COMMENTARY

Cardio Twitter: An Essential Tool for Staying Current

A Discussion With Bobby Yeh, MD

Interviewer: Robert A. Harrington, MD; Interviewee: Robert W. Yeh, MD, MBA

Disclosures

June 11, 2018

Robert A. Harrington, MD: Hi. This is Bob Harrington from Stanford University, here on theheart.org and Medscape Cardiology.

For almost 9 years now, I have been actively using Twitter as a means to communicate with the broader cardiovascular community. Sometimes I communicate about research that my group is involved in or that I find interesting in the literature. And sometimes I communicate more broadly about things related to heart health. I have tried to keep my persona in the area of cardiovascular health and medicine, but certainly I use Twitter to follow other things I am interested in.

Robert W. Yeh, MD, MBA

Over the past few years, many cardiology colleagues have joined Twitter, and #CardioTwitter has a really robust following online. Such hashtags as #RadialFirst have promoted the use of the radial access site in cardiac catheterization and intervention. Any time a major trial comes out, we see a lot of interest in the community, who share their thoughts and perspectives via Twitter.

Recently, my friend and colleague Bobby Yeh published a paper on academic cardiology and social media[1] that I found really interesting. I asked him to talk to our listeners and readers on theheart.org about the use of social media in cardiology, what he has gained from it, some of the things he struggles with, and some of the opportunities he sees. We will have a good broad-ranging conversation.

Bobby is an associate professor of medicine in interventional cardiology at Harvard Medical School. He is director of the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology at the Beth Israel Deaconess Medical Center in Boston. Bobby, thanks for joining us here on Medscape Cardiology.

Robert W. Yeh, MD, MBA: Thanks for having me, Bob.

Harrington: I enjoyed reading your paper on social media and academic cardiology, and I thought you hit some key issues on democratization, peer review, debate, and dissent in this environment, and digital truth.

Let's get started with your personal reflection. How did you get involved in Twitter, and how do you use it as part of your professional persona?

Giving Twitter a Try

Yeh: That is an interesting question, Bob. I joined Twitter a long time ago, probably soon after it was formed in the late 2000s, when I was a cardiology fellow. At that time, there was very little content on Twitter, certainly not much in cardiology. A group of us in fellowship decided to join Twitter as a means to essentially "group text" with one another. I do not think you could group text at that time, because we were new to the cell phone and smart phone— it was the generation of the first iPhones®. We were at the American College of Cardiology (ACC) meeting and thought it would be a great way to tell each other which rooms we were in and what were the great talks going on at the time. That was why I originally signed up for Twitter.

Harrington: That is a great story.

Yeh: It is sort of funny, because we used it only partially successfully at that meeting. Thereafter, it lay dormant for me. I did not even have a profile picture. My account sat idly for 7 or 8 years. It was not until 2014 or 2015 that I started reading such people as you and others who were active early in cardiology and Twitter. When journals started to have Twitter accounts, it became very real to me that this was a great way not only to decipher content and to have content filter toward me that was relevant to what I wanted to learn, but also to have interpretation from such experts as yourself and others who were participating in and starting to grow this new entity.

Before, it was limited to electronic tables of contents that I was receiving from an increasing number of journals, which over time became more and more unwieldy. Now, content was being filtered in a way that was practical. It helped me read literature that I was interested in. That is initially how I used it. Since then, of course, it has evolved into something bigger.

Harrington: I started using Twitter in 2009, shortly after it became available. I joined as a way to communicate what was going on and to keep up at medical meetings. I tweeted during medical meetings, and I would be busy and have fun throwing out comments and observations from different things that were being presented or from talks that I had just heard or were starting to hear. I really kept my presence to the medical meetings. People would joke and say, "Bob we know where you are." They would see that I was at ACC, American Heart Association, or Transcatheter Cardiovascular Therapeutics meetings. Like you, several years ago I started increasingly incorporating it into my broader professional activities. I have learned a lot.

