Twitter, Kardashians, and the Democratization of Clinical Debate

February 24, 2020

One of the country's preeminent physicians used an old-school editorial to weigh in on the potential of Twitter and its ideal role in public discussion on medical research, and to outline his take on the influence some users acquire — deservedly or not — from engaging legions of "followers."

Twitter and other forms of social media have the potential for "democratizing both dissemination and critique" of clinical trials, their results, and their lessons, "thereby bringing in the broad swath of the clinical practice and scientific community" to the public debate, Robert M. Califf, MD, Duke University, Durham, North Carolina (@Califf001), observes in the commentary.

But the commentary from a respected clinical trialist, renowned health outcomes and quality of care expert, and former Food and Drug Administration commissioner rankled a number of clinicians who are regular voices on Twitter.

They agree that it's a game-changing medium for sharing valuable insights that might otherwise never be heard, but saw themselves and others on the pervasive microblogging platform as targets of the editorial.

Twitter, Califf writes, "suffers from brevity and a dominance of Twitterati," that is, "people with a gift for promotion of their ideas by using short phrases" who can potentially attract large numbers of followers.

In an ideal world, he argues, researchers with the most publications and citations, that is, those "with the most important contribution of original knowledge, would have the largest Twitter following" in proportion to their influence on Twitter.

But in reality, "pundits with few publications with impact and a large Twitter following either may be expert commentators and analysts or may represent 'crackpots' with little real knowledge of the topics on which they are commenting," writes Califf in the editorial, published online February 5 in JACC: Case Reports.

The editorial accompanied an analysis, which was framed as satire, that makes use of something called the Kardashian Index, or K Index, a metric for influence on Twitter as a function of influence in the scientific literature, and which was named for a pop-culture celebrity.

Medical discussion on Twitter seems to follow two distinct avenues, Califf told | Medscape Cardiology. One, "I think it's good for discourse and debate. It's greatest value right now, I think, is for knowledge organization."

He said that refers to when, for example, an accomplished and respected scientist uses Twitter to curate and comment on important research advances, perhaps even providing links to the pertinent publications.

Califf singles out Eric J. Topol, MD, Scripps Research and Scripps Clinic, La Jolla, California (@EricTopol), who has about 190,000 followers, as a master practitioner of that approach.

On the other hand, "Busy practitioners who comment on the relevance of a study's findings to their practice, and their interpretation of it — I think that's fair game," said Califf, who has almost 10,000 followers.

"The bothersome thing to me is more the people who pontificate about the methods but haven't actually done trials themselves, and aren't participating so much. I think we need to reward the people who really participate," he said.

"My point was that it would be nice if the people who have the high Twitter following also really were part of the process of getting the studies done on which they're commenting."

To that end, Califf said, one goal of the editorial was to promote a sense of common purpose between the cardiology research community and cardiologists on the front lines of clinical practice who don't participate in much research or contribute to the literature.

In cardiology, "90% of our major recommendations are not based on high-quality evidence," Califf said. That points to a need for more aggressive research efforts that will have to involve clinicians in practice to be successful.

"We have an enormous gap of knowledge, and we need more people participating," he said. "One marker of participation is either enrolling people in trials or participating in the writing of manuscripts that get published with peer review."

He added, "The more knowledge people have about how trials get done, the better able they'll be able to discuss what they mean and how they can be done better."

But the editorial, some observers say, argues that physicians with the greatest contribution to the medical literature are most qualified to critique medical research, especially clinical trials.

Moreover, they see the editorial as taking aim specifically at them and other physician users who are primarily in clinical practice and thus don't have a lot of publications.

Among them is Ryan P. Daly, MD, Indiana Heart Physicians in Indianapolis (@DrRyanPDaly), who objects to the editorial's "tone," he explained to | Medscape Cardiology. "It was actually rebuking some of the people who have been using Twitter as a forum," he said.

"Basically it alienated a lot of people who are using Twitter, and minimized the contributions of some of the younger people that are very facile with it."

In a tweet referring to the Califf editorial, Daly said it sent a "stay in your lane" message.


It's important that clinicians primarily in clinical practice share in public debates on studies that will inevitably affect patient care, said Daly, who has more than 3700 Twitter followers.

"I just don't think that we should try to censor or marginalize people that have published less," he said. Such physicians should have a forum in which they can "push back" and explore whether research is sound, he added. "And if the data is strong, what do they have to worry about?"

