Once Burned, Twice Shy, Cardiologists Ditch X for Bluesky

For the last decade, Erin D. Michos, MD (Johns Hopkins University School of Medicine, Baltimore, MD), has consistently posted updates to her feed on X (formerly Twitter) for her more than 30,000 followers to read mostly about her field of preventive cardiology.

Now, she’s starting over. Earlier this month, fed up with the negativity she felt was crowding out the former value of her long-standing social media platform, she joined the drove of cardiologists opening an account on Bluesky, the fast-growing alternative 280-characters-per-post social site that was developed by former Twitter CEO Jack Dorsey.

When she began using Twitter, “I found it very helpful,” Michos told TCTMD. “I would see papers released on social media before I would ever become aware of them through the traditional routes [and] I would keep up with all my cardiology news. I was very active, and we had a great community there.”

However, “everything changed when the happy blue bird became the angry X,” she said, referring to the change in name from Twitter to X that followed when Elon Musk purchased the platform in 2022. At that point, Michos recalled, she sensed a palpable change in the algorithm which stopped showing her the content she wanted and replaced it with “so much angriness and misinformation, and statin and vaccine denialists, and all this anti-science. It was becoming a very negative space, and there were more bots and trolls, and I was getting more and more personal attacks. And it was terrible.”

For Michos, “social media was my outlet for fun and for scientists to engage. And I didn’t want to go and just see feeds of hate and negativity.”

Similarly, Fred Wu, MD (Boston Children’s Hospital, MA), told TCTMD that about a year ago he “went from being a pretty regular daily user of Twitter to pulling back from it because there was just a lot more negativity and just aggressiveness. It was really losing that positive experience that I really had enjoyed in the first place; that feeling of community.”

He explored other options at that time, signing up for Bluesky as well as other platforms like Threads, Instagram, and Mastodon. “It just didn’t feel like there was a quorum on any of the sites, because people just all went to different places and so it was just too fragmented,” Wu commented. No platform had “established itself as the alternative to Twitter, at least for medical people.”

Everything changed when the happy blue bird became the angry X. Erin D. Michos

However, about 3 weeks ago, Wu said he started receiving several notifications from Bluesky about new followers, and he became optimistic. Since then, especially as cardiology journals and societies have begun to create accounts, “it really seems to have gelled into a pretty cohesive community, so I’m very optimistic about it,” he said.

Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), who once said he learned about left distal radial access on Twitter, made a bold statement by leaving the platform in late 2022. “Twitter or X has become a pretty toxic environment as a whole,” he told TCTMD. “In an ideal world, it would be great if there was a medium that everybody used that was only cardiology or related things like that. . . . That doesn’t exist in a way where a lot of people use it. And so, I think people have limited options.”

Introducing Bluesky

Bluesky was created in 2019 by Dorsey as an experimental project while he was still CEO of Twitter. It became an independent company in 2021 and severed ties with Twitter in 2022, shortly after that company was purchased by Musk. Until February, users were required to have an invite to join, but since then it has opened up to the public.

For someone logging on the first time, the interface and much of its functionality is eerily similar to X, with some important differences. Notably, when making a post, users can select who can and cannot interact with it. Additionally, when a post is quoted by another user, the original poster has the option to remove that connection retroactively. There are also more muting and blocking functions available on Bluesky.

As a public company, Bluesky boasts an open-source community with no central authority. Right now, that means no advertisements and no global algorithm. Moderation is done automatically, manually by administrators, and also by the community at large. As this story was heading to print, Bluesky had nearly 23 million users, up more than 7 million over the last month alone.

To better curate user feeds, the platform offers “starter packs” which anyone can create around a central theme. In recent weeks, the scientific and medical communities have been flocking to Bluesky. The maximum 150 cardiologists have already joined the Cardiosky I starter pack with the second—Cardiosky II—filling rapidly. A starter pack of cardiology societies and journals also now has more than two dozen members. 

Lars Mølgaard Saxhaug, MD (St Olav’s University Hospital, Trondheim, Norway), who took it upon himself to create and manage the aforementioned cardiology starter packs said he feels a sense of duty to help foster the #CardioSky community on Bluesky, especially since he was one of the first cardiologists to be active on the platform.

