Flip it

Regina Holliday's painting for the Families USA conferenceFamilies USA invited me to talk this morning about the intersection of health care, social media, and digital strategy, along with Regina Holliday and Larry Swiader.

I decided to flip the presentation and start the conversation a week in advance, on Twitter, and post my slides publicly. If you’re not familiar with the idea of flip teaching, here’s the Wikipedia page. Essentially, the person formerly known as the teacher becomes a convener/expert guide and the people formerly known as the students become peer educators. In health care, there is growing interest in flipping the clinic — providing information ahead of time to patients and caregivers so they can prepare, letting them help set the agenda of a doctor’s appointment, etc.

Here’s where it gets a little meta, even a little sneaky. My job is to do excellent research and then, equally important, get the Pew Research Center’s data into the public conversation. By flipping the presentation, I reached many more people than will be in the room today, listening to me talk in person. I also kind of tricked my friends on Twitter into doing a big portion of my work for me — finding examples of social media use in health care. But I don’t think they mind. A lot of people thanked me for letting them know that Pew Research has new data on the demographics of social media platforms. And my slides have already been viewed over 1,200 times on Slideshare. Our ideas are spreading faster than any of us could travel.

So: what do you think? What else can we flip?

26 thoughts on “Flip it

  1. Susannah, what a great idea: flipping the presentation! Love it!

    How about also “flipping the clinical encounter”? Meaning that the patient send in his/her questions ahead of the appointment thus enabling the doctor to make sure he/she knows the answers and also have time to do some in-depth searches if needed.

    • Definitely! Here in the U.S. the Robert Wood Johnson Foundation is collecting ideas for what they call “flip the clinic” — and a lot of folks are already doing it, like Wendy Sue Swanson, aka @seattlemamadoc, who blogs about current health events and questions she gets from her patients & their families.

      I’m now back from this morning’s conference panel, which was wonderful. See the conversation on Twitter: #HA2014.

    • Sara, in case you missed it over on e-patients.net, Nick Dawson wrote about how he used Evernote to flip his last physical:


      Original post, with more comments: http://www.nickdawson.net/healthcare/evernoteemr/

      He also describes having to be a “data mule” between two clinicians who both use Epic, an electronic medical record system, and MyChart, the patient portal. Since the two systems don’t connect (!!) Nick was asked to print out and then fax his test results (!!!!) from one clinic to the other. Flipping the clinic becomes pretty difficult is everything is nailed to the floor, doesn’t it?

      Yesterday’s panel was moderated by Carla Uriona of Families USA who related a joke in her opening remarks.

      When she was describing our topic (the intersection of health care, social media, and digital strategy) in a planning meeting, someone joked that it must mean making the transition between mimeograph and fax.

      It got a big laugh, but of course there is an undercurrent — a nervousness or insecurity among older adults who may feel left behind by the transition to social media as a major communications channel, resignation or even fatalism among clinicians who are stuck with fax machines and EMRs that can’t connect, a sense of frustration on the part of policymakers who are trying to help drag health care into this century… That was all present in that one joke and that laugh, I think.

      I hope that Regina, Larry, and I were able to assuage people’s fears, give some clinicians hope, and let policymakers see that change could happen, even if it will happen first outside the clinical encounter.

      • No, not mine — but I love it, too! I think Ninjas for Health must have had it on hand. Grateful for all the tweets and this Storify.

        • As too-often happens with Storify, the Read Next Page link at bottom of the first page just spins and spins and spins. Lovely idea, that platform, but rottely un-rugged sometimes!

          I tweeted to them hours ago about it – no answer. I want my tweet stream:)

  2. It was a great panel, Susannah.

    Your point on flipping the presentation was a good way to open up the conversation with a health advocacy audience that spanned the spectrum of those engaged in social media and the spectrum of attitudes and perceived capacity to engage. I say, “perceived” because social media and technology (as you correctly point) can cause anxiety and consternation for folks who feel like they’re missing out but feel too overwhelmed to engage.

