E57 Sean Langenfeld On Social Media

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research, and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  01:13

Start off the new year with an episode on a controversial topic: social media. In this episode, we were joined by Dr. Sean Langenfeld. Dr. Langenfeld is a colorectal surgeon at the University of Nebraska and has spent a long time doing research and thinking about social media and surgery. We talked about the concept of professionalism on social media, the infamous “#Medbikini” and online reputation management. Dr. Langenfeld, thank you very much for joining us on Cold Steel today. It’s an absolute pleasure and an honor to have you on. Can you start by just telling us a bit about where you grew up and where you did your training?

Sean Langenfeld  01:53

Sure. Well, I grew up in Omaha, Nebraska. I went to college and medical school at Saint Louis University in St. Louis, did my surgical training at the University of Kansas, which is in Wichita, and then went to Houston, University of Texas in Houston for my colorectal training. So after 15 years of being away, I sort of ran right back home to Omaha as fast as I could.

Chad Ball  02:14

Please excuse my ignorance, but is Omaha where Warren Buffett is?

Sean Langenfeld  02:18

Absolutely, yeah. So he’s made a lot of people in this town very wealthy. So that means there’s been a lot of people to fund the arts and entertainment and all those types of things and sort of drive innovation. It’s a great town.

Ameer Farooq  02:33

Why did you end up going into colorectal surgery initially? If you can share that with our listeners?

Sean Langenfeld  02:40

I think, you know, like a lot of people I sort of evolved into it during training. At first I didn’t know what I wanted to do. I think the surgeries are very cool. Which I’m sure you guys would agree with, you know, as far as the complexity of the laparoscopic and robotic things that we do. I think as a specialty and as a community it’s very evidence based. There’s not as much surgical dogma as I’ve seen so many other specialties. The people I meet have always been fantastic. But you know, I think I knew I wanted to take out cancer for a living. At first i thought I wanted to do thoracic surgery. And then I felt that, it seemed like people were always saying no to the patients in clinic. And, you know, I feel like even the world’s greatest whipple surgeon still kind of has a losing record, if that makes sense. You know, even if the disease is just too aggressive. But the thing about colon cancer and rectal cancer with the quality of your surgeon. The quality of your surgery dictates whether you live or die. And I kind of liked that control over the outcomes, if that makes sense?

Ameer Farooq  03:38

Well, I’m right on board with you. In that front, during my colorectal fellowship in Vancouver. Dr. Ball might have a thing or two to say about whipples. But we won’t go down that particular rabbit hole.

Chad Ball  03:50

What do you mean, we cure everybody? What are you guys talking about?

Sean Langenfeld  03:53

Well I know, I think the complexity of operations is profound. And I actually have a great deal of respect, especially for my own surgical oncology colleagues here in Nebraska. But you just have to have a thick skin because I know you’re dealing with, you know, a very tiny margin. And it’s very respectful, but I kind of liked having, I guess, more wins on my belt. But you’re right, you know, you can make a difference doing about anything in surgery. So it’s just my preference.

Ameer Farooq  04:16

Absolutely. So, Dr. Langenfeld, we really reached out to you to have you come on the podcast, mainly to talk about something that I think everybody thinks about, but I don’t think anyone has really delved into to the same extent that you have, which is social media and how social media impacts surgeons and how surgeons sort of interact with social media. So I wanted to just start off by asking you how you got interested in the topic? Because you were writing papers and doing research on this kind of very, very early on in the sort of the academic interests, sort of the world academic interest in social media in terms of that history. So what interested you in the topic of social media?

Sean Langenfeld  04:59

It’s a fascinating thing; a very uncontrollable beast. And I think that I did get involved kind of early, which led to a lot of opportunities for me professionally. But the way that it started was I was new in practice. And I had a patient, I’d taken out a cancer in him. And he gave me this, you know, this thank you note, and then said, I see from your Facebook page that you have two beautiful daughters, perhaps you’d like to buy them a book, here’s a gift card to Barnes & Noble. And while it certainly was a noble gesture, I was like, “how the heck does he know that I have two daughters, my facebook profile is private”” So I went on there with somebody else’s account and found out, sure enough, there’s two pictures of my daughters on there. And I was kind of spooked out by that level of access, you know, that people had, and to physicians and what I thought I identified, there was sort of an unintentional overlap between people’s personal and professional lives that didn’t used to be there before. So I wanted to kind of find out what the general public could see. And then I just wanted to watch it develop over time, because you can see early in the beginning, you could really identify some trends and how this was going to become a bigger and bigger player in the way patients and physicians interact.

Ameer Farooq  06:10

You wrote a series of really, I think, important papers in sort of social media and surgery. And two of them, I think I’d like to focus on, were kind of back to back papers that looked at the assessment of social media use by first residents, and then you looked at attending surgeons. Can you talk to us about what led you to do those studies and your methods and sort of the results you found?

