Medical Black Humor, that is Neither Funny nor Appropriate.

19 09 2011

Last week, I happened to see this Facebook post of the The Medical Registrar where she offends a GP, Anne Marie Cunningham*, who wrote a critical post about black medical humor at her blog “Wishful Thinking in Medical Education”. I couldn’t resist placing a likewise “funny” comment in this hostile environment where everyone seemed to agree (till then) and try to beat each other in levels of wittiness (“most naive child like GP ever” – “literally the most boring blog I have ever read”,  “someone hasn’t met many midwives in that ivory tower there.”, ~ insulting for a trout etc.):

“Makes no comment, other than anyone who uses terms like “humourless old trout” for a GP who raises a relevant point at her blog is an arrogant jerk and an unempathetic bastard, until proven otherwise…  No, seriously, from a patient’s viewpoint terms like “labia ward” are indeed derogatory and should be avoided on open social media platforms.”

I was angered, because it is so easy to attack someone personally instead of discussing the issues raised.

Perhaps you first want to read the post of Anne Marie yourself (and please pay attention to the comments too).

Social media, black humour and professionals…

Anne Marie mainly discusses her feelings after she came across a discussion between several male doctors on Twitter using slang like ‘labia ward’ and ‘birthing sheds’ for birth wards, “cabbage patch” to refer to the intensive care and madwives for midwives (midwitches is another one). She discussed it with the doctors in question, but only one of them admitted he had perhaps misjudged sending the tweet. After consulting other professionals privately, she writes a post on her blog without revealing the identity of the doctors involved. She also puts it in a wider context by referring to  the medical literature on professionalism and black humour quoting Berk (and others):

“Simply put, derogatory and cynical humour as displayed by medical personnel are forms of verbal abuse, disrespect and the dehumanisation of their patients and themselves. Those individuals who are the most vulnerable and powerless in the clinical environment – students, patients and patients’ families – have become the targets of the abuse. Such humour is indefensible, whether the target is within hearing range or not; it cannot be justified as a socially acceptable release valve or as a coping mechanism for stress and exhaustion.”

The doctors involved do not make any effort to explain what motivated them. But two female anesthetic registrars frankly comment to the post of Anne Marie (one of them having created the term “labia ward”, thereby disproving that this term is misogynic per se). Both explain that using such slang terms isn’t about insulting anyone and that they are still professionals caring for patients:

 It is about coping, and still caring, without either going insane or crying at work (try to avoid that – wait until I’m at home). Because we can’t fall apart. We have to be able to come out of resus, where we’ve just been unable to save a baby from cotdeath, and cope with being shouted and sworn at be someone cross at being kept waiting to be seen about a cut finger. To our patients we must be cool, calm professionals. But to our friends, and colleagues, we will joke about things that others would recoil from in horror. Because it beats rocking backwards and forwards in the country.

[Just a detail, but “Labia ward” is a simple play on words to portray that not all women in the “Labor Ward” are involved in labor. However, this too is misnomer.  Labia have little to do with severe pre-eclampsia, intra-uterine death or a late termination of pregnancy]

To a certain extent medical slang is understandable, but it should stay behind the doors of the ward or at least not be said in a context that could offend colleagues and patients or their carers. And that is the entire issue. The discussion here was on Twitter, which is an open platform. Tweets are not private and can be read by other doctors, midwives, the NHS and patients. Or as e-Patient Dave expresses so eloquently:

I say, one is responsible for one’s public statements. Cussing to one’s buddies on a tram is not the same as cussing in a corner booth at the pub. If you want to use venting vocabulary in a circle, use email with CC’s, or a Google+ Circle.
One may claim – ONCE – ignorance, as in, “Oh, others could see that??” It must, I say, then be accompanied by an earnest “Oh crap!!” Beyond that, it’s as rude as cussing in a streetcorner crowd.

