COMMENTARY

Appropriate Airing of Professional Disagreements in the Era of Social Media

; Clyde W. Yancy, MD, MSc

Disclosures

March 27, 2014

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Revisiting the Topic of Civility in Professional Discourse

Robert A. Harrington, MD: Hi. This is Bob Harrington from Stanford University on theheart.org radio and Medscape Cardiology. A couple of years ago, Clyde Yancy and I had a discussion on the end of civility in professional discourse that was very wide-ranging in terms of the topics we covered. It was an interesting program in that we weren't talking about any specific research finding or clinical update but more about the environment -- the ecosystem, if you will -- in which we, as professionals, have discussions.

Clyde and I received a lot of feedback after the show, much of it positive in that people felt that this was an important topic to discuss. So here we are two and a half years later in the spring of 2014 having a follow-up discussion on the airing of professional disagreements in the era of social media.

Information is moving very rapidly now. We still have traditional peer review, but more doctors and other members of the community are tweeting and blogging. We are having a lot of discussion, but is it helpful discussion in terms of the ultimate goals, which are to move science forward and to bring better care to our patients? Organizations such as the Institute of Medicine are calling for more open data sharing. All of that plays in here, and it makes us think: If information is going to move so rapidly, what becomes the role of venues such as live meetings?

I would like to hit upon all of those topics. I can't imagine a better person to have this conversation with than my long-time friend and colleague, Clyde Yancy. Clyde is the Division Chief of Cardiology at Northwestern University and a Professor of Medicine at Northwestern University's Feinberg School of Medicine. Clyde, thanks for joining me here today on theheart.org | Medscape Cardiology.

Clyde W. Yancy, MD, MSc: Bob, I am delighted to be a part of this; and, like you, I was struck at the receptivity that the audience had to our earlier discussion.

The Times They Are A-Changin'

Dr. Harrington: In the earlier show, we talked about professional civility. Today we are going to broaden that a little bit and make sure that we bring in the social media aspect this time. Since September 2011, when we last had this conversation, are we less civil or more civil to each other? Are times different?

Dr. Yancy: The most important dynamic that has happened very quickly is that the world has changed, and the worlds of communication, media, and medical media are very different now. There are several studies for which you and I know the results because they have been released in social media and the medical media, but we still haven't seen the studies published yet, such as SIMPLICITY HTN-3,[1] and TOPCAT.[2] The dynamic is very different from what we had before, and it is even more different from what it was just 3 years ago, so my very first statement is a definitive statement. The world is different in terms of communication. What that begs us to address is how we should behave in this very dynamic, very fast-changing space. What are the "dos and don'ts" in the ways in which we manage our professional interactions?

It is appropriate to have critiques. It is very necessary to have pushbacks. Those are the checks and balances that yield the tenacity of the statements that we make and allow us to inform practice. But at what point does pushback and critique become an attack? That is something that we have to begin to think about more carefully because very few comments and very few people are under the radar screen, now. Everybody is front and center.

Dr. Harrington: Those are interesting comments. Let's take a couple of them. You make the comment that information (and maybe I will even change the word to data) is moving faster than ever. Whether we are turning it into useful information is another question, but data are certainly moving faster. But as you have rightly noted, data are not necessarily moving in the peer-review realm. Data are moving in media that are around the peer-review realm. Is peer review dead or should it be dead? Or should peer review take on a different format now that Twitter and the blogosphere are handling the peer review that used to be handled anonymously and quietly, behind the scenes? What is your current view?

140 Characters Is Not Peer Review

Dr. Yancy: I have 2 points of view. The first is that peer review couldn't be more important because now we are dealing with points of view that are restricted to 140 characters. Both you and I tweet at national meetings, and we try to be as clever as we can to pack as much context and information into 140 characters. We also know, as clinicians and scientists, that it is less than ideal to use that as appropriate commentary on a large, multiyear, multicenter study, so peer review couldn't be more important. We need the protection of peer review to allow the information to withstand the necessary tests needed to incorporate it into practice. Let's say that I emphatically endorse peer review, and I would encourage our peers to understand that Twitter or blogosphere comments are just those. They are comments, and they don't necessarily reflect appropriate filters on information. They just reflect a point of view, which we should rightfully entertain. That is my first comment on what you just said.

