Keeping Up With Cardiology: Old-School Learning Versus the Twittersphere

This feature stems from a TCTMD survey looking at how physicians involved with cardiology keep up with the field. See the full results here.

“Who reads at least two medical journals on a weekly basis?” Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), asked a ballroom full of general and interventional cardiology trainees this past April. The setting was a fellows’ course, the attendees no doubt some of the brightest, most ambitious minds in medicine.

Hardly a single hand went up.

Kirtane and his fellow panelists, all senior cardiologists, each paused with surprise. After all, despite their varying career lengths, each of them had been taught to keep up with the field of cardiology by consistently reading a select set of journals, cover to cover.

Reflecting on that experience in a recent interview with TCTMD, Kirtane said he realized in that moment “that I have to do a better job at coming up with what I think is a reasonable formula for continued learning, because it seems to me that a lot of the current formats that we have are not really reaching the trainees.”

It's not only fellows who are shifting away from traditional sources of practical information and research progress. According to Sameer Gafoor, MD (Swedish Heart and Vascular Institute, Seattle, WA), “there’s an old saying that 50% of what they teach you in medical school is wrong. The problem is you don't know which 50%.” As all physicians proceed through their careers, he told TCTMD, “we should expect that things should be challenged and updated throughout our lifetime, and we have to be open to all different avenues. Critical thinking is more important now than ever before.”

It seems to me that a lot of the current formats that we have are not really reaching the trainees Ajay Kirtane

Perhaps particularly for those practicing in the innovation-intensive world of interventional cardiology, their careers are inevitably an “ongoing learning process” that entails both cognitive and technical education, according to J. Dawn Abbott, MD (Brown University, Providence, RI). “It's really an interesting field to study when you think about it, . . . because I think the ways physicians gain new skills are different in those two realms. In some sense they are equally important because understanding which patients need a TAVR is as important as knowing how to put in the TAVR valve,” she told TCTMD.

Yet, the evolution of the field has also meant changes to how physicians take in that knowledge. Thirty years ago, “there were five good journals and you could read them regularly and feel up to date, and that’s just not the case anymore,” said Katie Berlacher, MD (University of Pittsburgh, PA). Now through mechanisms including email, print and online journals, social media, webinars, podcasts, and live meetings, there are multiple ways to learn the same content, “and it’s really just a matter of how you want to do it,” she told TCTMD.

The Numbers

TCTMD recently surveyed physicians involved in cardiology to ask how they keep up to date on advances in the field. Of the 130 respondents, about half said that the way they learn about cardiology research and news today is different than it was 5 years ago, with many citing easier access to digital resources and less reliance on paper journals. Additionally, 20.8% responded that they think the way they take in cardiology-related information is different than how their colleagues do.

Sergio Nabais, MD (Salisbury District Hospital, England), who took the survey, told TCTMD in a follow-up interview that he still reads some journal articles in full, “but not as deeply as before.” Given that he was a fellow 5 years ago, he added that “now I know more about cardiology—I know more about the basics—so I just need to keep updated on what's new, not on what is already known.”

A technique he finds useful for keeping up with the field on a limited schedule is reviewing the published guideline papers. “I read what's new, so the basic updates or the most important information, but if it's something that really interests me in the field of stents or acute coronary syndromes, I still go and read the full guideline text,” Nabais said, adding that he will also check cardiology news sites for summarized updates. “But I don't have as much time as I used to have.”

Understanding which patients need a TAVR is as important as knowing how to put in the TAVR valve. J. Dawn Abbott

To the TCTMD survey, 90% of respondents said they read journals, but only 2.3% indicated they read them “cover to cover.” Rather, 60% said they read abstracts and some articles that interest them, while 10.7% said that they only read abstracts that pique their curiosity. In addition, 79.2% of respondents said they rely on cardiology news websites to keep abreast of updates, 71.5% noted that they attend large cardiology conferences, 57.7% said they review presentation slides, and 56.2% indicated that they rely on in-person conversations with colleagues to stay up-to-date.

Today, physicians are “saturated with a lot of different ways to get information, and in a sense, it's good because there's rapid dissemination of information through Twitter and social media and even e-table of contents,” Kirtane observed. “But the challenge is to get systematic and understand how to read broadly and then also how to also read relevant to your individual patients.”

