Eric Postal, MD

Last week, I wrote about a communication-squelching trend that’s descended upon our social-media world. The first component was an ever-increasing ability to tune out voices one doesn’t wish to hear. Synergistic with this has been the (over?) eagerness of social-media providers and associated players to cut those unwanted voices off at the source.

Call it moderation or censorship. Ascribe it to good intentions, bad ones, or a complete lack of master-plan that’s blundering forward without considering where this might be headed. You can’t swing a digital cat online without hitting an argument over the issue.

An awful lot of people only start to find this concerning when it directly impacts them, or folks they know/like. So, if one doesn’t spend much time prowling Twitter or even Facebook, and hasn’t noticed friends getting “Zucked” or admired podcasters getting “canceled,” one might not perceive trouble.

Indeed, most of us healthcare folks are busy little bees, and haven’t got much spare time for such things. Why should we care if some conspiracy-theorists have a harder time getting their word out? After all, we’re told that only the “bad” voices are being targeted. Voices which, left unchecked, would propagate misinformation and possibly even threaten others’ safety and wellbeing.

My suggestion would be to look a little bit further down the road, and think about how this might apply to healthcare. Because there is nothing to stop it from coming to our doorstep, and if we wait until that happens, it’ll be too late to do anything about it. A scenario to consider:

The intermittent debate over whether screening mammography is worthwhile comes to a turning point. CMS and/or the insurance-conglomerate decide, whether based on data or dollars, that they don’t want routine screening mammos to be a thing anymore.

An awful lot of folks object to that – healthcare providers, patient advocates, maybe even professional societies. Pushing back against such a change is best done in the public square. Published articles, press releases, and, of course, social media to get the word out.

Unless, of course, CMS and the insurers convince enough of those venues that the case against screening mammos has been sufficiently proven. (Whether purely on the strength of the argument, or other, shall we say “persuasive pressures,” the government and insurance mega-corps can bring to bear.)

It, thus, becomes “settled science” that screening mammos are wrong. Anybody not accepting that is being unreasonable, possibly for self-serving reasons. Spreading such disinformation is bad; it might confuse the general public about whether mammos are good for them or not. And it might undermine confidence in the healthcare system, which would be dangerous.

So, labels get slapped on social-media comments advising friends, family, or the general public that breast-cancer surveillance is being kneecapped: “Disinformation warning!” “Healthcare professionals have determined that screening mammography is not a reliable means of preventing cancer, and, in fact, exposes you to unnecessary radiation!” Pro-mammo postings start getting summarily deleted. Particularly-vocal proponents’ accounts get suspended for repeatedly sounding an allegedly-false alarm.

Successfully “disappear” the folks who are trying to warn the public, and the only voices remaining are ones which agree that mammographic screening was wrong to do. The general population is left with a one-sided propaganda campaign. Any stray arguments to the contrary will look like con artistry or conspiracy-theory kookiness.

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This, alone, is enough to silence a whole lot of people who don’t want to lose their social-media presence. Even when not on COVID-lockdown, people depend on this stuff for a lot of their societal interaction, if not to help them make a living.

Of course, some determined docs might press the issue. Might even find a way to get the word out without social media. No problem; we’ve learned plenty of ways to cancel people. Pressuring medical facilities where the docs live should do the trick: Does your hospital really want to be associated with a screening-mammo insurrectionist? Because the social-media apparatus can be turned against you if you fail to disavow.

Suppose blackballing the intransigent doc with would-be employers isn’t enough to kill his livelihood. Why not go after his referrers? Pressure local insurers to drop him from their networks. Hell, start filing complaints with state Medical Boards – if this doc thinks he knows better than the rest of the industry, should he really be practicing?

Coming back from that dystopia, now let’s suppose you’re on the side wielding the power. Suppose you’re 100 percent in favor of mammographic screening. You (and healthcare as it currently stands) might not be happy when you hear dissenting voices, arguing against its efficacy or risk/benefit balance. Are you in favor of suppressing them, because they’re spreading bad information? Deleting their posts, suspending their accounts? Going after their livelihoods in real life if they persist, to make examples of them?

Or might it be better to keep those voices in the public square, where you can hear them? Be aware of their arguments and other actions, thus able to counteract them in front of a massive societal audience? Perish the thought, but suppose something they say turns out to have merit (on the subject of mammo, or something else)? Gives you a great idea you would not have otherwise had? Leads to some innovation that makes mammo even better than you ever thought it could be? A new modality altogether?

Screening mammos, of course, are just one possible subject of contention; feel free to substitute a topic of your own personal interest. Anything you feel strongly about, for or against. Or something central to your livelihood. Selective deafness and forced mutism, left unchecked, stand to threaten it all.

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What could happen if the subject of discussion is a widely used radiology exam?

