A case for bringing back paternalism?


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Paternalism has become a bad word in medicine. The physicians of old are caricatured as stern unapproachable male figures who commanded their patients to take the treatments they prescribed without any explanation. The patient’s own opinion didn’t seem to come into it at all. The term ‘paternalism’ also evokes the idea of a stern unloving father figure who rules the home with an iron rod and doesn’t hold back on punishment when his child misbehaves.

I’m not going to defend the old style of medicine  - nor would I want to defend the sort of strict uncaring style of parenting that gave no room for the child to develop.

Good parenting requires a progressive ‘evolution’ in parental behaviors and attitudes. The younger the child the more directive the parental advice and the briefer the discussion or explanation will be. The caring parent will provide a safe environment for the child by making decisions for them – with their best interest at heart. As the child grows and gains education and maturity they will be able to have an increasing role in decision-making until they are fully independent.

I would argue that doctors need to understand where their patients are on the continuum between the passive or less well informed patient and the patient who has a comprehensive knowledge of their disease and its treatment. In the case of rarer diseases the patient (perhaps with the help of online resources) may even build up a knowledge base that is superior to that of their specialist. The doctor should help the patient become better informed by guiding them to reliable sources of help and sometimes warning them where the sources are unscientific. Some would argue that a doctor’s job should be to dispassionately offer the information and leave the patient to make the choice (e.g. between two or three different Disease modifying drugs for arthritis). I think it is quite cruel to leave patients on their own to make these important decisions and not to use your skills of persuasion to help them to make the decision when they are afraid to do so, perhaps because of a particular side effect mentioned on the information leaflet.

I would argue that most patients want and expect expert help, guidance and advice from their doctor. Most patients expect us as specialists to have sifted the information and to speak from experience. It is not wrong to present them with a preferred choice and coax them into going along with our proposal – perhaps we should call this characteristic ‘benevolent paternalism‘.


A Focus on Patient Safety: time to sharpen up our act!

There seems to be no end to medical scandals in the media. In the UK, the focus recently has been on the Francis Report into care at the Mid-Staffordhire NHS Foundation Trust. The report found that there had been a focus on targets rather than on patient safety and quality of care. A real concern was expressed about the apparent silence of medical staff in raising concerns about the problems. The recommendations of the Francis report are wide ranging, but it is a wake up call for health professionals to take ownership and responsibility for the safety of patients under their care. We need to ask serious questions about quality of care and be prepared to speak out to expose problems – even when we do not have a ‘managerial’ responsibility.

If you can spare an hour of your time, why not have a look at this video from the patient safety congress. Thanks to Anne Marie Cunningham (@amcunningham) for sharing it. The first talk is by Jeff Skiles, an experienced airline captain who recently had to ditch his plane into the Hudson river – the second is by a doctor who is trying to apply some of the lessons learned in aviation in the health care situation. Note that his co-captain Sully Sullenberger also lectures on aviation safety (@CaptScully).

At the recent NI Confederation conference in Londonderry (#NICON13 on Twitter) one of the speakers from the Southern Health Trust Hugh McCaughey gave us six safety questions every service should be asking of themselves.

  1. How can we prove that our service is safe?
  2. What are our team’s objectives?
  3. What would success look like to our team?
  4. Can you provide evidence that we are learning lessons as we go along?
  5. What do users think of our service?
  6. What outcomes are we achieving?

These are tough questions, but I think that it is a useful exercise. In the next series of posts I am going to look at each safety question in turn for our own service. I will be asking other members of the team to contribute to this discussion so that our final statement will be agreed by the team.


Arth-rit-is-is- not-right


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Sometimes we are so busy doing our activity scores we don’t have time to really listen to what our patients are saying. Dorothy Logue is a talented poet who also happens to have rheumatoid arthritis – she has very kindly agreed to share this poem with us…

‘Arth-rit-is-is- not-right’

