Today I learned there were two more videos realted to the BlogWorld Expo, that I shouldn’t withhold you.
First, the ABC News Covered the Medblogger Track At Blog World Expo. Here is an interview with Dr. Val Jones with Dave Lucas of ABC.
The video “Medical Bloggers On ABC News: Empowering Patients With Accurate Information” is summarized as follows at her blogGet Better Health:
….”Dave Lucas is tired of all the false health information that fills his email inbox each day. He’s very relieved that there are physicians, nurses, and patient advocates “swimming against the tide” of pseudoscience and misleading health information online. Today Dave and I discussed how people can find accurate and potentially life-saving health information through peer-reviewed medical blogs, thanks to the health blogger code of ethics (administered by MedPage Today)”.
Another interview was with Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, and author of Running a Hospital. Paul participated in a panel discussion as part of the Medblogger Track (co-sponsored by Johnson & Johnson and MedPage Today). Because the video is barely audible, I just mention his main statements (highlighted in red in the video shown here at the JNJ Health Channel):
Paul writes his blogposts without any prior permission or approval process
It is quicker to fix a mistake on a blog, than it is in traditional media
Biggest regret is responding to sarcastic or hostile comments in kind instead of staying above the fray
Medical Bloggers On ABC News: Empowering Patients With Accurate Information
During my stay in Singapore from October 9th-16th there were 2 other great events, one of them being the Blogworld Expo, the World largest Conference on Blogging in the Las Vegas Convention Center. As a matter of fact, I would never have the opportunity to go to such a place, because I’m blogging in my spare time and although it has many spin-offs for my work, I would never have the resources and the time to go there. So, it was with a little jealousy and envy that I followed all those cheerful tweets from my colleague medbloggers. They apparently had a lot to talk about, -also outside the context of the meeting. I even understood that Bongi came all the way from South Africa. And I can’t say the video below eases the pain :
The opening keynote of the Blogworld Expo was delivered by Richard Jalichandra, CEO of Technorati, showing some highlights from their annual study following the growth and trends in the annual State of the Blogosphere. The report was released over five days. (See Techcruch for presentation and short explanation ; the entire report is available at Technorati)
What I found most interesting:
In Social Media the content is the conversation.
There is a rising class of “professional” bloggers.
But still Hobbyists represent 76% of all bloggers
(I have some problems with the division in ‘professional bloggers’ and ‘hobbyist’ though, since professional bloggers are those regarded as “earning some money” and hobbyists are regarded as those that don’t. I think there should at least be 3 main groups: those blogging as a profession (earn money), those blogging as an expert (mostly) in their free time (professionally) and those writing about their hobbies, children etc (hobbyists).
The hobbyists blog for fun and to express themselves
15% is part time professional, they blog to supplement their income and to share their expertise
9% is self-employed, 4% is corporate (see Figure below)
Of the professional bloggers 2 thirds are male, 16% are 18-44, are more effluent and educated than the general population and the hobbyist bloggers (hmmm that also pleads against medbloggers not belonging to this group)
73% of all bloggers use Twitter vs 14% of the general population (but nr 1 reason is to promote their blog)
26% of bloggers who also use Twitter say that the service has eaten into the time they spend updating their traditional blogs – though 65% say it has had no effect.
on average only .83% of the page views come from Twitter referrals.
Advise to succeed: be passionate.
Bloggers believe that politics (57%) and technology/business (44%-20%) are among the fields most impacted by the blogosphere, and that they will continue to be transformed by the blogosphere going forward. Health was only mentioned by 5%.
I wonder where/whether Science/Health/Medbloggers fit in? Are they underrepresented in the study? Or do they belong to a minority anyway? See here a discussion on Twitter (catched with QuoteURL)
Emma Tavender of the EPOC Australian Satellite, Australia reported on the survey carried out by the UK Cochrane Centre to identify the use of Cochrane reviews in guidelines produced in the UK ) (not attended this presentation) .
Pwee Keng Ho, Ministry of Health, Singapore, is leading the Health Technology Assessment (HTA) and guideline development program of the Singapore Ministry of Health. He spoke about the issues faced as a guideline developer using Cochrane reviews or -in his own words- his task was: “to summarize whether guideline developers like Cochrane Systematic reviews or not” .
Keng Ho presented the results of 3 surveys of different guideline developers. Most surveys had very few respondents: 12-29 if I remember it well.
Each survey had approximately the same questions, but in a different order. On the face of it, the 3 surveys gave the same picture.
Main points:
some guideline developers are not familiar with Cochrane Systematic Reviews
others have no access to it.
of those who are familiar with the Cochrane Reviews and do have access to it, most found theCochrane reviews useful and reliable. (in one survey half of the respondents were neutral)
most importantly theyactually did use the Cochrane reviews for most of their guidelines.
these guideline developers also used the Cochrane methodologyto make their guidelines (whereas most physicians are not inclined to use the exhaustive search strategies and systematic approach of the Cochrane Collaboration)
An often heard critique of Guideline developers concerned the non-comprehensive coverage of topics by Cochrane Reviews. However, unlike in Western countries, the Singapore minister of Health mentioned acupuncture and herbs as missing topics (for certain diseases).
This incomplete coverage caused by a not-demand driven choice of subjects was a recurrent topic at this meeting and a main issue recognized by the entire Cochrane Community. Therefore priority setting of Cochrane Systematic reviews is one of the main topics addressed at this Colloquium and in the Cochrane Strategic review.
Kay Dickersin of the US Cochrane Center, USA, reported on the issues raised at the stakeholders meeting held in June 2009 in the US (see here for agenda) on whether systematic reviews can effectively inform guideline development, with a particular focus on areas of controversy and debate.
The Stakeholder summit concentrated on using quality SR’s for guidelines. This is different from effectiveness research, for which the Institute of Medicine (IOM) sets the standards: local and specialist guidelines require a different expertise and approach.
All kinds of people are involved in the development of guidelines, i.e. nurses, consumers, physicians.
Important issues to address, point by point:
Some may not understand the need to be systematic
How to get physicians on board: they are not very comfortable with extensive searching and systematic work
Ongoing education, like how-to workshops, is essential
What to do if there is no evidence?
More transparency; handling conflicts of interest
Guidelines differ, including the rating of the evidence. Almost everyone in the Stakeholders meeting used GRADE to grade the evidence, but not as it was originally described. There were numerous variations on the same theme. One question is whether there should be one system or not.
Another -recurrent- issue was that Guidelines should be made actionable.
