Thoughts on tonight's #NephJC Social Media Chat

Last night I was reading John Weiner's personal reflection on social media in medicine. He posed the question of whether the definition of professionalism is fixed and we need to adapt our social media use to these standards or do we adopt our measure and expectations of professionalism to new tools and personal behaviors. His words:

For example, a joint initiative of the Australian Medical Association Council of Doctors-in-Training, the New Zealand Medical Association Doctors-in-Training Council, the New Zealand Medical Students’ Association and the Australian Medical Students’ Association has produced a document called ‘Social media and the medical profession’ (Mansfield et al., 2011). The advice includes, inter alia, this statement:

Our perceptions and regulations regarding professional behaviour must evolve to encompass these new forms of media.

I would argue that perceptions and regulations of professionalism, once properly espoused and documented, should be applied universally, in any day and age, and for any circumstance or technology. This is declared, for example, in the Royal Australian and New Zealand College of Psychiatrists Position Statement ‘Psychiatry, online presence and social media’ (RANZCP, 2012) where, although there are specific allusions to social media behaviour in the document, there is an over-riding clause that clearly states:

they must ensure their social media use and Internet presence upholds the ethical and practice standards required for Fellowship of the College. (RANZCP, 2012)

Others argue that social media is somehow different. After all, it has immediacy and reach and permanency. I cannot accept that a smart, well-educated student who has achieved entry to medical school does not know these properties of social media.

This question seems to be at the center of any discussion of professionalism in social media, we need to at least understand what we mean by professionalism. While at first blush it seems that standards are only standards because they do not change. But on deeper thought, it is clear society has evolved. Imagine 1985 Marty McFly driving his Delorean to 2015 Brooklyn. What would be his reaction to people:

• publicly share vacation photos for the world to see
• millions of public diaries open to the world
• restaurants full of people snapping and sharing pictures of their food
• people "checking in" to share their current location when they get to every social engagement

He would be shocked at this narcissistic hellscape. Our ideas of privacy have undergone radical changes in just a few decades. It seems to me that the codes of professionalism must evolve with the standards and behaviors of the time or they will lose relevancy and become just an exercise in conservatism.

Please join us for this chat tonight at 9PM Eastern or tomorrow at 8PM GMT (3PM Eastern/Noon Pacific), it should be great.

The AUA v ACP guidelines. Fight!

Tonight's and Wednesday's #NephJC is going to focus on the ACP guidelines. But it is important to recognize that a different group looked at the same data and came up with very different conclusions of what CPG should look like.

The systemic review that is the primary source...

...was the same in both clinical practice guidelines.

The American Urological Association Guideline (PDF) consists of 27 guidelines covering:

• Evaluation
• Diet therapy
• Pharmacologic therapy
• Follow-up

The AUA did consider 18 additional studies that were not part of the AHRQ analysis. The recommendations are graded and the authors interpreted the grades thusly:

1. Clinical Principle. This is a statement about a component of care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature. My sense this is, that these recommendations are so woven into the fabric of stone care that people would not be able to get a study of these practices past an IRB.
2. Expert Opinion. This is a statement, achieved by consensus of the Panel, based on clinical training, experience, knowledge and judgment for which there is no or insufficient evidence.
3. A or B level evidence translated into Standards
4. C level evidence becomes Recommendations
5. Options are non-directive standards that may or may not be based on evidence. There is only one and it was evidence grade B

Background

• The prevalence of stones is increasing. It has gone from 5.2% in 1988-94 to 8.8% in 2007-2010.
   
• It is affecting more women so that it is much male dominated. The male:female ratio has slipped from 1.7:1 in 1997 to 1.3:1 in 2002.

• They looked at the diet studies that used stone formation as the outcome. Those studies found that increased water intake reduced stones. It found beneficial effect by avoiding cola. 
   
• They looked at multicomponent diets and described the ability of a low sodium, normal calcium, low animal protein to reduce stones more than a low calcium diet.
   
• Two other studies restricted animal protein as part of a multicomponent diet and was unable to find any advantage.
   
• The authors point out that changes to urinary stone risk factors has not been validated as an intermediate endpoint.

The authors are transparent about one of the primary gaps in the use of diagnostic information about the nature of a stone in the therapy for that stone.

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One caveat, all the RCTs diet studies were done in stone forming men.

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The Guidelines

The 27 guidelines themselves are pretty straight forward and read like a description of what takes place in a well run stone clinic. The authors are again transparent, labeling many of the guidelines as Clinical Principle and Expert Opinion. In terms of the final score it looks like this:

Well over half the guidelines are opinion or clinical principle (which is just an opinion in a new hat).

Here is the breakdown by section:

Not surprisingly, only pharmacologic therapy has received significant RCT attention.

The AUA and ACP guidelines are based on the same evidence but ultimately look very different. The ACP guidelines look at this evidence desert and provide guidelines so sparse they end up functionally useless. The AUA, on the other hand, hitches the evidence to common sense, scientific innuendo, and long-held medical habit to provide fairly comprehensive guidelines that primary care doctors and part-time stone-physicians can use to actually take care of patients. The AUA guidelines paired with the AHRQ evidence analysis are documents I would have every fellow add to their iPad library. The ACP guidelines? Not so much.

In the end the ACP guidelines read like political statement protesting the sorry state of stone evidence, while the AUA guidelines provide a practical manual guiding stone care while still being transparent about the poor state of evidence.

Joel Topf, MD