Tuesday, June 24, 2014

Disparity in Doctors. Reflection on Washington Post Blog " The Outrageous cost of working in Medicine."

"The journey to and through medical school was challenging and expensive. " - Me

I grew up in a middle class family in New York City. My father was a civil engineer for the NYC department of transportation. He worked hard and gave us a humble and honorable upbringing. We had everything we needed in life. Everyone in my family made certain sacrifices to sustain our middle class life.
     Despite a New York City public school system that often gets criticism, I managed to get into a competitive exam based science high school. I never had extra tutoring or took a review course and therefore feel lucky to have gotten accepted. Today these high schools are extremely competitive and many students are paying significant amounts of money for tutoring and review courses to augment their opportunities.
     I also never had a job in high school and had time to focus on my studies. Fortunately I got into an excellent, albeit expensive university. In addition to loans, my parents luckily had the ability to stretch their budget to pay for my tuition. I also participated in the work-study program for 2 years until the mounting pressures of the pre-med life forced me to quit. I was able to focus on my MCAT's and had the financial means to pay for an expensive review course. The review course definitely helped a lot.
     I didn't get into a medical school right away and applied for 3 years. It was a process that cost me close to $10,000. Once again, my family was there to support this expense while I had a low paying research position. I persevered, got into medical school and finally was able to bear the entire brunt of my educational expenses in the form of loans in excess of $250,000. I'm recounting my educational journey through the financial lens to highlight that even starting in high school the journey has been an expensive one. This is a journey many students cannot afford to make.
    The Washington Post article highlights several critical issues facing healthcare today. The cost of medical school is immense and has been looked at as a key reason why medical students are opting for higher paying specialties instead of primary care.  I think this makes absolute sense. But interestingly, the article also highlights a very important separate issue. The fact is that only 3% of medical students come from families in the lowest 20% incomes and 60% of students come from the top 20% incomes. This reality directly correlates with the paucity of minorities (especially African American and Latinos) entering medical school and our physician workforce.
     The article argues that the cost of medical school is a reason why minorities veer away from medicine. I agree there is some truth to this. But it's a lot more than that. Getting into medicine is a series of hurdles scattered over many years. Broken public school systems, social and financial pressures make these hurdles significantly greater for students in lower socioeconomic groups. To optimize academic opportunities there are many added costs that only students and families with financial security can better handle. This includes tutoring, review courses, books and a myriad of extracurricular activities. This makes the gauntlet to medical school  immensely challenging for students in the lower socioeconomic strata. Even for middle class families, this process is a huge struggle. This is a key reason why 60% of the medical students come from families in the top 20% of incomes.
    This also brings us back to the question about why students are choosing higher paying specialties instead of primary care. There's no doubt the enormous cost of medical school is a big reason. But logically, you'd think if 60% of the students are coming from the top 20% of earners, they might have less medical school debt and therefore be more apt to choose lower paying specialties. But the reality is, one of the great motivators in human behavior is the fear of loss. In this case, if you're coming from a higher socioeconomic group, why would you pursue career paths that threatens that?
     I'm not criticizing successful successful parents who give their children every opportunity to succeed in life. Nor am I criticizing students for choosing career tracks that best suits them. But the current construct of our educational systems are not set up to solve some of the critical problems in healthcare.We have struggling primary and secondary education systems followed by woefully expensive undergraduate, graduate and medical schools. We don't have enough medical schools or enough residency spots.The people that do take those few spots are not doing primary care (the foundation of a successful healthcare system). We live in a diverse multi-ethnic country yet several key minorities are underrepresented in our healthcare system.
       This highlights just another one of the several systematic problems in our healthcare system that is self perpetuating with no end in sight.

Here's a link to the Washington Post piece.
The outrageous cost of working in medicine


Tuesday, June 10, 2014

The Calm before the storm. Tips for New Interns

It's June kids.
Time to ditch the short white coat, grab the long one and start being a doctor.

There's lots of helpful tips written by residents out there.
Here's a quick list of tips from the perspective of an Attending in Internal Medicine who primarily does outpatient work.