Gordon Guyatt, McMaster University, Canada, gave an outline of the GRADE approach and the purpose of ‘Summary of Findings’ tables, and how both are perceived by Cochrane review authors and guideline developers.
Gordon Guyatt, whose magnificent book ” Users’ Guide to the Medical Literature” (JAMA-Evidence) lies at my desk, was clearly in favor of adherence to the original Grade-guidelines. Forty organizations have adopted these Grade Guidelines.
Grade stands for “Grading ofRecommendations Assessment, Development and Evaluation” system. It is used for grading evidence when submitting a clinical guidelinesarticle. Six articles in the BMJ are specifically devoted to GRADE (see here for one (full text); and 2 (PubMed)). GRADE not only takes the rigor of the methods into account, but also the balance between the benefits and the risks, burdens, and costs.
Suppose a guideline would recommend to use thrombolysis to treat disease X, because a good quality small RCTs show thrombolysis to be slightly but significantly more effective than heparin in this disease. However by relying on only direct evidence from the RCT’s it isn’t taken into account that observational studies have long shown that thrombolysis enhances the risk of massive bleeding in diseases Y and Z. Clearly the risk of harm is the same in disease X: both benefits and harms should be weighted.
Guyatt gave several other examples illustrating the importance of grading the evidence and the understandable overview presented in the Summary of Findings Table.
Another issue is that guideline makers are distressingly ready to embrace surrogate endpoints instead of outcomes that are more relevant to the patient. For instance it is not very meaningful if angiographic outcomes are improved, but mortality or the recurrence of cardiovascular disease are not.
GRADE takes into account if indirect evidence is used: It downgrades the evidence rating. Downgrading also occurs in case of low quality RCT’s or the non-trade off of benefits versus harms.
Guyatt pleaded for uniform use of GRADE, and advised everybody to get comfortable with it.
Although I must say that it can feel somewhat uncomfortable to give absolute rates to non-absolute differences. These are really man-made formulas, people agreed upon. On the other hand it is a good thing that it is not only the outcome of the RCT’s with respect to benefits (of sometimes surrogate markers) that count.
A final remark of Guyatt: ” Everybody makes the claim they are following evidence based approach, but you have to learn them what that really means.” Indeed, many people talk about their findings and/or recommendations being evidence based, because “EBM sells well”, but upon closer examination many reports are hardly worth the name.
Chris and I will facilitate a web 2.0 workshop for the Cochrane (see here, for all workshops see here).
The entire program can be viewed at the Cochrane Colloquium site.
Chris Mavergames, Web Operations Manager and Information Architect of the Cochrane Collaboration will also give a plenary presentation entitled:
“Cochrane for the Twitter generation:
inserting ourselves into the ‘conversation‘”.
The Cochrane Collaboration is not unique in facing a considerable challenge to the way it packages and disseminates healthcare information. The proliferation of communication platforms and social networking sites provides opportunities to reach new audiences, but how far can or should the Collaboration go in embracing these new media? In this session we hear from speakers who are at the heart of the discussions about The Cochrane Library’s future direction, including the Library’s Editor in Chief. We finish the session with reflections on the week’s discussions with respect to the Strategic Review (…)
Request (for the workshop, not the plenary session):
If you ‘re on Twitter, could you please tell the participants of the (small) web 2.0 workshop your opinion on the following, using the hashtag #CC20.*
Notably, the preview version is expected to run for at least two weeksafter which the old PubMed will dissapear!(see NLM technical Bulletin, Sept 11) and Twitter). Since the playing time might be very short: start trying the new interface now!
As announced in the NLM Technical Bulletin (Oct 1) and on Twitter, there will be webcastsTuesday, Oct 6: 9:00*- 9:30 am, 11:00 – 11:30 am and Wednesday, Oct 7: 1:00 – 1:30 pm, 2:00 pm – 2:30 pm Eastern Time.
(*see here for the corresponding time in your timezone).
A very interesting presentation at the CECEM was given by the organizer of this continental Cochrane meeting, Rob de Bie. De Bie is Professor of Physiotherapy Research and director of Education of the Faculty of Health within the dept. of Epidemiology of the Maastricht University. He is both a certified physiotherapist and an epidemiologist. Luckily he kept the epidemiologic theory to a minimum. In fact he is a very engaging speaker who keeps your attention to the end.
Guidelines
While guidelines were already present in the Middle Ages in the form of formalized treatment of daily practice, more recently clinical guidelines have emerged. These are systematically developed statements which assists clinicians and patients in making decisions about appropriate treatement for specific conditions.
Currently, there are 3 kinds of guidelines, each with its own shortcomings.
Consensus based. Consensus may be largely influenced by group dynamics Consensus = non-sensus and Consensus guidelines are guidelies.
Expert based. Might be even worse than consensus. It can have all kind of biases, like expert and opinion bias or external financing.
Evidence based. Guideline recommendations are based on best available evidence, deals with specific interventions for specific populations and are based on a systematic approach.
The quality of Evidence Based Guidelines depends on whether the evidence is good enough, transparent, credible, available, applied and not ‘muddled’ by health care insurers.
It is good to realize that some trials are never done, for instance because of ethical considerations. It is also true that only part of what you read (in the conclusions) has actually be done and some trials are republished several times, each time with a better outcome…
Systematic reviewsand qualitatively good trials that don’t give answers.
Next Rob showed us the results of a study ( Jadad and McQuay in J. Clin. Epidemiol. ,1996) with efficacy as stated in the review plotted on the X-axis and the Quality score on the Y-axis. Surprisingly meta-analysis of high quality were less likely to produce positive results. Similar results were also obtained by Suttorp et al in 2006. (see Figure below)
Photo made by Chris Mavergames
There may be several reasons why good trials not always give good answers. Well known reasons are the lack of randomization or blinding. However Rob focused on a less obvious reason. Despite its high level of evidence, a Randomized Controlled Trial (RCT) may not always be suitable to provide good answers applicable to all patients, because RCT’s often fail to reflect the true clinical practice. Often, the inclusion of patients in RCT’s is selective: middle-aged men with exclusion of co-morbidity. Whereas co-morbidity occurs in > 20% of the people of 60 years and older and in >40% of the people of 80 years and older (André Knottnerus in his speech).
Usefulness of a Nested Trial Cohort Study coupled to an EHR to study interventions.
Next, Rob showed that a nested Trial cohort study can be useful to study the effectiveness of interventions. He used this in conjunction with an EHR (electronic health record), which could be accessed by practitioner and patient.