Furthermore, it seemed the tweet served no other goal as to be satirical, sardonic, sarcastic and subversive (words in the bio of the anesthetist concerned). And sarcasm isn’t limited to this one or two tweets. Just the other day he was insulting to a medical student saying among other things:“I haven’t got anything against you. I don’t even know you. I can’t decide whether it’s paranoia, or narcissism, you have”. 

We are not talking about restriction of “free speech” here. Doctors just have to think twice before they say something, anything on Twitter and Facebook, especially when they are presenting themselves as MD.  Not only because it can be offensive to colleagues and patients, but also because they have a role model function for younger doctors and medical students.

Isolated tweets of one or two doctors using slang is not the biggest problem, in my opinion. What I found far more worrying, was the arrogant and insulting comment at Facebook and the massive support it got from other doctors and medical students. Apparently there are many “I-like-to-exhibit-my-dark-humor-skills-and-don’t-give-a-shit-what-you think-doctors” at Facebook (and Twitter) and they have a large like-minded medical audience: the “medical registrar page alone has 19,000 (!) “fans”.

Sadly there is a total lack of reflection and reason in many of the comments. What to think of:

“wow, really. The quasi-academic language and touchy-feely social social science bullshit aside, this woman makes very few points, valid or otherwise. Much like these pages, if you’re offended, fuck off and don’t follow them on Twitter, and cabbage patch to refer to ITU is probably one of the kinder phrases I’ve heard…”

and

“Oh my god. Didnt realise there were so many easily offended, left winging, fun sponging, life sucking, anti- fun, humourless people out there. Get a grip people. Are you telling me you never laughed at the revue’s at your medical schools?”

and

“It may be my view and my view alone but the people who complain about such exchanges, on the whole, tend to be the most insincere, narcissistic and odious little fuckers around with almost NO genuine empathy for the patient and the sole desire to make themselves look like the good guy rather than to serve anyone else.”

It seems these doctors and their fans don’t seem to possess the communicative and emphatic skills one would hope them to have.

One might object that it is *just* Facebook or that “#twitter is supposed to be fun, people!” (dr Fiona) 

I wouldn’t agree for 3 reasons:

  • Doctors are not teenagers anymore and need to act as grown-ups (or better: as professionals)
  • There is no reason to believe that people who make it their habit to offend others online behave very differently IRL
  • Seeing Twitter as “just for fun” is an underestimation of the real power of Twitter

Note: *It is purely coincidental that the previous post also involved Anne Marie.

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Stories [8] How Not to Reassure (or Treat) a Patient

23 08 2010

The host of the next edition of the Grand Rounds is Fizzziatrist at A Cartoon Guide to Becoming a Doctor. Thus it is no surprise that the theme of this edition is “Humor in Medicine”. The Fizzziatrist:

When I host Grand Rounds, I will post the links in order of how many times each one made me go “ha!” (…) It’s all quite scientific.

Well that’s a tough job. First both as a medical librarian and  a patient, I’m not in the situation to experience a lot of the humorous aspects of a doctors job. Furthermore I’m not the HA-HA-HA LOL-REAL SCREAM type. I’m more of the smile and the grin.

So what to do? I hope you find the following enjoyable. And perhaps many little ha’s do make one big HA.

——————–

How not to reassure (or treat) your patients (own experience)

My GP (the leading character in this story; he resembles a bull in a china shop, sometimes, but other than that, he is o.k.)

  • At one of my first visits he was trying to (manually) find the card of my husband. 
    When he thought he found it, he muttered:
    “that old guy?”
    Apparently he had mistaken my father (I still had my maiden name) for my partner.
    Lucky (both for me and my gp)  he was wrong. But how embarrassing if he
    had been right.

    wikipedia (CC)

  • Once I phoned him for I don’t know what and he said:
    “I’m not seeing  you often”
    “Why, is that bad?”
    “Well, it is exceptional”
    “Exceptional?”
    “Yes, I see women of your age regularly”