Sean Langenfeld  06:36

Sure, yeah. So yeah, those are the first two that I wrote. And they were both when I was associate PD for our residency, and they were presented at the APDS annual meetings as a part of that process. But you know, the purpose of the study kind of stemmed from the same thing I talked about before. I wanted to find out how many residents were on Facebook. And then what sort of content was viewed by the general public. At that point, it wasn’t, you know, the level of literacy within social media was not as high, people really felt that what they were saying was just being shoved into a small room. And really, they were, you know, blooming it across the entire internet. And I wanted to use that to educate residents probably in the form of standardized curricula, and just basically show how little privacy they really had and how to avoid common pitfalls. And so basically, once we did that, and we found the results of that we decided to kind of extend that to look at faculty because I thought otherwise, you’re kind of pointing the finger, or wagging the finger. I wanted to look at our own behavior, if that makes sense. But what we did is, you know, going back, I believe this is about 2013. Maybe slightly earlier than that. We went online. And we got IRB approval for all these things. This is all publicly available information. There’s no snooping around here, we just went to websites and got rosters. We use our own Facebook accounts to kind of search these accounts and content and find out only what was viewed by the general public. I didn’t really want to know what they were saying behind closed doors, but just kind of what they said that a patient could stumble upon. What we found was about 12% of residents, and about 5% of faculty had what we consider to be clearly unprofessional behavior. These are things like, you know, HIPAA violations, racist jokes, homophobic jokes, some misogynistic behavior, inappropriate, you know, drug use. People, you know, with references to smoking marijuana and things like that. Things I don’t want a patient to see. Interestingly, among the faculty, we found that men had a complete monopoly on the unprofessional behavior versus within the residents, a little bit more evenly split. But you know, I used these as kind of talking points for years. Those papers kind of sprung me towards talking about the concept of professionalism within social media. And it’s very much a gray zone, how to define professionalism. And so I discussed kind of all these talks with inherent subjectivity that, I know it’s kind of a moving target that can harm people, you know, so all the research and all the talks I gave, were never really meant to police behavior, or tell people what they can or can’t do or weaponize professionalism. It’s just kind of saying, hey, do you know what you’re putting out there? Do you appreciate it’s not truly private? Do you understand the consequences that can occur for missteps, you know, and that was sort of the findings and I guess, the message from those studies.

Chad Ball  09:35

You know, I think that’s very eloquently stated. And I wonder a lot about your comments in terms of the gray of what’s defined as professionalism and unprofessional and of course, you know, there’s been some pretty high profile, a couple of manuscripts that have been walked back a little bit recently. With regard, to define that. And we’ll link those to the podcast. You know, so everyone can have a look at them. But what is your sense of professional and unprofessional beyond some of the really obvious low hanging fruit? Like, if you walk into the political side of things and you support, I don’t know, Joe Biden or Donald Trump, you know, in your most recent election does that, does that become unprofessional? Or, you know, where does that actually land?

Sean Langenfeld  10:24

Well, the thing about that that’s fascinating is, what’s fair and what you’re allowed to say, doesn’t really matter. It’s all the court of public opinion. And so there’s nothing unprofessional, inherently, about supporting a political candidate, but certainly you’re drawing yourself into hot water. So you just have to understand that in advance and know, kind of who you are, who you represent when you do so. If that makes sense. So if somebody is hanging their own shingle out, that’s fine. But if they’re representative of the faculty they work for or institution that they work for, they have to realize that if they made comments online, it’s not going to say, you know, “Sean Langenfeld, blank, blank blank, did this horrible thing online”, it’s gonna say, “Nebraska medicine surgeon did this horrible thing online”, you know? And so my institution is very effective. But the papers you talk about, those are very important because I was kind of pulled into this secondarily. But the concept is, like, #Medbikini was how it started. So I’m happy to talk about this, because this is something I kind of watched it unfold. If I, if my career, or at least my social media life wasn’t in jeopardy it would have been fascinating. But to be honest, it made me very nervous. Because they had this, you know, it was a poorly designed study, from the Journal of Vascular Surgery assessing unprofessional behavior among fellows, and whether it was true or not, because the reality of the matter is perception. But the perception was that they were targeting women, and the LGBTQ+ community. And I have to admit, when I was reading it, I kind of got the same sense. But you know, I don’t know their intention. But there was a huge Twitter outcry. And a worldwide movement. This is all over, you know, it was viral, the paper got retracted. And it was a big deal. The sad discovery that I made though, as I was reading the article was that they kind of cited me as their muse, if that makes sense. And so they said, “well, we used Langenfeld’s paper to define professionalism”. And so, you know, immediately without really doing the research people go well, Langenfeld must have had similar targets. But, you know, I never really targeted these people. If anything, we did the opposite, you know. We were calling out racist behavior, misogynistic behavior, homophobic behavior, we weren’t, you know, reinforcing it. And so, as an example, they go “inappropriate Halloween costumes, you’re saying I can’t wear a bikini for Halloween?” And it’s like, no, people were dressed up in blackface as Halloween costumes, you know what I mean? There was a lot of content derogatory towards women. Misogynistic jokes. And then the other thing is people said, well, you know, they’re snooping around people’s profiles and creating fake accounts to invade people’s privacy. And I have to admit, I didn’t really agree with the public on that, because I don’t know how they design their site. But for us, we just, you can just use regular Facebook profiles and type in the name of a person. And if it’s available to the general public, there’s no privacy there. And there’s no invasion of privacy, especially if we do it with the intent of making people understand what’s viewable. So basically, I was targeted as a result of that. I don’t think people really take the time to research the topic and fact-check, you know, they just sort of get angry. And so what I did was I put a statement out online, you know, cuz I wanted to address this. And say listen, your concerns are valid. All that I ask is that you read my studies. Read my studies, and then decide if I’m truly as horrible as you say I am, because the studies really don’t represent what you’re saying they do. And people were kind of almost intentionally distorting it to make it fit the narrative, which drove me nuts. And so most people kind of took that and agreed with it. You know, keeping in mind that the studies that I’ve done, I’m not trying to brag, but you know, they’ve been cited widely, they’ve been used as a basis for society guidelines and curriculum. So it’s not like this new thing that came out this year. They’ve been around since 2014. You know, but you can’t make everyone happy. And I certainly had some people banging the drum for quite some time, that I was a horrible person, and that my paper should be retracted. And eventually, it just sort of died out, which I think is important for anybody that catches themselves in a similar dilemma: is you have to remember that the attention span of these people when they get really angry and irrational is relatively short. You know what I mean? And so rather than engage with the people that were kind of ignoring the facts and calling me horrible names and fighting with them, I just sort of said my version and then let it go. And I think that was a better way to handle it, to be honest.