One of the diseases studied in this way, was Intermittent Claudication. Most commonly Intermittent Claudication is a manifestation of peripheral arterial disease in the legs, causing pain and cramps in the legs while walking (hence the name). The mortality is high: the 5 year mortality rates are in between those of colorectal cancer and Non-Hodgkin Lymphoma. This is related to the underlying atherosclerosis.
There are several risk factors, some of which cannot be modified, like hereditary factors, age and gender. Other factors, like smoking, diet, physical inactivity and obesity can be tackled. These factors are interrelated.
Rob showed that, whereas there may be an overall null effect of exercise in the whole population, the effect may differ per subgroup.
Patients with mild disease and no co-morbidity may directly benefit from exercise-therapy (blue area).
Exercise has no effect on smokers, probably because smoking is the main causative factor.
People with unstable diabetes first show an improvement, which stabilized after a few weeks due to hypo- or hyperglycaemia induced by the exercise,
A similar effect is seen in COPD patients, the exercise becoming less effective because the patients become short of breath.
It is important to first regulate diabetes or COPD before continuing the exercise therapy. By individually optimizing the intervention(s) a far greater overall effect is achieved: 191% improval in the maximal (pain-free) walking distance compared to for instance <35% according to a Cochrane Systematic Review (2007).
Another striking effect: exercise therapy affects some of the prognostic factors: whereas there is no effect on BMI (this stays an important risk factor), age and diabetes become less important risk factors.
Because guidelines are quickly outdated, the findings are directly implemented in the existing guidelines.
Another astonishing fact: the physiotherapists pay for the system, not the patient nor the government.
More information can be found on https://www.cebp.nl/. Although the presentation is not (yet?) available on the net, I found a comparable presentation here.
This week I was attending another congress, the Continental European Cochrane Entities Meeting(CECEM).
This annual meeting is meant for staff from Cochrane Entities, thus Centre Staff, RGC’s (Review Group Coordinators), TSC’s (Trial Search Coordinators) and other staff members of the Cochrane Collaboration based in Continental Europe.
CECEM 2009 was held in Maastricht, the beautiful old Roman city in the South of the Netherlands. The city where my father was born and where I spend many holidays.
One interesting presentation was by Cochranes’ 1st Editor in chief, David Tovey, previouslyGP in an urban practice in London for 14 years and Editorial Director of the BMJ Group’s ‘Knowledge’ division (responsible for BMJ Clinical Evidence and its sister product Best Treatments, see announcement in Medical News Today)
David began with saying that the end user is really the key person and that the impact of the Cochrane Reviews is most important.
“How is it that a Senior health manager in the UK may shrug his shoulders when you ask him if he has ever heard of Cochrane?”
“How do we make sure that our work had impact? Should we make use of user generated content?”
Quality is central, but quality depends on four pillars. Cochrane reviews should be reliable, timely, relevant and accessible.
How quality is perceived is dependent on the end users. There are several kinds of end users, each with his own priorities.
doctor: wants comprehensive and up-to-date info, wants to understand and get answers quickly.
patient: trustworthiness, up-to-date, wants to be able to make sense of it.
scientist: wants to see how the conclusions are derived.
policy and guideline-makers.
Reliable: Several articles have shown Cochrane Systematic Reviews to be more reliable then other systematic reviews (Moher, PLOS BMJ)*
Timely: First it takes time to submit a title of a Cochrane Review and then it takes at least 2 years before a protocol becomes a review. Some reviews take even longer than 2 years. So there is room for improvement.
Patients are also very important as end user. Strikingly, the systematic review about the use of cranberry to prevent recurrent urinary tract infection is the most frequently viewed article,- and this is not because the doctors are most interested in this particular treatment….
Doctors: Doctors often rely on their colleagues for a quick and trustworthy answer. Challenge: “can we make consulting the Cochrane Library as easy as asking a colleague: thus timely and easy?”
Solutions?
making plain language summaries more understandable
Summary of Findings
podcasts of systematic reviews (very successful till now), .e. see an earlier post.
Web 2.0 innovations
Key challenges:
ensure and develop consistent quality
(timely) updating
putting the customer first: applicability & prioritization
web delivery
resources (not every group has the same resources)
make clear what an update means and how important this update is: are there new studies found? are these likely to change conclusions or not? When was the last amendment to the search?
I found the presentation very interesting. What I also liked is that David stayed with us for two days -also during the social program- and was easy approachable. I support the idea of a user-centric approach very much. However, I had expected the emphasis to be less on the timeliness (of updates for instance), but more on how users (patients, doctors) can get more involved and how we review the subjects that are most urgently needed. Indeed, when I twittered that Tovey suggested that we “make consulting the Cochrane Library as easy as asking a colleague”, Jon Brassey of TRIP answered that a lot has to be done to fulfill this, as the Cochrane only answers 2 out of 350+ questions asked by GPs in the UK, a statement that appeared to be based on his own experience (Jon is founder of the TRIP-database).
But in principle I think that Jon is correct. Right now too few questions (in the field of interventions) are directly answered by Cochrane Systematic Reviews and too little is done to reach and involve the Cochrane Library users.
click to enlarge
During the CECEM other speakers addressed some of these issues in more detail. André Knottnerus, Chair of the Dutch Health Council, discussed “the impact of Cochrane Reviews”, and Rob the Bie of the Rehabilitation & Related Therapies field discussed “Bridging the gap between evidenced based practice and practice based evidence”, while Dave Brooker launched ideas about how to implement Web 2.0 tools. I hope to summarize these (and other) presentations in a blogpost later on.
*have to look this up
NOTE (2009-11-10).
I had forgotten about this blank “citation” till this post was cited quite in another context (see comment: http://e-patients.net/archives/2009/11/tell-the-fda-the-whole-story-please.html) and someone commented that the asterisk to the “the amazing statement” had still to be looked up, indirectly arguing that this statement thus was not reliable- and continuing by giving an example of a typically flawed Cochrane Review that hit the headlines 4 years ago, a typical exception to the rule that “Cochrane systematic reviews are more reliable than other systematic reviews”. Of course when it is said that A is more trustworthy than B it is meant on average. I’m a searcher, and on average the Cochrane searchers are excellent, but when I do my best I surely can find some that are not good at all. Without doubt that also pertains to other parts of Cochrane Systematic Reviews.
In addition -and that was the topic of the presentation- there is room for improvement.