In his blog, statistician Darren L. Dahly, PhD, University College Cork, Ireland (@statsepi), expressed a similar interpretation of the editorial.

"Citation-based metrics, whether applied to people, papers, or journals, are a poor proxy of scientific contribution." Among other issues, they "conflate quantity with quality," writes Dahly, who has about 10,500 followers.

"My larger objection, though, is the overall gate-keeping tone of the editorial. The argument seems to be that the people who conduct lots of research are the ones whose opinions matter the most, and apparently anyone else can just be ignored."

The idea that "people who don't have high citation counts are undeserving of the follower count" is "ignorant, arrogant, and even anti-academic," tweeted Venkatesh L. Murthy, MD, PhD, University of Michigan, Ann Arbor (@venkmurthy), who has about 10,300 followers and declined to be interviewed.


Moreover, the editorial has a subtext that may be out of step with the times, suggests a blog post from pediatrician Bryan Vartabedian, MD, Baylor College of Medicine and Texas Children's Hospital, Houston (@Doctor_V).

"Buried between the lines is the fear is that a dark horse could emerge that influences the trajectory of medical thinking, a trajectory once shaped and controlled by a select group of physicians," writes Vartabedian, who has more than 33,000 followers.

"This perspective perpetuates the idea that capacity for commentary should be based on pedigree rather than the originality of one's thinking. Unfortunately, this way of seeing the world sits in contrast to how the medical profession is beginning to share information and construct new ideas."

A similar interpretation of the Califf editorial comes from John M. Mandrola, MD, Baptist Medical Associates, Louisville, Kentucky (@drjohnm), who said when interviewed that he considers himself to be one of its intended targets.

The editorial highlights friction between the traditional hierarchical channels through which new data and insights exclusively used to reach the medical community at large, and the democratizing effect of social media, contends Mandrola, who is chief cardiology correspondent and a columnist for | Medscape Cardiology and has more than 35,000 followers on Twitter.

Its subject is therefore "the tension between the new platform that digital media affords vs the old platform, and who gets to control the narrative," he said. "You don't have to go through the ranks anymore."

In addition, "a lot of the pushback on the editorial was on the notion that if you are critically appraising a trial — let's say you're a doctor, or patient, or maybe a regulator or payer — that somehow it's personal and you should respect the people who did the trial," Mandrola said. "I just think that's a faulty notion. Critical appraisal is not personal."

Indeed, it may be one of Twitter's strengths. "Twitter offers, in an imperfect way, the wisdom of the crowds. Everything on Twitter is peer reviewed by the public," Mandrola said. "That's a huge plus."

Another virtue of medical Twitter, he notes, is that commenters usually own what they tweet. Most serious posts on Twitter, the ones that drive discussion, have a real name attached to them. That's in contrast to journals with traditional peer review, whose reviewers are seldom identified.

"Anonymous peer review — I understand it, but it's a real weakness," Mandrola said. "It's true that there are less-than-experts on Twitter. But I think that, in general, its filtering aspect is a counterforce to that. If you've got stupid ideas, you're going to get called to task. I'm not advocating that Twitter or a blog or podcast should be the only kind of peer review, but it is a different kind."^tfw|twcamp^tweetembed|twterm^1226651299216650240&ref_url=


Indeed, Twitter "has some real advantages compared to waiting for the peer reviewed journal to come out, and then waiting to go to a meeting," Califf acknowledged. "I mean, you can absorb and hear what different people think. It is democratizing. I think that part of it is good."

On the other hand, a loud Twitter voice, as measured by number of followers, "does not necessarily equate with more impactful work," concludes the primary article in JACC: Case Reports, for which Califf wrote the accompanying editorial.

That primary report took a satirical approach to convey the message that science and its traditional dissemination should get more respect and recognition beyond any measure of social media activity, Ankur Kalra, MD, Cleveland Clinic, Ohio (@AnkurKalraMD), one of the article's authors, told | Medscape Cardiology.

It was meant to be "humbling, for everyone including ourselves," said Kalra, who has more than 5600 followers. "All we really wanted to say was that level of scientific importance should not be equated to Twitter followership."

On the other hand, "I think that people who publish good science should also be active on social media, because once they become active, they'll automatically have a following just because they have published science that has changed the field."

And that, Kalra said, "gives the rest of us an opportunity to directly speak with them on questions and issues. Twitter has given a voice to a lot of us, and has sort of leveled the playing field."