Chad Ball  14:52

Yeah, I totally agree. You know, with Ameer and I watching from a distance, it seemed like you handled that very elegantly and we did wonder what was going on, you know,  inside of your brain because it certainly couldn’t have been easy. Now, the other question that comes to mind out of the gate, sort of surrounds insight. In 2020, when you classify or you look at, you know, quote unquote “unprofessional”, you know, social media behavior. And again, you can pick the low hanging fruit if you want, but what percentage of surgeons and trainees do you think actually have insight into the fact that they’re doing that? And I also wonder if it’s changed between your work back in 2012, 2013 and 2020?

Sean Langenfeld  15:39

Oh, I definitely think it’s changed. I think that… I don’t know what the correct word is, maybe like the social media literacy, you know what I mean, of people has gone up dramatically. You know, when I was doing these talks, we were having entire symposiums and we were like, “oh, here’s how you tweet”. And here’s how you create a Facebook account, you know, and all this stuff. I presumably targeted gray hairs who were gonna get into social media. But you know, the reality is people understand it much better now. And they also have kind of made this measured choice, they say, well, I understand that I’ll catch fire for this. But this issue is important, it’s up to me if they want to tweet about it, or support, whatever cause, and I’m fully supportive of that, if that makes sense. And so, I think the insight level has gone up. I also think that social media is such a distorted place. And surgeons are no different than any other consumer, we’re not above anything. And so we’re also maybe not self aware, in that regard. You know, there’s a lot of cannibalism going on where we hate one thing, but then when we’re sort of tested or countered, we sort of become the thing that we hate. And that’s one of the reasons I’ll be honest with you guys. Even though I clearly spent a lot of time on social media, I have sort of a love/hate relationship with it, because it reduces people so much. It just reduces the world to black and white. You know, you’re either with somebody or against them. If you have a disagreement, you’re a horrible person. It’s a really very polarizing environment, this place. And, you know, the concept of like, defining a group by the worst member of the group, or defining a person by the worst action that they’ve ever done, rather than by whatever their body of work is, over time, is a really damaging way to go about life. And, you know, I think that something that we could do, and I’m getting on a little bit on the soapbox here, so probably just cut me off. But you know, if we would just start giving each other the benefit of the doubt, in social media, it would be a much better place to hang out, as professionals and in our own personal lives.

Ameer Farooq  17:42

Yeah, someone who uses Twitter a lot, I totally agree with you. And it, you know, what we’re experiencing as physicians, I think, on social media is something that is maybe a unique facet, but part of a larger I think discussion about social media that’s going on throughout our society and our culture. And it is sobering to think about what it might be doing to the way that we we interact with each other. I wanted to just go back for a second to that whole concept of professionalism. I mean, there’s so much to unpack with you. And to talk with you about. But one of the things that’s always kind of struck me is that, you know, somehow people feel that suddenly now is the first time that people are trying to police or at least have some sort of insight or self regulation in terms of their public perception. But you know, if you were a surgeon in a small town, no matter what time period you were from, you know, before Facebook or Twitter or any of these social media platforms. There was a sense, and correct me if I’m wrong, but I think there still was a sense that like, you know, if everybody can recognize you at the grocery store, what you do from a public persona perspective does matter. And I wonder, do you think that somehow social media is different? I mean, clearly, it is different in terms of the reach. But do you think somehow there’s this sort of dual doublespeak, or dual think when it comes to thinking about how we regulate our professional identities on social media versus, you know, what people had to do if they were in a small town where everyone knew them with their public persona?

Sean Langenfeld  19:30

Well, the thing about that type of environment is it was proportional. You know, you knew your audience, you knew who you would see at the grocery store who would see you doing whatever you plan to do that day. The problem with the internet is it’s very unpredictable. And so you could go online and say something stupid, and nobody knows, right? Let’s say you got you know, 20 followers or something. Or that day, it just turns out that the social media guys were exceptionally hungry. There was nothing else outraging them currently, and they capture that. And then it becomes viral. And the reaction is very disproportionate and unpredictable. And that’s just a very different beast than what people dealt with in the past. You know what I mean? A similar concept is, you know, the permanence of it. And so, in the old days, if you said something stupid, and I think we, all three of us have heard our old bosses say some really stupid things, at least when I was in training, things I would never repeat. You know, maybe it was the era, but the reality is they said it and it was over. And maybe I could recall it, maybe I couldn’t. But social media has permanence. You know, you put something out there and it’s there forever. And so let’s say in 2012, I said something stupid. And then 2020, I get into a lawsuit. Let’s just say I’m getting sued. The first thing the lawyers are gonna do is scour social media, and they’re gonna find anything that can incriminate me, or make me look like a horrible person or make me look like an alcoholic. You know, and so a perfect example of that – I think about that, because when I was in training, I was told you should never really be, you know, pictured. Don’t take a picture of you holding a beer is what they used to say. For the newspaper, for whatever. The problem with it now is, if you do it now, the example I gave is there’s this residency, they did this thing called Sunday Funday, where they all went to the brewery, and it was all for charity – it was this great idea. And it was helping wellness, and everybody’s in a good mood. They’re all smiling and holding beers and drinking together. The problem is, we know all these people had surgeries on Monday or the next day. If they have a bad outcome, all this stuff is dated and timestamped. So the lawyer will be like, well I see that, you know, from your Facebook profile, you had a few drinks the night before, Dr. Langenfeld, how’d you feel that morning? And this is not fantasy this has happened. In the document on multiple occasions this is what the lawyers do, and what reporters do. And so it’s just a very different environment, because of how unpredictable and how powerful social media is, and how quickly things can disseminate. The rules aren’t as clearly understood. And so to me, that is a big difference. But no, you’re not wrong, people have always had to manage their public profile. If anything, we almost have more control over it. Now. It’s almost like the, you know, Instagram filters, you can make your life look beautiful online compared to real life by picking and choosing what you share and all these different things. And so if anything, it’s allowing the more manipulative component of our groups to have an edge, but it’s very different than it was in the past because of that power.