“I just started making [the starter pack] and other people were sharing it, and I saw that people were making use of it and finding it easy to migrate [from X] by using it,” he told TCTMD. “So that motivated me to continue to expand it.”

Now that Bluesky is growing, it’s feeling so positive and so much like the best times on Twitter. Lars Mølgaard Saxhaug

As a trainee who is also interested in critical care, Saxhaug said social media is important for him to have discussions with clinicians across the globe, especially to learn about variations in practice. “That has helped me immensely as a clinician,” he said. “[Hearing] about other people having a very different approach to things . . . is very helpful. With all the cases that were shared on Twitter, I think many learned a lot from the free medical education you could get.”

He sees Bluesky becoming “much more viable” now that many physicians have become more active on the platform. “I think it’s easier because it’s very similar to Twitter in how it works and at the same time, it fixes some of the problems with Twitter,” especially not being dependent on a central algorithm, Saxhaug said. “You can really shape what you see on Bluesky more than you can on Twitter.”

Similar problems that Twitter/X faced are likely to crop up with Bluesky, he acknowledged, but some of the built-in features and ability for users to better customize their feeds will make them less likely. “I don’t think the moderation of Bluesky is more active than Twitter used to be, but individuals have more tools to decide who they want to engage with,” Saxhaug said.

“Now that Bluesky is growing, it’s feeling so positive and so much like the best times on Twitter,” he said, acknowledging that all of the curation he’s chosen to do is “really taking up more time. . . . But as long as it’s positive, it’s good.”

‘Too Many Distractions’

Parham Eshtehardi, MD (Northside Heart, Atlanta, GA), is one of the many cardiologists who joined Bluesky over the last few weeks. Originally, he signed up for Twitter in 2018 as a fellow with the idea that it might help him expand his network and look for career opportunities. While he found friendship, learned about the latest advances in his field of cardio-obstetrics, and grew his following to almost 4,000 people, he said logging on over the last year started to feel onerous.

“We had too many distractions and much less control on what we could see,” Eshtehardi told TCTMD. “For me, it got to the point that I felt this was not the place that I used to have.”

Changing tracks to Bluesky right before the American Heart Association (AHA) 2024 Scientific Sessions meant that he was able to fast-track his experience with the new site in a dynamic way. He has opted to only follow the #CardioSky feed, saying that “since this was a 100% professional social media platform, I want to see 100% professional posts.” If something is important in the field, Eshtehardi reasoned, “it’s going to be reposted by many of the people who have the same interest and promoted and highlighted.”

For me, it got to the point that I felt this was not the place that I used to have. Parham Eshtehardi

Satisfyingly, his experience with Bluesky so far reminds him of “old Twitter,” something many who spoke with TCTMD for this story agreed upon.

Viet Le, DMSc, PA-C (Intermountain Health, Salt Lake City, UT), who was also once prolific on Twitter/X, said migrating to Bluesky aligns with his views of what social media in medicine should be. “I’ve always posted mostly positive things anyways,” he said. “But philosophically, I don’t feel comfortable being on a platform that just mainly feeds maliciousness.”

In the wake of the “mass exodus” of people in the cardiology field from Twitter/X, Le said he has enjoyed starting “all over again [with] folks that actually have a different intent—they just want to talk and disseminate information,” he told TCTMD. “Sure, they’re discussing their feelings about the election, et cetera, and I get that, but I don’t have to deal with the weird, troll-like nature of comments that you see on Twitter.”

He also appreciates not being “bombarded by . . . the weirdest, oddest ads.”

Julia Grapsa, MD, PhD (Guy’s and St Thomas’ NHS Trust, London, England), who runs social media for two European journals as well as enjoys posting on her own profile, said she began to get bogged down on X by “a lot of political posts, a lot of misinformation, and a lot of people that I didn’t know posting . . . radical posts that, to be honest, . . . were not near to my values.”

Bluesky’s personalization options have made “way that I interact with people much easier,” she added.

Mahadevappa Mahesh, MS, PhD (Johns Hopkins University School of Medicine, Baltimore, MD), told TCTMD that his perception of X really began to shift in earnest after the US presidential election. It became “untenable” to share ideas, especially with the general public, he said.

