The Use Of Social Media In Surgery–Podcast

By:  David M. Kashmer (@DavidKashmer) & Vivienne Neale (@SupposeIAm)


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DDD, bringing you the metrics behind the data. Here is your host, Vivienne Neale.

Hi, and welcome to DDD, which is Data Driven Decision Radio, episode five. My name is Vivienne Neale and I am delighted to be back with you. For those who have asked, my background is in education, training, broadcasting and social media. Of course, I am also a sometime patient curious to know what decisions are being taken in my name that might just affect me and thousands of people just like me. So, once again I am joined by David Kashmer, Chair of Surgery at Signature Healthcare. David is an expert in statistical process control, including Lean and Six Sigma. He has a specialist interest in new tools to improve healthcare, like gamification. David also edits and writes for a blog called So, hi David and welcome back.


Vivienne it’s great to be with you again today and I hope the weather in England is just as nice as it is here on this side of the pond.


Well, I have to say, yes it is. It’s a beautiful sunny afternoon, so we are very grateful for that, but the evenings are now getting just a wee bit cool and certainly we are in autumn, or should I say fall?


Well, it’s great to be back and what do you have to share with us from the news today?


DDD News…

Well, actually just a quick thing. Some of you might be aware of our export, which is Jamie Oliver who is a chef, who a few years ago, probably four or five now, was campaigning for better school meals and he did that in the UK and also in the US. He has just made another documentary where he has been showing the impact of the amount of sugar we are all eating in the UK. I assume that probably in the US its worse than where we are here, but he did a fairly shock jock type of documentary where he said although we are not recommended to have more than six or seven teaspoons full of sugar a day, most of us are eating between 30-50 with all the unknown sugars, or hidden sugars, that we have in various processed foods. So, he came up with a rather startling statistic that around 130 limbs a week are amputated in surgery by people with type 2 diabetes, which was a really, really shocking thing, and he explored what that means for our national health service. So, that’s what we’ve been looking at here. What about you?


Well, Vivienne, having been through the United States school system I can easily support improved meals and better food.




I also have to agree that it is not surprising that we would consume so much sugar beyond what’s recommended in various ways that we can’t even appreciate. So, I have an easy time believing that that’s our current rate of sugar consumption and it’s easy to get behind the idea that nutrition is a key thing and likely needs improvement in our diet as well. So, I appreciate the news, and I have a piece of news from the last week.




This is an update from last week’s show, and a bit of a correction. We were discussing new prosthetic limbs with 3D printing and you brought up an interesting question about a product called Ninja Flex. After reading the article briefly from it looked as if Ninja Flex was the neoprene sleeve used to fit a prosthetic or some variation of a similar sleeve. Well, it turns out that with further research Ninja Flex is one of the new 3D printing filaments on the market. The filaments are the different type of substrate that come to us on a spool that our printers use to build whatever it is we are looking to make. So, to the creators of Ninja Flex and to clarify for our listeners, Ninja Flex is an innovative product that allows for a flexible construction. So, whatever you build has some flex and give to it, unlike many of the other 3D printable filaments, like ABS and PLA that are very firm and rigid by comparison. So, to the creators and users of Ninja Flex, I am glad we have some clarity now and it seems like a great opportunity for prosthetics in the future.


Right. Let’s hope we don’t need too many. Of course, if anyone is interested in Jamie’s new ideas, he’s got a hashtag which is #JamiesSugarRush, and if you check on Twitter you’ll be able to see how much conversation is being generated by his particular documentary. He finally made the decision that like Mexico, who have put a tax on fizzy drinks, he is also going to impose a tax within all of his restaurant empire to start funding research and so on and so forth.


How interesting. Very interesting.




We are DDD. Data Driven Radio.


So, anyway, that was one aspect of the news. I’ve also been thinking about the number of data points being generated every day and I know that you are very much at the forefront of this research. So, I’m just thinking, well if you’ve got billions of data points being generated, surely some healthcare providers may well actually feel overwhelmed by all that’s being generated. I guess you could end up wondering just what to do with big data, and I think that’s quite understandable, don’t you?


Oh, very much so, Vivienne. With the incredible amount of data points that are out there, it is easy to contract what we often term ‘analysis paralysis’. Whether we have the inability to draw meaningful conclusions from the data or really just freeze in the face of it all. That’s a well-known phenomenon, as you described.