Ameer Farooq  22:37

Yeah, I completely agree with you. But, you know, I do want to push back a little bit on the idea that we’re more socially literate, or social media literate, if I can use your term. Because my sense is that more than ever, people sort of justify anything that they put online on social media as sort of like, well, I’m a human being, and I deserve to be treated as such. And I’m not perfect. And, you know, I think that was a big thing that kind of came out during that whole, #Medbikini controversy is that people said, “well, you know, I should just be treated as a human being, as who I am”. Should we expect physicians and surgeons to maintain a certain, you know, standard or a certain level of professionalism, more than other people? I guess, in some ways, that’s what this question fundamentally comes down to?

Sean Langenfeld  23:31

I think I understand you’re saying. I would say, just to answer, you’re not incorrect. Like that makes sense to me. I think that there’s a lot of positive things that come out of the people, to stand up and say that. Because they’re redefining “professional”. They’re kind of saying, you know, the conventional image of what’s professional is not modern, and it’s probably skewed towards, you know, white males, and so redefining professionalism is a good idea, right. But I also agree with you that you can’t just slap that tag on everything and say you’re allowed to act however you want, people still have to be, you know, there’s some common sense of professionalism that has to exist when you are a public figure, you know? If you are on your own, and you’ve got a shingle out, this is Dr. Langenfeld. And I’m just sort of representing myself that I can do whatever I want, and I can be as polarizing as I want, etc. But if I have entered an agreement with the university or I’m, you know, there’s an attending surgeon who’s agreed to mentor me and allow me to see his patients who came to see him and I’m just constantly making his patients feel uncomfortable because it’s important to me for my self expression, and I can’t think of a great example of what that looks like but you know, it could be anything that you think is going to upset your patient population. You say it’s about me, you have to accommodate me and you have to make me feel good. It’s not about you, it’s about the patient, you know, so for me, I definitely think the focus should still be on you know, patient comfort and you know, representing your institution well. Because when you screw up, it’s not just you going down, there’s a lot of collateral damage. And I think that as people mature, they see that. And I think that those messages are not black and white or opposite of each other. I think that’s the whole point of social media. It makes it sound like, if I say that, it means I clearly don’t want women to wear bikinis or something. And I’m like, no, that’s not the same thing. There’s nuance to it.

Ameer Farooq  25:26

Yeah, that nuance. That’s the real tricky part of what social media is. Just, it’s so hard to convey any nuance in, you know, a 280 character tweet. And on those lines, you know, I know you’re on Twitter, and you’re very actively involved in the ASCRS Facebook group?

Sean Langenfeld  25:48

Yes, yeah.

Ameer Farooq  25:49

Yeah. How do you treat those different social media platforms? Do you kind of think of them differently? Let’s say Twitter or Facebook? I don’t know if you’re on Reddit, or use Tik Tok or not. But do you think of those social media platforms differently? Or the same? And how does kind of the platform interact with the way you behave on it?

Sean Langenfeld  26:10

I think there’s there’s a lot of different, I guess, rules to these platforms. They’re different from each other. But the reality is privacy is equally unguaranteed or not guaranteed across all of them. So you know, I think the difference is the audience. And so if you’re in a closed Facebook group, and I do moderate, and I did create that ASCRS Facebook group, it’s great for in depth discussion. Among a selected group of professionals with common interests and common skill sets, it’s a great place to discuss difficult cases, a great place to learn new surgical techniques and learning from somebody that you trust rather than whoever just happens to have a YouTube account, right? So those close Facebook groups are fantastic for that. And the audience is other professionals. With Twitter, it’s great if you want to disseminate information in a big indiscriminate manner, to reach a big audience, a big wide audience, but it’s also a great place to get information that you didn’t know you needed, you know what I mean? So I can go on there. And I didn’t know there was a new article about antibiotics and appendicitis and the New England Journal of Medicine until I found out yesterday on Twitter, you know, and so the doctor from the study that I’d just somehow had missed. And so it’s a great way to find things you weren’t looking for, it’s a great way to follow, you know, podiums and abstracts. And, of course, I go there to argue with strangers a bunch, which I don’t know why I keep doing it. But you know, the reality is, that’s great. But some of the other platforms that are kind of, like, specific for physicians, you know? Like, the example that I thought of was the ACS communities, we sort of created for us to have these conversation. There’s a version of that for ACSRS, there’s doximity. The problem with those different platforms, which are designed for our use, is that there has to be an intentional choice to go there. You know what I mean? Yeah, I have to like, find my login and password, go to doximity. And decided what I want to look at. And the difference is with Facebook and Twitter is that utilization is already so high. There’s such a high percentage of surgeons already on there, looking at whatever, you know, their families, baby pictures or, you know, sports. And then they stumble upon a surgical conversation. And so utilization is gonna remain very high for those types of platforms, while some of these other intentional platforms are kind of ghost towns right now, to be honest. And so the rules are different. But I guess the one kind of universal truth is that you should definitely not assume that there’s any significant privacy across any of them, because they were not designed for professional use, you know what I mean? And so, when we use it that way, there’s going to be flaws.