    As I mentioned in our discussion on Saturday, it’s important for all of us to continue to help demystify the digital space and underscore the fact that we’re all communicators–social media simply allows us to keep doing what we’re already doing, and to promote the content that we’re already creating. But more importantly, social media provides a way to democratize the conversation–something immensely critical to the health care experience, one where patients have been traditionally left out, or in the dark and doctors alone have had the power of data and information.

    Your approach to your presentation–“flipping” the conversation to your followers, is another form of that democratization that social media provides us. It’s a way of crowd sourcing knowledge and opening up the conversation by having the participants drive experience. So the theme of “flipping,” in a meta sort of way, applies quite aptly to flipping the creation of a presentation, flipping the patient-doctor relationship and approach, and flipping the power dynamic of traditional communications to a more participatory approach that social media affords us. Managed well, these are all good things that allow us to ensure that social media contributes to inclusion and not exclusion.

    • Thank you! Events like this one spoil me for other conferences — something special started happening from the moment I got the invitation and we began talking about how best to serve the people who would be attending.

      I *love* your point about democratization of information at all levels and flipping all the power dynamics.

      Another way that I’ve tried to flip the dynamics of a presentation is by following Kathy Sierra’s advice to “disappear” in service of the user (the audience). Instead of trying to explain, I’ll just link to her great essay on it:


  3. I have flipped my doctor visits for years – it is something we used to teach EMTs in the fire department and then again with AIDS patients almost 15 years ago .. We use a one page form SBAR that was originally developed for NHS nurses to communicate with doctors at night and during care hand-offs as an EMT..

    S- Situation B- Background A- Assessment R- Recommendation (there are examples online)


    • Thank you!

      I was just reflecting on the new lessons I learned from my co-panelists. Larry’s discussion of how birth control is a constant decision rather than a one-time decision is sticking with me. He compared it to organ donation — if you can reach someone one time, they check off that box, and the decision is made. Hopefully they share that decision with their loved ones, but you’re pretty sure that once they’re in, they’re in.

      Vaccination is another one in that is more akin to organ donation than birth control, that is: “once they’re in, they’re in.” Larry didn’t talk about it, but I’m newly intrigued by work being done to identify “vaccine hesitant” new parents that can help predict future delay or avoidance of shots for a baby thanks to this paper:

      Vaccine Risk Perceptions and Ad Hoc Risk Communication: An Empirical Assessment

      What if hesitant parents could be identified and a conversation could start around them, to help them get the information they might benefit from hearing. Imagine what that social media campaign might look like.

      Contrast those two examples with birth control, which is not at all a one-time choice, but something that people (mostly women) need to think about on an ongoing basis. One of the stats he mentioned was that 7 in 10 pregancies among 18-29 year-old women in the U.S. are *unplanned* — and lots of women say that even though they know they shouldn’t, they will have unprotected sex. There are a lot of factors at play — lack of information, fatalism, culture, busy lives, forgetfulness — and Bedsider tries to position itself as the fun, sexy information/reminder service that women will choose to interact with. It’s a situation tailor-made for social media — the constant conversation that the vast majority of 18-29 year-old women are part of.

      I loved learning about Bedsider’s techniques and thinking about how they could be applied to other public health problems. Poor diet, poor sleep, poor exercise habits — those come to mind immediately. What else would benefit from a fun reminder service?

      • Susannah, I’m sorry to chime in so late to your great post. These are questions that I think about ALL the time. [By the way, I’m a big Dan Kahan fan.]

        I do think that on-going behaviors like taking a pill everyday at the same time require a quite different approach than on-time behaviors like a vaccination. For vaccinations, I might start with Kahan’s third suggestion to publicize the current “high levels of public support for universal immunization in the U.S.” And I would back it up by using social media “reminders” to present support–and challenges–from a wide array of people as Kahan suggests we might in this passage from a paper published in 2010 (http://ssrn.com/abstract=1160654), “Those engaged in seeking out and encouraging advocates of diverse persuasions who genuinely believe in their positions to participate on both sides of the debate can honest[ly] and credibly claim that their goal is not to manipulate the public to accept one position; rather it is to enable members of the public to decide for themselves what position to adopt in a climate calculated to permit them to consider the evidence free of a type of cognitive distortion persons of cultural persuasions resent.”