Now about the asterisk, which according to Susannah should have been (YIKES!) 100 times bigger. This was a post based on a live presentation and I couldn’t pick up all the references on the slides while making notes. I had hoped that David Tovey would have made his ppt public, so I could have checked the references he gave. But he didn’t and so I forgot about it. Now I’ve looked some references up, and, although they might not be identical to the references that David mentioned, they are in line with what he said:
Moher D, Tetzlaff J, Tricco AC, Sampson M, Altman DG, 2007. Epidemiology and Reporting Characteristics of Systematic Reviews. PLoS Med 4(3): e78. doi:10.1371/journal.pmed.0040078 (free full text)
The PLoS Medicine Editors 2007 Many Reviews Are Systematic but Some Are More Transparent and Completely Reported than Others. PLoS Med 4(3): e147. doi:10.1371/journal.pmed.0040147 (free full text; editorial coment on [1]
Anders W Jørgensen, Jørgen Hilden, Peter C Gøtzsche, 2006. Cochrane reviews compared with industry supported meta-analyses and other meta-analyses of the same drugs: systematic review BMJ 2006;333:782, doi: 10.1136/bmj.38973.444699.0B (free full text)
Alejandro R Jadad, Michael Moher, George P Browman, Lynda Booker, Christopher Sigouin, Mario Fuentes, Robert Stevens (2000) Systematic reviews and meta-analyses on treatment of asthma: critical evaluation BMJ 2000;320:537-540, doi: 10.1136/bmj.320.7234.537 (free full text)
I’m in Dublin to attend the EAHIL workshop 2009.
The EAHIL is the European Association for Health Information and Libraries.
The EAHIL -workshop 2009 really started Wednesday afternoon. Tuesday morning, as a foretaste of the official program I attended a Continuing Education Course,namely the Web 2.0 and Health Information course by Chris Mavergames.
Chris Mavergames is currently the Web Operation Manager/Information Architect for the Cochrane Collaboration. Before, he worked in the field of information and library science.
So Chris and I are really colleagues, but we didn’t realize until we “met” on Twitter.
On this hot day in June I was pleased that the workshop was held in the cool Berkeley Library of Trinity College. They have chosen real good locations for this EAHIL workshop. Most presentations are in the Dublin Castle, another place at the Heart of the Irish History.
The workshop took approximately 3 hours and consisted of two presentations, followed by short Q&A’s and an open forum afterwards.
The presentations:
“Web 2.0 and Health Information“,
A case study of the experiences of implementing and using these technologies in a large, non-profit organization (Cochrane Collaboration).
Eighteen people could attend. Each of us had a computer, which raised expectations that they were needed during the workshop. They were not, but they were handy anyway to look up things and to draft a post. And.. I could post this message on Twitter before Chris loaded a photo of his class on TwitPic. LOL.
Web 2.0 versus web 1.0
Chris began with asking the audience how many people either have used ..or at least have heard of Facebook, LinkedIn or any other social networking service. And then he asked which tools were being used. Afterwards he admitted he had checked everyone’s presence on various social bookmarking sites. Hilarious.
To my surprise, quite a number of people were familiar with most of the web 2.0 services and sources. Indeed, weren’t librarians the first to embrace web 2.0?
I got the impression Twitter was the least well known/appreciated tools. Most people were either on Facebook or Linkedin, not on both. This presumably has to do with separation of professional and personal things.
Chris first explained the difference between Web 1.0 and Web 2.0: Web 1.0 is a one way interaction, static. Web 2.0 is: “more finding or receiving, less searching”. It has a dynamic aspect: there is more interaction, the possibility to ‘comment, subscribe, post, add, share or as Chris puts it: “Web 2.0 allows you to have information “pushed” at you vs. you having to “pull”.
Another characteristic of web 2.0 is that technology has become easier. It is now more about content.
As an example he showed the Cochrane website from 2004 (web 1.0) and the current website. The first was just a plain web site where you could search, browse and email, the second has social bookmarking tools and is more dynamic and active: you can add comments, post on websites etc.. In addition the Cochrane Collaboration is now on Twitter and Facebook and produces podcasts of a selection of systematic reviews.
Another example of web 2.0 interfaces are MyNCBI of PubMed (for saving your searches) and i-Google.
Social Networking services These services allow you to create an online profile so that you can interact with others, share and integrate.
Examples are Facebook, LinkedIn and 2 Collab. What is used most, differs around the world. Linkedin is more a professional site, an “online resume” and Facebook is for more general stuff. “You’re mother is on facebook too, so..”. Most young people don’t realize what others can read. However, Facebook offers the possibility to select precisely who can see exactly what.
Twitter
Twitter is a microblogging system, that allows a 140 chracter message (tweet). At first, Chris wasn’t very much interested. He only knew Twitter through the automatic updates on Facebook, but “wasn’t really interested in a friend in New York eating a scrambled egg.”
It is as easy to subscribe to one’s updates as it is to unsubscribe. Chris uses Tweetdeck to filter for keywords that are of interest. But as he showed me later, he uses the i-phone to easily catch what people (he follows) are tweeting.
Although Twitter was created as a social tool it is now much more than that. It creates a so called “ambient awareness” and as such it is a perfect example of “push” technology: you won‘t see every tweet, but you will l be ambiently aware of the conversation (of your “friends” or the subject you follow). Twitter is also very useful for getting a real fast answer to your question. This is how Chris learned the value of Twitter. He had a question at a meeting. Someone said: just put it on Twitter with the hashtag of the congress (an agreed upon keyword with #in front, like #EAHIL2009). He did it and within 3 minutes he got an answer. Twitter is also very useful for sharing and finding links.
There are many “Twitter apps” around. Just search Google for it.
For professional use within a company the twitter look-alike Yammer can be a useful alternative, because only people in the company are able to follow the updates.
My personal experience is also very positive. Twitter and other web 2.0 tools can work synergistically, dependent on your Twitter community and how you use it.
Social bookmarking: Although librarians aren’t always very happy with user generated tagging, social bookmarking tools are and easy way of allowing users to share a collections of links.
Links used (directly or indirectly) for his presentation are available at del.icio.us/mavergames under the tag EAHIL.
Blogs, Wiki’s A blog can give a good summary of interesting articles in a particular field. Chris began a blog 2 months ago (http://mavergames.net) about a very specific subject he is involved in: Drupal. For him is it just an open notebook: a platform to share your ideas with others.
It is possible receiving updates via RSS (push).
Wiki’s are a very powerful knowledge gathering tool, a way to collaboratively create a resource, based on the principle of “Crowd sourcing” (The Wisdom of Crowds).
Platforms can vary from Google Reader, Yahoo, Bloglines, but you can also use i-Google or a specilized medical page where you can find links to all kinds of sources, like blogs, podcasts and journals. Perssonalized Medicine (http://www.webicina.com/rss_feeds/) is especially recommended.
Chris visits Laika’s MedlibLog and reads Cochrane PodCasts are available.
