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Medicine, Social Media and Clinical Excellence

May 6, 2012 By

The brouhaha about doctors and social media continues.

The Doctor by English social realist painter Luke Fildes, 1891. It was inspired by the death of his own son from TB

Dr Dike Drummond writes on KevinMD that medical Social Media is a bubble economy with “no return on investment” and it’s just  ”one more thing to burn you out”. Leave it alone, he says. Doctors with no interest in education outside their own patients, and whose only concern is financial, will take his advice.

At the other extreme, the Mayo Clinic has launched itself into the medical clouds and clearly plans to go for the stars. Their advice for doctors embarking on the same journey is a laconic 12-Word Policy: Don’t Lie, Don’t Pry, Don’t Cheat, Can’t Delete, Don’t Steal, Don’t Reveal.

Meanwhile, guidelines for doctors are appearing everywhere. Many contain good advice, albeit wordy, such as this recent 12 page report from the Massachusetts Medical Society.

I have always felt that any behavioural differences between Real Medicine and professional Social Media are moot. These views are expressed here and here. We learn ethical behaviour as students, we teach ethical behaviour to students. It’s exactly the same ethical behaviour expected in Social Media. There is no difference.

Actually, this post was triggered by a Tweet which caught my eye yesterday:

 

Clinical excellence is entwined with good medical practice. Good medical practice leads to good professional social media. Ergo, clinical excellence can be a professional tool in social media.

Let’s look at this more closely using the clinical excellence to which Dr Margaret Chisolm refers. It comes from the Miller-Coulson Academy of Clinical Excellence at Johns Hopkins. The report is here, and I reproduce their terrific definition of clinical excellence:

(Clinical Excellence is) “Achieving a level of mastery in the following six areas as they relate to patient care—(1) communication and interpersonal skills, (2) professionalism and humanism, (3) diagnostic acumen, (4) skillful negotiation of the health care system, (5) knowledge, and (6) scholarly approach to clinical practice—as well as exhibiting a passion for patient care, explicitly modeling this mastery to medical trainees, and collaborating with investigators to advance science and discovery.”

It is clear that communication and interpersonal skills, professionalism and humanism, and a scholarly approach to clinical practice are all immediately applicable to Social Media.

What does this all mean? It means an identity between real medicine and social media for physicians. It means a link between clinical excellence and social media for physicians. Medicine, Social Media and Clinical Excellence. Let’s do it.

 

Filed Under: AllergyNet Australia, Social Media in Medicine

How much of a social media profile can doctors have?

February 14, 2012 By

(This post is my rapid response published online by BMJ on 13 Feb 2012 in response to the  journal’s paper published 23 Jan 2012)
How much of a social media profile can doctors have? The answer is – as much of a profile as they have in real life. There is no distinction between social media and reality. So many words are posted/blogged/published about how social media is somehow different. It is not.

Should you say ‘yes’ if a patient rang you and said she wanted to be your friend? No. Therefore non-commercial Facebook access is out.

Should you say ‘leave the room please’ if a patient attended one of your public lectures? No. Therefore Twitter for education is fine.

Should you identify a patient in conversation on a crowded lift/in a public canteen/on public transport? No. Therefore you don’t identify them on social media.

In fact, should you talk to anyone about a patient apart from referring doctors/legal guardians/in court? No.

Should you discuss the operation/resuscitation/disease of an anonymous patient to a group at at party? No. Therefore you don’t do this on social media.

We learnt about this in medical school, as I did 40 years ago. Doctors can and should involve themselves in social media because, as the Mayo Clinic says: ‘Our patients are doing it, that’s where we need to be’

We cannot legislate or pontificate against stupidity. It requires the same undergraduate education about ethics that has been taught since Hippocrates.

The distinction between social media and real life is moot. Arguments about permanent storage and retrieval of your comments are irrelevant.

As I have said elsewhere, being Social on Professional Media – It’s Not Rocket Science

Filed Under: AllergyNet Australia, Social Media in Medicine

The God Proteus and Coeliac Disease

February 11, 2012 By

Let’s start with The Principles and Practice of Medicine by Sir Stanley Davidson. 1968 edition. I did read it in my 4th year of medical school, in 1969. What did it say about coeliac (spelt celiac in North America) disease? On page 941: “In coeliac disease of children and its counterpart in adults, malabsorption is due to an idiosyncrasy to gluten, a protein in wheat and certain other cereals”. THAT’S IT. Nothing else.

In 1969, the great imitator was still syphilis. If you couldn’t figure out what caused the rash/neurological problem in your final year clinical exam, and if you didn’t suggest a syphilis test, you failed.

Proteus. Woodcut by Jorg Breu 16th C

Syphilis had protean manifestations. After Proteus, the greek God who could change his shape in a wink. Fast forward to now, and Proteus has cast his mantle over coeliac disease.