Ameer Farooq  28:47

I do think from observing kind of how people behave on Twitter versus Facebook, like what you get out of those platforms really is affected by the actual limitations of the platform. Like the fact that Twitter puts limits on characters. And the way that tweets get amplified with retweets and likes, means that it kind of forces you to become a bit polarizing or inflammatory in the way that you say things. And so I wonder if you know, you talked about some of the pros and cons of using different platforms. Is there a platform that you like better? Like, do you enjoy being on Twitter more than Facebook? Or do you just use them, you know, for very specific, but different things?

Sean Langenfeld  29:35

If I want to know about something before anybody else, Twitter’s the best. That’s news. I can search the name of, you know, if I want to know the score of a football game, there’s just so many different things that Twitter is fantastic for as far as news. And you know, but if I’m looking for accuracy, I don’t know about that. It’s not a very accurate place. I think that I enjoy my discussions in the closed Facebook groups and whatever platform houses that concept in the future as we evolve over time, because that discussion is essentially like a virtual surgeon’s lounge, you know what I mean? For me, it’s great. I have the senior partner named John Thompson, who’s just a fantastic guy,who from day one of my academic careers has directed me in the correct direction. But if somebody is practicing in the middle of nowhere, then they’re in solo practice, and they don’t have that. So when they have a tough case, to be able to bounce it off people that they trust, is fantastic. You do the same thing on Twitter: number one, the risk of a HIPAA violation goes up dramatically. Number two, there’s some dummy that just gives you the worst advice ever. And he’s got, you know, 10,000 followers, versus if you’re in these closed groups, you can really have a nuanced conversation. And so the way I termed it in the past was e-mentorship. But I think it’s fantastic. I mean, you’ll have Eric Weiss or Steve Wexner, Rick Billingham, all these people are just giants in colorectal surgery, giving advice, real time advice, quick turnaround advice on big cases, and share their experiences, you know, with the younger audience. And so to me, I enjoy the closed Facebook groups the most. But Twitter has a completely unique value to me, as I’m still on there every day. I can’t help it. But I honestly think social media is an addiction. I’m clearly addicted. And so you know, I have to give that disclaimer.

Chad Ball  31:30

It’s interesting that you bring up that word addiction, because it’s certainly possible. There’s a relatively popular recent movie on Netflix that I’m sure we’ve all seen that tries to outline that. It was really interesting to me watching that movie, you know, as the software developers and the platform developers and where they were trying to come from, like the guy that said, “Well, we want to make the world a more positive, fun place. So we developed the likes and the dislikes. We didn’t mean it in terms of, you know, how its evolved and what that really means”. But you’re right. I don’t know if you have kids, or, you know, Ameer and I do and I don’t know when the the safe time to introduce this to them is, or how to manage that or what…

Sean Langenfeld  32:16

I can tell you it’s too early, because I learned what’s too early for them. But I don’t know what the correct age is.

Chad Ball  32:23

Yeah, it’s tough, isn’t it? You know, I’m curious, you’ve sort of sprinkled your comments and your advice around some of the pitfalls that you see, whether they’re defined as unprofessional, or whether they’re not. But what are the most common issues, the pitfalls that you see, just in general in the surgical community? And I’m also curious to get your advice. How do you interact with, or how do you provide advice to maybe one of your colleagues or one of your partners or one of your buds that is in the surgical world that maybe is bordering on trouble?

Sean Langenfeld  33:01

That’s an interesting… you know, I guess, I almost want to answer the second question first, because I know what you mean by that. You know, like, you stumble upon a person that you care about doing something that you see is potentially dangerous. I see that all the time. And I will admit that I occasionally reach out to people and go, “hey, just so you know, that could be interpreted incorrectly, here’s how it would be interpreted”. And, you know, maybe you want to change it or modify it, keeping in mind that once something’s out there, it’s out there. So you’re not, you know what I mean? I am guilty of that, but more from just helping people navigate away from rookie mistakes. It’s usually the early adopter, you know, the people that are learning it. What I’m not in the habit of doing is policing content, you know? I don’t feel like it’s my job to kind of tell them, “You can’t say this”, or “you should say this”, you know? All I want them to know is like, do you know who can see this? Do you understand how it could be misinterpreted? Or how it could be interpreted negatively? And do you understand what consequences can occur from that? And then if they get that and they still want to do it, then I don’t intervene. But I will say that I do that a decent amount. It’s hard, you know, sometimes there’s like a really great message out there, and you read it and you’re like, Well, you know, this is really powerful and uplifting, but you’re clearly violating HIPAA. So you’re like, this is a bad idea, because, you know, there’s plenty of stories of doctors getting fired for tweeting stuff out and Facebook and stuff out that violates HIPAA. So no, that’s a tough tightrope to walk. But as far as the common pitfalls, there’s different categories. They’re like, some are more of the philosophical pitfalls that I have to admit I get soapboxy on and then the more self damaging ones. And so, you know, I think people forget their audience pretty often. So they’ll share something personal or humorous. They think they’re interacting with a small friend network similar to Facebook, but in the real world, everybody can see it. That’s a super common pitfall. And when you do that, you know, you’ve provided this untarnished access to your personal life. And not everybody gets humor. I mean people on Twitter have the worst sense of humor, like especially sarcasm, which does not translate, you know, and so you gotta be really careful with that. I think people focus on fairness too much. They forget that social media is kind of inherently an unfair place in that they’re the subject of a court of public opinion. And things are going to be misinterpreted, they’re not gonna have background or nuance, the reactions are gonna be disproportionate. If they focus on fairness, they’re gonna make themselves miserable, because, you know, they have to have kind of a thick skin. And they have to appreciate this sort of an unfair environment. And then, more soapboxy, you know, I think one of the big pitfalls of social media is virtue signaling, you know? People go on there, they want you to think they’re a great person, they make it seem like they’re really supporting a cause. But are they truly working towards actual change? You know, everybody’s quick to demonstrate the behavior they think is desirable, similar to what you would see in a perfectly constructed Instagram or Facebook account, but it’s unclear how hard they’re truly working behind the scenes to improve things like diversity, equity inclusion. That’s the biggest topic. There’s a million topics that are similar, that I almost wonder if they’re disingenuous a lot of times, if that makes sense. You know?

