Esther Choo, MD, MPH (@choo_ek), is associate professor at the Center for Policy and Research in Emergency Medicine at Oregon Health & Science University in Portland. Last year, after the neo-Nazi demonstrations in Charlottesville, Virginia, she posted a series of tweets describing the unabashed racism she has experienced as a practicing Asian-American emergency physician. When that Twitter thread was retweeted by Chelsea Clinton, it went viral and was retweeted more than 25,500 times and seen by more than 4.5 million people, giving her, and her other work, an unexpected national spotlight. I recently interviewed her over Skype.

JF: When did you first join Twitter and why?

EC: It’s been six years now. I joined on the advice of a friend from medical school, Vivek Murthy, MD, MBA, who went on to be the Surgeon General of the United States. We were having lunch, and I was like, “I don’t even know what Twitter is. I don’t get what people do there, and I don’t know how to tweet,” and he said, “Trust me, this is a powerful thing.” I was super-skeptical, but I signed up and did some things with the Doctors for America and the Obama campaign around health care messaging. I participated and then kind of forgot about it. And then this FOAM [free open access medical education] thing happened, so I dipped back in and tried to participate in the ways that many people do. I met Seth Trueger, MD, MPH (@MDAware), and I was in the same office as Megan Ranney, MD, MPH (@MeganRanney). A bunch of us wrote a Twitter paper about what you should do with it in academia. Those were the days when most people thought it was a waste of time.

JF: How many followers did you have before your legendary thread about racism, because now you have around 25,000?

EC: I think I had four or five thousand.

JF: So at that point you were a fairly well-known academic on Twitter but this moment brought you a new type of following, right?

EC: Yes. Up until the low 1,000s, I had a tight circle. Even that number felt pretty tight. I knew who people were, mostly other physicians and health care providers, but it felt really rich. The beautiful thing at that range was feeling like I had colleagues internationally and a good mix of students, trainees, and people senior to me that I could learn from. When you hit that level, there’s momentum, and I felt like it became very interactive.

JF: You could say that you worked hard for years to become an overnight sensation.

EC: Exactly! I’m like, “I’ve been here the whole time!” When I look at people I admire in health care with huge followings, people like Eugene Gu, MD (@EugeneGu), Atul Gawande, MD, MPH (@Atul_Gawande), or Jen Gunter, MD

(@DrJenGunter), all of these people have been very on-message the entire time. Jen had this amazing blog for a long time before becoming so obviously known and getting a New York Times column. Their messaging and passion have been very consistent. You don’t become somebody else to do this. You’re just who you are and then you hit a moment where your message resonates with a lot people.

JF: Generally, the “tweet storm” or “thread” has become a natural outlet for you. Can you describe the mechanics of that?

EC: This is my favorite thing to do. I love the limited structure of Twitter actually. When you have to be brief, you have to choose your words wisely. But you miss a lot of nuance. I started doing this thing where you post something and then you respond to yourself. So when people pull it up, they see the whole string of messages, and some of them were really long because a bunch of doctors who weren’t on Twitter asked me to post [patients’ stories] in opposition to the AHCA [the American Health Care Act]. That was a nice balance between being able to say a lot but still using the thing about Twitter that makes it beautiful.

JF: And how did you develop the thread about the racism you’ve faced that went so incredibly viral?

EC: It was so organic. You have no idea how spontaneous and random that was. It was a mixture of circumstance and long-brewing thought. Charlottesville [the neo-Nazi protests] happened that weekend, and it was obviously really disturbing how overt the racism had gotten in the last year. I’m in Oregon where there are a ton of white supremacists, so it’s more in my face than ever.

I’m with my family. We’re going to the park, getting ready to play, and my toddler had fallen asleep in the car. So my husband takes the other kids out to the playground, and I’m just sitting in the car doing nothing. I was bored, and of course, as we do, I opened up Twitter, and I just tossed off the thread. The rest of my day happened. I was going into an overnight, so I slept and I went into my shift, came home, and Chelsea Clinton had retweeted it. It just went kaboom! My email box was just [sounds of explosion]. This was not premeditated or well-thought-out.

I thought there would be a few friends who would pick it up and like it, physicians who I had engaged with about racism, and it was directed at them, but I had no idea that it had general appeal. I still don’t totally understand it. I think it was timing.

JF: I think people actually do want to hear doctors’ frontline experiences with that authenticity. A lot of the responses you got were enjoyable, but you also received negative feedback from people who aren’t ready to hear these kinds of things. Could you describe what that’s been like?

EC: To some extent, the trolls will always come out. But there are a lot of people who said that they thought that I made it all up. There were over 2,000 comments on Twitter. There were Facebook posts that blew up even more than the Twitter posts. I really can’t go deep down into the Facebook posts because either they double down on racism or they say I made it up so I could get my “five minutes.” There’s a lot of that. Even with a bunch of other physicians chiming in and saying that it is completely believable and normal in our workplace, other people are like, “It’s too much or too extreme, and I can’t believe that happens.”

JF: You recently said, maybe tongue-in-cheek, that your whole life changed because of a tweet. In what way?

EC: For two weeks, I just got slaughtered with media requests. I had the CNN appearance, which was one of the most stressful experiences of my life because I’m not a public person, and I was trying to finish a research grant. I was ready for things to get back to normal. But I got on the map as a physician who could speak to a number of issues, and my Twitter following is now a ton of journalists. Almost every week, someone in the media reaches out about a new tweet. I’m contributing for SELF and for NBC’s new editorial site. Overall, it’s a positive thing and an opportunity to advocate for our field and portray physicians in a positive light.

JF: Now that you’re known as both an academic and a public figure, what do you think about the balance of FOAM, mainstream media, and peer-reviewed research publication? Which is more important, and how should the academic world respond to this?

EC: I’ve really come around on this. I used to be a bit of an academic snob, where the press part was this little blip at the end of research. Then I realized the power of having a big, public voice and how you can amplify your work by spending time on the public end of things. I have projects that I spent years on that eight people haven’t read even though it was published in a decent journal. I publish one thing in SELF magazine or the Huffington Post that gets thousands of reads on the first day, and so I wonder if learning how to cultivate relationships with popular press and spending time on social media should be carved-out time, with deliberate training and practice, just like we train people on how to write grants. If we really want to have translation to the public and public health, we should take that part seriously. I also have a number of hard-core academic accomplishments that have only happened because of Twitter. There’s no question that my academic work is stronger because of social media.