Editor ’ s Corner
Tiny Bubbles
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The content of the Editor ’ s Corner is the opinion of the author and does not represent the official position of the American Society of Hematology unless so stated .
“ DOUBLE , DOUBLE TOIL and trouble ; Fire burn and caldron bubble … For a charm of powerful trouble , Like a hell-broth boil and bubble .”
William Shakespeare , “ Song of the Witches ” ( from Macbeth )
he bubbles in which we live came into focus during the last U . S . presidential election , when the East and West Coast press were accused of completely missing the coming of Trump ( or was it a second coming ?) because they couldn ’ t see beyond the reassurances of people in their own liberal bubbles . I am myself a product of the East Coast liberal press ( my dad having been a political reporter for the Providence Journal-Bulletin in Rhode Island ) and thus lived in such a bubble during my formative years . Having been a resident in the Midwest for the past 15 years , though , I must say I was not as taken by surprise .
I was reminded again of the false consolation of bubbles during a recent conversation with my 13-year-old daughter .
“ Come over here and see this ,” I said to her , as I sat at the kitchen table scrolling through my Twitter feed on my phone . It was a typical Sunday morning : I made breakfast for the kids and we had reached that precious hour between our coming together briefly as a family and my chauffeuring them to various extracurricular activities .
She ambled over slowly , her curiosity piqued ( but not wanting to admit that it was piqued , lest she be accused of finding her middle-aged father vaguely interesting ).
“ Look !” I pointed to a recent tweet of myself with some other hematologists at a meeting . “ I sent this last night , and it got 17 likes !”
“ Mmmmhmmm ,” she mumbled , in as noncommittal a way as humanly possible .
“ What ? That ’ s not so bad !” I said . “ How many likes does one of your photos typically get on Instagram ?”
“ Usually about 350 ,” she answered , ever so casually . I think she may have even tossed her long , brown hair – the body-language equivalent of former World Wrestling Federation star Jimmy “ Superfly ” Snuka jumping from the top of the ropes to pin me to the mat .
“ Well , it may not be 350 likes , but the people who did like it are impactful !” I countered anemically , my bubble now fully burst . Her job done , she left the kitchen and the deflated carcass of my ego for the flies and jackals to consume .
Bubbles can be dangerous , because they trick us into thinking we are more correct than we may be , more influential with our self-selected captive audience , and they reassure us that we are surrounded by like-minded views .
Social media outlets such as Twitter , Instagram , and Facebook are ready-made for bubble construction : We choose who to follow ( and even who follows us ), allow ourselves to have our confidence stroked by numbers of followers ( even as some can be purchased to enhance the perception of our popularity ), and estimate our impact by numbers of likes . Yet , I would consider the 17 people who liked my photo to be friends more than colleagues , while the 350 people who like my daughter ’ s posts are all members of her 8 th grade class , in which the culture is to “ like ” indiscriminately ( sorry to break it to you , honey ). It ’ s all too easy to think we ’ re famous , but our fame has been self-constructed . Those likes don ’ t represent a championing of my viewpoint , nor a tacit agreement to promulgate my opinion , nearly as much as I ’ d like them to .
Bubbles also exist in the health-care workplace . Within a disease team , we may standardize our approach to treating
Mikkael A . Sekeres , MD , MS , is director of the Leukemia Program at the Cleveland Clinic in Cleveland , OH .
conditions such as leukemia , initially acknowledging which aspects of our care are based on well-designed studies and which aren ’ t . Over time , those standards become codified , though , as if handed down directly from The Mount . Then , we marvel at those who practice differently outside of our bubble and the “ reckless ” way they treat their patients . Of course , it ’ s not truly reckless ; it ’ s just not what we do . For leukemia , this could refer to post-remission therapies , treatment of relapsed or refractory disease , clinical application of next-generation sequencing results , and ( in the most egregious datafree zone ) neutropenic precautions . Yes , on our leukemia floor , we allow patients to have fresh flowers and even fruit . Have you ever heard of anything so reckless ? Research bubbles are the worst . We often choose our collaborators as we choose our friends , or those we follow on Twitter . We attend the same meetings , read the same journals , and check with each other before adopting a new practice – sometimes before we have made an independent decision about its value . As a result , we decide which research is valid and which studies are flawed , even when the methodology , power , and conclusions may be similar . One randomized trial demonstrating a survival advantage for maintenance therapy in acute myeloid leukemia ( AML ) is ignored in the U . S ., while another showing a survival advantage in an AML subtype that never knew it needed a special treatment approach gets the nod from guideline panels , in part because the latter study included investigators from our bubble .
And bubbles are probably unavoidable . In his book Being Mortal , Atul Gawande , MD , MPH , wrote about the aging process , and how we progressively narrow our circle of friends and family , the people with whom we want to have contact , as we approach death . Essentially , we are reducing the size of our bubbles , and taking solace in the reassuring warmth and familiarity they provide .
I suspect we do this throughout our medical careers too . The trick is in recognizing when we are making decisions , or interpreting reality , from within our bubbles and either acknowledging that fact , or bursting out of our small , safe universes to encounter other worlds and the discomfiture of new opinions .
But not necessarily the opinions of 350 8 th graders .
Mikkael A . Sekeres , MD , MS Editor-in-Chief
Have a comment about this editorial ? Let us know what you think ; we welcome your feedback . Email the editor at ACNEditor @ hematology . org .
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