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As uncertainties about Twitter's survival abound following its recent change in ownership and its , thousands of Med-Twitter users have migrated to a new platform.

Mastodon, which describes itself as a "free, open-source decentralized social media" network, launched back in 2016 as a sort of alternative to Twitter. In recent days, like a big, toothy elephant in the room, Mastodon's monthly active users have . And for physicians, other medical professionals, and those just generally interested in health-related topics, there's a that's piqued their interest -- Med-Mastodon.

In the roughly 2 weeks since its start, nearly 5,000 people have signed up to use Med-Mastodon, according to Nick Mark, MD, an ICU physician at Swedish Medical Center in Seattle, who .

"Med-Twitter has been a great place for many of us" both before the pandemic and more recently, Mark told 名媛直播. But all of the turmoil at Twitter in recent weeks has been making him feel "sad and worried" about the community that has been built there, which led to his decision to create the Med-Mastodon server as a "replacement home" -- just in case.

"I genuinely hope that this won't be necessary going forward," he added.

How Is Mastodon Different?

While there are many similarities between Twitter and Mastodon, the two platforms are inherently different. Mark said he likes to use the analogy of actual communities to describe some of the differences that users may experience.

Imagine you're living in a wonderful neighborhood in a big city, he said. Then, problems arise, such as civil servants being fired or leaving, or trash not being picked up. People may opt to move to a small town, where they have a say in their priorities.

"One of the biggest strengths of Mastodon is self-moderation," he noted.

Mastodon is an open-source, federated platform, he explained. Users can download all the code, and make their own servers. All of the servers are freestanding, but talk to each other, and there is no single person or server that is in control.

On the Med-Mastodon server, the rules are simple: no hate speech, no blatant misinformation, and no PHI (protected health information).

When it comes to the rule prohibiting misinformation, Mark explained that it doesn't mean there can't be debate. For instance, users would be free to engage in discussions about how effective COVID vaccines or antivirals are, but they wouldn't be able to post false statements that millions of people have died from the vaccines or that COVID isn't a virus.

To report a potential breach of the server's rules, users click a link to fill out an online form, and Mark, the administrator, is notified via email. Users or even entire servers are able to be banned if the rules have indeed been broken.

Other Med-Mastodon features Mark pointed to are the ability to type 500 characters rather than just 280, edit posts after sharing them, and add content warnings to posts. He also noted that the server boasts two dozen custom medical emojis.

He warned that Mastodon servers can be a bit slower than what users may be used to with Twitter. Moreover, users need a little more information than just a Twitter handle to find someone -- a user name that also includes their specific server.

"I think a lot of people are keeping both," Mark said of Twitter and Mastodon. "A lot of people are posting the same stuff on both."

What Users Are Saying

Jeffrey Matthews, MD, chair of the department of surgery at the University of Chicago, told 名媛直播 that he is doing just that.

Matthews signed up to use Med-Mastodon earlier this month after learning about it through -- what else? -- Twitter. He had seen a few people he admired on Twitter, friends and colleagues, set up accounts, and found it pretty easy to do so himself, he said. Since then, he has also linked his Twitter and Med-Mastodon accounts through an app, and finds it simple to cross-post.

Overall, Matthews referred to the process as "hedging your bets" in an uncertain time.

"Honestly, my enthusiasm for it is tentative right now," Matthews said of Med-Mastodon, "just because it's hard to go from having established an audience, having established a network of thousands of people that you follow and follow you ... to starting over again."

As in the early days of Twitter, he said Med-Mastodon feels a bit empty, but is starting to pick up. One of the things he said he has really enjoyed on Twitter has been being able to participate in broader conversations beyond a mainly medical community, and he wonders how exactly that will be replicated when it comes to the many different servers of Mastodon.

Though Matthews noted that he hasn't experienced an uptick in trolling against his Twitter account in recent days, he acknowledged it is something that happens there, adding that he has also seen a concerning uptick in anti-Semitism and white supremacy circulating on Twitter following the recent changes in curation and controls.

It's a situation that has left him and others "feeling torn," he said. If people leave and Twitter survives, that may contribute to the amplification of the negative side of the platform or the spread of misinformation, particularly medical misinformation, he explained.

Like Matthews, Rebecca Jaffe, MD, director of the hospital medicine division at Thomas Jefferson University in Philadelphia, also signed up for Med-Mastodon after seeing several connections of hers on Twitter do so. She also found the process simple, and said she believes it is perhaps the closest thing to a Twitter alternative at the moment.

However, she also noted that people may have to be a little more purposeful in finding some of the same types of broader connections or chance engagements that have easily existed on Twitter, particularly if they are interested in areas outside just the medical sector.

Given the concerns around the social and community aspects of Twitter -- if it becomes an "unregulated, toxic, and unreliable place -- I hope there will be viable alternatives," Jaffe said.

"Forming national communities is important in medicine," whether that be related to learning, promotion, or academic connections, she added.

At an Inflection Point

Matthews said that when others have asked him whether they should join Med-Mastodon or another online community, his answer is, "I have no idea."

"This is an inflection point or decision point for individuals who use Twitter," as well as for organizations that spread scientific information -- "how that strategy is going to change," he noted.

If Twitter doesn't survive, it's ultimately unclear what platform or entity could become "the Google after Yahoo," he added. In general, people are questioning whether to use all of them, whether to wait and see, and how fast something could happen.

Mark said he has heard from two camps of people -- those who are frustrated and saying, "I'm so done with Twitter," and those who are saying, "I want to be prepared," and signed up for Med-Mastodon as an option. "I think more people are in that camp," he said of the latter.

For the time being, managing the Med-Mastodon server has been doable, with only about one moderation issue per day, he added.

Should issues increase -- say, in the event that potential bad actors jump over from other platforms -- Mark said there may be a need for volunteers or an elected group to contribute to moderation.

Though there are several different ways to set up a Mastodon server, Mark said he is currently paying $129 a month to a third-party hosting company. He has also in the event that the cost of running the server increases as more users join.

Whether he and other Med-Twitter users will make the full migration to Med-Mastodon remains to be seen. In the meantime, Mark said the goal for Med-Mastodon is for it to be a "safe space for constructive dialogue."

Correction: An earlier version of this story misstated what PHI (protected health information) stands for.

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