He finds it interesting , goes to the Cochrane websiteand subscribes to the Cochrane podcasts with RSS.
He want to share this finding with others, so he decides to tweet that Cochrane podcasts are available.
He gets a response: Hé do you know the Cochrane is on Facebook, so he visits Facebook, joins and posts the news on facebook again. And so on.
Not only did Chris give a nice overview of Web 2.0 tools, but there was ample opportunity for discussions and remarks.
The two most common questions were: [1] When can you find time for this? and [2] what can you do when the IT-departments don’t allow access to web 2.0 tools like YouTube, Facebook, RSS? It really seamed the main barrier for librarians from many countries to the use of web 2.0. Nevertheless, Chris engaging presentation seemed to encourage many people to try the tools that were new to them at home. Afterwards I only heard positive comments on this workshop.
“We’ll be publishing a wide range of articles, from those that share anecdotes about why we need to improve the health care system, to examples of innovations and care that are working well, through to the policy recommendations that we need.”
Although I easily could give some anecdotal examples from the past about “failures or shortcomings” in Healthcare, I prefer to give some positive examples of how a web 2.0 approach can bring patients and doctors together. There are numerous examples of successful application of web 2.0 tools by patients to find and share information and to improve the management of their disease. There are also many healthcare people who use web 2.0 tools to write down their experiences (blogs, social media), to get their information (RSS) and to put information on the web (wiki’s) for patients or colleagues. There are hospitals that are actively engaged in social media and that facilitate patients to use these tools to gather information, but I’ve seldom seen a real web 2.0 based patient-doctor collaboration…. till recently…. close to home in Nijmegen at the Zorg 2.0 (Health 2.0) event, organized by Lucien Engelen (twitter: zorg20; and on linkedin). In fact, the whole meeting was a success with lots of interesting lectures (i.e. from Bertalan Mesko of Scienceroll and Maarten Lens Fitzgerald of Maarten’s Journey.) and workshops.
All podcasts of the Zorg 2.0 event can be seen here
Two presentations were given by two professors on patient centered care in the so called award winning initiative MijnZorgNet (MyCareNet): Bas Bloem and Jan Kremer.
I will discuss their two presentations in separate posts.
This post will summarize the presentation of Bas Bloem, neurologist from the UMC St Radboud Ziekenhuis Nijmegen and initiator of the Parkinson Center.
Bas Bloem began with his “take home message” (with which I couldn’t agree more):
Health 2.0 is not “the world of gadgets”, but a new way of thinking in healthcare:
the patient becomes centric, care becomes collaborative: the patient is not passive, he is “equal” to the healthcare provider. It isn’t “he asks, we provide”, but the patient definitively has a voice (and choice) in his own healthcare.
coherent and transparent healthcare.
expertise (few experts, but with very specialized knowledge).
He set up a program for Parkinson care delivery networks, first in the surroundings of Nijmegen and later throughout the Netherlands. Although his talk is about Parkinson, it can be seen as a model for all kinds of complex diseases.
Bas is an idealist. He believes most healtcare people choose their job to really help people. Doctors choose to care. Only the system doesn’t help them to realize this.
To change this, a paradigm shift is needed. Healthcare needs to be centered round the patient:
The patient has the right to see the best specialist -in a structured way; the assessment of the patient is “CENTRAL”, in an intramural setting, i.e. by a neurologist. In the present example, people from the first line can easily contact the specialists or plan an appointment in their agenda. In this way the patient is helped promptly and he notices the good cooperation between the two lines.
Daily healthcare is close to home, only performed by a handful of specialists (i.e. physiotherapists) specially trained to treat Parkinson patients. This is called the ParkinsonNet. Patients rather have someone with expertise who is within a 20 minutes distance, than a less experienced person round the corner.
There is optimal communication between the “two layers”.
The patient plays an active role.
How is this organized?
When the patient is referred to the neurologist, he first has to fill in a screening list and has to prioritize 5-10 health problems, which he/she would like to discuss when visiting the Day Center. So one patient may want to see a sexologist, a dietitian and a physiotherapist and an other a rehabilitation physician, gerontologist and a neurologist.
Doctors and patients sit round a table, each in the same position (no hierarchy).
Consumer reviews are shown (anonymously) on the Internet. This makes healthcare transparent. When scores are bad some action should be taken to improve it.
How is this achieved?
Selection of experts who get education (via e learning etc), on basis of geographic distribution. Patients have to travel a bit more, healthcare is canalized,
All healthcare workers work according a multidisciplinary guideline. Patients were active co-producers of the guideline.
Implementation (see above)
Yellowpages (paper and digital version) have been made of healtcare providers, enabling patients to choose.
Indicators are developed, patients are invited to give feedback and to grade the healthcare (providers). If someone performs bad, (gets the red card) he/she may ultimately be taken out of the network.
The experiment of patient empowerment in Parkinson’s Disease management has grown from very small (region Nijmegen) to almost national. The blank region (see Figure) is not included to be able to assess the effectiveness of this system compared to the traditional approach.
The next step is the creation of a virtual community. This is certainly important and not out of reach for the elderly. A transmural electronic health record is available (Parkinson dossier) both for the patient and the healthcare worker.
Last Sunday I was an invited speaker at a national congress for interns, the LOCA congress. LOCA stands for “Landelijk Overleg Co-Assistenten”.
This congress has been initiated to facilitate the contact between interns of all Dutch universities and to cover in depth subjects that usually don’t get much attention.
The LOCA congress offered a diverse program, varying from “minimal invasive and maximal effective surgery”, “memory training” and “a dirty mind is a joy forever”. You can see the program here (Saturday; Sunday).
The previous event I gave a Search Workshop, this time the subject was “Medicine 2.0″.
I didn’t realize in advance that this wasn’t a convenient day. First it was Mother’s day. My children weren’t pleased that I wouldn’t be around. Furthermore I had to prepare an Evidence Based Searching day the following Monday and several other workshops that week. Still, Sunday morning we spent together in the garden eating home made smoothies and muffins that my eldest daughter L made, with on them in colors: “Mama blog”, “L X M”, “Laika twitter”, “Success”, etcetera, which illustrates how they see me now.
Despite that I had 40 min. instead of the expected 60 min., and just about half of the workshop subscribers (it was a very sunny day) showed up, I found it a pleasant workshop. Mostly because the audience was very interested and interactive. Within those 40 minutes, however, I could only touch upon some aspects, giving most emphasis to the web 2.0 tools which can be used in daily practice by medical professionals to find information (social networking sites, RSS also in Pubmed, personalized home pages, blogs and wiki’s)
40 minutes is short and I promised the interns to provide them with some information afterwards.