1: Focus on the "WHAT" and the "HOW?" 
For the short term, focus less on the "WHY."
    As a new intern, your job essentially is to get things done. So constantly ask your resident/attending/nurses "What do I need to do?". Keep an organized list.
   Since you're  in a new hospital, also ask "How do I do this?". If you don't know how to get it done, don't wait to figure it out. Ask right away and get it done.
   As you get more comfortable and efficient, then you'll be able to ask the WHY questions.

2: Be humble.
    Yes, you're extremely smart, you're an MD/DO now and you've crammed your heads with tons of esoteric medical stuff which most people (even residents and attendings) have forgotten. But realize, you may know a lot of medicine, but taking care of patients is completely different. Humility will leave your mind and days open to learning and endless possibilities.

3: Try and have fun!
Don't get me wrong. This isn't going to be easy and there will be moments and days where your patience will be tested. There will be moments where that polaroid smile while seem like an insurmountable task.Nevertheless, try to see the glass half full and find the joy and humor in the craziness that is Internship.  Have fun for your own sanity, the sanity of your team and most importantly for your patients. If you enjoy what you do, patients will sense it and believe in you!

4: You are an incredibly important person in the team.
    Sometimes it may seem like your presence isn't that important and you're simply a cog in the machine. But to that very ill patient (in hospital or in clinic) you are critically important. You are the physician that's going to spend the most time with the patient. You are the first contact when things go bad. You are the eyes and ears for the senior resident and attending.

5: Residency is a PIT STOP in your life
Life is like a Nascar (or Formula 1) car race. It's a long race, hundreds of miles, it's relentless and it goes fast.  Residency is just a small fraction of your life. It's like a pit stop in automotive racing. The race may last a few hours but cars spend only a few minutes in a pit stop.

But if you know anything about car racing, teams work tirelessly to make those pit stops perfect. In fact, races are often won and lost in the pit stop.
You should approach residency the same way. Realize it's just a small part of your life, but strive to make it perfect, and work tirelessly at it to win the bigger race.

6:You are being evaluated by everyone
    This is the era of 360 evaluations which means everyone has a say on how you are doing. I can't tell you how many times I've seen excellent interns and residents rotation get derailed (Despite being an excellent doctor) by negative evaluations by medical students, nurses, residents, sub-specialists etc. Be a professional towards everyone!


That's all I've got for now. Hope this helps.

Good luck to all the new interns! You've made a great career choice and it's only going to get better!

Monday, June 2, 2014

Fast Food Medicine

"Would you like fries with that?” 
"Would you like to upgrade to a large soda instead of a medium?"
“Would you also like an additional blood test for Lyme disease?”

Sure why not? I love fries!
And a larger drink? Heck yeah, if it's only a few cents more.
I'll also take that Lyme disease test, just to be on the safe side!

The above sounds like a great fulfilling experience.
You get delicious inexpensive food, served by very pleasant and efficient people that were also willing to cater to whatever you want. You also get a doctor who seems to really care and thorough by ordering a battery of tests. It's the kind of experience and place that anyone would want to keep coming back to, again and again.

This is not the typical experience many patients (consumers?!?) have when they interface with our general healthcare system. Healthcare is not inexpensive, not convenient at all and the quality of the product is variable. And in many cases the experience is very unpleasant.

"Necessity is the mother of all invention."

What started out as filling a void for overcrowded emergency rooms and unavailable primary care physicians, urgent centers have been flourishing. It's simple supply and demand. Supply of primary care doctors are dwindling and the demand for more convenient patient care is increasing. Now in any of your neighborhoods, you can get coffee, fast food and some "healthcare" rather quickly and merrily. 

I've gotten used to counseling my patients on the dangers of obesity and its association to fast food. Lately, I've had to start counseling my patients on the dangers of fast food medicine. Although I recognize their need and why they appeal to patients (consumers!?!), I have serious concerns about the impact Urgent Care centers have on healthcare at large. Just in the past few years, these are the types of issues I've noticed from care provided by such places.

