The use of Twitter to facilitate sharing of clinical expertise in urology

Abstract

The use of social media in the urologic community is common and increasing. Although the potential benefits of platforms like Twitter have been described in the literature, the use of social media in the clinical context of Urology has not been explored.

In this case report, we describe how we used Twitter to share ideas about the clinical management of a complex urologic patient. By posting a clinical scenario, a timely discussion was generated with global participation and expert suggestions. This knowledge was applied to the surgical management of a patient with positive clinical outcomes.

The ability of Twitter to facilitate rapid communication with a wide network of contributors makes it a potentially useful tool for clinical decision making. Care must be taken to ensure patient confidentiality and caution used appropriately when evaluating the sources and content of the clinical information shared.

Background

Between 50% and 70% of urologists use some form of social media.¹ Twitter, in particular, has shown significant growth in the urologic community, where its use increased by 41% in 2013 and by 122% in 2014.² Twitter is a microblogging format that allows real-time communication via 140-character “tweets.” The benefits of social media use from an academic and professional standpoint are becoming well established in many medical fields. These include discussing published research, sharing patient education materials, tracking ongoing academic conference activity,^3,4 participating in journal clubs,⁵ promoting clinical or basic science research, and engaging in professional networking.

A potential advantage of using social media in medicine is in clinical decision-making and patient care. The opportunity to interact with colleagues and experts across the world and discuss patient management topics has the potential to improve patient care. The use of Twitter for medical consultation was initially reported in 2010 by Mesko, who posted a complex patient presentation and asked for diagnostic assistance.⁶ This highlighted the unique ability of Twitter to facilitate rapid communication with a potentially wider network of contributors than is afforded by other social media venues.

Clinical urology discussions occur on a daily basis on Twitter and involve topics ranging from epidemiology and screening (eg, the relationship between BRCA and prostate cancer, when to offer prostate-specific antigen screening), the use of emerging diagnostic modalities (eg, magnetic resonance imaging fusion biopsy, genomic tests), medical management (eg, the use of alpha blockers to facilitate ureteral stone passage), surgical technology (eg, scopes, wires, robotic instruments), and surgical techniques (approach to percutaneous renal access, closure of renal defect after partial nephrectomy, tips for salvage prostatectomy after high-intensity focused ultrasound). The input from these discussions, when applied to individual patient care, may improve outcomes. In this case report, we discuss an illustrative case in which Twitter feedback was used to formulate a management plan for a complex surgical patient who presented with a stone obstructing a calyceal diverticulum.

CASE REPORT

A 62-year-old female patient was treated at an outside hospital for a renal abscess.⁷ The abscess was managed by percutaneous drainage, and the drain was subsequently removed prior to her relocating to the New England region. Soon after arrival, she developed recurrent left flank pain and fever. Computed tomography was obtained, demonstrating a recurrent renal abscess with an associated 5 mm renal calculus, likely obstructing a calyceal diverticulum (Figure 1 ). Percutaneous drainage was again obtained by interventional radiology, and culture grew Proteus mirabilis. She was placed on culture-specific antibiotics and scheduled for a urology consultation, as there was a high clinical suspicion that the stone was obstructing a calyceal diverticulum, resulting in recurrent infection. A retrograde ureteroscopic approach was initially attempted as less invasive than a percutaneous approach; however, the urology team was unable to visualize the stone (Figure 2 ).

Figure 1.

Preoperative CT.

Figure 2.

Ureteroscopy with retrograde pylography. Stone not accessible endoscopically (arrow points to stone).

On further discussion of risks and benefits with the patient, we tentatively elected to approach the stone percutaneously, with the patient in the prone position, using a standard 24 French balloon dilation device with a rigid nephroscope. Due to the limited space afforded by the patient’s unique anatomy, it was decided that the equipment would be too large to safely access the renal diverticulum. Alternative approaches using a ureteral access sheath with a flexible or semi-rigid ureteroscope to provide a smaller entry into the target area in the kidney were discussed with the patient.