Can Silencing and De-platforming Come to Healthcare?

Once upon a time in this column, I shared a bit of wisdom gained from a very successful individual: Standing on a soapbox and proclaiming your sociopolitical views to the world is asking for trouble.

Is it your right to do so? Absolutely. But is it smart? Maybe if your livelihood is based on it, such as being a talking-head political pundit on some not-really-news show. For most of us, however, that doesn’t apply. Instead, all you’re doing is risking backlash from people who don’t agree with you. That can range from getting your car keyed on account of your bumper-sticker to having your company blacklisted and boycotted.

As the great Michael Jordan said, “Republicans buy sneakers, too.” God bless you if you’re so confident in your success that you’re willing to alienate 50 percent of your customer base by saying things that will make the other 50 percent like you a little better, but I don’t know too many non-monopoly enterprises that operate with that kind of a margin.

I’ll preface the discussion below by saying this particular column isn't just about the matter of playing around on social media, by the way. This all comes home to roost for us in radiology – and healthcare at large – so tune in next week, as well, for part two.

So, last weekend, I decided to open a Parler account. I had resisted for a couple of reasons—first, I’m not crazy about social media to begin with, so using more sites/apps goes against my grain. Second, it’s not like my Twitter account is a hotbed of activity; if I got just as many followers on P as I had on T, I still wouldn’t quite have three dozen.

(Third, on a petty note, the academician in me aggravates about Parler’s name…is it supposed to be the French verb “to speak?” If so, why are we not pronouncing it “par-lay?” Or, if it’s supposed to be a parlor, like a place where guests would meet and converse, why spell it differently? End of digression.)

In any case, I was convinced a few months ago that, as a regular columnist, I should have some kind of social media presence. Even if I only have a handful of followers, I can see that my posts get hundreds of views, so somebody’s paying attention. And there’s no predicting when lightning might strike and I suddenly find myself with a much larger following. 

 getting on Parler, the way things were shaping up, would diminish my visibility.

As luck had it, I established my account and downloaded the app mere hours before Parler got shut down (at least temporarily) by the combined forces of Google, Apple, Amazon, and an armada of other players. All I lost was the bit of time it had taken me to sign up and create my profile. It hardly felt like a severed virtual limb or a stifling of my ability to speak in the public square.

Others who had been using that forum (8 million as of November, with a subsequent voluminous influx—a cursory look fails to give me numbers), however, are feeling decidedly more suppressed. Many originally flocked to Parler to get away from other social media that were exercising an increasingly-free hand at suspending or banning users. Rightly or wrongly, lots of those users felt that they, and others with similar opinions to their own, were being unfairly targeted.

Their newly-adopted platform, itself, now being targeted, there’s a certain sense that an electronic Iron Curtain came crashing down. More than a little talk about what constitutes free speech and prevention thereof. Also what corporate behavior constitutes collusion, and should be reined in by antitrust laws. Not going into that here.

Being a diagnostician (radiological and otherwise), I’m more inclined to focus on root causes, how damage is being done, and, when possible, niduses of trouble that might be removed or circumvented to result in an improved state of affairs. As big as the issues referenced above, I think there’s something even larger and more fundamental that’s led to this juncture. An underlying pathology that might have made this inevitable. And may lead to worse, if not addressed/corrected. Like a patient with obesity or diabetes who hasn’t yet had a heart attack, stroke, or renal failure…but just had a scary TIA.

The fundamental issue is one you’ve heard about before: People not listening to one another. In the age of social media, with varying degrees of lockdown and physical isolation, there’s an ever-increasing ability not only to render oneself selectively deaf to unwanted voices…but now, also, to force mutism on those voices by banning, de-platforming, or otherwise “canceling” them.

Sometimes there’s a good reason for it. Someone threatening/planning violence or other criminal behavior, for instance. But I think we’ve gotten a little too comfortable with the notion of silencing others just because we don’t like what they have to say. It seems increasingly common to decide to silence them first, and conjure an excuse afterwards.

I’m sure that some folks see nothing wrong with the notion of stamping out all voices and even ideas that run contrary to their own. And I suppose it can be a heady thing if one is in ideological synchrony with the folks doing the muting—look how all the wrong-thinking villains are being squelched! That’ll show ‘em.

However, unless you’re embracing the idea of rounding up all of the people with objectionable ideas and putting them in re-education camps or otherwise “de-programming” them (I leave it to the reader to look up which talking heads floated those ideas this past week), the people you’re silencing are still going to be in this society with you. And it might not be in your long-term interest to prevent yourself from hearing what they have to say.

So, as I said earlier, this isn’t just a discussion about social media. This impacts us directly in radiology, as well, and I’ll address that next week in this space. Stay tuned.

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Selective Deafness and Forced Mutism

I’ve mentioned in this column that I’m not a handy kind of guy. Putting things together, fixing or otherwise tinkering with them, you name it.

That goes for anything hands-on, hardware and wetware alike. I knew very early on in my healthcare-days that I had no business in specialties that required manual tasks, such as surgery. Unsurprising, then, that rotations in interventional radiology (IR) saw me at far from my best.

Still, I did learn a few things. One of my more enduring recollections from the angio suites was a fundamental rule taught by the section-head: When you are feeding in a catheter or guidewire and meet resistance, do 

I’ll refrain from describing all the bad things that might result from ignoring that bit of guidance; suffice to say that a lot of damage can be done.

While my post-residency life has included not a single IR procedure in which I might have directly applied teachings from that attending, I’ve remembered that particular lesson well…and, a decent chunk of the time, abided by it.

Not purely in a physical sense—it’s actually served me well in a more philosophical way. That is, if I find myself in a situation where I’m trying to get something done, and my initial approach doesn’t work, I usually refrain from more forcefully trying the exact same thing again.

That’s easier said than done. I’ve mentioned in recent columns that our brains are efficient/lazy things, strongly biased towards whatever requires the least energy from them. If we’ve sized up a situation and decided on a course of action, we tend to cling to that decision, even if that action doesn’t yield desired results. More so when the situation is emotionally charged (for instance, we’re getting frustrated by our failed attempts, we’re pressured for time, or we’ve got other things demanding our attention).

Applying the “don’t just push harder” lesson came most readily to me with manual tasks, since they had the most in common with my fumbling efforts in the angio suites. As unhandy as I know myself to be, I’m pretty capable of breaking things when trying to force them to physically work: opening items that resist being opened, closing items that don’t want to be closed, etc. Learning to substitute “This isn’t working, I’d better try harder” with “This isn’t working, is there something else I can try” led to fewer broken items.

A good example of a less-physical application in my recent work: I stumbled across a glitch in the voice-recognition software used for dictating rad reports. On certain occasions, the software gets derailed by something I said. As a favorite aunt of mine likes to say, the program will “lose its mind,” freeze up, and close. Adding to the fun, when restarted, the software fails to accept 

 dictation; turning on the microphone and saying anything makes it crash again.

As mentioned earlier, my brain wants me to “just push harder.” The software 

 work. Even if it crashes, I should be able to restart it, hit the dictation-button, and resume work with nary a delay. Every time, the temptation is there to just fire it right back up and hit the button again, maybe getting righteously angry in the process. But that doesn’t work, and even if it occasionally did, it wouldn’t make the underlying problem go away.

So, after this had happened more than a few times, I reached out to Support so I could describe the issue to them, even demonstrate it with them remoted into my workstation. It made sense that they should gather all of the info they could so as to root out the problem, even though (thus far) I was the only rad having the issue. Ultimately they had no idea for a fix, but were presumably armed with data to present to the software-developers so they could figure things out.

At some point during all of this I found a workaround: After the first software crash, if I relaunched but 

 turn on the microphone, instead manually typing the next line or two in my report, I could then resume dictating without a problem.

Since the glitch still happens a few times each week, I can now circumvent the issue with my little workaround, instead of “pushing harder” by insisting on trying to dictate the normal way. At this point, I would even consider ringing up Support (“It’s happening again, do you have any updates on a fix? Want to remote in and gather more data? This is impairing our efficiency, you know”) to be pushing harder on an already-failed strategy.

Because my main purpose is not to be a software-tester and troubleshooter. I’m there to productively read cases. My workaround, irksome as it is that I have to use it, gets me back on-mission most quickly and effectively…whereas getting ahold of Support means that I sit idle until they get back to me, watch me demo the issue, try fixes, get screenshots, etc.

An even higher-level application of the “don’t push harder” philosophy I’ve learned is in dealing with other people or organizations, when there’s a difference of opinion or some other interaction where everyone isn’t on the same page.

It frankly amazes me how some people seem to think that the best way to debate is to repeat the same argument over and over, as if saying it enough times will somehow “get through” to the other side. Sometimes punctuated by talking more loudly, aggressively, even insultingly or threateningly. Instead of A) offering other lines of reasoning, or B) gathering additional information to better understand the other side.

I will close by with an incident from one of my later IR rotations, where a catheter or wire met resistance, and we paused while the attending came to the suite to feel things out for himself. A bit of fiddling with his more-expert hands, and he regarded us for a moment before saying, “Good, you’ve learned not to just push harder. Now you’re ready for the advanced lesson: Sometimes, if you’ve had enough experience, you can tell when it’s time to push harder.” Then, he successfully advanced the device.

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Sometimes taking a step back can help you find the path to keep moving forward.

Don’t Just Push Harder

I’ve mentioned once or thrice in this column that I do not consider myself an intrinsically-brilliant radiologist. I’m no academician, I never took to research, and I’ve yet to invent any new gizmos or imaging techniques.

