functioning well enough to appreciate the adulation their work had earned.

There is another very large category of praiseworthy doctors whose medical knowledge and skill does not tower any higher than the rest of us, though their dedication and tenacity might.  Each list has physicians, mostly still alive and working, who enabled people at the margins of medical care to have better access.  Some travel into the Third World to bring this about.  Some set up rural clinics, some make a career of treating medical pariahs, the modern version of lepers perhaps, people who a lot of us would groan if we saw those patients on our schedule.

One final category that appears on every list, probably no more skilled medically than anyone else, but who endured unusual challenges to complete their medical degree.  These include professional and Olympic athletes, refugees from war zones partly completed with their education who had to flee and reapply with some difficulty in an unfamiliar country with a new language.  One started as a patient, a teenage surgical ICU alumnus with life threatening gunshot injuries who became captivated by what the surgeons were doing for him and then pursued his education under burdensome conditions but prevailed.  One does not need to be the most prodigious clinical or science maven to excel.  Pursuing a dream relentlessly is an option available to most of us in some form.

So what becomes of these people?  The medical scoundrels amass quite a lot of prison time.  Do they remain bottom feeders in custody, or might there still be some spark of benevolence that once got the favor of the Admissions Committee?  Do they sit in their cells and mope or do they impart the literacy skills and science aptitude that they have to be of benefit to other inmates who had less going for them at the time of their arrests than the doctors did?  There are medical reporters for Medscape and elsewhere that could pursue that direction.

And the Top Docs who are active, do they continue to inspire colleagues and patients with that same persistence they used to excel so that others might be more dedicated to self-management and responsibility for the diseases that they have?  Appearance on the Medscape exceptional list should have an enduring presence beyond the 15 minutes of fame or infamy that Andy Warhol thought all people are entitled to have.

Abandoning SERMO

Been reading Robert D. Putnam's iconic Bowling Alone on declining social attachments, which is probably applies to the medical profession as much as anything else.  He notes a number of transforming events, now and historically, including the rise of corporations and cities before 1900, the diversion of people from work to entertainment with the movies after World War I and TV in my childhood years.  The book has a publication date of 2000, which is the time  when people became connected in cyberspace.  He had no means of knowing the impact of this and it remains a social process in transition, but there is a precedent of the telephone which connected people over distance but mostly people you already knew.  Posting sites have changed that aspect of the landscape, an immense opportunity that may be going bust.

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.