    “For what kind of disease, if I may ask”.
    “Well, the flu .. and for pill or IUD-controls”
    [sneering] “Sure, but I’m never seriously ill and I have a gynecologist for the latter”.
  • When I was pregnant of my second child, I phoned him for a prescription for anti-Rh antibodies, which I needed for prenatal testing. Since I hadn’t visited my gynecologist after my first child, and the hospital nurses had assured me that gp’s and midwives normally prescribed, this should not be a problem.
    I began: “I’m a few weeks pregnant and ….”
    He interrupted me, confused: “but that..….. but ….. you were pregnant a few months ago“.
    He was half right. I had had a miscarriage then. (Dang! A heavy blow)
    After a curt explanation, I hung up.
  • Later he phoned me back (with a thin excuse) and I asked him for the anti-Rh antibodies, but he just didn’t get it.
    Ask your  midwife”.
    “But I don’t have a midwife”
    “Everyone has got a midwife, nowadays”
    “No, I got a gynecologist”
    “Then  ask your gynecologist”
    “But  I’m not his patient anymore”
    “Then ask him to be your doctor again”
    “But I need the prescription right now“.

    I tried to convince him in vain. He finally mumbled something like: That is of my beat, I don’t do pregnancies and deliveries anymore.
    [luckily one phone call to the gynecologists’ wife was enough to get the prescription. She passed the message immediately, and said that if I liked him to take care of me again, it was best to make an appointment soon after the test.]
  • My gp had the same attitude another time.  I had signs of a Addison crisis. I tried to explain to him what might be wrong. He asked one or two things, shrugged and then said: “You better make an appointment with your specialists. This disease is beyond my practice.”
    At the time it seemed ok to me, but my endocrinologist said it was irresponsible: “Suppose he wouldn’t immediately refer someone with an acute crisis: that could be fatal. [I was hospitalized in this case, but it was not that urgent] See also “the Doctor and the Patient”
The Doctor, by Sir Luke Fildes (1891)

Image via Wikipedia

My gynecologist/obstetrician [a friend of mine recommended him, because he was kind and puts you at ease. It really is a wonderful doctor, and after all those deliveries he still considered birth a miracle. However, his way of reassuring was not always effective]. 

  • March 31, late afternoon: “It is time to get your baby ( 2,5 weeks post-term), but we better postpone it for two days. It is not such a nice day to celebrate the child’s birthday, don’t you think” (meaning April Fools day)
  • When I had my first check-up he warmed the speculum, trying to break the ice with some humor: “they do warm the cutlery for each course at the Chinese”, don’t they?
    (I found it rather tasteless, but remained silent: he meant it well)
  • When we discussed where I would deliver, he said that that would be in his hospital. I sighed with relief. As any new mother I was nervous about it.
    But he didn’t want me to have false expectations:
    Of course I hope I can personally deliver your baby. However, the chances are real that someone else will be around at that time. But believe me, if the moment is there, you don’t care who stands at the foot of your bed. Even if it is a gorilla..”

My Dentist (the best, most skillful, pleasant dentist there is, but still ….  a dentist)

  • Once, just finished drilling, she said carefully: “Don’t be scared when you look into the mirror….. I just touched your tongue”.

This concludes my experiences.  If you would like to read more serious stuff about “how (not) to reassure”, then you can read this old article The Art Of Reassurance (PDF) or this recent blog post at « HealthSkills WeblogIs reassurance reassuring?

One main advise (from the latter blog):

Never reassure a patient about something they are not already worried about. It would be a mistake, for example, to earnestly reassure patients that they do not have cancer when the thought had never entered their minds!”

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The Trouble with Wikipedia as a Source for Medical Information

14 09 2009

This post was chosen as an Editor's Selection for ResearchBlogging.org

Do you ever use Wikipedia? I do and so do many other people. It is for free, easy to use, and covers many subjects.

But do you ever use Wikipedia to look up scientific or medical information? Probably everyone does so once in a while. Dave Munger (Researchblogging) concluded a discussion on Twitter as follows:

Logo of the English Wikipedia
Image via Wikipedia

“Wikipedia’s information quality is better than any encyclopedia, online or off. And, yes, it’s also easy to use”.