Over prescription of antibiotics
Unnecessary use of broad antibiotics
Shot gun blood work with spurious findings
Recommendations to pursue unnecessary advanced imaging
Unnecessary recommendations to see specialists
Patient expectations for over treatment and extensive work ups

These are just broad generalizations but after a years, my patient sample size is growing.

I'm not a business man, but in the "for-profit" world" you do things that get you paid (x-rays, blood work?) and you give the consumer what they want to ensure return business. These are dangerous business concepts when applied to healthcare and urgent care centers are rapidly becoming the prime example of this. 

As the cost of our healthcare approaches 20% of our GDP and medical educators at all levels preach value and cost, urgent care centers, retail clinics and their profit incentives threaten to undermine this entire movement.

I'm not the only one that is worried about this.

The link below comes from a blog post on Kevinmd.com echoing similar sentiments. 

Reflection from Spring APDIM 2014

    A little late, but this is a small piece of my Spring APDIM experience that I forgot to publish.

      For the second time, I had the privilege of attending an APDIM conference.  For spring 2014 it was held in Nashville, Tennessee. And just like Fall APDIM 2013 in New Orleans, the streets were filled merriment, music and food while the conference halls were filled with bright minds, ideas and tokens of inspiration for medical educators like me. 
     This was essential my first trip to a "southern city" (Florida doesn't count). True to southern tradition, hospitality was abundant. Though diverse in its population, the southern twang was prominent and enjoyable for a Yankee New Yorker like me. Downtown was lined with bars and restaurants all staged with talented musicians raucously playing traditional country, rock and honky tonk into the late hours as locals and tourists danced with each other in small smoke filled venues. Add to this, jubilant fans of the UCONN huskies women's basketball team emptied Bridgestone arena into downtown one night. "Nash-Vegas" as my taxi driver called it, was kicking. 
     It was this same taxi driver who on my first night in Nashville brought me back to my physician roots and reminded me why I was there in the first place. As a primary care physician, I love stories. It is the story of each life, whether it is drama, tragedy or comedy and its successful completion under our watch that makes this a gratifying career choice. It was his successful story that makes our field an important part of the fabric of American society.
     As we drove to downtown Nashville, he told me he was from Acapulco Mexico. He immigrated to the USA in hopes for a better life 25 years ago. He started in Texas and left despite the large Mexican community. He took a chance on Nashville. He worked nights driving a taxi so that he could purchase a home for his family. Eventually he turned his 1st house over for a profit and built a dream home.  He was quick to tell me his home would cost millions in New York. Along the way, he fell in love with a nurse, raised two kids who currently attend top rated colleges. His story doesn't end there. He continues to work nights to save up to start his own business. He wants to create a Latino southern themed department store to cater to immigrant populations that are homesick and struggling to find their own American dream. I never asked what medical problems he had or what role his doctor played in fulfilling this life. But I know every day when I see patients in my office, whether it's through prevention or managing chronic illness, my mission is to ensure illness doesn't derail a story like his. And if illness does catch a gentleman like him, we as primary care physicians treat and guide them so that his story has a happy ending. 

Friday, May 30, 2014

Uganda Medical Mission

I wanted to use this post to highlight  the blog on one of our  Med-Peds chief residents here at Stony Brook University School of Medicine.

Dr. Robert Abdullah (@docbobert) is a terrific person and physician who recently participated in a medical mission to Uganda. His blog has several posts from that experience and an incredible array of pictures.

I really enjoyed following his experiences and I think you will too!

It's also his birthday today!