The report's authors, led by Muhammad Shahzeb Khan, MD, Stroger Hospital of Cook County, Chicago, Illinois, described their use of the previously defined K Index, the ratio of the number of Twitter followers a person has amassed to the number theoretically deserved based on their number of literature citations.

In their sample of 1500 leading cardiologists, only about 16% were on Twitter. Of those, about two thirds scored a K of 2 or less, signifying a low level of influence via the service.

The analysis, which was meant to be playful, Kalra said, showed that only about 10% of the 238 cardiologists on Twitter had a K index greater than 5 and could therefore be thought of as Kardashians. It was an unscientific suggestion that maybe their social media following was out of proportion to their influence in the literature.

"Our work reinforces the fact that very few cardiologists are 'Kardashians' of social media," the report concludes.

Kalra said that the report was meant to urge cardiologists on Twitter, "myself included," to question the value of their social media influence compared to their research accomplishments. "And if the answer is something we're not proud of, then maybe we should strive to be better scientists than better Twitterati."


In his editorial, Califf describes the K Index as "an oblique way of addressing an issue that is bothersome to researchers who have paid the hard price of designing, conducting, analyzing."

When research is discussed on Twitter, Califf writes, "Another person who may have only casual knowledge of what is involved in the research may then make a comment that attracts enormous attention. People with a high K-Index may be those who thrive by commenting on the work of others rather than doing their own work."

The medical community "will have to come to grips with the right balance of doing research versus interpreting and commenting on research. There is a need for both," the editorial observes.

"We should hope for few Kardashian-style commentators and many more professionals who do the hard work and then use social media to develop a mutual understanding of what it means."

The heated public response to the Kalra report and Califf editorial may have been based on misunderstandings about the K index they so prominently showcase. Some interpreted their arguments as inappropriately serious uses of a bogus metric.

When interviewed, Califf acknowledge the playful nature of the K Index. "The Kardashian Index is tongue-in-cheek, but, like a lot of quasi-humor, it actually points to something that we ought to pay attention to."

But not everyone has been willing to laugh at the editorial's use of the index. "The very notion that the K-index is actually a measure of anything, much less anything that anyone would be interested in, is laughable," Dahly contends in his blog.

"It's a parlor trick," he writes. "The idea that smart people are giving it serious discussion is astounding to me."

Interviewed, Daly called the primary Kalra report "lighthearted and fun. I actually thought it was poking fun at ourselves." As for the editorial, "I find it distasteful to call other cardiologists and colleagues 'Kardashians.' At worst it's disparaging."

The editorial didn't include any names of Twitterati to whom it may have been referring, Daly observed, "but you can kind of figure out who he's talking about."

But the K Index "was always meant to be a kind of a joke with a small point associated with it," its inventor, genomics researcher Neil Hall, PhD, told | Medscape Cardiology. "It was not intended to be taken literally!"

In his 2014 "proof of concept study," Hall plotted the number of citations of 40 scientists against each one's number of Twitter followers. From that he derived a formula for the Kardashian Index, "which allows a simple quantification of the over, or under, performance of a scientist on social media," writes Hall, who directs the Earlham Institute, Norwich, United Kingdom.

Hall had hoped the satire would be apparent from multiple, sometimes overt clues in the report's text. About his cohort selection, for example, he writes, "I did not devise a clever way of doing this randomly (after all this is just a bit of fun)."

Another clue: the index's unlikely name borrowed from popular culture. Reality-television star and entrepreneur Kim Kardashian West (@KimKardashian) "comes from a privileged background and, despite having not achieved anything consequential in science, politics, or the arts," Hall writes, "she one of the most followed people on Twitter and among the most searched-for person on Google."

Kardashian West has 63.5 million Twitter followers.

Regarding her eponymous index, "I'm a big skeptic of any simple metric like this," Hall said when interviewed. "It's easy today, when there's so much information and opinion out there, to look for something simple to filter what you consume. My worry is that it can be self-fulfilling, that people with a lot of citations will be listened to, and will be cited more. And then we get stuck in dogma."

Califf is an employee of, and stockholder in, Verily Life Sciences and Google Health. He discloses receiving director fees, serving on the Board of, and being a stockholder in, Cytokinetics. Topol is Medscape editor-in-chief. Kalra and his coauthors have disclosed no relevant financial relationships. Mandrola has disclosed no relevant financial relationships.

JACC: Case Reports. Published February 5, 2020. Report, Editorial

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