Chad Ball  36:35

Yeah, it really does.

Sean Langenfeld  36:36

Um, one thing that I think is important to keep in mind is that we’re all kind of subjects and at the mercy of this beast, and so, another pitfall that I hate is cannibalism. You know, people can be righteous about their agendas, but then they’re quick to adopt the same behavior, when they become outraged. You know, one example is, even when somebody says something horrible online, I cannot stand it when the way that doctors punish that person is by going and leaving fake negative reviews on doctor rating websites, because it’s so cannibalistic. Because we all obsess over our own reviews, you know. And so that type of behavior just drives me nuts. But those are common pitfalls I think. A lot of the early stuff like, “oops, I tweeted something I didn’t mean to”, that’s just not happening with the current literacy being higher than it was. People are all very aware, like I used to literally get invited, you know… if I got invited to give a rectal cancer talk, I would be shocked. I’m much more likely to be asked to give a talk, you know, for visiting professorship on social media. And I would give them all these shocking examples of people getting in trouble for bad online behavior. And they didn’t believe it. “Oh it’s just a tweet, what’s the big deal”, or “it’s just a post”, but now I think people are, because so many celebrities, and so many physicians as well have gotten in trouble for bad behavior. I think that that’s no longer shocking to people, you know, and I think they understand that that’s something that can happen.

Chad Ball  38:05

Yeah, I think that’s a beautiful summary. And it’s, you know, words to live by, and words to think about. And I think at the end of the day, it takes me back to what you said earlier, which was the concept of benefit of doubt. You know, that’s not only a good social media concept, it’s a good concept in life. But by no means are you guaranteed that or even frequently to receive that by the greater collective. I think you’re right, that’s important to keep that filter up. Because you know what could come your way.

Ameer Farooq  38:34

You know a slightly related, but different topic is the way that I think research has been impacted by social media. And obviously, you’ve been very heavily involved in ASCRS and DCR. Obviously, you know, that many journals tweet out visual abstracts, and, you know, really are trying to spark a lot of online discussion about their publications. How do you think that has changed the way that we consume and understand research?

Sean Langenfeld  39:05

Well, I think it’s revolutionized it for sure. Again I did spend three years as the Social Media Editor for the Journal of Surgical Education. So I have made so many, you know, visual abstracts in my time just watching that concept evolve, it’s certainly become more sophisticated, more useful than it was in the beginning, where it was just, you know, a couple of funny pictures that we found on the internet. But I think that research in social media is kind of a double edged sword. You know, on one hand, we’re exposed to way more literature, way more data than we ever were before. And it’s done in a manner that’s very distilled and very digestible. You’ll give me the take home points, you know, and I think that that’s wonderful, if you can trust the resource, you know, and so I love that component of it. We’ve also become very lazy because, you know, we read liver conclusions and we retweet it but I don’t know how many people are going in, downloading the PDF and reading the method section. You know what I mean? And that’s a very big, you know, important component of review that we were all taught to do in med school that we’re kind of abandoning. I mean, the perfect example is people will send out the wrong link to an article, it’ll just be a mistake. And it’ll still get retweeted like 20 times, like, please, people are clearly are not clicking on the link, you know. Accuracy is not guaranteed. There’s no peer review, you know. I don’t want to pick on Jenny McCarthy, but she’s got like 1.4 million followers on Twitter and in all for opinions about, you know, vaccines and autism have a much bigger audience than mine, you know? Kim Kardashian has got 50 million followers, right? And so there’s this disproportionately loud voice that kind of outweighs the pure, the true expert, you know, opinion. But the goods far outweigh the bads. I think there’s a lot of opportunity for collaboration. I think that essentially what you described, you know, is a perfect way, you know, because like, if I can’t pay to fly to San Diego to go to the ACRS, I can capture it from home now. And that is something I could never do before. And so people can stay up to date a lot easier than they used to. And that’s certainly a great thing. And then obviously, people can collaborate. There’s tons of people that just met through social media, and that has led to research collaborations internationally. And that’s something that never used to happen before.

Ameer Farooq  41:31

You know, lately Twitter actually introduced this new function where…before you could retweet something… I don’t know if it always works. Like I found when I’ve tried to retweet things, sometimes, this happens. I get this message. And sometimes I don’t. But sometimes you get this message that says, like, you need to read this or consider reading this tweet before you retweet it out or something like that. Just recently. Do you think little tweaks like that to that platform are gonna make a difference? Do you think you know….I mean, most people just spent the whole time complaining about the change in the format to the way that retweets are done now. But I wonder if you see any ways going forward, to actually improve that sort of aspect of things, where people are just retweeting things, or talking about things without actually having read the papers or actually done any critical analysis?