I’m too busy at the moment with my regular job, but I expect that the promised information will be available within 1-2 weeks at:
But I won’t withhold a series of tweets (Twitter messages) specifically directed to the interns of this workshop. You can view the tweets labeled with #MOVIR, here at Visibletweets. They have been tweeted by doctors, a patient, a nurse and a physiotherapist. Please see them all, the first tweets are shown last.
Twitter is only for people telling what they’re doing right now, like “what they eat for breakfast”. Right?
Twitter is a kind of web based Short Message Service, which is largely for ego-trippers sharing the -largely uninteresting- private parts of their life, isn’t it? YouTube is mostly for teens and twenties enjoying music videos. And similarly Facebook and (in Holland Hyves) are just a hype. O.k.?
And blogging, ha, blogging…. Doctors shouldn’t blog, because of privacy issues and because it is a waste of time. Doctors don’t even have time for it, nor should they have… Yes?!
Social media are useless and perhaps even “dangerous” (distracting staff, viruses, wrong info, privacy concerns) and hospitals should keep them behind their firewalls!!
Right?
Wrong!
Wrong. At least that is what many US hospitals are thinking. More and more they are embracing social media. Why? To connect, to interact, to disseminate new research, to share in-depth medical information and to gather communities of employees, patients and their families.
One tool they use is Twitter (@mayoclinic). First they protected their updates on Twitter, didn’t follow their followers back. Twitter was mainly used for“branding”, but later they realized that this didn’t work and that “they needed more than an audience”. By interacting with their followers they got more response. They also reached more people, because interesting tweets were retweeted by their followers. So even people that don’t follow @mayoclinic (but are followers of its followers) are alerted to the news. It is also an important virtual mouth-to-mouth-tool for new patients.
More than Facebook, Twitter enables you “to connect with people you don’t know but share the same interest with. It is for the friends you don’t know yet”
Mayo Clinic actively supports its staff and its patients to use the social media tools.
One question on Twitter was if one could see the Mayo Clinic guidelines of Twitter usage. They are for instance on the Blog of Ed Bennett (see this link).
The first preliminary list of Dutch hospitals officially using social media has now been compiled by Lucien et al. It should be stressed that the list is based on what is known, but needs to be confirmed the hospitals (a mailing is being send). See blogpost on Zorg 2.0 (Dutch) and this pdf with preliminary data.
There is reason to believe that the results will not be essentially different.
Indeed, I don’t know of any initiatives of our hospital to use social media (Academic Medical Center, Amsterdam)
Thus looking at the enormous differences between the USA and the Netherlands one wonders:
Europe (the Netherlands) isn’t it about time that you join?
At least get acquainted with Social Media and Web 2.o!
Look what others are doing and see what is in it for you, your staff ànd your patients!
You may not (want to) do it, but your patient will do it anyway.
Preliminary data From: http://hospitalseu.wordpress.com/ (Hyves is the Dutch Facebook)
By the way, 5 days ago I personally experienced that Mayo Clinic is really interactive. I followed one of their links in their tweets to find that I could not access the news item they referred to, because it was password protected. I tweeted about it -just in general-. Mayoclinic immediately picked this message up (because they have a search for “mayoclinic” on Twitter). But more importantly they immediately responded in a pleasant way ànd immediately took care of it. This illustrates that they are not only “interactive” in words but also in deeds: they really “listen” and “respond” to their Twitter followers. Many individuals on Twitter don’t even bother.
This year’s theme was FEAR. The program was as follows:
Welcome – Rinnooy Kan
Presentation of new work of art of Albert van Westing (1960), recently bought by the AMC – Wim Pybes, director of the “RijksMuseum”
“Mit Freud und Freud ich fahr dahin”- Johan Sebastian Bach. 1.”O Jesu Christ, mein’s Lebens Licht” 2. Gottes zeit ist die allerbeste Zeit – Baroque Ensemble “Follia d’ Amsterdam”together with the choir“Nuovo Musico” , conducted by Gustav Leonhardt (above is another version). The cantatas express both fear for death and faith in God.
Audiovisual presentation of the assay ” de vertrouwenscrisis” (what went wrong with the fundamental trust in the Dutch society?), written by 19 different publicists.
Audiovisual impression of pupils of Amsterdam High Schools attending lectures in psychiatry: funny and disarming.
And the climax: a 50 min lecture of Prof. Arieh Y. Shalev, M.D. (Head Department of Psychiatry at the Hadassah University Hospital of Jerusalem, Israel) about living with fear.
I will try to summarize the main points of Shalev’s lecture as I remember them (no notes).
There are several factors that may influence how people react to fear:
DNA (fixed), inherited differences – (written composition in musical notation)
Epigenetic Mechanisms (mostly but not exclusively determined postnatally). (tuning of the piano, quenching the middle register)
(Gene) Expression(Accordion register determining ranks and timbres, determined by the accordionist)
Exogenous factors (i.e. empathy and affection) (the people singing, the acoustics)
Fear is an emotional response to threats and danger, meant to protect against a threat (fright-fight-or-flight). It is a basic survival mechanism occurring in response to a specific stimulus, such as pain or the threat of pain. Recognizing a person in agony is easy. The facial expression of fear includes the widening of the eyes (out of anticipation for what will happen next); the pupils dilate (to take in more light); the upper lip rises, the brows draw together, and the lips stretch horizontally. Muscles used for physical movement are tightened and primed with oxygen, in preparation for a physical fight-or-flight response. When the stimulus is shocking or abrupt, a common reaction is to protect vulnerable parts of the anatomy, particularly the face and head. When a fear stimulus occurs unexpectedly, the victim of the fear response could possibly jump or give a small start. The person’s heart-rate and heartbeat may quicken (from Wikipedia).
The amygdala, an almond shaped complex of related nuclei, located in the middle of the brain, is a critical processor area for fear. Connected to the hippocampus, it plays a role in emotionally laden memories. It is part of the limbic system.
Fear, begins with arousal. For instance:
You hear a sound. The amygdala is alerted.
You see a face, the amygdala is alerted to a greater extent. Your pupils enlarge, your breathing and hartbeat quicken.
You recognize the face; it is nobody to be afraid of: the fear response is dampened. The heartbeat drops to normal levels, because you are reassured that there was no danger.
But suppose (1) you’re walking in a dark alley and (2) you see a gun. (3) Next you see a man holding that gun. (4) He shouts something threatening. There are no breaks anymore (by prefrontal cortex/hippocampus on the amygdala) and the fear machine starts running at full speed. Thus, in case of a major threat, in a split second all alarm bells ring: the abovementioned reflexes occur immediately and with no point of return.