Wikipedia is an admirable initiative. It is a large online collaborative, multilingual encyclopedia written by contributors around the world.
But the key question is whether you can rely on Wikipedia as the sole source for medical, scientific or even popular information.

Well, you simply can’t and here are a few examples/findings to substantiate this point.

RANKING AND USE

E-patients

When you search  for diabetes in Google (EN), Wikipedia’s entry about diabetes ranks second, below the American Diabetes Association Home Page. A recent study published in the J Am Med Inform Assoc [1] confirms what you would expect: that the English Wikipedia is a prominent source of online health information. Wikipedia ranked among the first ten results in more than 70% of search engines and health-keywords tested, and outranked other sources in case of rare disease-related keywords. Wikipedia’s articles were viewed more frequently than the corresponding MedlinePlus Topic pages. This corroborates another study that can be downloaded from the internet here [10]. This study by Envision Solutions, LLC, licensed under the Creative Commons License, concluded that the exposure of Internet user’s to health-related user-generated media (UGM) is significant, Wikipedia being the most reference resource on Google and Yahoo.

The following (also from envisionsolutionsnow.com, from 2007 [10]) illustrates the impact of this finding:

According to the Pew Internet & American Life Project*, 10 million US adults search online for information on health each day [1]. Most (66%) begin their research on a search engine like Yahoo or Google. In addition, Americans are saying that the information they find on the Internet is having an impact. According to Pew, “53% of health seekers report that their most recent health information session [influenced] how they take care of themselves or care for someone else.” In addition, 56% say the information they find online has boosted their confidence in their healthcare decision-making abilities.

And according to an update from the Pew Internet & American Life Project (2009) [11]:

In 2000, 46% of American adults had access to the internet, 5% of U.S. households had broadband connections, and 25% of American adults looked online for health information. Now, 74% of American adults go online, 57% of American households have broadband connections, and 61% of adults look online for health information.

Thus a lot of people look online for health care questions and are more inclined to use highly ranked sources.
This is not unique for Health topics but is a general phenomenon, i.e. see this mini-study performed by a curious individual: 96.6% of Wikipedia Pages Rank in Google’s Top 10 [12]. The extreme high traffic to Wikipedia due to search referrals has  even been been denounced by SEO-people (see here) [13]: if you type “holiday” Wikipedia provides little value when ranking in the top 10: everybody knows what a holiday is 😉

Medical students use it too.

A nightmare for most educators in the curriculum is that students rely on UGM or Web 2.0 sites as a source  of medical information. Just walk along medical students as they work behind their computers and take a quick glance at the pages they are consulting. These webpages often belong to the above category.

AnneMarie Cunningham, GP and Clinical Lecturer in the UK, did a little informal “survey” on the subject. She asked 31 first year medical students about their early clinical attachments in primary and secondary care and summerized the results on her blog Wishful Thinking in Medical Education [14]. By far and away Wikipedia was the most common choice to look up unfamiliar clinical topics.

AnneMarie:

‘Many students said I know I shouldn’t but….’ and then qualified that they used Wikipedia first because it was easy to understand, they felt it was reasonably reliable, and accessible. One student used it to search directly from her phone when on placement..

50% of the doctors use it!

But these are only medical students. Practicing doctors won’t use Wikipedia to solve their clinical questions, because they know where to find reliable medical information.

Wrong!

The New Scientist cites a report [15] of US healthcare consultancy Manhattan Research (April 2009), stating that that 50 percent of the doctors turn to Wikipedia for medical information.

A recent qualitative study published in Int J Med Inform [2] examined the “Web 2.0” use by 35 junior physicians in the UK. Diaries and interviews encompassing 177 days of internet use or 444 search incidents, analyzed via thematic analysis. Although concepts are loosely defined (Web 2.0, internet and UMG are not properly defined, i.e. Google is seen as a web 2.0 tool (!) [see Annemarie’s critical review [16] the results clearly show that 89% of these young physicians use at least one “Web 2.0 tool” (including Google!) in their medical practice, with 80% (28/35) reporting the use of wikis. The visit of wiki’s is largely accounted for by visits to Wikipedia: this was the second most commonly visited site, used in 26% (115/44) of cases and by 70% (25/35) of all physicians. Notably, only one respondent made regular contribution to a medical wiki site.