I am not my usual self, for days I’ve felt unwell.
I’ve lost my mojo, anyone who knows me can tell.
I feel so ill, my back hurts, my arms and legs hurt too,
My neck is so sore, I really don’t know what to do.
I could ring the doctor again, what good would that be?
I could go visit him but there’s nothing new to see.
I cannot drive today, my fingers are so sore.
I can just complain and mope and it is such a bore.
No one knows how I feel, I can’t make them understand,
When you feel as low as this, your thoughts get out of hand.
I’m not a hypocondriac, nor one to complain,
I could whinge all the time but that would be in vain.
Unless you are a sufferer, you wouldn’t believe
The lengths I will go to, to have the pain relieved.
Maybe tomorrow morning when I get out of bed
I will feel much better and love the day ahead.
Days I ask myself questions, there are no answers back,
Days I go out and enjoy myself, life is back on track.
I keep my pain and suffering private so no one will ever know,
They only see the “ME” which I force to “get up and go.”

by Dorothy Logue


Bayer and the birth of ‘Big Pharma’

There is a growing resentment against what are seen as the excesses of modern Pharmaceutical companies of profiteering from over-charging patients and marketing direct to the patient. ‘Big Pharma’ has been brilliantly lampooned in a hilarious rap video by ZDoggMD. So where did it all begin, and is ‘Big Pharma’ completely malevolent or just capitalism working well to make the industry more efficient?

I am not an expert in the history of the pharmaceutical industry, but in my reading around the discovery and marketing of Aspirin, it seems striking that at the end of the nineteenth century Bayer revolutionized the pharmaceutical industry and sparked a series of scandals and controversies that rumble on today.

Following on from my recent post, here’s what Ackermann had to say about Bayer in her  scholarly article on the history of Aspirin. “However, despite the change in the products being manufactured, Bayer retained many of the methods used previously in the sale of dyestuffs in highly competitive markets: sales representatives, advertisements in trade journals, and the use of patents and trade names.” She quoted McTavish, a noted medical historian, who remarked:

By restricting its market to the pharmaceutical and medical professions, the chemical industry avoided the unseemly trappings of the nostrum trade and established itself as a member of the ‘ethical’ fraternity

This quotation illustrates that – according to the author – Bayer originally distinguished itself from the deceptions of that era by resisting the temptation of  selling their drugs directly to their patients. The picture below of ‘Walcott’s Instant Pain Annihilator’ was typical of drug adverts that period: dramatic and wildly optimistic claims for efficacy, with nothing at all said about the content of the potion in question (thought now to be ethyl alcohol and opium).

Advertising 1863 style

Drug Advertising '1863 style'

Ackermann also points out that Bayer used its existing business methods (sales representatives, patents, and advertisements in trade journals) to promote its new pharmaceutical products – with spectacular – and international – success. Within 4 or 5 years both Aspirin and Heroin were being widely sold across the US as well as Europe. So Bayer made pharmaceutical development more business-like and efficient. And there is also no doubt that Bayer brought together a team of highly talented scientists working together in laboratories where vigorous lab testing came before  animal and then human testing. This logical scientific approach to drug development made it possible for them to rapidly gain medical approval via the scientific journals of the day such as the BMJ and Lancet.

However, the story of subsequent scandals, patent battles and intrigues surrounding Bayer is a fascinating one, as they are perhaps the prototypical ‘Big Pharma’ company.

So, what do we want from our pharmaceutical companies in these modern times? It seems that the era of chemically creating simple and effective remedies based on old herbal cures has long passed and now painstaking scientific research into the origins of disease is needed to get new and highly targeted treatments. Most of the research by this method results in drugs that either do not work or are harmful, resulting in a high and expensive ‘dropout rate’. In addition, the manufacture of some of these new products such as the monoclonal antibodies is sometimes much more expensive. But in the case of anti-TNF monoclonal antibodies it is quite scandalous that the enormous cost of the drugs have not significantly fallen over the 13 or 14 years since they were introduced. This is in spite of the entry of a number of competitors who have all chosen to price their drugs at very similar tariffs.

We don’t want to stifle change and innovation, and we recognize that quantum leaps in therapeutics are difficult and costly to achieve. However, there is a wide recognition that Pharmaceutical companies are getting larger and more powerful in their influence both with politicians and on the lay person. Has anyone drawn up a Charter for ‘Ethical Pharma’ fit for the 21st century?


Bean-counters, Lamp-posts and Rheumatologists

bean counterI was talking to some medical students recently about the use of outcome measures in rheumatology. I happened to mention that ‘big data’ was the next ‘big thing’ in medicine. Cue blank faces. Followed by quizzical looks and a sly smile. I suddenly realised to my chagrin that not everyone has read Topol’s ‘Creative Destruction of Medicine’ and that my students are beginning to doubt my sanity. I rapidly tried to regain some semblance of dignity by explaining that outcome measures are all the rage in rheumatology right now.

