Likes, dislikes and reposts: The new age of the vascular surgery influencer

The brave new world of social media, with its TikToks and Kar­dashians, has now invaded our once-sane specialty. No, this is not a veiled reference to controversial swim attire events in our past, but rather a totally new phenomenon.

Whether on Twitter, LinkedIn, Instagram, or YouTube, vascular surgeons are posting their “successful” cases like never before. Why the constant need to do this… a cry for validation? Sometimes it appears to be a not-so-subtle show of support for a friendly vendor, as is evidenced by the “clot warriors,” posting dramatic lengths of coagulum in an effort to prove mine is bigger than yours. Could it be that vascular surgeons just don’t feel championed by their own specialty, and they’re in dire need of basic validation, a simple pat on the back? Is there such a void of mentorship in our chosen specialty? Do we need to practice in a stadium full of adoring fans, hanging on to every stitch and stent like the Rolling Stones at Wembley? If I sold tickets to my next tibial bypass, would fans crash the Ticketmaster website like the Swifties?

The psychology of this phenomenon is curious. More than any specialty, vascular surgery is marred by complications. It’s the nature of the patients we treat. We treat very sick patients with difficult problems, and yet only successes are posted. Why not the failures? From our first days in surgery, we discovered that morbidity and mortality (M&M) rounds are where we learn the most valu­able lessons. A sensible surgeon will assess and reassess any complication incurred and apply rigor to all outcomes, even those that are viewed as successful. However, despite these lessons learned through our training and practice, there is still a need to “virtue signal” curated images and scenarios on social media and disregard any possible criticism that may be levied.

Virtue signaling is loosely defined as attempting to show you are a good person, or in this case doctor, through the expression of viewpoints (using angiograms, CT scans, etc.), usually on social media. It’s concerning that as phy­sicians, we carefully curate our best cases on social media, like others post luxurious Italian villas or diligently choreo­graphed Cardi B dance moves. The psychology behind the need to have this external validation from the public, many of whom are unknown, is puzzling. One would suspect that good outcomes and happy patients would suffice for many, but it appears this is not the case. There are concerns about this from many angles. What message does this send to the public? Many will view these posts and assume validity based on the detail of the information provided. It is also concerning that this becomes an example for our trainees, many of whom also follow on social media, that this external validation is required as a means of attaining relevance and satisfaction in their careers. Finally, it is not a huge stretch to foresee the HIPAA violations created by the specificity and detail presented in these cases.

Recently on LinkedIn, a vascular surgeon presented an absolute banality of a case—a cephalic arch recanalization and stenting. The waterfall of accolades was simply bewil­dering! Should it even matter that we all know that this will fail? When I made a comment to that effect and suggested a surgical alternative, I was sent an old article with a small series of cases where patients were treated successfully with stent-grafts. The surgeon also made a somewhat snide com­ment that he only believed in randomized controlled trials, and that this was an endovascular forum. This individual evidently failed to see the irony of his comment, but the absurdity naturally did not escape me. Of course, further interaction was futile. So the question begs, why post a case if it is not to engage in an open discussion about pros and cons? Is it really so basic that the person posting is merely petitioning for some emoticons that reinforce their greatness or dispel their insecurities? A stent-graft deployed in front of an army of fans where none dare to question the decision-making, regardless of the outcome?

It may be somewhat naïve to ex­pect those within vascular surgery to be transparent about their motivations for presenting cases. It would be helpful, though, to know the surgeon’s incentives behind their posts—no different than a disclosure slide in a presentation at a conference. Perhaps, before an intervention video on Twitter, a post should warn that DR. SIMPSON IS POST­ING THIS AWESOME CASE IN THE HOPES THAT YOU WILL CALL HIM AWESOME. Or maybe: DR. CLARK WOULD LIKE TO DECLARE THAT HE HAS ONLY RE­CEIVED RUDIMENTARY ENDOVASCULAR TRAINING BUT PLEASE SMASH THAT LIKE BUTTON!!!!

Should we suggest that fact-checkers evaluate cases post­ed for value and accuracy? In reality, we should be able to police ourselves without resorting to any sort of censuring. Still, one should be concerned about what is posted on social media, a public platform.

It is also crystal clear that the Federal Trade Commission (FTC) has very explicit guidelines on how to manage dis­closures when networking on social media If you have any financial interest with a brand… disclose it! As a surgeon on social media, you are an influencer because posts influence consumers (other physicians, patients). Don’t pretend to hide under the guise of a clinician, particularly when mo­tives are not transparent.

In the time preceding social media, these cases would continue in anonymity unless submitted, peer-reviewed, and published in a journal where they can be consumed by people familiar with the procedures at hand. In the social media era, the very key point of peer review is missing, allowing any charlatan to publish results and claims that may or may not have any academic or physiologic basis. This, again, gets back to motivation and disclosure. Is the incentive to garner social media “likes” in order to further promotion? Job security? Reputation? Financial gains from corporations? By circumventing the peer-review process, this arena has become the Wild Wild West. There are snake oil salespeople everywhere.

The misuse of social media has certainly not gone un­noticed by the state medical boards in the U.S. Recently, a plastic surgeon in Ohio had her license suspended for exploitation of Snapchat and TikTok by airing live videos of her surgeries. This doctor has a popular TikTok account, which, prior to being suspended and then set to private, had 841,600 followers and 14.6 million likes. Her Instagram account, now also set to private, has 123,000 followers. One of her pa­tients was quoted as saying: “I went to her because, I thought, from all of her social media, that she uplifted women. That she helped women em­power themselves. But she didn’t.” Plastic surgery has been plagued by a social media presence that often flirts with unethical standards. This space suffers from a lack of regulation, surveillance, consistent rating scales, user authentication and ethical accountability. People are building entire reputations based on Altmetric Attention Score (#altmetrics), which has, to a great degree, replaced the more traditional academic bibliometrics like h-index. The Altmetric Attention Score is a weighted count of all the online attention for an individual research output. This includes mentions in essentially every public forum, and social network platforms play a particularly important role. With the advent of endovascular techniques, vascular surgery is very analogous to plastics in that the graphics of the procedures make them very “post-” and “like-” worthy.

In 2015, Prestin et al estimated that 70% of adults got their medical information from the internet. Social media, therefore, is an extremely powerful tool. How we engage in that space plays a significant role in defining vascular surgery as a profession and speaks volumes about our character as individuals. Our posting habits and decisions have the power to sway consumers as well as dictate the reputation of our specialty.

Jean Bismuth, MD, is a vascular surgeon at Katy Heart and Vascular Institute in Houston and an associate professor of surgery at Louisiana State University. Jonathan Cardella, MD, is an associate professor of surgery at Yale School of Medicine in New Haven, Connecticut, and program director of Yale’s integrated vascular surgery residency.