Coeliac disease is an autoimmune disease, not an allergy. It is triggered by gluten found in wheat (and wheat sub-species), barley and rye. We know coeliac disease increases with age. There is also some evidence that coeliac disease is increasing in prevalence within a particular age group. This is based on analysis of frozen serum from past decades (I appreciate feedback from Alex Gazzola via Twitter @HealthJourno for this information).  It is diagnosed more easily because of a simple blood test. As a result, we now realise about 1% of the population suffers from this disorder. In 1969, you had to have chronic malabsorption of the bowel before a gastroenterologist would perform a duodenal bowel biopsy. That was the only way a diagnosis was made.

The blood test has opened the door to Proteus. Here is a sample of chronic conditions now linked to coeliac disease:

  • Bowel: irritable bowel symptoms, indigestion, acid reflux
  • Brain: depression, ataxia, neuropathy, psychosis
  • Blood; anemia, iron deficiency, thromboembolism, coagulopathy, hyposplenism
  • Skin; dermatitis herpetiformis
  • Oral: aphthous ulcers, cheilosis, dental enamel problems
  • Growth: failure to thrive, short stature
  • Bone: osteoporosis
  • Limbs: neuropathy, muscle cramps, joint pains
  • Liver: abnormal liver tests, fatty liver
  • Immune: low IgA, malignant lymphoma, autoimmune diseases
  • Nutrition: low B12, folate, vit D, copper
  • Reproductive: Infertility (male and female), delayed puberty
  • General: fatigue, loss of weight
You can scan the literature and add more. The list is incomplete. And association does not prove cause and effect. But, and I say this with complete confidence, you will never go wrong, whether you are doctor or patient, if you remember:
Any undiagnosed chronic medical problem is coeliac disease until proved otherwise
Which means request a blood test BEFORE you start a gluten-free diet or you’ll get a false negative result.
It is estimated that most people with coeliac disease remain undiagnosed. Virgil wrote that Proteus only answered truthfully if you caught him and held him despite the appearance he took. There is a lesson here.
Filed Under: AllergyNet Australia, Diseases and Research

DANGER! GERMS! EVERYWHERE!

December 3, 2011 By

Social media is agog with warnings about germs.

Nosferatu (1922): vampires killed victims by inoculating germs

Nothing new. Movies from Nosferatu (1922) to Contagion (2011) prey on human loathing and disgust of microbes. OK, there are important nasty strains, pandemic flu, resistant Staph, but here we are talking about a surge in paranoia about everyday exposure to germs. Witness the fetish for using germicidal soaps and sprays in the home.

Remote controls came under scrutiny after a study in a hospital found more germs on the TV remote that the toilet. Yipes! The news spread quicker can a virus in a pre-school, and was immediately extrapolated to remotes in hotel rooms. Dirty, dirty remote controls. Don’t touch them. You could use the controls on the actual set…hang on, the last 50 guests knew this trick. Yuk. Or press the buttons with the end of the ubiquitous pen in the room. Then, whatever you do, don’t touch the end of the pen.

The next headline involved Malls. Yep, there are eight places that are dirty, really dirty, in malls. They are: makeup samples, gadget shops, clothes in fitting rooms (quote “that’s why it’s important to wear underwear” – I knew there must be a reason), toy stores, ATMs, handrails, tables in food courts (I’ll let you in to a secret – you’re more likely to get sick from the food), taps in the bathroom.

No-one has mentioned the buttons in elevators. I reckon they must be filthy! So if you work on the 21st level, do not use the elevator. Go up the stairs. Do not touch the handrail. Warning: you may die of a heart-attack.

It’s not the number of germs, folks, it’s the type. There are 10 times as many germs in the human body as cells. These are normal. The collection is now referred to as the human microbiome, and important for good health and good immunity. When you touch, kiss, or even talk with someone, there is a pleasant exchange of germs. Live with it. Relax.

If you touch people, or food, for a living, there are strict precautions. And the severely immunosuppressed need care. Vaccinations work where available. There are sensible tips when you travel. But for everyday life, just follow these three rules:

  • wash your hands after going to the toilet
  • wash your hands before a meal
  • don’t suck your thumb
Filed Under: AllergyNet Australia, The Practice of Medicine

The Case For Reductionist Medicine..or..Let’s Not Jumble The Message

November 13, 2011 By

Reductionist Medicine is based on a piecemeal scientific dissection of disease to determine the cause of symptoms and the treatment. Lots of people don’t like this approach. Why?

  • humans are complex organisms
  • complex organisms are not simple
  • if you only look for simple causes then you ignore the whole person
  • if you ignore the whole person then your treatment is incomplete

Even William Osler, one of the best physicians of the 19th Century, said “It’s more important to know what sort of patient has a disease than what sort of disease a patient has”.