Scribe for Life- Dr. Robert Abdullah


Wednesday, May 28, 2014

Climb YOUR mountain

     There's a lot to be done in our healthcare system today. Wherever you look, there's a problem that needs to be solved. Sometimes it seems like we have less and less people with the right training and attitude to take on these challenges and re-engineer our healthcare system.
     Most people start their career with the intention of not just practicing medicine but also working towards making healthcare better. But once you start your career it all gets overwhelming very quickly. As patients come in droves, many of us are simply trying to stay afloat with providing good patient care. After a few years of getting comfortable with this, I finally was able to take a breath, take a step back and start looking at doing something else with my life in addition to seeing patients. I once again started asking myself, how can I make the world around me (our healthcare system) better? As I began to figure this out (and this takes time, introspection, education) and develop my own interests, I got wrapped up in other things. I got caught up in the moment and the immediacy of the problems around me. I did a lot of good things but before I knew it several years passed and veered further away from what initially got me excited.
      The amount of time, energy that's required to happily succeed in medicine is immense. The only way to sustain energy and momentum, is to be passionate and have a greater purpose that you sincerely believe in. Hard work and a desire to do the right thing can overcome a lack of passion. But if you have a greater purpose in medicine, you have to stick to your guns, get back to things that get you excited and fulfill that sense of purpose.
      We all have the proverbial mountains to climb in our career. Just make sure it's a mountain of your choosing. You don't want to spend your life climbing, and in the end, not enjoying the journey or the view from the top.

Thursday, February 27, 2014

A Wasteful Week

     I'm a bit of a backseat driver these days. As a result of the economy and the number of people who have lost insurance (and gained Medicaid) we're seeing a lot of new patients who previously had commercial insurance plans and were being seen by community providers that do not accept Medicaid. Some of them reluctantly come to our resident clinic, but the majority are very grateful for the opportunity to receive excellent comprehensive care from our well intentioned trainees during a difficult transition in their lives.
I've never really worked as a private practitioner in the community, but this influx of patients switching to our clinic has given me some (albeit very limited) perspective on the care they receive in the community with commercial insurances. For the most part, everyone receives excellent care and they often express disappointment that they have to leave their long standing doctor. But on several instances, when we investigate their past medical histories, we've been seeing several instances of what appears to be wasteful unnecessary care.

In 1 week, here is a sampling of a few of these cases.

1: Middle aged gentlemen in good health, well controlled high blood pressure and some family history of heart disease was getting yearly stress tests because " My doctor  was thorough and wanted to be sure."

2: Gentleman who got his first colonoscopy at age 47 because according to his wife "We had really good insurance."
3: Twenty something  year old female, with mild occasional anxiety was getting yearly EKG's as part of her "Annual Exam."
I know I'm looking at these cases as a backseat driver. Perhaps I was getting an incomplete history and there were good reasons why these tests were ordered. But my instincts, medical knowledge and perspective on our current healthcare system suggests it falls under the category of wasteful care.
Reuter's Report on Healthcare system waste 2009

We are all guilty of practicing wasteful care and it's a multi-factorial problem. It start's by changing our mindset towards healthcare by looking at things in terms of value. We also need to make a concerted effort towards following the evidence, and when the evidence is overwhelming, use validated clinical decision support tools.

Case 1: See number 2. Choosing Wisely (American College of Cardiology)
Case 2: USPTF Colon Cancer screening guidelines
Case 3: Rethinking the value of the annual exam

We also have to hold each other accountable for these problems, and sometimes that means being an annoying backseat driver with a computer and a blog :-)