Philosophically, I don’t feel comfortable being on a platform that just mainly feeds maliciousness. Viet Le

In sharing his thoughts on radiation and cardiac CT, Mahesh used to enjoy positive interactions with people on Twitter/X. “I used to see . . . my followers were growing, but it kind of stopped,” he said. “And I see that new people are not engaging because they are tired, or at least those who are there on Twitter are not interested in my tweets. That’s why I’m beginning to use Bluesky and LinkedIn. I’ve been able to reach a lot more of my colleagues, my patients, and other people.”

Potential Pitfalls

Though many cardiologists once turned to Twitter for meaningful learning experiences, only a few years later some of those same doctors criticized the platform for the way in which it let bickering and vitriol run rampant. Further, a 2021 study found that almost one in four physicians reported personal attacks on social media.

If there’s anything to be learned from the evolution of social media sites, it’s obvious that nothing stays the same, but cardiologists seem optimistic about what the future holds for Bluesky.

From Grapsa’s perspective, X suffered from allowing misinformation to spread in the name of free speech. Bluesky “seems a more secure platform,” she said. “But of course, I’m very cautious” that things could change.

“Nothing stays pristine forever,” Le observed, acknowledging that though critics have already likened the feeds of Bluesky to an “echo chamber,” different viewpoints are necessary. “But the nonsense that happens on Twitter is not a different viewpoint. It’s just yelling at each other.”

Eshtehardi, too, said, “I don’t think there is a guarantee that this will not change in the future.” But, he added, the open-source nature of the company will likely give users “much more control on the platform in the future.” He remains “hopeful that we can recreate the happy place we had on Twitter or X on Bluesky.”

“Probably there is too much hype right now” with Bluesky, Mahesh acknowledged. “I’m very skeptical about any new aspect, claiming it’s going to solve everything. It’s not going to solve everything.”

Regardless, “it really was not about the platform, it was about the people—the community we created to engage and stay connected with each other all over the globe,” Michos said. “I think we can recreate this, and after many other platforms have tried, I feel like Bluesky is the closest to be a really viable platform alternative.”

Balancing Multiple Platforms, For Now

Though his favorite way to use social media is to make “nerdy jokes about cardiology,” Wu said he does credit his experience on Twitter/X with opening the doors to many professional opportunities, and that feels hard to give up.

Additionally, Wu said, he enjoyed the diversity of people on Twitter/X, especially being able to interact with patients with congenital heart disease and “amplify” their voices.

That’s part of the reason why he’s not planning to fully divest from X just yet. “The way I’ve been treating it so far is I keep my account there and I pop into it every now and again,” Wu said. “Just the other day I got a message from a patient . . . asking for some guidance. I know that a lot of people are still on there for now. And so, I want to at least be available.”

It really was not about the platform, it was about the people—the community we created to engage and stay connected. Erin D. Michos

Eshtehardi agreed that he’s not ready to leave X behind completely, acknowledging that “I personally don’t have the bandwidth to use two platforms.”

This is the primary reason why Grapsa said she plans to keep a presence on X. “I share some updates because I know that it’s difficult for some people to join Bluesky because they don’t want to be on multiple platforms,” she said. “So gradually what I’m trying to do is to limit X, and then eventually to move to Bluesky.”

Michos said she is “permanently off X and I just have to figure out if I’m going to deactivate my account completely.” She worries about protecting her username from someone else using it to impersonate her, so has decided to leave her profile as private.

Mahesh said he will dabble in as many social media platforms as he can until he finds the best fit for which he can move on from X. He has seen more interaction from colleagues on LinkedIn, but those posts can become too long to read and clouded by job promoters. Regardless of platform, however, he hopes “more cardiologists and more physicians interact, share their research, . . .  and try to be positive.”

As for Kirtane, while he admitted to being “partially tempted” to join Bluesky recently, he’s keeping fully offline. “My mental sanity and health is so much better once I stopped being on ‘social’ media. I honestly don’t think humans are meant to talk to each other as much [as social media encourages us to],” he said.