        Bedsider takes the approach of presenting all the information and trusting people to be rational and process it in a way that benefits themselves. In this way, I think Bedsider “flips the consult” by believing in the importance of agency, but with so much information out there, and so many birth control methods to consider, regular communication is a must. Social media addresses that need.

        Bedsider’s communication is also positive and empathetic–we never dismiss the very real experiences women report. But in flipping the clinic we mix “you can do it” messages in with good information about birth control and reminders to ask yourself, “Am I using the right method for myself at the moment?” All this amounts to a much better experience, we hypothesize, when a woman sees her healthcare provider. This all assumes the healthcare provider is ready for a patient with confidence in her questions and decisions, and some may not be so accepting. In the end, it takes two, or more, to really flip the clinic.

        Back to reminders, I think they are under-utilized. What’s so great about them is the promise of delivering information at exactly the right time. People rarely dismiss messages that they deem to be tailored for them and are even more unlikely to dismiss text messages. According to Techipedia in a 2011 article (http://www.techipedia.com/2011/sms-marketing), 98% of SMS messages sent are opened, and 83% of them are opened within 3 minutes. That not only shows the opportunity behind texting as a communications medium, but also how crucial it is to get it right — because you’re talking with people in a medium they clearly find extremely important. Relevance is everything.

        But it is easy to get wrong. It’s tempting to slip into our comfort zones with safe organization-centric messages. I fight this tendency all the time. And even when you succeed in remembering that it is all about them, not you, there are other battles to fight. I was once asked on a webinar for which I was once a presenter whether the human-centered design approach we used for Bedsider would work for teen drunk driving. My answer was that it would but the messages they would need to send would have to acknowledge and likely have to accept, at least somewhat, the lifestyle of teen drinking in order to reach its target audience. That would be difficult to get by the many gatekeepers. So, we end up with messages that are easy to dismiss; messages that feel like they are coming “from them” rather than tailored “for me.”

        I think there is a lot of potential for messages tailored reminders that are all about the receiver of those messages and where the sender is only a good facilitator.

  4. Check this out:

    “Right now, people still think of the website as a dead, static document – as this thing that just sits there. And then they use tools like Facebook and Twitter and other platforms to do their connecting with their audience. We see that changing,” [Adam Bonnifield] says. “We see a rebirth of the website to be more contextual, more fluid, and more conversational. The other things we’re working on are an extension of what we’ve already built…where you’re thinking of the website as a community and less as a document.”

    Full article:
    Data Scientist As A Service? Spinnakr Raises ~$1 Million From Andreessen Horowitz, 500 Startups & Others For Smarter Web Analytics

    I’m going to give a talk on Monday at the National Cancer Institute, weaving together all that I learned during the panel at Families USA, focused on how cancer specialists and communicators can harness the latest tools to reach the public. If anyone has other new resources or inspiration to share, please post it here!

  5. Susannah, this is (as always) a really thought-provoking synthesis of ideas. Between you and @joyclee I’m now motivated to try to “flip” my next lecture. Thank you!

    2 thoughts on the comment section:

    1) I love the idea of presenting “both sides” and then letting people decide for themselves. But most of the research I’ve seen (e.g. http://www.pewinternet.org/2014/02/20/mapping-twitter-topic-networks-from-polarized-crowds-to-community-clusters-2/ and http://www.theatlantic.com/national/archive/2013/02/the-whole-dysfunctional-national-conversation-about-guns-on-twitter-in-one-interactive-graph/273499/) suggests that social media discussions stay within very polarized crowds.

    So how does one diffuse the message to people who may not want to listen?

