Trial by Twitter: How a 280-Character Count Is Reshaping Cardiology

On #CardioTwitter, researchers say they must be prepared to defend their work in what can be a caustic environment.

Trial by Twitter: How a 280-Character Count Is Reshaping Cardiology

#CardioTwitter is a game changer in cardiovascular medicine, tweeters say: it flattens traditional hierarchies, increases collaboration across the globe, and allows instant access to data. By eliminating the middleman, Silicon Valley has enabled doctors in distant outposts to chat with clinical investigators running $100-million clinical trials, debate results, praise or rebuke a study’s methodology, and question the clinical interpretation of new findings.

But this rapid-fire form of peer review is showing some growing pains. Comments directed to clinical trialists or researchers that in the past might have followed the more protracted route of a letter to the editor now come fast and—sometimes—furious. The cardiologists who first flocked to the Twitterverse like ducks to water still believe it’s a great resource for sharing and debating medical advances. Yet a growing number say their enthusiasm has been tempered somewhat by the snarling that has erupted around a range of blockbuster trials.

“It’s a fairly unique thing where you have this open forum where everyone can discuss the important topics of the day, including recent trials and recent developments,” said cardiologist and researcher Marc Dweck, MD, PhD (University of Edinburgh, Scotland). “That has to be a good thing fundamentally, particularly as we have an opportunity to interact with people from all around the world, including the experts in their field. Often the discussions become very interesting and you get a diverse group of people commenting on the trials and problems and issues.”

But the speed with which questions and criticism can spiral out of control is relatively new for a field accustomed to slower, more methodical communication. “The great strength of Twitter is also part of its weakness,” Dweck said. “People are often reading things quickly and firing off quick tweets and then things accelerate quite quickly.”

The great strength of Twitter is also part of its weakness. People are often reading things quickly and firing off quick tweets and then things accelerate quite quickly. Marc Dweck

Mirvat Alasnag, MD (King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia), describes herself as a big fan of #CardioTwitter, particularly given that she practices at what she called “the other end of the world.”

Alasnag believes most physicians participating in online Twitter discussions are quite levelheaded, with only a few engaged in the bickering that has broken out around high-profile trials. She does worry, however, that if that type of vitriol becomes more commonplace on the platform—as it has elsewhere on social media, or for other communities—some voices will be lost.

“It’s sad, but the tone, the reckless posts, can be a deterrent for people to step away from social media,” she said. “We don’t want to see people quit.”

Snail Mail vs the Tweet Button

Unlike letters to the editor or audience microphones at major meetings, Alasnag told TCTMD, Twitter has “no filter and it’s not moderated.” A nasty or unscientific letter to a journal would never make it past the editor. “If you’re writing nonsense, it’s not going to be released to the general reader,” she said. “The same with the microphone. When you get there, if you’re saying something that’s not accurate in terms of statistics or in terms of the data, the moderator or panelist will direct the course of conversation and correct it. Unfortunately, Twitter, and social media in general, is not like that.”

Dweck also reminisced about old-fashioned letter-writing.

“The nice thing about the letter to the editor, and it still is, is that people have some time,” he told TCTMD. “You read the study in depth, because you’re not going to prepare a letter until you’ve really got your arguments together. You’ve read the trial, looked at the data, gone through the supplemental data, and really have everything lined up. You take some care and precision in what you’re going to say. The same with the response. The passage of time makes that a more-detailed and perhaps a more-thoughtful interaction.”

It’s sad, but the tone, the reckless posts, can be a deterrent for people to step away from social media. We don’t want to see people quit. Mirvat Alasnag

Despite the growing presence of Twitter in medicine, it’s only a minority of cardiologists who have taken to it, according to one recent survey. In a study looking at the so-called ‘Kardashian Index of Cardiologists’—a metric that clocks the correlation between the number of journal citations for the physician/scientist against the number of Twitter followers—researchers surveyed 1,500 cardiologists randomly selected from the top 100 cardiology hospitals and found that only 238 were on Twitter.

For this and other reasons, there is still a place for letters to the editor, said Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY). “[Twitter] is a different format, but it’s also limited because of the character count, whereas a thoughtful letter to the editor, or [an] editorial, is a different thing altogether,” he said.

On the other hand, even the most thoughtful letters might not have the same impact as 280 characters fired off by a physician with tens of thousands of followers. And while Twitter expands the discussion to a broader range of voices, which is critically important, Kirtane said, such ease of use can draw out voices who might never have considered having the authority to pen a letter to the editor of a major journal.

“There are times when the voices being heard may lack fundamental training or experience necessary to understand some basic assumptions of clinical trials,” Kirtane told TCTMD. “When that occurs, especially in an accusatory or inflammatory way, that can be ultimately destructive and harmful to patients, especially if it’s amplified. A lot of times, there may be simple questions that can be answered easily, but if one doesn’t answer immediately—checking your computer or your phone all the time—and something stays out there for some time, it may get amplified and disseminated more broadly without being corrected.”