Monday, February 17, 2014

Wegener's and Wikipedia on a cold winter morning, 2008

     The year was 2008 and I had a real swagger about me. After another long Philadelphia winter, the calendar was about to flip to March and spring. More importantly, the end of my internal medicine residency was within reach. It seemed like every day, I was doing something else for the last time. My last admitting shift, my last ICU rotation, my last 30 hour call. These were the many little aspects of a grueling residency that seemed so terrible at the time, but today is a memory I'm proud of.
     I carried that same swagger into my last morning report presentation. A miraculous catch by David Tyree and a Super Bowl victory by my New York Giants gave me the confidence to present my case with ease despite an audience full of Philadelphia Eagles fans. I presented a case about a gentleman that I had admitted for acute renal failure from Wegener's Granulamatosis. It was a great case that generated a lot discussion between students, residents and faculty. I concluded my presentation like others by reviewing some of the evidence and literature for its treatment. With my last PowerPoint slide, I paid homage to my interests in medical history by revealing the onerous story behind the gentleman for whom Wegner's was named. German pathologist Friedrich Wegener apparently had ties to the Nazi regime.
     My digression into medical history was well appreciated. It was a welcome break from discussing antibodies, drugs and the pure science of my case. I looked across my audience and started to notice eyes perk up as the decibel level in the room slowly increased while my presentation neared its end. I concluded my digression about the infamous Dr. Wegener by displaying my reference. It wasn't a journal or a textbook. It was "Wikipedia, The Free Encyclopedia that anyone can edit."
     My reference was met with a variety of reactions. There were those who looked confused and probably had never heard of Wikipedia. But there were those who laughed and found the reference humorous or perhaps comical. I wasn't surprised by the laughter or snickers. My residency and its faculty prided themselves in the strong academic traditions of evidence based medicine. Some residents even hesitated to cite established resources like The Washington Manual or Up To Date because it wasn't JAMA, or NEJM or Annals. I suspect back in 2008, a reference to a quirky online fad where any Joe or Jane could pose as an "expert" had little or no place in the halls of medicine academia. But as far as I could tell, the world was changing.
    Wikipedia is obviously not a fad. It is rapidly becoming the go to reference for everyone. Since 2008, the number of articles on it has doubled to 32 million, 4.5 million in English. Back in the day, I had a 25+ volume edition of the encyclopedia Britannica. I used it for all my school projects and I never questioned its authenticity. I never checked up on its references. I accepted it as truth and it got me through my academic life until Wikipedia. Modern education systems are and should rely on Wikipedia as a vital information resource just as I did with Britannica. In my opinion, Wikipedia is a monumental leap forward in civilization since it has democratized knowledge by taking the price tag off of it and allowing every citizen to contribute. One could even argue, it is everyone's civic duty to contribute to Wikipedia, just as we expect everyone to pay taxes or perform jury duty.
   In medicine we love our traditions and the knowledge that we guard is sacred. We also have a very high standard for the quality of that knowledge. It's part of the reason why we will probably be the last to accept Wikipedia as a legitimate source of information. But it's already happening whether we like it or not. In my own social media study at my institution, nearly all the students who responded are using Wikipedia for both personal and professional reasons.

Social Media in Medical education student survey, Blog Post

In my day to day work with residents and students, Wikipedia is a fast, quick reliable source of pulling up a variety of types of information. I find it especially useful pulling up basic sciences information (anatomy, biochemistry, physiology etc) which is often forgotten in the fast paced clinical real world.

I think medical academia is finally understanding that we cannot hide from the digital world and that we should understand it, participate in it and help shape its future. The University of California in San Francisco medical school is embracing this.

UCSF First US Medical School to offer credit for Wikipedia articles.

The Cochrane collaboration will also be partnering with Wikiproject  Medicine to help advance this movement.
Cochrane + Wikimedicine

These are just a few examples of how medicine is embracing something like Wikipedia and the body of literature supporting it is rapidly growing. It is part of the ongoing evolution of medicine as it looks to reshape its concept of knowledge and in the process better meet the educational needs of the next generation of physicians.

Thursday, January 2, 2014

Our healthcare and "The Wire"