Yeah. So, I suppose the whole idea that data can be difficult to manage, but of course we’ve got that dilemma that is absolutely impossible to ignore, not that we should of course. What happens if you do feel your department’s information isn’t being represented or you are wondering where to go next? Do you have any experience of situations like this?


Vivienne, in line with what we spoke about briefly last week, I do. The challenges are many, just as you say, owing to the amount of data that’s out there. What I’ve found useful, along with many others in my field, is to make sure you have a clear vision for strategy first. Where you want things to go, the type of care you want to deliver and where your focus is. Having that clarity allows you to know what type of data you are looking for and the questions that you can pose in the face of these huge data sets. So, I think with more data than ever I have seen data represented poorly, I have seen data that asks questions that really don’t have a lot of meaning, like the classic how many angels can dance on the heads of a pin? Interesting question, but probably not very applicable to what we do every day. So, it really refocuses us on strategy. When we see data that asks questions that aren’t necessary of gives answers that are either Archaean or really just not useful in any way. So, yes, I have seen it, I have lived it and avoiding it starts with having a strategy for your department and team.


I would say that it’s not even a strategy, but not wanting to split hairs here, but like a philosophy. I think that the whole department has to believe in what they are trying to do and that data isn’t literally, and this is not a joke, an add-on, but is actually part and parcel of everything that’s being done and the conversations and being made and the changes that you want to see are being driven by this.


Well, you’ve said it… I think you stated it much more succinctly than I did. You’re right. It’s how to make data an everyday part of improvement for your system and how to have a strategy to deal with it and the questions it can ask. I think you’ve stated it really nicely. The team has to understand that effective use of data is part of what we do on a daily basis. So, really well said.


Well, thank you, but I’m going to throw a curve ball at you now. As I am not a mathematician and I’m not a data analyst or data scientist, I actually find that my background in literature studies has put me in a really good place to start asking the stories beneath the stories generated by data. I find that I am creating a narrative which is really quite different from people who are used to analysing data in that conventional, almost mathematical way. So, I think that actually the quality of the insights that are being delivered, you have to really think about that, and what sort of insights have been delivered by your department when using big data, and do you ever bring in anybody that’s not medical to help you out? Just a question.


We do, especially in those sections that use data according to a standard required by whatever governing body. What I mean by that is, in the United States the American College of Surgeons plays a strong role in trauma care and it mandates that a certain registry be kept with certain types of data. It is pretty rare in healthcare Vivienne that we have people who know how to build models out of data and ask questions in certain ways, and we’ve talked about that in other episodes. The challenges of extracting a meaning from your data. So, yes, I have used other Six Sigma black belts for projects and other people who have deep knowledge of what questions you can ask data and its limitations. I really like what you said about using your literature background to extract meaning from data, it’s a well-known technique to use a story to highlight data to make it more human. So, for example, if we have data that says we are not being as responsive as we are to the emergency department, because we tracked all our response times and we saw the distribution of them, and there was a really large variation and that creates defects where we don’t show up in a timely fashion for our patients, however we may define timely. Then, we tell a story. We say, “Well, this patient coming into the system, Miss Smith, is likely to experience this based on our data”, where if we have a Miss Smith who did experience a certain finding, we use that to highlight our data. So, I really like your take on humanising the data by telling stories that line up with it. I’ll share with you that doing the reverse, using a story and saying, “Well, this is how it goes”, and driving change with one story is actually not always as effective. The reason why is there’s such a distribution of times, if we don’t know that distribution, Vivienne, we don’t know our performance rigorously. We may pick a story where we did unusually well and we may extrapolate from that that, boy, we do a great job, but in fact that one person, that story that we picked does not indicate our true performance. I’ve seen that very frequently with process improvement. So, I really like your idea of looking at the data and humanising it with a story rather than going right for the story not having a sense of the systems performance. That hasn’t been as effective in my experience.


In fact, there are different types of data, aren’t there? Like structured, unstructured, semi-structured, and internal and external data. I quite like… I don’t know how much you make use of, and maybe you don’t, of external data, which is that which is created or generated outside of your department that you don’t own or currently have access to. Some external data is free to access and some is not. Do you ever factor that into any of your analysis or not?