The main motivation for using the Internet for information seeking was the accessibility and ease of use over other tools (like textbooks), the uptodateness, the broad coverage and the extras such as interactive immages. On the other hand most clinicians realized that there was a limitation in the quality or usefulness of information found. It is reassuring that most doctors used UGM like Wikipedia for background or open questions, to fulfill the need for more in depth knowledge on a subject, or to find information for patients, not for immediate solving of clinical questions.

The Int J Med Inform article has been widely covered by blogs: i.e. see Wishful Thinking in Medical Education [16], Dr Shock, MD, PhD [17], Life in the Fast Lane [18], Clinical Cases and Images Blog [19] and Scienceroll [20].

Apparently some doctors also heavily rely on Wikipedia that they refer to Wikipedia articles in publications (see the Int. J Cardiol. PubMed [3] abstract below)!!

8-9-2009 14-03-15 Int J cardiol wikipedia references 2

WHY WIKIPEDIA IS NOT (YET) A TRUSTWORTHY AND HIGH QUALITY HEALTH SITE

Whether the common use of Wikipedia by e-patient, medical students and doctors is disadvantageous depends on the quality and the trustworthiness of the Wikipedia articles, and that is in its turn dependent on who writes the articles.

Basically, the strength of Wikipedia is it weakness: anyone can write anything on any subject, and anyone can edit it, anonymously.

Negative aspects include its coverage (choice of subjects but also the depth of coverage), the “overlinking”, the sometimes frustating interactions between authors and editors, regularly leading to (often polite) “revision wars“, but above all the lack of ‘expert’ authors or peer review. This may result in incomplete, wrong or distorted information.

Positive aspects are its accessibility, currency, availability in many languages, and the collective “authorship” (which is an admirable concept).

The following humorist video shows how the wisdom of the crowds can lead to chaos, incorrect and variable information.

SCOPE AND ACCURACY (What has been covered, how deep and how good) :

Too much, too little, too ….

With respect to its coverage one study in the Journal of Computer-Mediated Communication (2008) [4] concludes:

Differences in the interests and attention of Wikipedia’s editors mean that some areas, in the traditional sciences, for example, are better covered than others. (…)
Overall, we found that the degree to which Wikipedia is lacking depends heavily on one’s perspective. Even in the least covered areas, because of its sheer size, Wikipedia does well, but since a collection that is meant to represent general knowledge is likely to be judged by the areas in which it is weakest, it is important to identify these areas and determine why they are not more fully elaborated. It cannot be a coincidence that two areas that are particularly lacking on Wikipedia—law and medicine—are also the purview of licensed experts.

It is not unexpected though that Wikipedia’s topical coverage is driven by the interests of its users.

Sometimes data are added to Wikipedia, that are in itself correct, but controversial. Recently, Wikipedia published the 10 inkblots (Scienceroll, [21]) of the Rorschach test, along with common responses for each. This had led to complaints by Psychologists , who argue that the site is jeopardizing one of the oldest continuously used psychological assessment tests (NY Times [22]).

The actual coverage of medical subjects may vary greatly. In one study [5], abstract-format, 2007) Wikipedia entries were screened for the most commonly performed inpatient surgical procedures in the U.S. Of the 39 procedures, 35 were indexed on Wikipedia. 85.7% of these articles were deemed appropriate for patients. All 35 articles presented accurate content, although only 62.9% (n=22) were free of critical omissions. Risks of the procedures were significantly underreported. There was a correlation between an entry’s quality and how often it was edited.