My second comment is that you have gone from "information" to "data," and I like that because information is the requisite step to inform another thought process, and you said maybe it is not information -- maybe they are just data. I am going to take that a step further and say maybe it is just noise. A lot of what we are doing right now is managing the noise and waiting for the data to emerge so that we can decide what is the right information.

Dr. Harrington: It is an interesting way to think of it, and I am glad you mentioned that both you and I tweet. Let's get into that a little bit because both of us are also traditional academicians in that we work within a university, and we participate in the running of clinical and research enterprises. We are engaged in traditional peer review and writing traditional papers, but at the same time we are also participating in the new media. Tell me why you started tweeting and what you get out of it. Do you think it adds or detracts from what you are doing?

From the Hallways to the Twittersphere

Dr. Yancy: I am always a little anxious when I use Twitter because you don't know who is in the space. It is always a little awkward for me. Having said that, it really isn't a new dynamic, if you think about this. During our entire careers, when we have heard information or when we have been a part of the information flow, we have always had sidebar commentaries or offline discussions, and all we are doing now is bringing some of those very important comments and discussions into a venue where those thoughts can be accessed by others.

The process that you and I and many others have gone through of synthesizing information and then providing a perspective is not a new dynamic. The newness of this is that we are taking it from the hallway conversation to the digital conversation. We are learning as we go, and what we have discovered is that it is a means to help promulgate thoughts, particularly if there is something that we believe is a point of emphasis. In that way I view what we do as a means to endorse, promulgate, or support best science by saying, "Hey, guys, this really is important. If you don't hear anything else, here is something you should hear." Then, I think it's okay.

The other point I’ll make about the presence of people like you and me in the Twitter space is that the world is very different. I am going through a process now with the American Heart Association (AHA) where we are revisiting our live meetings because we want to stay current, but one of the dynamics we are recognizing is that not everybody can attend the meetings anymore. The pressures of time and economics are real. So the opportunity is for a person like Bob Harrington to be at a meeting and say, "Hey, I'm physically here. I just heard the data. I think this is important," and try to replicate that experience. It provides a service to the community at large because people want to know what you think. Some people want to know what I and many others who are doing this think. So, this isn't new. It is just that the approach we are taking is new.

Tweeting the Meetings

Dr. Harrington: Yes, I agree with you. I love your phrase -- that we are bringing the sidebar and hallway conversations out into a larger space. From my own perspective, that is how I view Twitter. I see it as complementing the other things that I do, particularly the writing or the speaking, and Twitter gives you a chance to pull out that little nugget of information that you have just heard or read about and make a short, hopefully pithy, comment to get some traction and get some people to read it. Over the last few years, I have been tweeting from the major meetings, which is largely how I use Twitter. I use it as a way to provide some commentary on the major cardiovascular meetings. I get feedback from people out there who say, "Hey, thanks for sending this to me. I was not able to come to the meeting this year; I am covering the practice."

Last year in San Francisco, the American College of Cardiology (ACC) had a running Twitter board of what was being said about the meeting, and people were standing there in front of it at the meeting just picking up what the trends were and what the important issues were. For the sake of our listeners, what is the name that you tweet under?

Dr. Yancy: It is @NHMheartdoc (Northwest Memorial Hospital heart doc) because Twitter has a little bit of levity to it, a little bit of lightheartedness. But back to the more serious point: We both endorse the concept that perhaps we are providing a service through the tweeting of important information to benefit those who aren't physically there.