Readers of my blog may have not be surprised to hear that at times I can get a little obsessive about the science of measurement in medicine. So as a form of necessary self-therapy and reflection I am going to explore the darker side of measurement science using a couple of well-known quotations.

einsteinblackboard03The first quote, usually attributed to Albert Einstein (but possibly more accurately credited to a Professor of Sociology, William Bruce Cameron), is as follows:

“Not everything that can be counted counts, and not everything that counts can be counted.”

So not everything we measure or count actually matters. We need to be very selective before we decide that some measurement is essential or routine. There seems to be an assumption that the more we measure the more scientific our care will be and therefore the outcomes will improve. In the case of rheumatology there is now an assumption that if we have a patient with rheumatoid arthritis and we do not complete a ‘disease activity score’ and a disability assessment in every patient we are in some way negligent as doctors. Now I would be the first to argue that early arthritis trials have demonstrated the need to adopt a ‘treat to target’ approach using objective and quantifiable measures to gauge response – but to extrapolate this to patients with 30 years of arthritis may not be either scientific or kind to the person in front of us, particularly when they mention that they have had a recent bereavement. In times like these, ‘feeling the pain’ will often trump feeling the joints. Some measurements may be eminently ‘scientific’ but completely worthless, particularly in managing the individual.

The second part of this elegant chiasmus claims that not everything that counts can be counted. I hope that every health care worker is acutely aware of this fact, but it is at the core of an empathic approach to medicine. How the patient feels cannot easily be reduced to a score on a questionnaire. How well does the doctor understand the narrative from the patient’s perspective? Can we really quantify how well or badly the doctor or nurse empathises with their patient?  There is a feeling that recent changes in the organisation of medical work have disrupted the continuity of care and the integrity of the ‘team’ looking after the patient. Medical ‘clerk-ins’ are reduced to ticking boxes in lengthy proformas and medical handovers are reduced to a rapid fire exchange of facts and figures. Increasingly, doctors complain of being tied to the computer screen completing page after page of data, and having no time to have a proper talk with the patient.  maninfogIn the midst of this swirling fog of data, have we lost sight of the patient? When we teach our students the importance of rigorous data collection and outcome measurement, will we remember to refocus their attention back on the importance of empathy and the art of medicine?

The second quotation has been attributed to AE Houseman or Andrew Lang:

People Use Statistics as a Drunk Uses a Lamppost — For Support Rather Than Illumination


This is justifiably a popular quotation and any medical researcher worth his or her salt will doubtless be familiar with the dark arts of manipulating statistics to make the data seem to support your hypothesis. Reviewers of publications have become wise to this, and statistical scrutiny is a little more rigorous than it used to be. Even better, clinical trials registration requirements and ethics reviewers will insist on you defining the primary and secondary outcome measures before the study begins. This only goes to prove that nowadays you need a higher level of statistical jiggery-pokery’ to baffle your readers and ‘stay ahead of the game’.



Managers Use Statistics as a Dog Uses a Lamppost — For ‘Marking their territory’ Rather Than Illumination


The third quotation could be attributed to a certain PV Gardiner, the writer of this blog. He has clearly borrowed heavily from the afore-named Andrew Lang. He has also used polite and politically correct language within the quotes which readers may wish to replace with more descriptive and direct terminology.

I’ll tell you a story to illustrate the point. A few years ago we were told that we were obliged to carry out an ‘audit’ on our use of biologic drugs in the region. Nothing unusual with that, you may say – they are very expensive drugs, after all. However, we did detect quite a hostile and accusatory sub-text to the discussions. After a little ‘digging’ we discovered that somebody  in management ‘on-high’ had ‘discovered’ that we were using biologic drugs twice as much as the average in the UK. We thought we were using the same NICE guidelines to treat similar patients, so this seemed odd. Cue some anxious head-scratching and navel-gazing by the chastened rheumatologists. Strangely, our own figures hadn’t seemed to suggest any problem at all. Eventually, we discovered that someone in management had been using a single figure (the prevalence of RA in our region) that had changed everything. This figure suggested that RA was only half as common as in the rest of the UK. We were most intrigued. Could it be something in the pure Irish spring water? Could it be our fondness for Guinness or Bushmills whiskey? How had they arrived at such a figure, when there had never been a study of the epidemiology of RA in our region? We have never had a diagnostic database to record the prevalence of RA. In fact, they had obtained the figure from a reference found in none other than the official National Audit Office report into RA in England. That article had briefly referred to comparative data in other nations, and the quoted statistic actually came from a paragraph in a local newspaper where a journalist had mentioned in passing the estimated number of people with RA in our region. Well, it is just as well that we discovered the source of these scurrilous rumours. Otherwise the aforementioned honourable rheumatologists might well have wound up propping up the local lamp-posts (or was that the other way round?). We live to fight another day…