We do. We use multiple data sources that are external to our department, including what is called NSQIP, which is another body of data from the American College of Surgeons, it is pay to play and it benchmarks you versus other centres in some anonymous fashion. The centres tend to be anonymised that you look against, but Vivienne, I will share with you that there are challenges to benchmarking. Meaning the definition of what may be called a wound infection or how other centres come by the ability to tag something as a wound infection. It may be different than what you call a wound infection. I use would infections, but in fact every end point that you’re looking at may have a slightly different operational definition or the data may be cleaned better or worse by one centre than it is at another. So, I’ll share with you that the process improvement take on it, at least the way I was educated is to rigorously improve your system with data and before you benchmark, make sure you have an operational definition of what you’re looking at, which matches up with eventually how you are going to benchmark. The bottom line is, don’t benchmark it first. You probably have a long way to go, and once you’ve gone down that path to improvement, then look to those external benchmarks and external sources of data. It’s a different take on it than some others, but it’s been very valuable.


If you are saying that actually some people are not naming things correctly, should there be… or consistently rather than correctly, do you think there should be some state or national take on this that everybody does things in a similar way, or is that inappropriate?


Well, there often is a national or a CDC guideline or a definition mandated by the College of Surgeons. Let me explain a little further. For example, pretend I work at a centre and this is not the centre I currently work at. I want to be clear that this is a fairy tale, but pretend I work at a centre that seems to have a very increased risk of wound infections among wounds that are clean. It has… boy, it just seems like too many wound infections in clean wounds. Well, believe it or not, in the United States, one of the most common reasons or difficulties we have with labelling things as wound infections in clean wounds is that different raters, different people do not get the same classification of wound when they look at it. In other words, when they use the system of wound classes 1, 2, 3 and 4, the typical way wounds are classified to extrapolate risk of wound infection, they don’t call the same things class 1. One place may call the wound a class 1 and one may say it’s a class 2. That completely changes the expected outcome or the probability of a wound infection. In other words, Vivienne, sometimes certain measurement systems are limited. The wound classification system, 1, 2, 3 and 4, has an interrater reliability which is not perfect, meaning it’s not always reliable that two people using the same tool come to the same conclusion. Now, why is that? it’s a little beyond our scope, but I’ll share that it can be because if you have a surgeon reopen a wound, some centres would say, “Well, that wound is now a class X”, and another centre may say, “Well, that’s a class Y”, and it’s because different descriptions of the wound classification system don’t make it really clear what that would be. Now, my bottom line here Vivienne is, it may not be that another centre is counting things wrong or poorly. It’s not always that clear. It just can be that your centre counts things differently or somehow improperly. That’s why, again, I stress you have to make sure your centre is as improved as it can get by looking internally. Fix what you can fix and then go outside and benchmark against other centres. I’ve found when you do that it really gets you a lot further. You’ve built the infrastructure for how to improve, you have the data collection on what it means and you have a rigorous way to do better and achieve the lowest defect rate you can, and then you benchmark. Usually, when you wind up doing that, you find out you’re doing pretty well.


So, that moves me onto the notion of the social media use in surgery. So, if you were actually tweeting what you were doing and maybe it was something to do with wound infection, for example, does that mean that people will end up starting to ask questions about the nomenclature, to use that word, or the naming of particular… whatever you were talking about, about the type of wound, classification X or what have you. So, for example, if you were tweeting then perhaps that would actually open up a dialogue.


Fascinating question, and I am all for us, as patients, knowing what we’re getting into as much as we can. It’s a tough balance though between friction, blocking physicians from doing what they need to do, and respecting the years of education they have in this. Yet balancing that with the fact that we have a right to know about our bodies and what’s happening to us. So, it’s interesting. When I look at this like other professions, it’s rare that, for example, I would see a lawyer tweet about how they’re looking at ipsa res loquitur or a legal doctrine as they’re considering my case. There is a boundary between where it becomes obstructive versus useful. Now, they have to get done what they get done as lawyers, similarly physicians and surgeons have to get done what they have to get done. Yet I think in very select circumstances tweeting and the use of social media can be very valuable. So, I don’t have an easy answer on that one, but I think in general, conversation about what’s happening to our bodies as patients is a good thing.  One option is to automate tweets ahead of time so that they are put out at regular intervals.