A few months ago, I finally started watching "The Wire.” For anyone unfamiliar with it, “The Wire” is a police drama on HBO that takes place in Baltimore, Maryland. It takes a hard look at inner city drugs and violence from the multiple points of view of an incredible tapestry of characters. It's a wonderfully gripping show and I give kudos to the creator David Simon for painting this haunting and tragic picture of modern urban Americana.
I don't watch a lot of TV, but right now I can’t stop thinking about this show. The show has a lot of social commentary and I’m finding its messages everywhere around me. No, I don't work in the inner city, though I'm somewhat familiar with it. I grew up in a humble New York City neighborhood that over the years started to struggle with drugs and violence. I did my residency training in downtown Philadelphia, and as a young doctor saw many facets of inner city life from a medical perspective. Although I don't currently work or live in the harsh inner city streets, I do exist in a place that is failing its citizens just like "The Wire." Our healthcare system sometimes seems just as tough, destitute and hopeless as the streets of Baltimore as depicted on the show. 
Instead of street drugs, we have diseases in healthcare. But the story of "The Wire" isn't about the drugs itself, but rather how its omnipresence shapes the lives of the entire ecosystem. The same can be said for diseases in healthcare. Diseases are the constant in healthcare and how all the players deal with its presence is diverse and fascinating. But drugs in the show and diseases in healthcare are not the antagonists in these stories. The TV show makes this painfully clear. Any attempt to physically remove drugs from the streets by arresting the end users is an exercise in futility. In medicine simply fixing one artery, treating one infection, doing one CT scan or taking a pill, solves a problem temporarily for the end user  (the patient) but does little to answer the bigger question of why someone struggles to overcome a chronic illness or in the case of "The Wire" why citizens struggle to climb the social ladder out of the ghetto. 
The show also has an incredible cast of characters. Most of them have positive attributes and an innocence that is constantly challenged by drugs and violence. I feel for  these characters. As I watch them, I cross my fingers and hope they find a way out before the "the game" catches up with them. As a primary care physician, I peer into the lives of my patients just like the characters in the TV show. I get to know them, their hopes, dreams, and their intentions while they face difficult odds against conditions like morbid obesity, diabetes, psychiatric illnesses, HIV and heart disease. I cheer for my patients while hoping that my interventions will avert some catastrophic event in their life. In "The Wire" a teenagers’ dream to become something in this world may get derailed by a random act of violence that inevitably pulls them into a life of drugs. In my world, a heart attack, stroke or any other random medical malevolence sets of a chain reaction that often makes it very difficult to meaningfully recover from.
The show also shows the perspective of the police department, the good guys. I like to think I'm one of the good guys. Instead of the guardians of the law, I view myself as a guardian of health.  In the show, the police department is depicted as a bureaucratic mess with leaders pushing misaligned incentives and convincing the hard working street cops they are doing the right thing. Street level arrests (aka "rip and runs") of low level drug users and dealers are depicted as ineffective to curtailing drug violence and therefore a complete waste of resources. Nevertheless, arrests fill up stat sheets for the police department and numerically give the false impression that good is being done. As a primary care physician, I feel like the street cops, at the front lines of healthcare. Instead of arrests, I'm trying desperately trying to achieve numerical benchmarks which some might think are good indicators of excellent medical care. Although these numbers look good on paper, I question how effective they are in the grand scheme of changing healthcare outcomes and improving lives. True investigative work that looks deeply into patients’ lives to solve and treat root cause is not rewarded in our healthcare system nor are the investigators appreciated who take this approach in the show.
Finally, I've read that the creator of the "The Wire" views his show as a modern day Greek tragedy. Greek tragedies often describe a doomed people who exist at the mercy of angry, greedy, vain and selfish Olympus gods who hurl lightning bolts, pestilence and misery at their subjects. In “The Wire,” the modern gods come in many forms. Politicians, police commissioners, corporations, drug kingpins all have a responsibility to protect and help their followers, yet inevitably fail them time and time again to their own benefit. In my world, the gods are politicians, insurance companies, drug companies and perhaps the physicians themselves. In their efforts to serve, politicians fight over policy decisions while people remain without insurance. Insurance and drug companies continue to profit despite questionable business practices that often hurt average citizens. Too many physicians, despite their best intentions, mired in debt and bureaucracy blindly plunge ahead doing more and more in a fee for service world without ever stopping to see if we're not only helping but also hurting our patients.
Occasionally I get asked about the myriad of healthcare related TV shows and which one is the most realistic. The easy thing is to point to any show that has doctors in it, be it a comedy, drama or reality show. Though “The Wire” isn’t about healthcare, its themes are very relevant to what I see every day as a primary care physician. With one more season left to watch, I’ve unfortunately come to expect a tragic hopeless ending. With several seasons left of my own story in primary care I expect many tragic story lines. But in this case, hopelessness will never be in the script.