Blindspots and Reflections in Acute Medicine



20130901-172904.jpgHave you ever pulled out into the fast lane and narrowly missed a car coming from behind you? You think to yourself ‘How on earth did I not see that car?’. We all know that this wouldn’t happen if we always checked properly before we pulled out, but few of us can pay full attention all of the time. After decades of many such needless accidents (estimated 800,000 per year in the US), car manufacturers finally introduced the convex wing mirror. This may not have been the most exciting innovation, but it works and saves lives. This reminds me of some of the avoidable problems with medical errors. It is surely about time that we recognised common ‘blindspots‘ and did something to improve patient safety. If these situations are predictable, we should be discussing these issues frankly with each other and especially with our trainees. When we teach our students we need to admit that we have personally made mistakes, but show them how we are learning from them so that patients can be protected from these errors in the future.

Have you ever reflected on a acute medical ward round and realised that you have missed something that should have been obvious to you? After passing the ‘milestone’ of 20 years as a consultant physician I can see some recurring themes. You might think that we should have learnt from our mistakes, but some things seem to happen again and again. And when we get older we need to be even more aware of our limitations because other staff may not have the confidence to point out our mistakes.

A Typical ‘Blindspot’ in Medicine: The ‘alcoholic’
We call it the ‘revolving door’ syndrome. These patients often come in to hospital intoxicated with alcohol levels that would put the rest of us in intensive care or worse. After a day or two of confusion and aggression the medication helps them settle with and they leave, promising never to drink again. Sadly, many walk straight to the local off license and the whole process starts again. Eventually the well of empathy can run dry. Medical and nursing staff can be just a little less attentive, and this can lead them to make serious errors they would normally never make.

Here are a couple of stories that I hope will help to illustrate how this can happen.

A man came in to a hospital agitated and confused with a very high alcohol level. He was an alcoholic who had been in many times before in a similar state. He usually woke up after a day or two and went through the detox process. The examination in the ED was a brief one, if the notes were anything to go by. On that occasion his confusion didn’t settle and he deteriorated. A CT scan was ordered – belatedly – and it turned out that he had an undiagnosed skull fracture with multiple contusions in his brain. If it wasn’t for the alcohol the scan would have been done on arrival into the ED. Head injury guidelines have since helped to make this sort of error less likely to happen, but sadly it is not an exceptional case.

Another man with chronic alcohol problems came in to a hospital in a similar intoxicated state. On recovery a couple of days later he complained of a pain in his shoulder. He had thrown things at the nursing staff the night before and there wasn’t a lot of sympathy around. After a brief examination his shoulder was X-rayed and to nobody’s surprise no fracture was seen. He was sent home. He was readmitted two days later and a fractured cervical spine was diagnosed. Would the assessment have been any more careful if he had not been an alcoholic? I am sure it would have been.

These stories are not particularly newsworthy and I’m sure you could easily have come up with similar reports. Judging from the headlines in the press, these incidents are not unique to the hospitals I have worked in.

There are a few lessons I am trying hard to put into practice:

  • Alcohol is a powerful analgesic, and serious injuries can easily be missed when an intoxicated patient is admitted.
  • Taking a clear history & performing a careful examination is often difficult or impossible when your patient is drowsy, confused or otherwise unco-operative. So don’t just rely on first impressions. Go back and re-examine. If in doubt, do the imaging.
  • Make sure that there is a good protocol in place for managing alcohol withdrawal including the use of scoring systems such as CIWA-Ar. This will help to prevent periods of agitation, confusion or drowsiness.
  • Set the example by always treating the alcoholic with respect, even if you are getting abuse.