Let me make 2 points about that. Remember that the advantage of peer review and the astute editors at our major journals is that nuances can be picked up and corrected, so by the time something goes to print, it is pretty clean. You don't have that opportunity with Twitter. You have just put something in the public domain that will live forever, and it was created, edited, and proofread by an N of 1. Ironically, the bar is higher if you decide to tweet because you don't have the benefit of an editor or peer reviewer to help you correct the nuance.

The second point, which is even more important, is that somehow we have to continue to impress upon everyone that a Twitter comment or a blogosphere comment is not the entirety of what someone ought to know about a clinical trial. There are nuances that are very important (and for some they will be more important than for others), but for anyone who is going to use that information for clinical purposes, please don't stop with the Twitter comment. Please go to the next level and use that as an entrée to become more aware of the database. That is the right use.

Dr. Harrington: I could not agree with you more. A great example -- something that we both tweeted about -- is the prevention guidelines[3,4] that were rolled out at AHA in 2013. During the early rollout of the prevention guidelines, there was a lot of discourse, much of which was not helpful, and on the last day of the meeting when we had a large panel discussion with all the principals of the guidelines -- the National Heart, Lung, and Blood Institute, the AHA, the ACC -- the authors and multiple different constituencies were represented. A member of the press came up to me and said, "Wow, that was really helpful," and my comment was, "Well, this is the essence of what science is. It actually has some depth to it. If you only learn what is going on [by reading the comments of] people who are only reading 140 characters, you will miss a lot of the details that are absolutely critical."

Although these short, rapid commentaries can be very useful and add a level of nuance to discussions, you can sometimes miss the details, which are not just equally important but many times far more important.

Dissent and Discord: The Prevention Guidelines

Dr. Harrington: Do you want to reflect on the issue of the prevention guidelines? It brings out that issue of the veracity of the data vs the civility of the discussion. Usually it is the interventional cardiologists who get pretty nasty with one another, but the prevention guidelines community got pretty nasty with one another during that discussion.

Dr. Yancy: That experience was really remarkable because it wasn't until the last day of the AHA scientific session that we finally had a public discussion of the entirety of the process, the findings, and ultimately the definitive recommendations. Everything before noon on the last day was commentary, pithy statements, sharp statements, and some caustic statements. It was remarkable that the horse was turned around. We didn't lead with the head. We didn't lead with the most relevant database. We took a different approach.

As the smoke as settled, a huge service was done by the explosion of commentary following the release of the guidelines. There is no audience to whom I can speak today that isn't aware of the cholesterol guidelines or the new risk calculator. If what we wanted to do with these guidelines was say that we have taken an entirely different approach, and you need to pay attention because this is a radically different way of doing things, then "mission accomplished" -- albeit painfully and with a lot of heartache for a lot of good people who have been involved and a lot of lingering questions. But we can't say this guideline entered the space quietly and will leave the space quietly. It made its statement. It made its presence known. There are many who will say that up to a degree, any noise is good noise when you are talking about a new concept.

Now, did we swing the pendulum too far and get to a space where we lost some of the decorum? We should gravitate towards that decorum issue because even though it is the thorny issue on the table, it is not one that we should avoid. Dissent is healthy, and disagreement is appropriate, but questions should arise from the process that one uses to address that.

Dr. Harrington: It is a topic that we should spend a couple of minutes on. It is this notion of the civility of professional discord or professional discussion.

Our mutual friend and colleague Rob Califf, from Duke University Medical Center, likes to remind me that if you are not ticking someone off, you are probably not doing anything interesting; and Rob, as you know, is one of the great provokers. He likes to poke and prod, but there is an important difference between poking and prodding in a civil and healthy way (even when aggressive) and some of the things that we are seeing with the cloak of anonymity that the Web can provide. There are some pretty nasty discussions going on out there, which can detract from the overall messages. It can distract people from what is actually important and focus their attention on the nasty piece, which certainly makes for good headlines but doesn't necessarily make for good science.

Tweet Unto Others...