One’s memory of what happens consists of separate “pictures”: (1) the alley, (2) the gun, (3) the man, (4) a loud voice (and perhaps smell). Normally, moments of fear will takes it’s place along other memories, although this may take some time.
However, depending on the kind of fear, your personality and external factors, memories to the incident causing fear may stay at the foreground. It may become a memory that comes to the mind frequently and spontaneously or evoked by one of the remembered associations. For instance any alley may cause the full blown fear response again in the abovementioned example.
Shalev telling this, I suddenly understood my reactions to a car accident. While driving on the highway, the driver lost control of the vehicle, causing it to skid and finally ending against a huge concrete wall. I was sitting in the back and while the car was turning I saw “the wall hitting us”. My “last thought” was “that was it”. The car was total loss, but luckily all 5 (members of a dancing group) survived. Apparently because of the “fear of death”, the impression of that very moment staid long with me. For almost a year I felt frightened not only in a car, but also when I saw a car or motor turning fast around the corner or when moving sideways in an airplane during landing. It must have been a similar feeling as when the car turned and hit the wall. The resemblance of that moment brought the memory and the fear back in quite un uncontrollable way. But as time passed by, so did this emotional reaction. The memory itself was still there, but at the background and slowly all intense associations with that frightful moment faded.
This is what normally happens with frigtening experiences. Fear can be retriggered by a memory (smell, picture, situation) linked to what happened, but can extinguish over time. Thus responding to a conditioned stimulus (CS) spontaneously recovers with the passage of time indicated that extinction does not erase the conditioned memory, but is a form of (active) inhibition. The brain (prefrontal cortex/hippocampus) learns how to coop with it and suppress the emotional fear reflex (amygdala).
However, some fears don’t extinguish and have a lifelong impact. For instance in post-traumatic stress disorder (PTSD), which is a severe and ongoing emotional reaction to extreme physical or psychological trauma.
Shalev gave several examples of people with PTSD other than PTSD in war veterans . For instance, a mother who lost her daughter on the complications of a simple (and unnecesary) intervention. The daughter died of sepsis and from that moment on the mother continued to live in the past, persistently reexperiencing the traumatic event.
This was what the mother remembers as the most frightful moment:
I entered the door, my hand still holding the knob. There she lied staring with pupils so dilatated that her irisses were no longer visible. Death was inevitably approaching. I wanted to scream for help, but there were no doctors present and nurses were all running around. I could do nothing about it.
That was a recurrent theme in all examples: feeling desparate and helpless while facing the inevitable.
In PTSD patients the normal extinction mechanisms don’t work. PTSD patients remain in a state of arousal.
Shalev also emphasized that the mere reiteratation of the traumatic event doesn’t help the patient. If the patient is in fear it doesn’t help to bring him to an alley all over again, and to leave the alley again as soon as the patient gets frightened. This only reinforces fear. What should be done is to learn the patient to associate the alley with positive events through psychotherapy. Trust, empathy, friendship can all help as well.
Because extinction is a form of learning some medical treatments given soon after the trauma will not help to reduce the PTSD. In a Randomized Controlled Trial presented at the American College of Neuropsychopharmacology 46th Annual Meeting (December 8-12, 2007), Shalev and coworkers showed that cognitive therapy or prolonged exposure therapy (a type of cognitive behavioral therapy) within 1 month had a reduced prevalence and severity of PTSD at 5 months to 20%, whereas early treatment with a selective serotonin reuptake inhibitor (SSRI) fared no better than individuals randomized to placebo or spontaneous recovery (wait-list) groups (60%). According to Shalev this is a phantastic effect. (Source: Medscape ).
Still, although cognitive therapy is effective, many PTSD patients remain symptomatic despite initial treatment.
————-
This post was (also) written for next Grand Round hosted by Mexican Medical Student. Enrico had a tentative theme in mind (with some flexibility to change it ) but these words should be applicable: renewal, metamorphosis, change, transformation. Well, this story was about how extreme fear can transform you in another person. Furthermore death, referred to in the Bach cantate, is our ultimate transformation.
Finally I hope that Enrico, being both a medical student and a classical pianist likes Bach.
SPOETNIK was a 17 week course on NEW (web 2.0) internet communication methods for librarians. The main target group consisted of UBA (University Library of Amsterdam) librarians. In total, there were more than 160 course members, each having his own blog.
14.00 Opening by Robin van Schijndel 14.10 Since SPOETNIK – part1: Blogging after SPOETNIK by Jacqueline (alias Laika)
14.25 Since SPOETNIK – part2: Colleagues about SPOETNIK by Alice Doek
14.40 Group discussions
15.30 Koffie- en theepauze
15.45 Feedback from the discussion groups
16.15 Since SPOETNIK – part 3: New applications by Pascal Braak 16.30 Closure and drink
The symposium started a few minutes later because Jacqueline was a bit late: she had to take off Laika’s astronaut suit (well kind of, she torn her new pantyhose and had to find a new one (that didn’t fit), she dubbelchecked whether she took her USB-stick with her and she forgot her glasses). It could have been worse, because it was just a few hours in advance that Jacqueline found out that the meeting was not in THE Doelenzaal at the Kloverniersburgwal but in the (also beautiful and old) Doelenzaal (zaal = room) in the UBA (main library of the University of Amsterdam). Of course, everyone else just knew this. That underlined the feeling that the Academical Medical Center and most other departments of the UBA are both physically and mentally apart, although still connected.
The atmosphere was very relaxed. Before the speeches, there was a lot of rumor or as Alice said: it is like a reunion. And that ’s how it felt! Finally I had the chance to meet my colleague bloggers in real life. I met Boekenvlindertje, Duijfje, Dyoke of Zygomorf (which I had always wrongly pronounced as Díe Joke, should be Dieuwke) and Turquoois, and I had long chat with Bert of “Een beetje adjunct” and finally with my blogmate George of Brughagedis, the one with whom I shared Google Docs, but never a drink, before. Both Bert and George have written a blogpost about this meeting (see here and here)
Although George doesn’t want to be in the picture, he was mentioned in the introductory speech of Robin as one person that ‘meant a lot for the course’. That is certainly true. You need some active contributors to inspire the rest. Besides George was the first to create an OPML-feed of all blogs (together with Pascal) which made it a lot easier to keep up with all Spoetnik blogs.
My talk was next. In 15 minutes I had to outline “Blogging after Spoetnik”. How did I continue when the course was finished? Here is my powerpoint presentation.