#Cardiotwitter

Some in the cardiology community have flocked to Twitter for continued learning and discussion. Why? According to 30% of the TCTMD survey respondents who said they use Twitter for professional reasons, the always-available online community affords them the opportunity to learn about new research, network with experts, share opinions, and engage in conversations and debates.

A well-known, often contradictory presence on #cardiotwitter, David Brown, MD, (Washington University School of Medicine, St. Louis, MO), told TCTMD he only signed up about a year ago to fulfill a marketing duty requested by a journal as part of his editorial board role. “I just joined because I wanted to do what I was asked and I wanted to help out the journal, and then I just kind of stumbled into the cardiology aspect of it,” he told TCTMD. “The benefit of being on Twitter is that you can debate ideas in real time as papers come out and presentations are given and posted online.”

Brown said Twitter gives him the opportunity for discussion not even available at in-person conferences. “You can go to a late-breaking clinical trial at TCT or AHA or the European meetings, and you can sit there and listen,” he said. “The number of questions that are allowed are minimal and usually I don't have great questions within the first two minutes of hearing something. It's after I kind of let it marinate for a while that I have questions, so that format is completely inhospitable to questions that come up and feedback.”

Since he started using Twitter, Brown has kept track of the number of scientific papers he saves in his personal files that come from other people’s tweets. While half still come from other sources, the other half now come from Twitter. “I have this whole hugely magnified reach into what other people are reading, and now I'm pulling from that pool of papers to keep manuscripts for my own future use,” he observed.

I have this whole hugely magnified reach into what other people are reading, and now I'm pulling from that pool of papers to keep manuscripts for my own future use. David Brown

As it turns out, Brown said he rarely retweets articles from the journal that first asked him to sign up for Twitter in the first place. “I stay on it for the stimulation and to publicize my sort of alternative points of view about certain things so that people have the opportunity to hear different sides of the argument,” he said. Contrary to what some might think about him, Brown insists that he doesn’t post controversial tweets “just to pick a fight. I do it because I think there are alternative explanations or interpretations and if I'm not going to do it, then it does become an echo chamber.

“It's all of our responsibility to interpret the data ourselves,” he said. “That's what makes cardiology fun.”

For Kevin Shah, MD (Cedars-Sinai Medical Center, Los Angeles, CA), a current advanced heart failure fellow and avid Twitter user, social media is “complementary” to reading journals and “can be a very helpful tool just to stay up-to-date and to feel like you have your finger on the pulse of what's going on in cardiology.”

Berlacher said she signed up for Twitter partially because her medical students were talking about it, and she felt out of the loop. “The more that I was on it, the more I realized you can network on it, you can engage people on it, you can have conversations on it, you could really support people on it,” she said.

Journals are also hopping on the Twitter bandwagon. Andrew Choi, MD (George Washington University Medical Center, Washington, DC), who serves as the social media editor for the Journal of Cardiovascular Computed Tomography, told TCTMD that his role requires that he read and analyze every article published by the journal so that its Twitter account can promote not only the best, unbiased science, but also do it in a manner that will be best received by those online.

“Physicians and scientists have increasing demands on their time,” he said. “They have multiple clinical responsibilities. They may try to keep up with 10 or 20 different journals that are all on paper, and in a society where we have computers, we have amazing media and global technology [that] allows us to put all of this information in the palm of your hand. Social media is a way for that busy physician or scientist to be able to track very, very quickly what he or she thinks are the most important areas of research interest to his daily work and then to be able to parse out that information and then take a deep dive.”

‘Twitter-Based Medicine’

Back in April, Kirtane’s question about journal reading to the room of fellows was sparked in part by a blog post by Milton Packer, MD (Baylor University Medical Center, Dallas, TX), entitled Do You Practice Twitter-Based Medicine? Admitting that he didn’t use the platform, Packer poked around and ultimately concluded that “if Twitter is your primary source of reliable and up-to-date medical and scientific information and discourse, then you practice EBM—emotion-based medicine. More precisely, you practice self-declared expert-based medicine. In reality, you practice opinion-based medicine.” Worse, he continued: “The Twitter opinions that you rely on for the care of patients are someone else's opinions of the medical literature. They are not even yours.”