Let's talk about what you have learned. You have become very active on Twitter. Your Cheetos tweetorial really caught my attention, because you used it as a format to help educate the community. Talk to the audience a bit about how you are using Twitter.

Twitter as a Teaching Tool

Yeh: Education is one of the great ways Twitter can be used. All of us in academic cardiology spend so much of our time teaching. We teach on the wards, and we teach if we are associated with medical schools. But it has enabled us an incredible reach. The same content used for PowerPoint® slides made for a lecture audience of 10 can be disseminated to an audience of tens of thousands over Twitter. That has been a real revelation for me.

The same content used for PowerPoint slides made for a lecture audience of 10 can be disseminated to an audience of tens of thousands over Twitter.

As you know, I have a particular passion for and interest in clinical research methods. Certainly, our group has that too. Sometimes when we are interested in applying particular methods to certain things, we see that things maybe could have been done differently in a paper here or there that is being talked about. Stringing together a few tweets to teach subject matter that may not be accessible to many people has been a great opportunity. In the community, if you are outside the educational environment of a school, maybe you do not get that resource handed to you on a daily basis. There is an incredible reach associated with Twitter.

Harrington: I have been impressed with how you put methods in a very friendly language. Did Twitter teach you to do that or did you naturally teach that way in your classes or in your lectures with fellows, for example back at the Beth Israel?

Yeh: I teach at the School of Public Health, and we also have a didactic methods course we run out of the Beth Israel. I always try to do that in the lectures I give. But I will say that Twitter has made it more essential. With coursework, you have an audience of people who are ready, engaged, and have a certain basis in that subject matter. But with Twitter, you are reaching out to people who might not even know that this is relevant to them. With the shortened number of characters you have to work with, the limited attention span of your audience, and the fact that you may be teaching something to somebody who may not initially be receptive, I think catchiness and pithiness have become essential elements.

It has improved my ability to teach outside of Twitter. I now know that instantaneous feedback has much traction. For example, the Cheetos tweet was about immortal time bias, which is an esoteric idea but becomes clear when you put it in plain language. I was sitting back and trying to think of some ludicrous example that could really illustrate this concept that everybody would get. I threw it out there. The amount of traction it got was enlightening for me. It showed that this is an effective way to teach—both inside and outside of Twitter. It was an aha moment for me.

Harrington: I agree with you. Your Cheetos tweetorial really captured my imagination for how one might think about teaching. It makes me reflect on our mutual colleague, Mike Gibson, who might be the most active cardiologist on Twitter. What Mike does so well is combine pithiness with interesting insights into cardiovascular medicine. I see more and more people doing that, which I think is a friendlier way to teach. I have begun to rethink some of my presentations. I find myself using more pictures or a single graph. Like you, I am a data nerd, and if I cannot tell you something five times in five different pieces of data, I feel like I have not done a good job. I am starting to learn that maybe that is not the best way to teach.

Yeh: I have had the same experience. Along those same lines, our research group has embraced the concept of data visualizations—trying to explain a research paper in one slide. Now with many of our research studies, we put out simultaneous visual abstracts. If Andrew Ibrahim, a surgical resident at the University of Michigan, did not invent the concept, he was certainly one of the first people who put it forward in a digital way for a broad audience. He put forward this idea of visual abstracts—using one- slide presentation of papers—and that idea has caught fire at journals and in research groups. Twitter works in synergy with this idea of single-slide visual representations of studies to help disseminate new research findings.

Harrington: You made me think of another colleague on Twitter, Frank Harrell, who is a biostatistician at Vanderbilt and was the chair there for many years. I knew Frank back in the days when he was at the Duke Databank for Cardiovascular Disease. He is a big proponent of data visualization. In addition to providing visuals, he is a pretty tough peer reviewer on Twitter, isn't he?

Yeh: Yes, he sure is.

Harrington: What I love about his tweets is that he frequently refers you to his blog or to somebody else's writings where they dissect the method. That has caused me more than once to change my perspective on something. I think, "Oh wow, I did not realize that. That is an interesting piece of information."