Motor Vehicle Accidents can also be prevented by paying attention to the rear-view mirror: if you see a high powered motorbike approaching you might know from experience that it is likely to overtake you rather sooner than expected. An important skill in medicine is to develop the habit of honest reflection.



Buzzing the brain in Fibromyalgia?



Proposed ‘Neuropoint’ machine

A recent study reported in the journal ‘Pain medicine’ could point to a new type of treatment for people who suffer from Fibromyalgia syndrome. In this small study a group of patients received over 20 brief twice weekly treatment sessions of direct current stimulation to the brain over a 3 month period. The improvement in the treatment group was quite impressive (see below).

The use of transcranial direct current stimulation for treating chronic pain is not new, but studies using this technique in patients with FMS had not previously shown dramatic improvements. The concept behind this type of therapy is that the application of low voltage current to the cortex of the brain can change the excitation level of nerve cells or neurones. Although the nature of FMS cannot yet be proven, current evidence seems to support the theory that it is characterized by central ‘sensitisation’. One hypothesis to explain this suggests that this is due to the resting state of neurones in patients with FMS being ‘over-excited’ and always at or near the threshold for firing. This is sometimes called ‘hyper-vigilance’ If the ‘thermostat’ for pain could be ‘reset’ back down towards normal this could help kick start people into the sort of lifestyle changes needed to bring about long term improvements.

In this study, the authors claim that the use of a combination of high and low frequencies to deliver current helps to ‘permit passage of the low-frequency components to deeper cortical tissues with minimal attenuation’. Since other studies seem to indicate that the problems with signal interpretation, amplification and/or networking in FMS lies deep in the brain, this would seem like a good area of the brain to target.

The positive results reported in this study are quite impressive for those of us used to reviewing FMS studies – they reported major improvements in pain, sleep quality, fatigue and overall quality of life. Results were reported for two groups with 35 patients each: one group received the direct current treatment, the other group ‘sham’ or placebo therapy. On average the patients had a 10 year history of FMS, so these were patients with quite chronic symptoms. The average reduction in the number of ‘tender points’ in the treated group was 7.4 (from a starting point of 17) so it is important to make it clear that this treatment did not cure the patients of their pain. However, the change in the placebo group was 0.2 (not significant). The pain threshold reduced from 36 by 19.6 in the treatment group, but by only 3.2 in the placebo group. The quality of life index (FIQ) improved by 15 from 61.5 in the treatment group with no change in the placebo treatment group. Side effects were few, with 0.3% reporting a short-lived headache.


I was at the session at the American College of Rheumatology meeting where this research was presented in 2010. There was a lot of interest in the results which almost seemed too good to be true. We have had a lot of ‘false dawns’ in FMS treatment, and as a result I’m a bit cautious and keen to wait for the full evidence to come out. The results in the full paper published in Jan 2012 are unchanged, but it is interesting that the conclusion states that the treatment ‘provided modest improvements to pain, tender point measures, fatigue and sleep’. Before we all go out and order a ‘Neuropoint’ machine (see above) to deliver this high/low frequency current to our FMS patients, we really need someone else to independently replicate these results. I do wonder if the ‘blinding’ was effective or if the patients receiving the real treatment felt something more than the placebo group. The paper notes under ‘conflicts of interest’ that the lead author (JBH) has intellectual property interest in the technique used to deliver the current and is a shareholder in the Cerephex Corporation set up to market the equipment used in this study.

The Cerephex Corporation web pages indicate that a follow up study has been carried out: “at 45-months past end of treatment, 76% of surveyed patients reported reduced or eliminated need for pain medications, and 71% report reduced or eliminated need to see doctors or caregivers”. This is an even more impressive result than that reported in the original trial – but again, it needs to be independently verified. If validated, it would seem that the course of treatment could be considered something that provides long lasting relief and not just short term symptom relief. The device – which they are calling ‘Neuropoint’ has not yet been licenced by the FDA and to my knowledge is not yet available in Europe. I understand that a larger trial is about to commence to get further evidence to support an FDA approval.

Jeffrey B. Hargrove, Robert M. Bennett David G. Simons, Susan J. Smith, Sunil Nagpal, and Donald E. Deering. A Randomized Placebo-Controlled Study of Noninvasive Cortical Electrostimulation in the Treatment of Fibromyalgia Patients
Pain Medicine 2012; 13: 115–124


Caffeine and the Rheumatologist


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As a passionate fan of coffee, I feel like a real ‘killjoy’ when I advise people with arthritis not to drink too much coffee. So why all the fuss?