Unsurprisingly, the community of cardiologists on Twitter reacted passionately, and several blogs and op-eds were published in response, but the outcry has rekindled debate about just what constitutes cardiology learning in 2018.

Berlacher said her chief circulated Packer’s article around her department asking for brainstorming ideas as to how they could get their trainees to read more journal articles. “I was like, that’s not the question. The question is: ‘How do people learn?’ . . . and not having judgement on how others learn,” she said. “If you actually look at adult learning and the theory behind how adults learn in general and learn best, it’s not passively reading an article. That's one of the worst ways to learn.”

Because social media allows for active learning and “live” discussion of the science, “one could argue that that interaction is what affords you [the opportunity] to truly learn rather than think that you're learning when you're reading an article,” Berlacher mused. Journal reading, she added, is “what’s familiar to [Packer] and to a generation of people, but I would argue that we have no proof that there was actual learning with that. . . . We need to stop being so narrow-minded about the ways that it used to be. I think people get stuck on reading the whole article or reading a whole chapter. I understand where they’re coming from and I think you have to have a big picture, but adults don’t have time for that.”

Brown argued that physicians not on Twitter can also be guilty of skimming articles and feeling like they’ve really digested the information in them. “That's a human fallacy. It's not a media shortcoming,” he said. I think you can get into these papers in great depth without Twitter and you can get into them very superficially without Twitter and same thing if you're on Twitter. In a way, it's easier because you see multiple viewpoints that you can consider alternative interpretations that may not come to you if you're just sitting at your desk reading an article, even if you're trying to think critically about it.”

That said, Gafoor cautioned that the “vast majority” of leaders in the field of cardiology are not on Twitter, and because of that, “it easily can become an echo chamber.”

Shah said he also shares Packer’s concern “in that it is really easy to consume the interpretation of information by a crowd of people and interpret that as your own belief. I actually agree with Dr. Packer in that I think it's an important aspect of being a physician to still feel comfortable in interpreting and understanding primary information independently.”

Asked whether using Twitter is an appropriate tool for continued learning, Choi said, “I think it's becoming a crucial way of keeping up.” However, he cautioned, social media is designed “to catch your attention.” Choi said that he conveys to his cardiology fellows that they still need to understand articles in full and “really dissect what the implications are” before discussing it in any forum.

Kirtane also warned against some potential pitfalls of Twitter, including accidentally disseminating confidential patient information or engaging in discourse that becomes more heated than helpful. Also, “unless you make a really dedicated effort to be one of the people who wants to comment on Twitter, I can't see how super busy practicing physicians have time to be able to deal with and/or respond and go back and forth in the conversation on Twitter. There's just no way.”

Berlacher admitted that she, too, worries “that the lines and barriers of what's appropriate on social media and what's professional on social media get blurred much more quickly than they do in person. . . . You can hide behind it a little bit or there’s this distance that social media sets up. You don't have to take quite as much personal responsibility for it as before.”

Breadth vs Depth

An overarching issue in continuing medical education, no matter what form that takes, is the balance of breadth versus depth. Scientists have already documented the ways in which 24-hour access to search engines is affecting people’s ability to access information they’ve already learned, in detail—this phenomenon is keenly felt in medicine, where instant recall of medical knowledge can be a matter of life and death.

“It's so easy to Google something and get the information that way, that then you start committing less and less to memory,” Kirtane said. “There are people that would argue, ‘Well you don't need to memorize that. Why should I memorize that when I can look it up right away?’ But I would say, and maybe I'm too old-school, but by memorizing some things, you then can more accurately Google, you'll know when to Google, and you'll know when not to believe Google. . . . There's definitely something to be said for somebody who has comprehensive knowledge.”

On the other hand, case-based learning, which has seen rapid growth at cardiology conferences in recent years, is great for learning depth, but how that translates into clinical practice is unknown. “You may have seen all the back and forth on a specific case, but does that mean that when it's not that specific clinical scenario or that specific device or equipment that you know the rest of it?” Kirtane asked. “Certainly, when I attend and do teaching rounds, it's clear to me that there are certain areas that people know a lot about, but there are a lot of areas that people know very little about.”