William Zoghbi, MD (Houston Methodist DeBakey Heart & Vascular Center, TX), a deputy editor of JACC: Cardiovascular Imaging who joined Twitter in 2012, said the social media website has been nothing but empowering. Journal clubs, he noted, have always been used by physicians and researchers to critically evaluate new research findings, and Twitter is a natural extension of that discussion.  

"In the old days, it took some time for people to know where a study was published, and if you wanted to react to it, you sent a letter to the editor [that] might conceivably be shared with other people,” Zoghbi told TCTMD. “There was a filter there. Nowadays, it's available to you and you have a different forum, which is a journal club almost if you will, [with Twitter] talking about the study or paper."

Instead of a dozen physicians discussing a particular cardiovascular issue, there is the potential to interact with thousands of people from around the world, said Zoghbi. “Sometimes people get something completely wrong, but you can ignore it.”

Questioning the Evidence—and the Researchers

Defending clinical research, however, is not the same thing as correcting inaccuracies or mischaracterizing publicly available data. Kirtane gave the example of the controversial presentation at the annual meeting of the Society of Thoracic Surgeons (STS) by Anthony Furnary, MD (Providence Health System, Portland, OR, and Anchorage, AK), that was debated furiously on Twitter, fomenting divides between interventional cardiologists and cardiac surgeons.

Kirtane pointed out that, in this instance, a lot of the data being argued about on social media as if they were bombshell revelations were in fact already online or had been previously reported. Having physicians weigh in who are not clinical trialists, or who aren’t familiar with US Food and Drug Administration processes, can quickly muddy the waters, he said. “By calling [the trial results] into question, without expressing an understanding of the difference between appropriately conducted subgroup analyses and the background of how the FDA review process works, can be detrimental.”

Dweck, one of the SCOT-HEART investigators, pointed to the mixed reactions to the trial’s 5-year results, which were published in the New England Journal of Medicine. In their study, the use of CT angiography as a gatekeeper in patients with stable chest pain reduced coronary heart disease death and nonfatal MI by more than 40%, but some high-profile physicians took to Twitter to question how an imaging test could reduce hard clinical outcomes. There were also some questions about the definition of MI used in the trial.

“Even if you don’t like it, and I do like Twitter, you have to learn to interact with it and deal with it,” said Dweck. “An important part now of being a researcher, particularly if you’re publishing important clinical trials and research—which will always have some controversy associated with them—is that you need to be prepared on some level defend it on Twitter or discuss it on Twitter.”

Trials on/by Twitter

Several cardiology clinical trials have been put through the wringer on Twitter, none so much as the ORBITA trial. The 2017 study showed that PCI offered no symptom improvement compared with a sham procedure in patients with stable, single-vessel CAD, and the social discussion that greeted those results got a “little nasty at times,” said Michael Savage, MD (Jefferson University Hospitals, Philadelphia, PA).

“Speaking personally, most of the people I respect on Twitter sign off when it gets shrill like that and move on to a different discussion rather than get into online battles,” said Savage. “ORBITA was one of the big controversies on Twitter, but I think it’s specific to the topic. When you have the so-called ‘turf wars,’ where you have somebody saying stents are just a placebo, it will rub people the wrong way. You can see it with the conflict between interventional cardiologists and surgeons with regard to EXCEL. I think it’s specific to the topic.”

Twitter’s response to the recent EXCEL trial of PCI versus CABG for left main CAD has driven this wedge wider. As reported in depth by TCTMD, the controversy got its start when David Taggart, MD, PhD (University of Oxford, England), broke with the trialists by claiming that MI data had been concealed and the mortality risks with PCI downplayed. When the EXCEL investigators, led by Gregg Stone, MD (Icahn School of Medicine at Mount Sinai, New York, NY), denied those accusations and issued a lengthy rebuttal, more back-and-forth between surgeons and interventional cardiologists ensued in real time on Twitter, some of it vitriolic.

These heated arguments, say cardiologists, are harmful to the community as well as to patients.

“If you look at the history of cardiac interventions and the heart team concept of having the multidisciplinary team where cases are discussed, it’s a collective decision about what’s appropriate for this particular patient,” said Alasnag. “Online, you can see cardiologists bickering about whether patients should have CABG or whether they should have PCI. That’s not appropriate. We’ve moved away from that turf war. With TAVR, for example, it’s a combined project, it’s a combined procedure. We’ve come a long way, so to see it go back is not right.”

Some wags predicted that the long-awaited ISCHEMIA trial, released at the American Heart Association (AHA) 2019 Scientific Sessions, might “break” Twitter. Instead, Savage cites the discussions surrounding this National Institutes of Health-sponsored trial as an example of physicians working with each other and with the data. The discourse following its AHA presentation last fall was, in his opinion, very civil. About a week later, Savage posted an online poll questioning how physicians would now treat a 70-year-old patient currently taking medical therapy with documented anterior ischemia, type 2 diabetes, and angina symptoms. 