Subsequently, we offered the patient the opportunity for a second opinion using Twitter to consult with colleagues at other institutions. We assured her that there would be no identifying information on the case description or images, and she enthusiastically provided informed consent. Next, 1 author (KS) posted a short case description and related radiographic images on Twitter. A prompt online discussion ensued. Although the initial query was addressed specifically to a few international colleagues, many other urologists with similar expertise joined in the discussion. Ultimately, this consultation involved 11 participants from 5 different countries. Suggestions were made regarding the renal access technique (eg, placing the needle directly onto the stone, coiling a safety wire in the abscess cavity) (Figures 2 and 3 ) and the equipment to use for stone removal.

Figure 3.

Percutaneous access to the stone with coiling of wire in the abscess cavity.

The majority of participants favored using a mini-percutaneous nephroscope, which involves a 1-step dilation and sheath placement device with a smaller diameter, because the technique allows for better access to the region of interest (Figure 4 ). However, the hospital did not own the equipment, so 1 author (KS) contacted a representative of Karl Storz (El Segundo, CA, USA), and delivery of the recommended mini-percutaneous nephroscope was coordinated in time for the scheduled procedure. On the day of surgery, the patient’s stone was safely removed and the obstructed calyceal diverticulum successfully accessed (Figure 5 ).

Figure 4.

Mini-nephroscope sheath placed directly onto stone.

Figure 5.

Antegrade nephrostogram after removal of the stone and opening of the obstructed diverticulum.

DISCUSSION

In this case report, the clinical management and equipment used to treat a patient with a stone obstructing a calyceal diverticulum were guided by a Twitter discussion. The potential benefits afforded by the use of platforms like Twitter to improve patient care may be limitless.⁸ Despite the character limit unique to the Twitter format, pertinent clinical information can be conveyed in a concise and often creative way that can further enhance interaction. Participants in Twitter discussions interact by choosing topics of their interest and expertise. Further, urologists who have specialized training in different surgical techniques and access to unfamiliar or new technology and equipment can give guidance to colleagues for upcoming surgeries. Also, interactive discussions on diagnostic studies and screening methods may help improve clinical decision-making. Finally, Tunnecliff et al.⁹ demonstrated that social media platforms are an effective method to deliver pertinent clinical information and change clinical behavior. These communication venues may become an increasingly important component of medical practice with the increasing specialization among surgical groups.

Challenges certainly exist regarding the use of social media in the clinical context of medicine. First, the field of urology has established guidelines specific to the appropriate use of social media in clinical decision-making processes.^10–12 Maintaining patient confidentiality is the most important priority, especially when public formats like Twitter and Facebook are utilized. To this end, several groups have created various platforms to decrease the risk of compromising patient privacy, such as physician-only social media platforms and private groups on Facebook. Second, health care professionals have expressed concern about the validity and accuracy of clinical information on social medial platforms.⁸ Along those lines, individuals who are active in social media often share similar interests in the use of technology in health care. This may introduce bias (or “groupthink”) into the discussions and recommendations. The individual practitioner should take this into account when evaluating the use of social media for medical decision-making and, more importantly, when building a clinical plan. While applications (eg, Figure 1) have been developed to present and discuss patient cases and incorporate features to obtain patient consent to ensure confidentiality, health care professionals must establish guidelines and processes to ensure that the clinical information is pertinent and up to date.

In The Wisdom of Crowds,¹³ Surowiecki describes the decision-making process in groups. He notes that in many instances, groups of individuals are able to develop better solutions to various problems. In addition, technology companies like Healthtap have been created with the goal of creating an online medical community to optimize patient care. The benefits of the marriage of online and social media technology with health care are apparent on multiple levels. Although achieving universal adoption seems challenging, we believe that social media platforms and international medical societies working together could create the infrastructure necessary to transform both medical education and clinical decision-making. The opportunity to consult about complex patient cases with surgical colleagues with different backgrounds, training, and experience, in different parts of the world with unique perspectives, or working with different resource constraints has the potential to increase knowledge and further improve patient care.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector. SL is supported by a Young Investigator Award from the Prostate Cancer Foundation.

Competing Interests

None of the authors have any competing interests to declare.

Contributors

KMS contributed to the conception of the work, drafting of the manuscript, and final approval of the work. SLL contributed to the conception of the work, editing and revising, and final approval of the work. DC contributed to the conception of the work, editing and revising, and final approval of the work. LD contributed to the conception of the work, editing and revising, and final approval of the work. MHT contributed to the drafting of the work, editing and revising, and approval of the work.