That gets into two things in your paper that I would like to discuss. What did you mean by "democratization of voices," and what are you seeing on Twitter that is contributing to a healthy discussion in academic cardiology?

Twitter Gives Users an 'Equal Voice'

Yeh: It is a concept that many people have raised about Twitter and how Twitter and cardiology can interact. Everybody effectively has an equal voice on Twitter. You can ask a question of anyone, and anyone can ask a question of you. Put that in contrast with what might happen at a major academic society meeting, where there is a clear hierarchy. There is a panel or a speaker—often luminaries in the field—raised on a podium, and then there is an audience that is set quite literally beneath the podium. There may be a microphone or two set out in the audience, but I can tell you that it is really intimidating to stand at that microphone and ask a question to such an august group on stage when you are surrounded by what could be 1000 people in the audience.

Twitter takes away barriers to being able to ask a question. It is so easy to ask a question to luminaries in the field. That has promoted good conversation because at every level —whether you are a first-year medical student or just interested in it, a patient, or a father of a field —everybody has good questions. Twitter has raised the level of dialogue.

On Twitter, everybody is the same.

One of the ways we establish hierarchies socially is how we address each other in titles. I probably would not go up to Dr Eugene Braunwald and call him by his first name, but I think he would certainly feel comfortable addressing me by mine. On Twitter, everybody is the same. It removes the very first way that we establish hierarchy, and that is how we address each other. We all address each other the same way on Twitter, and I think that, and everything else that follows, gives everybody an equal voice and allows equal participation.

Harrington: That is so well said. I have had some great conversations with people over Twitter whom I then meet at their institution or at some medical meeting. It does change the dynamic, doesn't it? I first met one young woman who is a cardiology fellow on Twitter. Her name is Briana Costello, and she has a fantastic voice on Twitter. I developed an interaction with her over Twitter that has been really helpful. When visited Texas Heart, it was fun to see her live and face-to-face, and then to continue to engage in that conversation. I do agree with you, it has opened up my eyes to a lot of different ways to engage with the broader community.

I had another observation at this years' recent ACC meeting. The organizers tried to remove some of those barriers to participation by having more questions moderated on the iPad®, so that people did not have to get up to the microphone. More was done on the exhibit floor, where there was no stage and you were standing facing people in a much more conversational way. And I was part of a panel in one of the lounges. Do you think that is part of the trend of trying to get more voices into the conversation?

Yeh: I had the same observation, and I think those types of strategies to decrease the amount of separation between who is supposed to be speaking and who is supposed to be listening has helped those meetings recently. That has been a movement particularly in the past year or two. I would love to see that continue. There are even more innovative things that we can do in that space. I would like to think that Twitter and social media are part of what has fomented that move among the society meetings.

Why Use Twitter?

Harrington: Tell the audience how you use Twitter. Give us a day in the life of Bobby Yeh on Twitter.

Yeh: It is varied. This week, I am not using it much.

As a practicing interventional cardiologist, I can count at least five things I do differently now in the cath lab that I learned on Twitter.

Harrington: Let the audience know that that is because you just had your third child. Congratulations, by the way.

Yeh: Thanks. I was debating whether or not I should announce it on Twitter.

Harrington: As an aside, you did note that I announced via Twitter that we are opening up a job at Stanford. I think that was much better than placing an ad in the New England Journal of Medicine.

Yeh: Things that we want to reach a broader audience are great for Twitter. On Twitter, I am a content producer and disseminator, and also a content consumer. I started out primarily as a consumer of content. I use Twitter as a great resource to parse through the tremendous and overwhelming amount of information and literature that practicing interventional cardiologists or participating academic cardiologists should know. Twitter helps me parse down that content. I can see what other people are talking about and participate in that conversation. When I want to, I link through to the primary content because that is available. It is an entrée into diving more deeply into content.