But you know, it really is all about disease. Examples: you’ve got worsening abdominal pain – Reductionist Medicine diagnoses acute appendicitis. You have it removed, you don’t die, easy. Or, you have recurrent infections, chronic sinusitis, asthma, dermatitis, food allergy, hypertension, obesity and depression – Reductionist Medicine determines you have an immunodeficiency, you are allergic (atopic) with sensitivity to egg, house dust mite and cats, your airway disease and infected skin are triggered by both your immune and allergic problem, your hypertension is persistent, your obesity morbid, and your depression severe. You are managed with allergy treatment, immune treatment, drugs and referral to a dietitian for weight loss, you improve but are not cured. In both scenarios, a good doctor will talk to you, maybe not for long, but with empathy.

It’s NOT about normal health. If you are healthy, and you seek constant treatment while you remain healthy, then you are one of the “worried well”. It’s not hard to reduce (not eliminate) your risk of losing your health. You know, normal weight, reasonable exercise, no smoking, alcohol in moderation, varied diet, vaccinations, preventative assessments according to age and gender, and so on. There are very little other evidence-based interventions that are useful. In Australia, there are many good General Practitioners who can sort this out for you. We are a lucky country in that respect.

What is the alternative to Reductionist Medicine. Well, at its most banal, it’s called Holistic Medicine, at its most sophisticated, the term Systems Biology is used. A good summary is provided by a Harvard Group in PLOS medicine, presented as two articles called The Limits Of Reductionism In Medicine and The Clinical Applications Of A Systems Approach. I have read these, and many other similar papers, carefully. I am not impressed by a ‘new’ terminology: pseudoscience at its best, mumbo-jumbo when bad. Here is one example from the PLOS papers: “Circadian rhythms are an example of oscillatory behaviour, and complex heart

Ahn AC et al, PLOS Medicine Open Access, July 2006. My comment? I feel that Systems Science is nothing without a Reductionist Approach

rate variability (an example of) chaotic behaviour”. Does this really add to the armamentarium of a skilled Reductionist doctor? No. And you can view a summary of their ideas in the diagram. The more I look at the diagram, the more I see it as an exercise in semantics.

What about psychiatry? Is this the bastion of Holistic Medicine? Not in my opinion. Even in psychoanalysis. There may be little scientific evidence for a lot of statements made, but the good psychobiologists are reductionist in approach. There is a wonderful book called Neurosis And Human Growth by Karen Horney. She was a terrific psychoanalyst. The book looks and feels holistic, nearly 400 pages of intense psychiatric analysis of the whole person. But you know, you can summarize her arguments on personality disorder on one page with a few circles and arrows. I suspect she did that before she wrote the book. It is Reductionism at its best. By the way, if you will allow a digression, my favourite quote from the book which I have mentioned elsewhere is from one of Horney’s patients: ‘If it were not for reality, I would be perfectly all right”

So, let’s get back to our opening statements. Reductionist Medicine often diagnoses and treats disease effectively while recognizing complex interactions in humans, and, when treating disease, will treat the whole person, but only as much as required. And William Osler’s quote?  His quote may have been accurate in an era without antibiotics, without effective treatment for gastric ulcers, without good blood pressure drugs, and so on. For 2011 I would paraphrase his quote as: “It is AS important to know what sort of patient has a disease AS what sort of disease a patient has”

Pieter Peach’s post on his blog makes some excellent points, tangential but still relevant to these concepts.

Incidentally, Osler also said: “What is the Student but a Lover courting a Fickle Mistress who ever eludes his Grasp”. Is this a Reductionist or Holistic statement? I’ll leave that to you.

Filed Under: AllergyNet Australia, The Practice of Medicine

Band-Aid: A Temporary Solution – Or Is It?

October 30, 2011 By

It’s the commonest metaphor I hear at work: ”Doctor, I am sick of band-aid solutions. I want to know the cause of (here insert symptom/disease) and I want to fix it”

Let’s start out with the most famous and useful band-aid in all of medicine. Insulin. Just read the description in Medical News Today: “(In 1922) the scientists went to the other wards with diabetic children, most of them comatose and dying from diabetic keto-acidosis. They went from bed-to-bed and injected them with the new purified extract – insulin. This is known as one of medicine’s most dramatic moments. Before injecting the last comatose children, the first started to awaken from their comas. A joyous moment for family members and hospital staff!!”

Insulin pens. Wiki Commons

Yes, this still brings a tear to my eye. And yet insulin was, and still is, a band-aid. We are close to resolving the immune nature of Type 1 diabetes and with that will come a remedy for the cause, no doubt. But hey, insulin beats the alternative.

And there are band-aids for lots of problems: hypertension, migraine, depression.. And band-aid treatment can improve quality of life and often reduce mortality. People feel better, can function socially and at work, and with some diseases, may live longer. Although some diseases are cured by  finding a cause, in the majority the actual curable origin remains elusive.