    2) Lawrence’s point about the challenges of putting intervention messages in tailored, population-appropriate language….. **yes**. Not only is there the issue of what our IRBs, etc, will let us say — there’s also the difficulties of getting good answers to what people want. Even when asked, folks often have difficulty articulating what will truly resonate re: behavior change. And then, of course, what people say they want may not translate into what will actually change behavior. We’re also limited because traditional theories of behavior change seem to not work so well in the digital health sphere.

    Hopefully more people will be publishing research on the development of CONTENT for social media/mhealth – which is, arguably, the most important factor in its efficacy?

    • Thanks, Megan, for making the jump from Twitter after I posted my notes for the (now cancelled) talk I was planning for tomorrow at the President’s Cancer Panel meeting.

      For those just tuning in, here’s what I tweeted:

      87% of US adults use the internet http://pewrsr.ch/1mIfB5b

      73% of online adults use social networking sites

      —————>71% Facebook
      –>22% LinkedIn
      –>18% Twitter


      If @PresCancerPanel wants to catalyze cancer communications related to prevention, @Bedsider is a model.

      If @PresCancerPanel wants to catalyze cancer communications around community building, #bcsm is a model. (People tweeted back other examples: #lcsm; PatientsLikeMe; Inspire; SmartPatients; “MmRF and cystic fibrosis foundations”; and Reg4all.)

      If @PresCancerPanel wants to catalyze cancer communications with a gov’t-wide campaign, @AIDSgov is a model: http://aids.gov/using-new-media/


      I’d love to keep the conversation going and include more people — I know the President’s Cancer Panel folks would appreciate the input, too. Comments will stay open…

  6. Whenever government (always somehow partisan) is involved in this sort of discussion there is an implicit concern as to a coercive and/or propaganda goal.
    One must first define the agenda and biases of the various participants – is goal to promote certain universal vaccinations, treatment protocols, or ACA/Obamacare preferences or is this a true “Everything is on the table” discussion of options?
    A whole bunch of potential input will be lost if this is perceived as one-sided advocacy rather than an honest discussion.
    As a result you will inevitably miss a large segment of the population and the “informing the public” goal will fail.
    Partisanship is often the enemy of truth.

  7. Socialization of healthcare has new meaning! :-)

    As ‘consumerization’ of healthcare meets ‘socialization’ there is an opportunity to educate consumers/patients/pre-patients in many areas, starting with the right insurance coverage model.

    • Yes, very true.

      You might enjoy an essay co-written by Michael Millenson in which he talks about the “consumer” approach to patient-centered care. It’s downloadable as a PDF from this page:


      One relevant quote:

      “Roles and expectations switch back and forth. The consumer may choose a high- value hospital, but it is the patient who waits anxiously for the procedure to begin. The woman who uses a smartphone app to select her doctor assumes the marketplace mantra of caveat emptor will not replace the clinical imperative of primum non nocere when she walks into the exam room as a patient – but should she? Policy discussions about patient- centeredness and consumerism must directly address these emerging dilemmas.”

  8. Brilliant! What I love is learning there is a name for what I’ve been doing. I called it brainstorming and crowdsourcing ideas for my presentations, but now I can say I am flipping it. It’s a little like when i first learned about the term ePatient a few years ago and got very excited when I realized I had been one for years! On another note thank you for all the amazing data that you release to the public from Pew..my own presentations are so much stronger because of it.

    • Thank you! This means a lot in two ways:

      – helping people to find the language to describe a phenomenon is one of those “I don’t get paid for it but I love doing it” activities.

      – hearing that the work I *do* get paid to do is useful to someone like you = gold.

  9. I believe that flipping also means framing and tailoring messages so that “research” is posted on platforms that both patients and academic researchers can share. I think making content friendly to wider audiences is challenging. With budgets tight – can anyone here suggest how one proves the return-on-investment for making material friendly, accessible and taking the time on social media?

    • Great (huge) question! You might look at recent discussions in the scientific community about the importance of effective communication around, for example, climate change.

      Your question also prompted me to think: “Well, if the research isn’t widely understood and incorporated into the public conversation, then what’s the point?”

      Some thoughts on that:

      What’s the point of Health 2.0?

      Public service researcher

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