The theme I choose was “Blogging is navel gazing?!”. I notice that many people (including myself in the pre-web 2.0 phase) consider blogging as something egocentric, just an outlet for one’s feelings and frustrations, or hobbies and thoughts. What I hoped to show is that web 2.0 is not just a set of web 2.0 tools, but it is a whole philosophy. It is the philosophy of gaining momentum when sharing. But to do this you have to be patient, you must have a story to tell (content) and than you have to find readers, else you will remain ‘lonely’. I recommended twitter as a very good source to build up a community, if you use it the right way (find people to share things with). Although I have to say that it is a lot easier for me, as a health 2.0 blogger to find a large global community than someone specialized in Dutch linguistics.
Thus I feel committed to write an introduction on how to use Twitter effectively. Preferably in Dutch: at least 2 UBA colleagues spontaneously said they regret that I had changed to English.
Alice told us the origin of Spoetnik and gave an overview of the opinions of many other well known Dutch librarians about the course. The comment of Wowter was missing however, possibly because he expected Alice to use a web 2.0 way of finding it (Feeds and Twitter). (You can read his -Dutch- comment here). Many other libraries will follow the example of Spoetnik and 23 Dingen, although in a shorter version.
Pascal showed us that there were many new web 2.0 tools ( a few slides with last week’s additions), but according to Pascal none of them was really new, but all variations on a theme. He did whisper that he had a new twitter-firefox api for me, so I hope he will provide me with further details.
In between we discussed in groups what we had learned from the course, what we liked and didn’t like about different tools. Using Google Docs, we brainstormed about how we could implement web 2.0 tools in our library, UBA-wide. A very interesting part of the program, this exchange of thoughts. Robin gave a quick overview of the ideas, but shortly all input will be available at the Spoetnik-website together with the presentations.
As can be read in the ‘About’ section, this blog was started as part of the online course SPOETNIK on NEW (web 2.0) internet communication methods for librarians. The main target group consisted of UBA (University Library of Amsterdam) librarians. In total, there were more than 160 course members, each having his own blog.
Does web 2.0 knowledge matter to your work and/or daily life? Do you use RSS to keep abreast of the latest developments in your area? Did you catalog all your books in Librarything? Did you continue blogging and is your blog becoming popular? How will new applications affect library service?
14.00 Opening by Robin van Schijndel 14.10 Since SPOETNIK – part1: Blogging after SPOETNIK by Jacqueline (alias Laika)
14.25 Since SPOETNIK – part2: Colleagues about SPOETNIK by Alice Doek
14.40 Group discussions
15.30 Koffie- en theepauze
15.45 Feedback from the discussion groups
16.15 Since SPOETNIK – part 3: New applications by Pascal Braak 16.30 Closure and drink
I’m very excited to meet my Спутник in real life. Although we organized a small meeting directly after the course, I couldn’t attend it. I hope that many Спутник will be there now.
For those Спутник reading this posts and coming to the symposium, are there any issues you would like me to address in my short presentation “Blogging after Spoetnik”?? You can mail me or give a comment here.
Dit blog werd gestart als ‘n onderdeel van de online cursus SPOETNIK over nieuwe web 2.0 communicatiemethoden voor bibliotheekmedewerkers. De cursus werd georganiseerd door de UBA (Universiteitsbibliotheek van Amsterdam) en richtte zich vooral, maar niet uitsluitend) op UBA-medewerkers.
In totaal, deed een onwaarschijnlijk groot aantal cursisten mee: er zijn wel meer dan 160 blogs aangemaakt. De voorloper van deze cursus, 23 dingen, was even succesvol, hetgeen aangeeft dat dergelijke cursussen toch in een behoefte voorzien. Een behoefte die ik zelf niet echt onderkend had. Ik deed gewoon maar mee om te kijken of ik er wat van opstak. Wat web 2.0 of bibliotheek 2.0 nou voorstelde, ik had er geen idee van. En blogs? Niet interessant, ik las ze nooit. Maar nu ben ik 180 graden om.
Wat is er sindsdien gebeurd met de opgedane kennis ? Welke rol speelt de ‘webstof’ op het werk of in je privé-leven? Gebruik je bijvoorbeeld RSS-feeds om op de hoogte te blijven, staat je complete boekencollectie mèt omslag op LibraryThing, maak je furore met je blog? Hoe zullen de nieuwe toepassingen onze dienstverlening beïnvloeden?
14.00 Opening door Robin van Schijndel 14.10 Sinds SPOETNIK – vol.1: Bloggen na SPOETNIK, door Jacqueline (alias Laika)
14.25 Sinds SPOETNIK – vol.2: Vakgenoten over SPOETNIK, door Alice Doek
14.40 Discussie in groepjes
15.30 Koffie- en theepauze
15.45 Verslag vanuit de discussiegroepen
16.15 Sinds SPOETNIK – vol.3: Nieuwe toepassingen, door Pascal Braak 16.30 Afsluiting & borrel
Ik kijk met spanning uit naar de RL ontmoeting met mijn Спутник. Hoewel ik mede een borrel had georganiseerd na de Spoetnikcursus, heb ik het zelf toen moeten laten afweten. Erg jammer. Ik had toch heel graag mijn vaste Спутник ontmoet. Hopelijk lukt het nu.
Voor die Спутник die dit bericht lezen en naar het symposium komen: zijn er nog zaken waarvan jullie willen dat het in mijn presentatie “Bloggen na Spoetnik” aan de orde komt? Of laten jullie je liever verrassen?
Today I learned there were two more videos realted to the BlogWorld Expo, that I shouldn’t withhold you.
Another interview was with Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston, and author of Running a Hospital. Paul participated in a panel discussion as part of the Medblogger Track (co-sponsored by Johnson & Johnson and MedPage Today). Because the video is barely audible, I just mention his main statements (highlighted in red in the video shown here at the JNJ Health Channel):![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_b.png?x-id=bdb5d7d2-1971-4733-8288-f583748f438d)
:
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_b.png?x-id=3407a313-1270-4fec-818a-e0b99de9f98f)
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_b.png?x-id=78623648-ef4e-4c52-9120-d3c7e144a4c2)
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_b.png?x-id=ec183532-e91b-4032-8ba6-ca945879f18b)
Since last week ![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_b.png?x-id=d91ef868-2647-4436-aaac-c74997afc5cc)
![Reblog this post [with Zemanta]](http://img.zemanta.com/reblog_b.png?x-id=b3b8c131-cdca-4280-b7b7-296ba9677c89)
) but these words should be applicable: 
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