Thursday, December 5, 2013

Top 10 reasons I use Twitter in Healthcare

This post also appears on the Stony Brook Internal Medicine unofficial Blog
Stony Brook Internal Medicine Blog

I’ve been on Twitter for almost a couple of years now and when I talk to people about it, I still get a healthy dose of skepticism.
So I've put together a top ten list of why as a physician and medical educator, I use Twitter.
10: Connecting with Leaders
To be lead, you must know what your leaders are thinking. Twitter has made leaders accessible. Now, instead of spending time looking for their opinions or hoping to catch a handshake or meeting at a conference, they send their thoughts directly to me, in small increments of 140 characters, everyday!
9: Connecting with Followers
As physicians, you are a leader. Whether it ‘s in your office, your patient panel, your learners, your colleagues, your academic society, you have the opportunity (and responsibility? ) to lead and lead effectively. Twitter allows you to share your thoughts in small increments, reach a vast audience with minimal effort. Quoting #10, “To be lead, you must know what your leaders are thinking.”
8: Networking
The importance of professional networking cannot be understated. Twitter easily connects people with similar interests. In less than 2 years, I have been able to access a vast network of people interested in things that are important to me such as Primary Care, Medical Education, Social Media, Evidence Based Medicine and Healthcare Technology. In the past, networking for me occurred in spurts, at pre-determined locations over a finite period of time. With Twitter, networking happens 24/7, with little effort no matter where you are (and in your pajamas, while watching tv!).
7: It makes me an active learner.
All through my education I took notes. Writing things down helped solidify that piece of knowledge. A notebook was also useful for exams, reviewing and reinforcing information. Now instead of a notebook, I have a tablet and instead of a piece of paper, I use twitter. The 140 character limitations forces me to be succinct which makes my virtual notebook very easy to review.
6: I can educate the world
This is a grandiose statement, but Twitter makes it real. As a Medical Educator, I take pride in being able to influence the learners in my immediate proximity. With Twitter I can take all those notes  (See reason #7) and broadcast it to learners in other cities, states, countries and continents! Currently I’m using the the hashtag #sbmgr to broadcast what we’re learning in our Internal Medicine Grand Rounds every Wednesday 8:30 to 9:30 AM.
5: I can attend multiple conferences simultaneously, year round.
Until human cloning technology advances, Twitter is the best way to be at multiple places at once.  I wish I could attend every medical conference out there. But thanks to people who prescribe to reason #7, I can virtually attend other conferences through my smart phone, all throughout the year. There are thousands of people out there like myself, live tweeting from conferences. This year, I personally attended ACP and APDIM live tweeting from both. But in addition, while being back home, I followed the tweets from Kidney Week and Chest in the past couple of months.
4: It’s a forum for debate
Healthy debate is part of our lives as physicians. New guidelines and treatments are always coming up, and Twitter I get immediate access to viewpoints from a wide variety of people. I often get immediate feedback on my own opinions.
3: My mom taught me to share
We are all online, all the time. As a physician, I’m always finding a great journal article, an interesting blog,  or an important news article. Before twitter, I had no mechanism to share that, besides e-mailing to a small set of people or writing it down somewhere and hope that I have an opportunity to suggest it to people. Now, every website has a Twitter link. You see something cool, you can share it with a large audience with just a few clicks.
2: The world at any given moment
Whenever I have a free moment, Twitter  is my go to activity. In 2 minutes, I can scroll through a myriad of messages and get a burst of information from a network of my choosing.  So it’s whether pumping gas, waiting for an elevator, a 15 minute lunch, a commercial break during the football game, Twitter helps me use these small snippets of time, constructively.
1: It broadens my mind
In patient care we are emphasizing a team-based approach that values the roles of every individual in a healthcare team. The same can be said for my continuing medical education. I think I have something to learn, from everyone. As a result I follow folks in Internal Medicine, sub-specialties, family medicine, psychiatry, surgery and so on. I follow nurses, physical therapists, social workers and patient advocates. I follow patients (not my own) sharing the story of their medical conditions. I am learning something from everyone from the palm of my hand.
If this doesn’t get you interested in Twitter, here’s a a blog post from someone who’s listed 140 Health Care uses for Twitter
In addition, here’s another post to help you make the leap.
This is written by Dr. Vineet Arora who is Director of GME Clinical Learning Environment Innovation and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago.