My Twitter journey so far

It is an honest confession about what I have been able to achieve and put it in perspective. Is the social microblogging website, beneficial?

  1. I have been lucky to come across many excellent individuals! Medical Physicists, Radiation Oncologists and the fraternity which gets together and deliberates on matters of mutual interest.
  2. I had to use a lot of muted words because most people don’t realise that Twitter is meant for “manufactured outrage”. It is lazy person’s means of “activism”.
  3. I follow many accounts, but some of them are muted because their tweets add no value to the discourse here.
  4. Some Twitter users are great. They read whats on their platter, but Twitter sorts out interaction based on algorithms. It means you are likely to miss out on a lot of important things. Your likes, re-tweets or other signals are factored in what you ultimately see. It isn’t educative nor informative.
  5. I participated in my first virtual conference for ESTRO. It was an enjoyable experience, and I have written and shared my ideas extensively. If you wish to factor in Twitter as part of an interactive platform, you need to have a coherent strategy. A generic hashtag adds little value to the overwhelming noise. I would, on any given day, have a Telegram channel, instead.
  6. I am dismayed by the constant barrage of advertisements by many organisations. It is good to promote diversity of thought; however, it is clear that these accounts have been outsourced to different agencies. It appears phoney; as if they are drunk of kool-aid. My bullshit filters typically go up at the very thought. I am not naming them, of course, but it gets my goat. Likewise, for a respected “physician-scientist”. It may be acceptable to make political statements, but it is like mixing wine with water. The result- academics+politics doesn’t make any sense.
  7. Gender politics on Twitter is too stupefying; I am gender neutral (if that is the term) and I prefer to see individuals as such. There is no meaning of gender for me (as far as academics is concerned). Using your Twitter account to wash your dirty linen in public (because you have a specific gender) is labelling your back with the tag of “stupid”. Ultimately, it is your choice as to what you wish to achieve with social media. I usually prefer to stick to a personal account on Twitter or better still; I prefer Telegram.
  8. The click-through rate for articles is abysmal. If you wish to see an improved version of click-throughs for the posted links, you will need to have a large number of followers.

Has there been any luck with getting people to switch over to Telegram? Nope. Nada. Zilch. It is because of my tacit understanding as follows- Twitter as a medium for beginners is intimidating. Many users prefer to stick with the known than to start with something new. It is not laziness, but everyone has a motive to be online using Twitter. Some wish to have a more significant exposure; some users want to interact with peers, some want to express outrage or crib about life’s not fair. There is no one reason. Telegram is much more personal compared to Twitter. I have a couple of groups and channels with me on Telegram. It is good to spend time by consuming content passively. Groups allow more fine-grained control and better-nuanced interaction. And the recent moves by Twitter to force users to access it through web-alone is a stupid move.

Twitter is a bitter-sweet experience. Yes, the constant stream can be tiring and distract you cognitively but it is fun in parts. On the flip side, you end up meeting amazing individuals and people from different departments across the world.

Twitter for oncologists: More reflections.

One thing is apparent. Twitter as a service, is for sharing links alone. The original premise was to get the overall perspective of how users discuss issues in “real time” and function as a “real-time” search engine. Google, at some point, listed Twitter results but it ended for reasons best known to them.

The more the people on any platform leads to an excessive banter. Separating the signal from the noise becomes even more difficult as informational deluge overwhelms us. While it is fanciful to have more Twitter (or Instagram) followers and show off as “influencers”, it doesn’t help much because of abysmal rates of engagement. While I may consistently get a large number of “Tweet impressions” (mumbo-jumbo of acronyms that Twitter is marketing), this is useless as it doesn’t translate to real life behavioural change.

It is evident from the fact that engagement with my shared links is abysmally poor. My idea of being on the social network is an academic exchange. Suppose I share in a link which is opened and read by another- it would foster a dialogue of information.

On the other extreme, I have come across “verified” accounts of “star-influencers” in Oncology community who push out links with annotations, pictures, survival curves and proper attribution to the authors. How do those “star-influencers” manage it?

I have a strong reason to believe that these links are pushed by dedicated teams using enterprise accounts. A lot of window dressing takes place and after “approval” is “tweeted” out. You have to see the pattern to understand it. It is impossible to juggle professional commitments with tweeting links all the time. There has to be a team involved.

The race for “followers” has polluted the ecosystem. Automated bots propel the specific “likes” making it impossible to differentiate legitimate traffic from bot sponsored and propagated traffic.

I am not cynical. I use Twitter for ideas to write on this blog here. I observe trends. I interact with virtual selves of humans, genteel people scattered all over the planet. It is fun to learn from there, to ping them and understand their perspectives. The trick is to moderate, turning off retweets which don’t concern you, muting specific words and staying focused on what you wish to gain. As a result, I have whittled down to less than half off my previous unread tweets on the timeline. It took time to cull away the deadwood and the fresh perspectives soak in. In the end, it was worth it.

Social media: Caveat emptor!

The debate about doctors being on social media hasn’t ended. Most people, I have spoken to, have very negative connotations about it. They feel, very strongly feel, that Twitter is nothing but an echo chamber of bigotry, lies and cussedness. It “might” be true but then technology is what you make it out to be!

Facebook is another different beast. Their claimed usage is about 2 billion users, but no has independently verified these numbers. They have been able to grow this because of powerful network effects. Most users feel comfortable here because it allows them to interact with “friends and family”. It also means that most users are reckless about it.

Facebook is a global surveillance system that gives dopamine fuelled high to be voyeuristic or exhibitionist. Their terms of service point towards collecting the data and being able to share it with “third party affiliates”. I often chuckle when people get horrified that the service they depend on its utility, for administrators, for psychological manipulation. What would it take to learn the lessons?

Social media is as good as we make it out to be. The best ideas for the blog post appear in my Twitter timeline. I get ideas, dwell on them and then write. One way out could be to learn from different specialities, see how they are using it and adapt it yours. The ideas take their shape and pretty soon, a rich interactive web form that enriches it even further.

(I prefer Telegram app).

Research and biotech: Asking right questions

The Ken is a wonderful resource for myriad issues.The staff at The Ken is constantly churning out some of the highest quality journalistic write ups in India. Their focus is mostly on start ups, biotech and increasingly now on security of digital assets. The reason why I recommend it is to broad-base your reading sources and think laterally beyond our narrow confines. Financial crunching may not be everyone’s cup of tea but it has spurred me on to understand more about it’s complexity. In the end, it is a deep dive learning experience to write effectively. In the sea of otherwise hopeless mediocrity that Indian journalism has seeped itself, The Ken (and to some extent, Business Standard) redeem themselves.

Today’s post was motivated by an excellent coverage of biotech sector and this prodded me on to think about what the research goals ought to be. Biotech companies are chasing the end of the rainbow for the pot of gold. The reason why US remains the “gold standard” for these companies is because of a perverse incentive that pharmaceutical companies and hospital corporations have to milk the consumer. That’s where the big money is. And these companies are pushing themselves to crack the market in order to get the first mover advantage.

I will not name a few companies that I have worked with (due to non-disclosure agreements with them and that included not calling them names publicly). There were some great individuals, that I had the good fortune to learn from, as well. This aside, they are mostly floundering pushing their luck. In proverbial terms, trying to see what sticks to the wall.

In one presentation, they presented a “case scenario” which showed how the medical oncologist based his decision on genomic details for lung cancer. In another, they were keen to show for cool-rectal cancer. All laudable but with one significant omission. They did not have any follow up for outcomes! Not only this, none for any clinical trial, suitability for a vast majority or how the specific gene sets were chosen to be marketed.

Its stupidity compounded by idiocy. Over and over again.

Sadly, the translational science hasn’t made specific progress and now we have the buzz words like “precision medicine”. Pray, what is precision medicine?

Hype fuels another set of hype cycles. It is a good thing that all of this looks great on dossiers or fanning our collective egos in fancy conferences but they remain a collective effort for intellectual masturbation. We need hard core data sets and equally hard nosed questions before we thrust all of this in front of hapless patients.

The company mentioned in The Ken write up hasn’t specifically mentioned as to how they will find out the difference in the genetic mutations (from primary index lesion) to the current state. I had earlier explored this concept in an editorial arguing for liquid core biopsies as means to monitor the course of treatment in lung cancers because of the range of molecular mutations.

Rest assured, I have a healthy disdain for pharma company sponsored trials with results that appear too good to be true. When it is translated into actual clinical practise, it doesn’t live up to it’s hype. Remember the Cetuximab “landmark trial”? Or even for that matter, Bevacizumab?

Lets pause. Think.

There ought to be healthy skepticism. A side note to fellow radoncs- there is a lot that can be achieved in Radiation Therapy. We need to explore different fractionation schedules or even radiation sensitisers. Combination therapies do-not always work out. That is the subject for another blog post.

Inbox Zero: Fastmail for academics.

Who wants this?

It is simple.

Sign up for Fastmail.

Have a custom domain, if you want. Or else, existing domains offered by Fastmail work fine.

Have an alias for each website. For example, if you order pizzas, have one for that. For a travel website, have another. The trick is NOT to give out your actual email id but give the alias for that particular site.

This is how it plays out. Go to dominos and have an alias like (or whatever domain you want). It will immediately segregate your email. If you are spammed for that domain, it is a matter of deleting that alias. Simple. Quick. Painless.

I have folders for all incoming mail, and Fastmail allows setting up rules to sort them out automatically. For example, if I have a newsletter subscription, it is set to flow in that folder and marked as read. Or anything else that I wish to read later.

Achieve that today!

RANO: Working plan for the use of patient-reported outcome measures in adults with brain tumours

Lancet Oncology, 19 (2018) e173-e180. doi:10.1016/S1470-2045(18)30004-4

Why is this paper important?

It is because there are no reliable means of patient-reported outcomes (PRO). These metrics are an essential part of monitoring the course of treatment as well as quantifying the impact of the same. For years, we have been relying on metrics like Mini-Mental State Examination. I have found that examination to be sorely limited because it is full of biases and highly dependent on the cognition/mood status of patients. There has to be a more robust metric.

Hence, the great blurb from this paper:

The first step would be to provide an overview of the guidelines of previous initiatives on the collection, analysis, interpretation, and reporting of PRO data

It is the step in the right direction because of it an acknowledgement of what we don’t know. I have attempted to involve formal psychometric testing, but it usually takes hours and have limited clinical utility. The existing tests have undergone validation in different “trials” (most of which are either single author led studies or institutional trials) leading to much confusion. Do we have a standard way of reporting them?

Not yet.

It leads us to the second step.

The second step would be to identify what PRO measures have been applied in brain tumour studies so far. As mentioned, several PRO measures are already used frequently (e.g., MD Anderson Symptom Inventory Brain Tumor Module, Functional Assessment of Cancer Treatment-Br, EORTC Quality of Life Questionnaire C30 and BN20, and the Barthel Index)

Content validity should also be culturally sensitive. What applies in one geography doesn’t translate in another part of the world (which adds to the complexity of the task).

Therefore, I feel that the third step is the most crucial question in patient-reported outcomes.

The third step would be to establish the content validity of the existing PRO measures identified in the second step. Are all essential aspects of functioning and health for patients with brain tumours covered by these instruments?

The next excerpt nails this in the right direction. It is not the patient defined outcomes alone but has to be validated by physician scoring system as well.

How is this going to shape up?

This framework refers to a patient’s functioning at three distinct levels. The most basic level is a patient’s impairment in body function, such as muscle weakness. Assessment of these impairments can be done with PRO measures, such as a symptom questionnaire, but also with clinician-reported outcome measures such as a neurological examination

Last but not the least is the psychometric properties-it has to prove its reliability as well! This, of course, applies to reproducibility across different domains.

The fourth step is to identify the psychometric properties of the detected PRO measures. How valid and reliable are these instruments for patients with brain tumours

To achieve this goal, the committee proposes to use COSMIN taxonomy and defines it as such:

The COSMIN taxonomy distinguishes three quality domains: reliability, validity, and responsiveness, each of which includes one or more measurement properties. Reliability refers to the degree in which the measurement is without measurement error, whereas validity refers to the degree in which an instrument truly measures the construct intended to measure. Responsiveness refers to the ability of an instrument to detect (clinically relevant) changes over time.

These criteria will help to shape up the course of treatment beyond the survival outcomes and focus on preservation of quality of life.

More on that later.

Why a Telegram channel for brain tumours was created?

The idea behind setting up a Telegram channel and a group was inspired by holding a Twitter-based discussion with a colleague. I am placing this on record here.

The central premise is a straightforward thing. If I were to face a similar situation, what would have been my state of mind? What is the ideal way to go about this? So, I decided to set up something in a way which I would have wanted. The first and foremost is the platform wherein I could access psychological support. These issues hit from nowhere, and it is essential to know that I am not vulnerable nor alone. While a lot of emphases has been placed on breaking bad news by the oncologists, handling the aftermath of emotional distress by a patient is an unaddressed issue. Having access to psychological resources or a support group becomes imperative at that moment.

How do I choose a support group? Ideally, one that has an active involvement of a clinician in some capacity. Most patients hit Google with a furious pace to know more about the disease. It is essential to guide them efficiently to informed sources about what we are dealing with, the likely side effects and estimated financial impact. Like a multi-disciplinary set up in a hospital, it should reflect some of it’s moving parts in a chat group as well. Patients should reasonably be expected to be guided through a simple workflow; a place where their queries are answered.

That, in simple terms, is the purpose of having a dedicated Telegram group. It is envisaged that patients would find others who have gone through similar experiences, interact with rehabilitation specialists (the medium should allow exchanging large files like videos or multimedia content) and access all old messages about the same thread (through a global search or use of hashtags). These are the broad contours to get the project off the ground and fine tune it as we go along.

Besides, regular updates and events about brain tumours need to be disseminated. A stream of messages in the proper group would become too overwhelming for every participant. Telegram offers a mechanism to copy the link of a particular message in the channel and share it anywhere (each exchanged message has a unique link available for the administrators). This would make it more efficient to share content across the application.

As with any application, users would need time to get used to the user interface. Twitter isn’t intuitive but is most widely used (along with Facebook). Twitter is meant for the immediacy of events, as they unravel. Hence, it becomes difficult (or even overwhelming) for a vast majority of users to get used to it. Like for example, no one subscribes to public lists of patient advocates that I have curated and collected, because most users aren’t aware of how to use Twitter effectively. As a result, their timelines are cluttered forcing them to spend more time. Due to process improvements, I usually skip over my timeline (using Mac desktop version) in less than 15 minutes because everything I need to focus on is there.

I hope that users find Telegram a vital addition to their daily lives.