The problem is that caffeine has an effect on a chemical in the body called adenosine which is also the target of Methotrexate. In theory taking too much caffeine could stop Methotrexate working, and some studies (in rats, I have to admit) suggest that this  is a real effect. If you want to read about this in more detail, check out a recent article by Bruce Cronstein. Dr Cronstein and his co-workers have done much of the research so he knows what he is writing about. Methotrexate causes release of adenosine which may have an anti-inflammatory effect whereas  caffeine blocks the adenosine receptor (i.e. stops it working). Interestingly, he also says that adenosine helps put us to sleep and this may be why people taking Methotrexate often feel tired. From a practical point of view, if your Methotrexate is working well I wouldn’t worry too much about this, but if it hasn’t had the desired effect then cutting down on caffeine might just work! There are some pretty good decaff coffees so you mightn’t have to give up your favourite drink, after all.

Finally, a poem about coffee and the thinking man…

21st Century Rodin

The upper right-hand
corner of my desk blotter;
a fresh, stark canvas
this morning, now a sepia
montage of concentric
I sip,
I Think.
I sip,
I think.
I sip…
I think.
Colin Harmon, award winning barista, in Dublin brews concoctions here!Sip.
Big sip
sip sip sip
sip sip sippppp.
Final sip, cup down.
A caffeine-laced
still life of a Slinky.
was-I-ever productive

-Mark L. Lucker


Carrots and Sticks in the Workplace

amazon-warehouse-4In many ways you have to admire Amazon as a business.

They do organisation very well. They do big data very well. They collect and make use of their customer’s opinions in a way that has to be admired.

However, there are some who suggest that from an employee’s perspective, things might look a little different. A Panorama documentary recently exposed some of the ‘incentives’ used to encourage maximum productivity among the ‘pickers’ in their warehouses. This has also been the subject of an excellent article by Sarah O’Connor in the Financial Times.

What is not in doubt is that Amazon closely monitors their workers’ movements in order to increase the speed and efficiency of their work. The workers carry computer bar-code readers that count them down to the next ‘pick’ and start beeping when they make errors or get too far behind. As the worker’s performance improves, their targets are increased progressively. They meet with their managers regularly to discuss their performance and temporary workers face the prospect of early ‘release’ if they under-perform. This sort of intensive monitoring may be commonplace in the U.S., but in the U.K. the reaction has suggested that Amazon may be favouring stick more than carrot. So is it the monitoring that causes stress or is it the incentive? What if instead of being afraid of a penalty you could win a prize for the best performance of the day/week? What if you got a bonus for doing more than your target? What if you were competing for the best ‘team’ in the warehouse? I’m sure there are many workers who would westatsportslcome the challenge.

viper_podAn exciting example of the high-tech monitoring of movement at work is the use of the ‘ViperPod’ by most of the UK Premier League football and rugby clubs as well as GAA clubs such as Tyrone. An article in the Daily Mail shows how this small device captures a wealth of highly accurate information about the sportsperson’s movement, energy expenditure and physiological state. The Irish company STATSports now has an impressive international list of clients. Sports scientists Alan Clarke and Sean O’Connor have cleverly combined the latest gyroscope/accelerometer sensors with high frequency GPS and radio-frequency transmitters allowing detailed information on each player on the pitch to be analysed in real-time at the pitch side using their proprietary software. One of the STATSports analysts explained to ‘TheScore’ how this information can be used to prevent injuries as well as optimise performance. The way in which clubs use this information to influence their players could have either a positive or negative effect on their productivity and creativity.

Employers have started to look at using ‘gamification‘ techniques to boost employee health and productivity. Can measuring movement be used to create positive incentives to healthy lifestyle behaviours and improve employee health? Blue Shield have used several, including Shape Up Shield and MeYou. Healthrageous used personalised coaching to encourage healthy choices among employees via their mobile devices, but the business failed to thrive and it was taken over last year by the health and insurance giants Humana. Should people be given a discount if they can prove that they are adopting a health active lifestyle? Or is this an invasion of privacy?