It would be interesting to see what other people would feel about that. I mean, there would be possibly issues of privacy as well, wouldn’t there?


Absolutely. When you do tweet something, like live tweeting from a surgical procedure or something similar, you have to, in the United States, respect the HIPAA laws, or health information portability and accountability act. You need to be very careful with how you do it regarding protected health information.


Yeah, but it’s interesting because I know sometime, about three years ago, you had written about the fact that one in four physicians was using social media daily, and I assume that has gone up considerably since that time. So, these and other data indicate that twitter is one of the least used platforms by physicians, and at that time, three years ago, it was 7% of total use. Do you think that’s gone up much since then?


Experientially it seems to have. I’ve seen more physicians use twitter on a daily basis and even health systems allow tweeting from the OR in select circumstances. So, I do think that it’s becoming more useful and although I don’t have the hard data, I would estimate that that 7% has increased. There is even data regarding now the factors that influence the adoption and meaningful use of social media by physicians. So, people really have looked to tease out what is making us use it more or less and using it with meaning. There are these external factors such as how useful we think it is and how easy it is to use and then other drivers for our behaviour. In fact, there is an entire journal now dedicated to looking at things like this. So, really fascinating.


More specific data on social media use in Surgery here.


Yes. So, thinking about it, given the prevalence of social media usage, where do surgeons fit into the fold, do they?


They do. Despite that 7% usage that we talked about, tweeting from the OR happens every day and during cases, both laparoscopic and open procedures, surgeons do use twitter to highlight, educate and advertise for their programmes and how well they’re doing. Rex Healthcare, for example, in Raleigh, North Carolina, did join the growing roster of hospitals that have experimented with live tweeting. This is also being done in academic medical centres and beyond.


So, what do you personally see as the major benefits of this development?


Well, currently surgeons blog and tweet routinely, as we said, and they do that about the challenges in modern day surgery. They also share useful professional facts and opinions. Some of the business influencers in our field can add a lot to our practice and our approach. They can tweet out different things coming with the International Classification of Diseases version 10, ICD10, and other similar things. So, it’s this constant stream of ideas and an exchange of ideas across the county. So, in any event, tweeting, blogging and use of social media is now common, which represents a huge shift in my understanding of use of social media. Very different than when I trained, at which time we avoided things like that at all cost.


Yeah. I think in many ways it’s quite interesting, even in teaching. Teachers were encouraged not to be part of social media at all, but in fact without being part of this new phenomenon you can’t possibly understand it. I think it’s essential that we do make use of it, but each profession appropriates social media to fit their particular needs.


Well said. As you’ve mentioned before when we’ve talked offline, social media content is not all upside. Things that take just a moment to tweet can last a lifetime and have serious implications for professionals. Also, professional advice given out online can take on a life of its own. So, there are several strategies to mitigate this, including attempting to make it more than one click for professionals who want to ‘tweet angry’ or ‘blog angry’ or say something otherwise inflammatory. There is a real focus on putting useful content out there that staff in similar circumstances around the country can focus on. So, as you say, social media is not all upside, it can be very useful, but if used improperly, highly inflammatory and almost like an online permanent record of what we’ve done and it’s something we really need to be careful with.


So, you are saying that there are still many potholes you need to negotiate.


Well said.


Well, that’s that. We’ve sorted it. It would be really interesting to talk to physicians and surgeons that make innovative use of social media at times of surgery or pre or post-surgical experiences. It would be lovely to add yet another voice to this DDD podcast.


Well, Vivienne, I think in the next coming weeks we’ll have some colleagues on who have tweeted from the OR or have seen social media used to great effect from the hospital or operative side. So, watch for that coming in the future. I think we’ll have several of our colleagues on here soon. I would also add that one of the useful things to avoid those common mistakes with social media are guidelines written both here, by the American Medical Association, and abroad, about responsible use of social media. So, as I think it would be said on your side of the world, do have a look in on those useful guidelines for physicians and other professionals as our listeners begin to use social media more and more.


Well, thank you very much, David. Certainly I think we’ll have a lot to consider over the next seven days.


I think so.