Many of us active investigators use it to disseminate our research. We do that in the form of links to articles that we have just published and visual abstracts. In the beginning, there was sort of a discomfort with that. I will admit that it felt very self-promotional if I said that we just published some study. I have gotten over that a bit. We publish research and we do research in order to disseminate it. To the extent that Twitter is a vehicle for helping us get our message out for what we think is important, I have become less embarrassed about doing that. But it has taken some time to overcome.

Finally, it is a great way to converse and to meet new people and to learn new things. As a practicing interventional cardiologist, I can count at least five things I do differently now in the cath lab that I learned on Twitter. That might seem funny to nonproceduralists, but there are little tips and tricks, such as how you set up a table or something like that. I think Twitter is the best vehicle to quickly disseminate new techniques that would never undergo a peer review process because they are small changes. It has been really fantastic for that.

Harrington: I call myself a reformed interventionalist. As somebody who practiced interventional cardiology for a long time but no longer does, I have enjoyed following the interventional community to stay current just for my own observations. I agree with you—there are little tricks. #RadialFirst has been a fantastic example of how one can use Twitter to promote techniques, technologies, and tips.

Bobby, two things you said really struck me. One is that you use Twitter to scan the literature. I used to get my journals and go through them, then I used to look at the email table of contents. But now I follow a bunch of journals on Twitter that interest me, including ones I previously had not read. It is easy and a fantastic way to keep up with the literature, because you can constantly search the New England Journal of Medicine, JAMA, Circulation, Journal of the American College of Cardiology, and European Heart Journal. I can also start getting into others, such as Nature, Cell, and Science. Are you using Twitter to search the literature?

Yeh: I am doing the same. I follow most of the major journals and then new ones, as you said. The other thing that helps me is crowdsourcing my literature searches. Certainly, the collective reads more broadly than any individual. Something really interesting or relevant in the economic space or the social sciences space sometimes shows up on my feed. To be able to digest that and then dive in there to see how it applies to what I am doing has been really eye- opening. I often forward these papers to my mentees in our research group and say, "Look how they applied this interesting method" to a question totally unrelated to cardiology, but incredibly relevant to what we do or what we might ask in cardiology.

This has been a terrific part of joining Twitter. I would never see that if I limited my reading to what I got in the mail or email. Part of that is choosing people to follow who as a group are really engaged in or interested in a diverse set of topics.

Harrington: I will endorse that approach as well. I follow a group of people whom I consider to have great taste in science for that reason. They have broadened my horizon. As you say, they are not necessarily in medicine or healthcare, but they have some really interesting views on science. They follow and digest a great deal of literature. I pull PDFs off of Twitter and put them in my "to read" folder and read them on my iPhone if I have time. It has opened my eyes to other areas of research that might be quite useful. Even though on the surface, you might think it is tangential to what you do, it might be very apt for what you do when you get into the methods.

Truth and Civility

Harrington: I want to discuss two topics in closing, and I think they are related. You brought up one in your paper, called "digital truth. " There have been serious discussions in society about how do you know what is true on the Internet and how do you know what is true as we begin to digest it. Crowdsourcing is one way. I think you also captured it in the title of your paper : "The Wisdom and Madness of the Crowd. " Some have called it at times "the tyranny of the crowd. "

This brings us to the second issue I would like you to touch on: civility. Clyde Yancy and I devoted a couple of these podcasts to the concept of civility in social discourse. Although I am no stranger to disagreements and arguments, sometimes things on social media, maybe with the cloak of anonymity, can get a little nasty. Could you talk about truth and civility?

Yeh: Both are really important issues and issues that are common to everybody who engages on Twitter, cardiologist or not. Certainly, we talk about truth in terms of "alternative facts" and what is going on with the political discourse, but I think the first issue related to truth, specifically to cardiology, shows up in interpretations of research. Some studies are highly controversial, and some are done with different levels of rigor. Interpretations of those studies have different levels of validity. Sanjay Kaul showed me a quote originally from Nietzsche, which was " There is no truth, only interpretations." I love that quote because I think it is highly applicable to Twitter. [Editor's note: The Nietzsche quote is usually translated as "There are no facts, only interpretations."]