“My expectation after ISCHEMIA was that people would treat the patient medically, yet only about 25% voted the medical therapy option,” he said. “Part of that might be because my followers are biased as interventional cardiologists, but even so, there was a wide disagreement among people, with some saying they would stent and others saying medical therapy only, but it was a civil discussion. It wasn’t rancorous.”

The Good With the Bad

Dweck, who has fielded the SCOT-HEART criticisms on Twitter, said the ability to respond immediately to questions helped quell any potential controversy. Had he not seen the tweets and questions, that controversy might have taken on a life of its own, and the narrative surrounding the trial might be very different than it is today.

“Looking back, are those bad things? I’m not sure they are. It’s probably a positive. If you’re going to publish these studies, then you just need to be prepared for it,” he said. “It’s become part of the job description a little bit. It’s a little bit of ‘trial by Twitter.’ It’s always been there—research has to stand up in front of your peers—but on Twitter the process is accelerated.”

Additionally, while Twitter can be acrimonious at times, Dweck said his experiences with it have been positive. Physicians and researchers have different inherent biases, and part of his job as an academic cardiologist is either to reinforce their beliefs or change their opinion. He doesn’t believe most physicians are setting out with specific agendas or axes to grind.

Why do people watch car accidents? It’s morbid, but it’s the same lesson on Twitter. People sometimes pay attention, looking for the next controversy to erupt. Ajay Kirtane

Most of the people who spoke with TCTMD highlighted Twitter’s upsides: easy access to and awareness of new publications and presentations, a chance to network, the ability to learn “tips and tricks” in complicated cases from other experienced operators, and a level playing field that allows residents, fellows, or junior physicians a voice on par with chiefs of cardiology at world-class institutions.

Savage, who spearheaded the #CardioQuiz trend along with David Fischman, MD (Thomas Jefferson University Hospitals, Philadelphia, PA), notes that being on Twitter has led to collaborations between himself and other physicians he met online, such a recent book on antiplatelet therapy he wrote with Fischman and Mamas Mamas, BMBCh, DPhil (Keele University, Stoke-on-Trent, England).

James Rudd, MD, PhD (University of Cambridge, England), the social media editor for Heart, also called Twitter “a force for good,” particularly for its ability to disrupt medicine’s strict hierarchical pecking order. “A medical student, or somebody who is not affiliated with an academic hospital or facility, can reach out to a principal investigator of a study or a leader in cardiovascular science and more often than not they’ll get an answer,” he said. “It’s hard to imagine that before Twitter.”

In a personal capacity, Rudd said Tweetorials about cardiology, statistics, imaging—anything allied with his field—are definitely useful, including the online discussions between colleagues. Additionally, like Savage and Alasnag, Rudd says he uses Twitter to identify potential collaborators. He noted that while some of the debate surrounding clinical trials can appear tense at times, it’s rare for people to overstep their bounds. Sometimes a person’s sense of humor, or sarcasm, might not always be evident (specifically some British cardiologists, he joked), which can lead to miscommunication.

Patients Are Reading Your Tweets

What puts all of the pros and cons of #CardioTwitter in the spotlight is the fact that unlike traditional letters to the editor, or even journal clubs, the interactive discussions take place in the public sphere.      

“This isn’t in a conference or a medical journal that nobody else is reading,” said Dweck. “It’s in a public place, and I’m not sure if it’s a good thing or not. Maybe we should ask patients if the discussion in the public space is a good thing? I’ve had a few patients come in and say, ‘I’ve seen some of your comments on Twitter’ and I think ‘Uh, OK, I hope I was polite.’ I think that’s probably not a bad rule. When you’re writing your tweets, and your replies, think: patients are reading this and I need to maintain my professional standards.”

I’ve had a few patients come in and say, ‘I’ve seen some of your comments on Twitter’ and I think ‘Uh, OK, I hope I was polite.’ Marc Dweck

That means that patients are also reading the mudslinging over clinical trial endpoints, findings, and conduct. Pointing to the EXCEL controversy in particular, Alasnag noted that there are many patients who received a stent for left main CAD who now might needlessly worry or even question whether their physician made the right choice. Kirtane added that he suspects that many residents and fellows are also watching online even if they are not chiming in, and that many educators feel a duty to teach and communicate with them in the medium they best relate to, such as Twitter. That can be tough when the site becomes a minefield.

Kirtane believes #CardioTwitter has become more caustic in recent years, more accusatory. However, logging off entirely is a catch-22: while it might offer some respite, there is still a clear need and benefit of #CardioTwitter-based education, beyond simply correcting mistakes or mischaracterizations about data.

“I’m not for silencing voices at all,” he said. “I think it’s important to get input from as many people as possible and this medium allows that. Just shutting it off isn’t an option. It’s not going to work, and it would be detrimental. But you do wish at times that the more easily answered questions—say, the questions related to the complex practicalities of clinical research—could be resolved without a full public accusation and amplification [of that accusation].”

And Kirtane admits that, for some, the disharmony is part of the attraction. “Why do people watch car accidents?” he said. “It’s morbid, but it’s the same lesson on Twitter. People sometimes pay attention, looking for the next controversy to erupt.”

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