The nature of Twitter

A new way of saying goodbye?

Shortly after I joined Twitter he replied to something I wrote, and retweeted it. It was a thrill. His follow-up comments were insightful, incisive and justified. The exchange drew in some more established Tweeps, a few of them followed me, and I felt that I had truly joined the conversation. We followed each other. Thereafter we had the odd interaction, not many, but I tended to agree with him, and he with me. Once, when I felt demoralised after receiving some personal criticism during a controversial debate, he supported my point of view. Coming from him it felt important, and it cheered me up.

Months later I read a Tweet reporting that he had died. I was shocked because he had Tweeted just a few days before. Quite a few commented on his passing. I wrote something, although, never having known him, it was necessarily shallow. I didn’t include his ID…that felt too direct. The brief eulogy was based on the impression I had formed over a matter of months, based on fifteen, perhaps twenty micro-posts. But I was not indifferent, and had to say something.

Then I noticed that an automated daily round up of topics that had interested him was still being generated and posted in his Twitter account. His avatar kept popping into my timeline. Every time it appeared I felt a pang of grief. Then I saw that others who had been referenced in his updates were replying, thanking him for the mentions.

A week later, still haunted by these strange, autonomous updates, I tapped his avatar, took a last look at the hand-drawn likeness, and touched Unfollow. It felt like a disloyal act. Our peculiar, virtual relationship was over.

I have subsequently learned that he was a keen proponent of social media, and a very generous man. I hope Twitter will bring me into contact with even more people like him…(it already has). I suppose an inevitable part of broadening your social and professional circle is that death will touch you more often. It’s not yet clear to me how you respond to the death of a person whose thoughts you are accustomed to reading, but whom you have never actually known. Perhaps, just as Twitter provides a new way of knowing people, it demands a new way of saying goodbye.


Disappearing doctors: the limits of medical debate on Twitter

My adoption of Twitter coincided with the Liverpool Care Pathway (LCP) controversy. Naturally, I ‘joined the conversation’. The compact exchanges that followed forced me to examine and re-evaluate my views. The links to press stories (in newspapers I would not normally read) and blogs helped me appreciate how broad the spectrum of opinion is. The cases described in the media are enough to open anyone’s eyes to the risks, but the additional voices on Twitter, their views expressed vehemently at times, reinforced the fact that many more have witnessed, or at least perceived, poor practice. I am happier now to accept that the Pathway has not been used well universally, and perhaps, even though the pathway is intrinsically helpful, it needs to be changed to ensure better application. Nevertheless, because I have seen the benefits of the pathway, I have argued forcefully in its favour.

Engaging in the argument demands patience and moderation, because Tweets can be provocative. Accusations of murder are common, and for some this forms the backbone of their case against the LCP. It soon becomes clear when your interlocutor’s mind cannot be changed. The intensity rises, the argument gets personal. In some cases it becomes clear that the individual in question had a relative who died in difficult circumstances. Trust in the medical profession and the way it manages end of life care was damaged, and when things go wrong so close to home that damage tends to be irrevocable. Whatever the evidence, however overwhelming the number of voices in favour of the pathway, you are unlikely to overturn the misgivings of someone who has vivid memories of a relative dying in hospital.

Nevertheless, it seems reasonable to continue to argue, for Twitter is a place that gives you time to compose your arguments, and time to digest the points made by others. But here the difficulties arise. As doctors we are trained to sympathise and empathise with the relatives. When we talk with a relative of a dying patient we try to inhabit their point of view and understand what they are saying. If they are angry, we absorb that emotion. If they accuse us, or the hospital, or the system, of making mistakes, we do not challenge them; it’s not the right time. These are universal qualities of course, not restricted to doctors, but they are qualities that we have actively developed as part of our vocation.

This is why I find it difficult to maintain opposition to someone whose views are so clearly coloured by personal experience. In trying to overturn their doubts I fear that I am actually belittling their memories of a loved one. So, just as I would never allow myself to become involved in an argument with a patient’s relative on the ward, however much I disagreed with them, I am increasingly reluctant to have arguments with those who wish to banish the pathway. The same applies to those affected by poor care at Mid-Staffordshire, or relatives touched by medical error elsewhere. Doctors seem wary of challenging the validity of HSMR statistitics, knowing perhaps that Tweets may be read by families involved. It seems impolite. Does this reticence lead to a stifled, incomplete debate?

Perhaps doctors are too ready to adopt a ‘customer is always right’ approach. We often find ourselves speaking with people, be they patients or relatives, who challenge us. But we absorb the emotion, the occasional animus, the very rare invective; we step back, give it space, let it mellow with time. You can’t do that on Twitter, it’s about the here and now. And it’s loud. When doctors find themselves losing their rag, raising their voice, making it up as they go along, they tend to remove themselves from the scene. They disappear.

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