Wikipedia may even be less suitable for drug information questions, questions that one-third of all Internet health-seekers search for. A study in Annals of Pharmacotherapy [6] comparing the scope, completeness, and accuracy of drug information in Wikipedia to a free, online, traditionally edited database (Medscape Drug Reference [MDR]) showed that  Wikipedia answered significantly fewer drug information questions (40.0%) compared with MDR (82.5%; p < 0.001) and that Wikipedia answers were less complete. Although no factual errors were found, errors of omission were higher in Wikipedia (n = 48) than in MDR (n = 14). The authors did notice a marked improvement in Wikipedia over time. The authors conclude:

This study suggests that Wikipedia may be a useful point of engagement for consumers looking for drug information, but that it should be supplementary to, rather than the sole source of, drug information. This is due, in part, to our findings that Wikipedia has a more narrow scope, is less complete, and has more errors of omission versus the comparator database. Consumers relying on incomplete entries for drug information risk being ill-informed with respect to important safety features such as adverse drug events, contraindications, drug interactions, and use in pregnancy.
These errors of omission may prove to be a substantial and largely hidden danger associated with exclusive use of
user-edited drug information sources.

Alternatively, user-edited sites may serve as an effective means of disseminating drug information and are promising as a means of more actively involving consumers in their own care. However, health professionals should not use user-edited sites as authoritative sources in their clinical practice, nor should they recommend them to patients without knowing the limitations and providing sufficient additional information and counsel…

Not Evidence Based

German researches found [7], not surprisingly, that Wikipedia (as well as two major German statutory health insurances):

“…failed to meet relevant criteria, and key information such as the presentation of probabilities of success on patient-relevant outcomes, probabilities of unwanted effects, and unbiased risk communication was missing. On average items related to the objectives of interventions, the natural course of disease and treatment options were only rated as “partially fulfilled”. (..)  In addition, the Wikipedia information tended to achieve lower comprehensibility. In conclusion(..) Wikipedia (..) does not meet important criteria of evidence-based patient and consumer information though…”

Wrong, misleading, inaccurate

All above studies point at the incompleteness of Wikipedia. Even more serious is the fact that some of the Wikipedia addings are wrong or misleading. Sometimes on purpose. The 15 biggest wikipedia blunders [23] include the death announcements of Ted Kennedy (when he was still alive),  Robert Byrd and others. Almost hilarious are the real time Wikipedia revisions after the presumed death of Kennedy and the death of Ken Lay (suicide, murde, heart attack? [24).

In the field of medicine, several drug companies have been caught altering Wikipedia entries. The first drug company messing with Wikipedia was AstraZeneca. References claiming that Seroquel allegedly made teenagers “more likely to think about harming or killing themselves” were deleted by a user of a computer registered to the drug company [25], according to Times [26]. Employees of Abbott Laboratories have also been altering entries to Wikipedia to “eliminate information questioning the safety of its top-selling drugs.”(See WSJ-blog [27] , brandweeknrx.com [28], and recently Kevin MD[29])

These are “straightforward” examples of fraudulent material. But sometimes the Wikipedia articles are more subtly colored by positive or negative bias.

Take for instance the English entry on Evidence Based Medicine (in fact the reason why I started this post). Totally open-minded I checked the entry, which was automatically generated in one of my posts by Zemanta. First I was surprised by the definition of EBM:

Evidence-based medicine (EBM) aims to apply the best available evidence gained from the scientific method to medical decision making. It seeks to assess the quality of evidence of the risks and benefits of treatments (including lack of treatment).

instead of the usually cited Sacket-definition (this is only cited at the end of the paper):

“the practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research”

In short, the whole article lacks cohesion: the definitions of EBM are not correct, there is too much emphasis on not directly relevant information (4 ways to grade the evidence and 3 statistical measures), the limitations are overemphasized (cf. chapter 7 with 6 in the Figure below) and put out of perspective.

Apparently this has also been noted by Wikipedia, because there is a notice on the Evidence Based Medicine Page saying:

This article has been nominated to be checked for its neutrality. Discussion of this nomination can be found on the talk page. (May 2009)

9-9-2009 9-55-04 wikipedia EBM start smal

Much to my surprise the article had been written by Mr-Natural-Health, who’s account seems not to be in use since 2004  and who is currently active as User:John Gohde. Mr Natural Health is a member of WikiProject Alternative medicine.