Sean Langenfeld  42:25

I think certainly shifting the focus helps. Because I mean, we were very focused on like, impressions. You know, when we first started following hashtags for this D, national meetings, or company impressions we got, but the impressions are worthless, right? It’s kind of like how good is the content? How reliable is the content? And so if you can educate people, and assume social media is going to be a component of surgical education moving forward, and educate them during med school about how to critically evaluate these things, it’s gonna make a big difference. Because once they realize the percent chance something is inaccurate versus the chance that something is accurate, it’s changes the whole game. You know what I mean? I can’t remember the number. I think I can find it on my computer. I’m sitting here talking to you guys. But the sheer number of links for Twitter that are bots would blow your mind. Let me see if I could find the data here. It only takes me a second if I do it correctly. 80% of all tweets from American adults come from the top 10% of tweeters, so the average user tweets two times a month, the top 10% tweet 138 times a month, right. And then 66% have tweeted links. So all these news and politics and science. 66% of tweeted links are made by suspected bots. And so it’s just so inherently inaccurate. If you can train them to be skeptical, then that skepticism that served us well, part of social media will continue to serve us well in the new era.

Chad Ball  43:51

Wow, that’s such good advice. Honestly, it’s something to consider moving forward probably forever. We had an interesting podcast recently with an Executive Director of sort of the General Surgery Society, across the country in Canada, very much like the American College of Surgeons, or our version of it. And she was fantastic. And she talked about the incredible change that we’ve seen with COVID with regard to meeting construction, and the reality, at least in her view, is that, that entire industry would move at very least to hybrid meetings forever. And it echoes what you said, you know, if you can’t travel to a meeting, you can probably get so much of that content in the future, from wherever you’re working. How has social media been changed by this rapid past nine or ten months of COVID? Have you seen anything that is particularly relevant to the surgical side of things?

Sean Langenfeld  44:47

That’s a good question. I think that the activity overall has gone up dramatically. I just, I mean, and I don’t have any science to prove that but certainly people are more interactive online. Because they have the time. That sounds horrible to say, but I think that it’s going to be the job of social media in the future to promote these meetings in a much more meaningful manner than it used to be. In the past just kind of say, oh, today Dr. Johnson is talking about this. But now you got to bring home the salient points, drive them to the correct link, so that they can actually watch it and get the content. The first society I think to be successful with that was the ACS, the American College of Surgeons. Their meeting that they just had, a couple months ago, where, their interactive platform was so sophisticated compared to what I’ve seen in the past that I just thought to myself, this is definitely… it’s not social media, but it’s social media’s job to navigate people to the correct place, you know? And I think that that has become a new, essential thing for us. And so we’ll see what it looks like. I don’t think the in person meetings are going away. I think that if you looked at the impressions and the engagement in that meeting, the biggest meeting we have for surgery in the United States every year, people were super engaged for a couple days, and it just sort of tapered off because they realized, oh, I can watch this anytime. So I don’t have to do that now. And then guaranteed most of them did not end up watching the videos they were supposed to. And then the other thing is, you don’t have a captive audience. I wasn’t in San Francisco, I believe that’s where we were supposed to be now I can’t remember. But as a result, I had cases and so I don’t have the ability to spend all day listening to meetings. I’m certainly not going to take days off to do it. So I’m not traveling, you know, and so the lack of a captive audience, the lack of engagements can be a real issue. And then I don’t know about you guys, but I mean, how much time do you spend in the actual lecture hall? And how much time do you spend in meetings or making connections and networking? There’s such a social component to these national meetings. It’s so cathartic for people that are working super hard and I just can’t imagine that can be duplicated virtually. But we’ll see. Because, you know, who knows? Who knows what the future holds. But certainly the hybrid concept’s not going away. And I’m glad it’s not, because it’s just going to make our meetings more sophisticated.

Chad Ball  47:18

Yeah more sophisticated, more engaged. I totally agree. Sean, the last thing we wanted to talk to you about is the a concept of online reputation management. And I know you had said that this is a huge topic and worthy of a podcast in itself. But for the listeners, maybe that don’t know about it, can you frame that concept and chat about it a little bit?

Sean Langenfeld  47:36

Yeah, no, I can. I think it’s super important. So that was sort of the natural evolution of me looking at this stuff, because I realized social media is great for people who interact with each other. But you know, how do patients interact with doctors and societies in their hospitals. And so when I think of reputation management, I think of basically, you know, patients are going online to search health related topics, and they’re googling you. And so we kind of know what to see when they get there. And we kind of need to be able to manipulate it to make sure they’re getting accurate information, because of how inaccurate everything is. So the first thing you think about is physician rating websites, and I can’t speak to Canada. But in the United States, there’s just an innumerable number of these vitals, health grades, RateMDS.com, where patients can go to rate their doctor and rate their experience. And the utilization of this is very high for patients. In the old days, they got referred by their primary doctor, somebody the doc trusted, and that’s how they found patients. But now it’s a consumer driven market. So they’re going online, they’re researching the doctor, and that’s how they’re choosing. And to be honest, it’s big business. The problem with these websites is they’re very inaccurate. It’s impossible to opt out. So you can’t go on there and go, “I just don’t want to be on your website”. Because they don’t do it for you. And they’re much more negative than what real life is like. And so there’s a sample bias there. And so I think that the reality is for online reputation management, it’s sort of the doctors obligation to kind of go on there and find out what people can see and how they can drive people in the correct direction. And so, I mean, without it, like I said, it’s a big talk. But you know, Google: old research shows that 91% of people on Google don’t go past page one. And 50% don’t even go past the first day results on page one. So you don’t have to get rid of bad content. You just have to elevate good content. And by doing that, you’re sort of driving these third party rating websites and driving negative information further down the search and in between the patients and in their Google search. And so what that means to a practicing surgeon is you know, talking to website designers for institution and asking if they have algorithms to make sure that when you Google Sean Langenfeld, the Nebraska Medicine’s websites is the first thing that pops up. If they tell you they don’t have the algorithms you need to get new website designers because they absolutely do have those algorithms, and they’re effective. And then, you know, making accounts on social media, Research Gate, Doximity, Twitter, that usually fills up the top of your search. And that certainly kind of, we talked about, you know, low hanging fruit or whatever. And that’s an example of that. But the more, I guess the more sustainable solution, which I think a lot of people in the United States have adopted, is the concept of using your own institutional website to publish the ratings that patients are giving you, via Press Ganey scores and electronic questionnaires. It sounds intimidating at first, but what you find out pretty quick is that those scores are invariably higher than what you find on third party websites. And they’re more representative of your actual patient population. Because each patient gets to vote once and they’re a verified patient. And so we do that at the University of Nebraska and you know, people listening the podcast, feel free to Google me, just don’t leave anything negative, you know? Positive feedback only. But, you know, on there, not only are the ratings more positive, they’re also more representative. And so, if you do get a negative rating, which I’ve gotten before, you take it to heart, you know? So I have mostly positive reviews, but if you go back far enough, you’ll see that one thing that I’ve gotten dinged with intermittently over the years is patients feel that I rushed them. They feel rushed in the clinic, and I see sometimes 20 to 25 people in an afternoon. And I understand that. And it’s real. And so I’ve worked really hard over several years trying to actually improve their experience, so they don’t feel as rushed. That they got all their questions answered. And I think that’s really helped quite a bit, you know? And the benefit of doing all this is, depending on your practice environment, you know, some people go, you know, one thing, one problem we had locally was that our gastroenterologist would do some transitions where they were kind of understaffed, and they weren’t scoping. And so they’re not scoping, then they’re not finding colon cancers, right? And diverticulitis. And so as a result, a lot of people around me kind of had a slump, but my clinic stayed full. And I think it’s because I had a pretty strong online reputation. And people were finding me through Google. And so it kind of makes you slump-proof. And so I think that the concept, like you said, it’s an hour long talk, but certainly there’s some places people can go for more information. And just understanding that it’s a priority is the first step. If that makes sense.