I do flatter myself that I bring more than a few things to the table, however. When it comes to churning through an imaging worklist, I have an ever-growing “bag of tricks” that gives me an edge. Some of those tricks boost my productivity, some limit my liability, and some, I daresay, make me a better physician.

My repertoire grows in various ways, the most important of which is keeping eyes and ears open as I witness other rads doing their thing. Certain behaviors stand out to me as being particularly useful, and I adopt them. (At the other end of the spectrum are actions so maladaptive, I promise myself that I will never do the same.)

One of the good items harks back to my post-grad training or soon after. Another rad, reading a stone-CT, noticed that the patient had undergone an ungodly number of CTs within the past year for the same reason. He made a point of this in his report, emphasizing the patient’s cumulative radiation dosage and suggesting that it be kept in mind. The rad didn’t come right out and say, “Were all these CTs really necessary? Try an ultrasound, you quacks!” The message was, nevertheless, diplomatically conveyed.

When I add something like that to my bag of tricks, I’m not just waiting for precisely the same situation to recur so I can execute the same behavior. Encountering something nifty and new gets me thinking in ways I previously didn’t, and my mind eagerly looks for other ways to play with its new toy.

I’m pretty sure that stone-CT incident, thus, opened a new door in my mind, to the effect of “I can tell clinicians useful things that aren’t on the actual images I’ve been given to interpret.” Useful things that, from my perspective as a radiologist, I am uniquely suited to point out.

For instance, in scenarios like that stone-CT: Commonly, a given patient’s scans are ordered by two or more different clinicians, unaware of how frequently other docs have done the same. Some might not even have it on their radar that there are alternatives to CT for checking on stones. A radiologist reading the current scan, aware of prior imaging, might be the best suited to point this stuff out.

Analogy: You’re making your way through a crowded plaza (assume post-COVID society if this makes you anxious). If you were trying to get a sense of how many in the crowd were wearing red shirts, you’d only be aware of the people immediately around you. Now imagine you’re standing on a 5th-floor balcony, overlooking the area. That perspective gives you an advantage in the same way our access to the imaging record gives us a perspective that the “boots on the ground” referrers don’t have. Even when they have equal access to our databases, clinicians are often too busy with other things to do much digging. But, we are in a position to give this info to them on a silver platter.

I’ve taken this approach out a new door from time to time. It’s rarely a sudden, “Eureka!” moment. Rather, I’ll gradually become aware of situations where I can fill a void in my little corner of the healthcare system. One might just have come to a head this past week, but the ball got rolling years ago:

Similar to serial stone-CT patients, I’d noticed some folks would have brain scan after brain scan for the provided history of “fall.” Most frequently, there was nothing acutely the matter on the images – just the expected senescent patterns of atrophy, microangiopathy, etc. No change from prior, or the prior before that, or the one before that…

Of course, there are any number of reasons for elders to be more susceptible to falling, or assumed to have fallen (for instance, found on the floor without signs of trauma). But, how many of these patients are wrongly assumed to have nothing more significant underlying their falls? What if the referrers ordering these numerous scans don’t realize just how many episodes of falling there have been?

A patient might, for instance, have scans for falls ordered by a doc at a nursing home, an internist during a hospital admission, a neurologist at some other juncture, and multiple ER staffers in the area over a course of months. Any one of whom might be unaware of falling-incidents beyond the one that they, personally, are evaluating.

So at some point, it occurred to me to upgrade my baseline suspicion for subtle signs of normal-pressure hydrocephalus (NPH). Even with equivocal images, my awareness of multiple prior scans for falls might just make me include an extra line in my report, noting the number of falls in the past year or two as potentially meriting clinical consideration of NPH.

This past week, the thought evolved further: Even without imaging findings to suggest that particular pathological entity, I still might have something to offer in this scenario. What would any other conscientious healthcare provider do if they noticed a patient in their care was falling a lot? Hopefully not just rule out injury or other acute issues and, then, forget the matter.

Instituting “fall precautions” or a “fall-prevention plan” might prevent future episodes with more severe consequences. A comprehensive evaluation could include medication review, nutritional evaluation, targeted physical exam, etc. Even a home-visit to investigate environmental risks.

A quick glance at the literature tells me that “recurrent falls” are defined as two or more episodes in an interval of six months and should be evaluated for treatable causes. Maybe I can get that process started a little earlier for some folks by pointing out how frequently they’ve been imaged for falls, rather than just saying their images are stable with nothing acute.

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What if you report things that aren’t on the scan you’re given?

Eric Postal, MD

Articles

Can Silencing and De-platforming Come to Healthcare?

Selective Deafness and Forced Mutism

Don’t Just Push Harder

Things That Are Not on Images