So, what has all this got to do with the jobbing Rheumatologist? Perhaps not very much, but we’re clearly reaching the point where monitoring ambulatory activity in an accurate and scientific way is both feasible and affordable. And it is also becoming clear that this information can be used to alter behaviour, promote rehabilitation and perhaps even prevent injury. In my next post I’ll be looking at the first attempts to measure ambulatory activity as an outcome in arthritis patients.


Computer gaming as a new paradigm for medical education

In a recent Tweet Eric Topol, guru of digital medicine and author of the acclaimed ‘Creative Destruction of Medicine’, called for the ‘Gamification‘ of medical devices. Could this person centered approach also be applied to medical education?

What would you like to do today?

Instead of expecting that everyone wants to learn, it might be better to assume that everyone enjoys having a bit of fun. The benefits of play based learning has been well established in young children – can we make it work for adults as well? Computer or console based gaming is now a hugely successful industry which involves the gamer in ever more ‘immersive’ scenarios. As games have become more sophisticated they have become more interactive and many of the popular games have an online component. If medical learning is to get heard above the hub-bub of sounds and images in the new digital world perhaps we need to learn and adapt – fast!

Where would you like to start today?

Education can be fun and interactive, but it should start at just the right level for the learner and then progress at the right speed so that the user doesn’t get bored by material that is too simple or overwhelmed by material well above their level. Just as a computer game has multiple levels, a medical education tool could have levels that are unlocked by entering a code or by completing some problems. If this flexibility was to be built into the interactive learning modules it would mean that potentially the same educational resource could be made available to everyone and material could be shared by students at different levels. Students, doctors, non-medical health professionals and the general public would be able to tailor the material to their needs and contribute. The main aim of this would be to encourage participation rather than to restrict involvement e.g. to members of a professional club. The student should be able to dip in and return where they left off – the computer will record everything they have done. The huge success of the online maths ‘Khan academy’ has shown how this can be used to show the student and/or their tutor how much time they have spent on the system watching videos or working out problems and identifying areas of learning need more work/help.

How do you want to learn today?

Some people prefer text, others may prefer images or video. Some will have ‘gaps’ in their education which they would like to address to help them understand the more complex material more effectively. So why shouldn’t the learner be able to pick out their choices from a ‘menu’ of options? They could use the developer’s description of the material and view the ratings of other users. They could even choose to follow the menu choices of another user from a similar educational background. This way of exploring the educational ‘menu’ would be unique to them and their tastes, although at intervals a ‘waiter’ type advisor could prompt them with suggestions as to how they could progress.

What level of certification do you want to achieve?

The same open-source resource could be used to just give people information for answers to a specific question or problem – or form a module or even a major part of a university level degree. Employers are still likely to require some evidence of an adequate standard of learning before they will employ someone in the health service/industry. Open source models can seem unrealistic because of the financial risk, but if they prove popular there may well be a viable financial model. This could be based on online revenue, but in the early stages the revenue stream could be through tried and tested University e-Learning models. The ‘paid’ part of the resource – provided through a University – would provide personal support (tutors, face to face sessions etc.), practical sessions with the aim of leading to a validated stand alone certification. This could be a module toward a postgraduate MSc in Rheumatology for GPs or Allied health professionals or be used to provide approved CPD in Rheumatology for specialists.

Who do you want to learn with?

The majority of children and adults in Europe and the US now spend a lot of their time using the internet, and the explosion in usage of social media and youtube shows that people not only like to view images and  video but they also love to share their personal experience and discoveries with others. In one sense, they are ‘educating’ their network of friends – perhaps about what sort of person they are or what they like or find interesting. This reminds me of how students in Harvard University can ‘pick and choose’ their lecturers by asking other students to find out who the most popular ones are. If learners using the module are encouraged to do the course with others they know (who may be in geographically distant location) they may have more incentive to participate and contribute. Participants can help each other – some sites give members points or stars for posting comments and additional stars for giving good advice to others. In the case of ‘World of Warcraft’ over 11 million users invest on average 22 hours per week hours gaming, resulted in a massive Wikipedia resource. I would guess that usage of ‘Modern Warfare 3′ and similar games is similar: type in ‘modern warfare’ and YouTube into Google and you get over 380 million videos. That’s a lot of educational material!

These points and more are well illustrated in this infographic by Knewton:

Gamification of Education

Created by Knewton and Column Five Media



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