Like many web-savvy physicians, Abbott said she often consults UpToDate, a point-of-care reference available on every hospital computer at her institution, when she needs a quick piece of information. She serves as a topic editor for the service within cardiology, and “if a new study comes out and it is going to change clinical practice, it is in there within weeks,” Abbott said. “That's where you should go because if you go to the textbook, it's 2 years old. The textbook is great if you want to know some kind of physiology or something that hasn't changed.”

She also advocates for using tools provided by industry partners. “There's nothing wrong with going to pull up a video. If it's something where you just need to know what order to pull a tab or move a lever, like if you've had an in-service or you did and you didn't use it for a few months, some physicians pull back and watch these instructional videos frequently before doing a procedure just to remind themselves how to deploy something or use something.”

It’s true “that people surface learn and don't do deep dives,” Berlacher said. “As individual learners, the onus is on you to kind of make sure that you're doing your due diligence and diving deep every once in a while. I think it’s unreasonable to expect us to dive deep in everything that we learn or expose ourselves to. But I do think that learners have to take a little bit more personal responsibility in their learning. It’s no longer going to be a spoon-fed thing.”

An individual’s level of learning may also depend on his or her career trajectory. “One of the things that happens when you're a few years out of training is you feel like you know a lot,” Kirtane said. “And as I've gotten a little bit older—so I'm now 10 years out of training—I realize that I don't know as much as I thought I used to know, that things change. So I have a more open mind.”

No ‘One-Size-Fits-All’

Looking forward, Abbott said it’s inevitable that cardiologists will “have to use more diverse learning modes to be good at what we're doing and keep up.”

I think it’s unreasonable to expect us to dive deep everything that we learn or expose ourselves to. But I do think that learners have to take a little bit more personal responsibility in their learning. It’s no longer going to be a spoon-fed thing. Katie Berlacher

And it’s the responsibility of educators to be flexible and meet people where they want to be learning, according to Berlacher. “I think it's unreasonable for us to ask our learners to do things that we did 15 years ago or 10 years ago or 5 years ago even,” she said. “I believe in multimodality learning and teaching and I think that’s probably where the future is. There's not going to be one and only one way in which we do it, and that it's not only on social media or only in person or only in print that we do all of our learning. That it's a mix of all of these things because that’s more real.”

Berlacher also said that the conversation has to move away from being generation-focused. “It’s easy to say it’s generational” given that the learning styles of trainees are so “starkly different” from many senior physicians, she said. “I would argue, though, that when a lot of the senior people get introduced to more than just one way of learning, they actually really enjoy it.”

She hopes that the resisters of new learning methods will eventually come around. “We have to figure out ways to incorporate everybody, not just the new learners, because inevitably we're going to alienate some,” Berlacher said. “As a community, we are better served if we invite everybody . . . and also accept that some people are never going to be Twitter users or some people are never going to be print journal readers.”

The “big question” for Choi is if there will even still be paper journals in 10 years. Likely yes, he said, but social media will likely “become an even broader part of how people get that information.”

Brown said he hopes he doesn’t “get so lazy that I quit reading journals altogether,” but he envisions a system where he can follow all of the journals on Twitter, or an “all-cardiology-all-the-time” version of Twitter, in a similar fashion to how he receives the rest of his news today.

I would not be surprised if 10 years from now there's another tool that's out that's just as effective, and I'm sitting there going, 'I might not have time for that tool.’ Kevin Shah

Even live conferences might go the way of the dodo. “I'm surprised that conferences have lasted as long as they have,” Brown observed. “Even before Twitter, you could go online and see things, and now . . . you don't get the information any faster being at the conference than you do being on your computer or on your phone.”

Ultimately, Shah said it’s important to “understand that people absorb information in different ways, and I don't think there's a one-size-fits-all for a topic like this. I think over time there will be new ways to receive and kind of consume information, and I would not be surprised if 10 years from now there's another tool that's out that's just as effective, and I'm sitting there going, 'I might not have time for that tool.’”

“Just because an idea comes in through a traditional method doesn't mean it's outdated, and just because an idea comes in through a social media method doesn't mean it's new,” Gafoor concluded. “It’s important for us to know what’s been done before to figure out which way to go.”