Okay. Thank you. I hope you’ve enjoyed today’s episode and if you want to keep up to date with David Kashmer’s approach to quality and statistical process control, business model innovation and critical practice, do join us for the next programme. In fact, we are very interested to hear what innovative practices are being undertaken in your health provision. If you’d like to appear on the show, contact us through our website. We are looking forward to hearing from you. Meanwhile, if you’ve liked the show, do leave us a rating on ITunes. It’s one way we can ensure the word is spread. We look forward to being with you next time. Bye for now.


We are DDD, Data Driven Radio. Catch us on Soundcloud and iTunes.

3 Reasons To Add This New Specialty To Medicine

by:  David Kashmer, MD MBA (@DavidKashmer)


By now you’ve probably heard of 3D printing.  Sometimes, 3D printing enthusiasts are referred to, collectively, as “makers”.  Well, let this maker tell you:  3D printing has wide applications in Medicine–so much so that it could do very well as its own specialty.  Here are three reasons we should create a new specialty in Medicine that focuses on 3D printing:


(1) Truly Personalized Medicine


The push to serve patients with a focus on their unique needs is on in full force.  Whether it be genetic testing to predict response to anti-coagulation, recognition of the necessary Prograf dose as adjusted for metabolic variation, or a focus on specific social factors, personalization of the practice of Medicine is becoming a buzzword that’s hotter and hotter all the time.


3D printing is a way to truly personalize that medical experience.  The vascular surgeon can size your aortic graft preoperatively from a model created from your own CT scan…or surgeons can even replace / stent your trachea with a new one generated from images of your old one.


This can already be done and is getting easier with time.  So, much like the rise of Radiology focused on imaging studies, let’s consider getting really good at creating personal models, devices, and anatomic replacements by creating a field devoted to just that.


(2) One-off, Specialized Medical Devices


Having a hard time fitting an ostomy appliance near an open wound?  Is the effluent from the ostomy leaking into the wound bed?  Why bother with all that?  Create a custom printed ostomy appliance from a 3D scan of the patient’s abdomen.  (We can already do that.)


Want to get really fancy?  Upload your custom-tweaked design as an .STL file to the “app store” of compassionate-use approved, one-off medical devices.  (Here’s something that’s an early version of what I describe.) No manufacturer could justify a large batch run of the perfect device you’ve created for a small (but important!) patient population…but those of use with printers (and those same patient issues you have) could go to the “app store”, download the .stl file, and create that medical device to solve their patient’s issue.


A field devoted to creation of these models, knowledge of filament types, and understanding of model usage would go a long way toward spreading this technology.


(3) …In Hard To Reach Places and Beyond


A 3D printer and system could allow creation of useful devices and models at even hard-to-reach, remote locations.  Consider rural centers, international areas, and even forward military venues.  Need a prosthesis fit to your patient’s stump?  Make it from a white light 3D scan and printer.  Viola.


A team of Makers could easily be responsible for creating the prosthesis from imaging.  It could ensure both fit and tensile strength.


Soon, Grasshopper, The Future Is Coming


Just imagine a day where a patient has a CT scan and, immediately, necessary equipment and devices are created according to their own personal requirements.  As physicians, we could create everything from special use medical devices (eg ostomy appliances that fit near difficult wounds) to highly personalized cervical spine immobilization collars.


Want to take your gallstones home with you?  (We can’t give them out anymore right?) Well now we can give you an awesome copy for your morbid fascination or other interest.


Who Would Pay?


Hospitals currently have add-on services such as baby photos and other fee-for-service add-ons.  Perhaps 3D modeling could be another.  Filaments like PLA and ABS are inexpensive, after all, and the initial costs would come, mostly, from a one-time hardware expense of less than twenty thousand dollars.


…and if the hospital couldn’t make a business model out of the direct revenue, it could definitely justify the expenditure in terms of patient satisfaction and niche marketing.  After all, I would be much more content, as a patient, if a physician could show me how my spleen was injured using a model of my very own spleen.  I’d like to take that home with me, and would give even higher Press-Ganey scores to hospitals that could create that model of my particular injury and send me home with it.  Will that hold for most patients?  I don’t know…maybe a study is in order.


Let’s consider creating a subspecialty of Makerology, where we develop a system of creating special use medical devices (we could even have an app store for the .stl files) for rural, international, or under-served areas.