Decrease in deaths in people with hypertension. Source: CMAJ 2008

Take hypertension. In about 10% a cause is found and corrected – and  your blood pressure drops. In the rest, well, some factors are modified (you know them – obesity, exercise and so on) but a cure is not possible – yet. And yet treating this hypertension with drugs (the dreaded ‘D’ word) lowers mortality. A band-aid is saving lives!

What about allergic and immune disease? We cannot find the cause of many cases of chronic hives and chronic sinusitis. These conditions lead to a great deal of pain and discomfort and embarrassment. All we offer are band-aids: antihistamines tablets, nasal sprays, sometimes even cortisone or steroids. But used judiciously, these drugs can often (not always) improve your life.

Asthma deaths in Australia. Source AIHW

Finally there is asthma. Trigger factors are important. But the ultimate cause escapes us. So what do regular inhaled corticosteroid preventer sprays do? Less hospital visits. Less time off school or work. Better sport performance. And a contribution to lowered mortality. Not bad for a band-aid. So, stick to your asthma action plans at all times.

The patient, carer and doctor must work together to find a cause for illness. Once examination and tests fail to find a reversible cause, it’s band-aid time. Whether you like to wear a band-aid for your illness depends not only on your perception of it being just a band-aid, and a balancing act between effectiveness and side-effects, but also a realisation that band-aid treatment is not necessarily evil in itself.

Which leaves us with old age. As someone in that group, I know the wonderful advantages of many band-aids. But senility is progressive, live with it, and listen to Woody Allen: “I’m not afraid of death; I just don’t want to be there when it happens”.

Filed Under: AllergyNet Australia, The Practice of Medicine

Being Social On Professional Media

July 17, 2011 By

The Doctor And His Patient, Jan Steen 1665, Rijksmuseum Amsterdam

 

It seems 2011 is the year of “Beware The Physician On Social Media”. There’s a lot of stuff flying around. Doctor Tweeps have made degrading jokes about their patients and been outed. A comprehensive survey of Physicians on Twitter demonstrated that 3% of Tweets were unprofessional, either profane or identifying patients. Both Australian/New Zealand and UK medical associations have felt the urge to publish guidelines on Social Media. And then there is the question that physicians who never use Social media always ask: ‘Isn’t it all just ‘NOISE’?’

It boils down to HOW to use  Social Media professionally, and WHY it should be used at all.

First the ‘HOW’.

Let’s look at those medical association guidelines and lump their recommendations together. There are 3 categories.

Hippocrates, public domain, Wiki Commons

The first relates to doctors. Breaking patient confidentiality and making personal derogatory remarks. We may never have actually sworn on the Hippocratic oath which, in part, goes ‘All that may come to my knowledge on the exercise of my profession or in the daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal’. But we know exactly what it means to maintain confidence. Talk to the patient, or parent if a child, or an attending physician, or if legally obliged. No-one else. Period. It’s not hard.

The second can affect anyone. These are concepts of online image and defamatory remarks and security, relevant to all who use the Internet. The stuff you post is there forever, right?

And the third is the most difficult: Can I be your friend? Well, Twitter and Blogs are fine, it’s the market place, no invitations, people come and go depending on what they want to see and hear. It’s real life. But where there is a request to be invited, that’s when Media should be split into Social v Professional. For SM, no former or current patients. For PM, it’s set up like a business or education site, no personal stuff, no problems, you’re all invited. Easy.

Now the ‘WHY’. Why should physicians engage in Professional Media? Katherine Chretien @MotherinMed and her co-authors say it all: Twitter can be a useful way of spreading good health information. I agree. Good information about vaccinations. About government health policy. About drugs and operations. About diet. There is so much awfully biased and even dangerous anecdote about health on the internet that it is the responsibility of physicians to get involved. The British Medical Association guidelines don’t mention anything good about professional media. Neither do our guidelines in Australasia and I’m surprised because they were published by Doctors in Training.

Does this mean a bit of ‘NOISE’ among all the serious stuff. Sure. In my consulting room, with real, not virtual, people, there is ‘NOISE’. I talk to people about their job and about language and the old days and religion and Aussie politics and Masterchef and music and stuff. It’s called being social. I get to understand the person who is ill, not just the illness that the person has. And it works the other way. They  have the opportunity to assess what I’m like, as a human being. And they can do that in the consulting room, and by the professional media that I post. That’s where I would differ from the UK guidelines which warn doctors not to blur the boundary between their private and professional lives. If I do the ‘HOW’ properly, for the right ‘WHY’, then a bit of ‘NOISE’ is OK.

There you are – Being Social on Professional Media – It’s Not Rocket Science

Filed Under: AllergyNet Australia, Social Media in Medicine
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