A trial is a set of information and facts, but the interpretation can vary widely. In the paper, I wrote about ORBITA, which was a great example of a trial having multiple interpretations. Some of them, frankly, were not accurate. There are shades of gray, and we can agree and disagree on what the final interpretation of a trial such as ORBITA should be, but certainly there was a lot of misinformation put out at that time on both sides.

As a consumer, like a patient, how are you supposed to decipher through that information and be able to tell what is actually true? It really requires you to go into the original information, find the PDFs, and come up with your own opinion. If one just relies on the opinions of whom they follow, one could easily be [relying on misinformation], depending on whom they follow and how much of an echo chamber was actually created. We do not know truthfully what the Twittersphere looks like. It could be one huge echo chamber a lot of the time. If you are not careful, you can easily go down a pathway of believing something to be true and actually be a little bit wrong. I say that that is true about all of us, myself included. I am sure you feel the same.

Harrington: I definitely do.

I think it is very important to follow people you disagree with.

Yeh: This is one of the important reasons why I think it is very important to follow people you disagree with. A real challenge of Twitter is knowing what your digital sphere look likes. What does my Twittersphere look like relative to the universe of opinions out there? I think for all of us, it is not a representative sphere to the extent that we can all challenge ourselves to follow people that we disagree with in a civil way. That will only increase the likelihood that we arrive at truth.

This gets us to your second question, which is, how should we be disagreeing on Twitter and what is the role of dissent, disagreement, and civility? I listen to your podcasts and read the article you wrote with Dr Yancy with great interest. You and I have had offline exchanges about this. I think we are of the same opinion that, if nothing else, interaction needs to be civil. We owe that to one another. We are all there for the same purpose, which is to get out something that is true and not spread falsehood. We do that best when we are kind and civil to one another.

Regarding anonymity of the interaction, I always use the analogy of road rage. There is something about being one level removed from somebody. When you are behind a windshield and another person is behind a windshield, we do things and treat people in a manner that we would never do if we had bumped into them in the elevator. Imagine that you bumped into someone on the way into the elevator and then treated them the way that you treat someone who cut you off on the road. There would be brawls inside an elevator.

I think it is the same way on Twitter. People often talk to each other in that way. Many, in addition to you and Dr Yancy, have raised the issue that we ought to be better about this. Many conversations have degenerated into name-calling and ad hominem attacks, to the point where people felt the need to block one another and not engage in that conversation. That is really a shame. I think blocking is the first window into truly creating your self-created echo chamber. I know you have a lot of opinions on this.

Harrington: You have captured a lot of it. Like you, I work at a university and I always say to our faculty and trainees and staff, "We are at a university. We ought to be disagreeing with each other, because only through disagreement and debate will we get to a reasonable place to be. However, if we are going to disagree with one another, let's treat each other respectfully and professionally." It does not mean you cannot disagree with passion, enthusiasm, and vigor, but it is critical that it be done with professionalism and respect for other people's opinions. Even in the university community, there can be intolerance of perspectives that disagree with one's perspective. We need to guard against that. We need to be able to have civil discourse and robust professional disagreements. Come armed with data, and let's have that conversation.

Bobby, this has been a fun conversation. I could keep going, but I want to be respectful of our listeners and their time. This has been a great review of academic cardiology and social media.

Dr Bobby Yeh is an associate professor of medicine at Harvard Medical School and the director of the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology at the Beth Israel Deaconess Medical Center in Boston. Again, congratulations on a very nice paper, and I hope people keep following the two of us on Twitter and engage us in conversation.

Yeh: Thanks so much, Bob. It has been a lot of fun.

Follow Bob Harrington on Twitter @HeartBobH and Bobby Yeh on Twitter @rwyeh

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