Ameer Farooq  52:22

The thing I really like about the way you framed that, is that you actually took seriously some of the comments that you saw as recurring. Because I think a lot of people just say, “oh, well, you know, those are online ratings”. They don’t hold any value or any merit. But you actually like took those comments and ratings to heart, like do you think there is some value and some actual positive or constructive things that you can actually glean from googling yourself and seeing what people have have commented or written about you?

Sean Langenfeld  52:56

Yeah, it’s so tough. I mean, have you guys Googled yourselves before? I don’t know. I’ve done it. I do it periodically, it sounds like narcissism, but I do it because I want…you know, I think it’s self preservation.

Ameer Farooq  53:05

You can’t help it.

Sean Langenfeld  53:07

But if you google yourself, especially if you have a relatively unique name, I mean, you have to have thick skin, because you’re gonna find negative stuff on there. I mean, that’s the reality. If you’re seeing 40 to 50 patients a week, not everybody’s happy, and they love having this power getting back at you. And they can do it a million times. They can leave 10 bad ratings if they want, you know, but yeah, there’s value in it. Man, I think that, you know, if the patient had negative experience, then you probably have something you could improve upon. The problem with the third party websites is it’s sort of…it’s unilateral. They can sit there and rate you 100 times negatively. It’s anonymous. You can’t respond. Even if you think you know who it is. If you respond, you could end up violating HIPAA. Right? And it’s huge sample error. And so I just think that there’s so many flaws in that, that the flaws far outweigh the rewards. But if you can actually have a trustworthy system for reviews, I think that is all about, first of all, it’s about patient experience, improving the patient experience. And second of all, it’s about improvement, self improvement. Because you can learn a lot from that. I certainly realized I was moving too quick, you know. And you know, just something along the lines but, it stings though? First time you read, like,” the doctor just always seems like he’s in a hurry”, you know, it hurts because you’re like, “no, I mean, I feel like I do so well”, but the reality is of how I’m perceived, or obviously myself is not how the patient sees it. And so it’s super valuable information. Especially now that we’re kind of looking at all these patient reported outcomes. Those are becoming a much bigger component of what we find to be important.

Ameer Farooq  54:41

Dr. Langenfeld, it’s been an absolute pleasure to have you on the podcast, and I’m sure Dr. Ball and I could sit and talk to you in for another hour. There’s so many other things that we could talk to you about. In closing, one of the questions that we always ask all of our guests, is if you could go back in time, especially now, having seen maybe the unexpected ways your career has gone. If you could go back in time and give yourself advice as a trainee, what would that advice be?

Sean Langenfeld  55:12

Well, you put down the protein shakes, because it’s all gonna turn to fat after your kids are born.That’s the thing I would have told myself. I think that one thing that I learned is that there’s no shortcuts. And that hard work pays off, if that makes sense. And so I think that realizing that everybody around you is talented, and everybody around you has gifts, and if you really want to separate yourself that the only secret is hard work. I think I figured that out early on, but confirmed it over time. And then there was a, let’s a quote from Charles de Gaulle, and I’m probably misquoting this, so I apologize if I am, but he basically said, like, “the cemeteries are filled with indispensable men”. You know, and certainly, that’s a dated, sexist way of putting it, but the point being is like, you just think, oh, if I go home, this place is gonna fall apart, you know? And no, I can go home and spend some time with my kids. And, you know, I’m not that irreplaceable, you know, and I shouldn’t treat the job like it is that, you know what I mean? And so I think that that was something. I mean, I’m only nine years into practice now. So I’m still very early on in my career, but I’m already regretting some of the time I’ve spent in the office after hours just doing academic work. Because my CV looks great, but, uh, you know, I probably could have spent more time with the kiddos. And thankfully, they’re still young enough where I can make it up to them. But the reality is that it just becomes progressively more evident over time: that work is not everything.

Ameer Farooq  57:01

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com, or connect with us on Twitter @CanJSurg. Thanks again.