Dr. Yancy: There should be a litmus test that everyone ought to exercise before tweeting or entering the blogosphere or some email string with a potentially negative comment or harsh criticism. If that comment was directed at you or your work, how would you receive it? Your answer might be that it is reasonable to push back -- this is controversial, and you would be happy to get the critique even if it is harsh. Or you might look at the comment and say, "If that was about me, I would want that person to rethink what they have written." People should exercise that litmus test and realize that none of us is immune, and we don't have Teflon coatings. If you are about to make a comment, and you know that if it was in the context of your own professional space or professional work, it wouldn't be welcome, then I would rethink either the language or the intent of the comment.

Dr. Harrington: That is a very useful construct for thinking about these things. My litmus test, to use your phrase, has always been if you wouldn't feel comfortable standing up at a microphone in a public place and making your comment, then you shouldn't be making it at all. My observation has been that the more caustic comments are hidden behind the cloak of anonymity, and when you actually have your name attached to something, it becomes more difficult for people to stand up and say nasty things.

I am with you, Clyde. I am 100% in favor of disagreement and dissent, but just do it professionally. Professionally means having respect for your colleagues even when you vehemently disagree with them, and vehement disagreement is healthy, particularly in the kind of work we do.

Dr. Yancy: Let me give you just a quick example of how it can be. You and I both serve in editorial capacities for different journals. Rarely have I ever seen a written peer review of a journal article, even in the restricted comments to the editors, that was nasty. It might say that the research is not done well, but it is a critique that ultimately, even though it might be professionally upsetting, you could share with another person. So you can go through this process; you can achieve the greater good of having the best science that has been vetted in the most appropriate way without it becoming personal. We have seen it for years in the standard peer-review process, and somehow we have to export the standards of peer review to this new dynamic of the social media space.

Traditional Values in a Nontraditional World

Dr. Harrington: In closing, give me your views about the young members of our community who we are trying to draw in. The fellows in training, the postdoctoral students, and the young faculty members have grown up in a different environment from the academic environment. They want to participate. Some of the fellows' blogs out there are fantastic, giving us a new perspective on the meetings. Early career day at AHA has been fantastic and engaging. The ACC has similar activities with the Fellows in Training program. How do we pull our young colleagues into the meetings and into the world of scientific discussion?

Dr. Yancy: The fellows are the reason that we are having this conversation today. Not only has the world changed since 2011, but the world is totally different for the new professionals entering our space. We are products of our own social experiences. You and I like to turn pages because we grew up turning pages. These young people abhor turning pages. It has to be something easily accessible on a platform that is portable, so this conversation is most important for that group. We are reminding that group that it is absolutely a great idea to have rapid communication and interactive discussions almost at the moment data are released. It is the best idea out there. But the traditional values of civility, appropriate discourse, dissent, criticism, and the strength of peer review need to be respected in some dimension in this new space. This new space should absolutely go forward. It is the language of our younger professionals, period, and all we are trying to do now is say that in the new vernacular, think about some filters that have traditionally served us very well. If you can incorporate those filters into this new vernacular, then we will thrive going forward.

For those of us who are late to the party, we are having to learn how to do this correctly and not walk away from our traditional approaches. It is an exciting time, and that is why we do this. That is why we think about novel ways to reinvent our meetings because they are the future of cardiovascular medicine and cardiovascular health. That is a pretty heavy responsibility, but I believe that they are more than up to the task.

Dr. Harrington: This was a great discussion, very wide-ranging, as would be expected, with some good insights from you, Clyde, so thank you for joining me. Our topic today has been the airing of professional disagreements in an era of social media. My guest has been Clyde Yancy, Professor of Medicine and Chief of Cardiology at Northwestern University and the Feinberg School of Medicine. Thank you for joining us on theheart.org radio.

Follow Clyde Yancy, MD, (@NHMheartdoc) and Robert Harrington, MD, (@HeartBobH) on Twitter.

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