Now why in earth would some advocate of CAM write the Wikipedia EBM-entry? I can think of 4 (not mutually exclusive) reasons:

  1. When you’re an EBM-nonbeliever or opponent this is THE chance to misinform readers about EBM (to the advantage of CAM).
  2. The author was invited to write this entry.
  3. No EBM-specialist or epidemiologist is willing to write the entry, or to write for Wikipedia in general (perhaps because they find Wikipedia lacks trustworthiness?)
  4. EBM specialists/epidemiologists are not “allowed”/hindered to make major amendments to the text, let alone rewrite it.

According to Mr Naturopath point 2 is THE reason he wrote this article. Now the next question is “exactly by whom was he invited?” But the TALK-page reveals that Mr Naturapath makes it a tough job for other, better qualified writers, to edit the page (point 4). To see how difficult it is for someone to re-edit a page, please see the TALK-page. In fact, one look at this page discourages me from ever trying to make some amendments to any Wikpedia text.

SOLUTIONS?

Changes to Wikipedia’s organization

Wikipedia has long grasped that its Achilles heel is the free editability (see for instance this interview with Wikipedia’s founder [30]). Therefore, “WikiProjects” was initiated to help coordinate and organize the writing and editing of articles on a certain topic, as well as “Citizendium” which is an English-language wiki-based free encyclopedia project aimed to improve the Wikipedia model by providing a “reliable” encyclopedia. “It hopes to achieve this by requiring all contributors to use their real names, by strictly moderating the project for unprofessional behavior, by providing what it calls “gentle expert oversight” of everyday contributors, and also through its “approved articles,” which have undergone a form of peer-review by credentialed topic experts and are closed to real-time editing.”

Starting this fall Wikipedia will launch an optional feature called “WikiTrust” will color code every word of the encyclopedia based on the reliability of its author and the length of time it has persisted on the page: Text from questionable sources starts out with a bright orange background, while text from trusted authors gets a lighter shade.

9-9-2009 15-25-36 wikipedia wikiproject medicine

The Wikipedia EBM article is within the scope of these two projects, and this is good news. However, Wikipedia still clings to the idea that: “Everyone is welcome to join in this endeavor (regardless of medical qualifications!).” In my opinion, it would be better if Wikipedia gave precedence to experts instead of hobbyists/ people from another field, because the former can be expected to know what they are talking about. It is quite off-putting for experts to contribute. See this shout-out:

Who are these so-called experts who will qualify material? From what I’ve seen so far, being an academic expert in a particular field hardly protects one from edit wars–Julie and 172 are two primary examples of this. Meanwhile, the only qualification I have seen so far is that they have a B.A. Gimme a friggin’ break! (and before I get accused of academic elitism, I make it known that I dropped out of college and spend an inordinate amount of time at work correcting the BS from the BAs, MAs, and PhDs).

While anyone can still edit entries, the site is testing pages that require changes to be approved by an experienced Wikipedia editor before they show up, the so called Flagged protection and patrolled revisions. (see Wikimedia) This proposal is only for articles that are currently under normal mechanisms of protection (i.e. the Obama-article cannot be edited by a newcomer).

Although this seems logic, it is questionable whether “experienced” editors are per definition better qualified than newcomers. A recent interesting analysis of the Augmented Social Cognition group [31], (cited in the Guardian [32]) shows a slowdown in growth of Wikipedia activity, with the activity slightly declining in all classes of editors except for the highest-frequency class of editors (1000+ edits). Here is an increase in their monthly edits.

In addition the study shows growing resistance from the Wikipedia community to new content. The total percentage of reverted edits increased steadily over the years, but more interestingly, low-frequency or occasional editors experienced a visibly greater resistance compared to high-frequency editors . Together this points at a growing resistance from the Wikipedia community to new content, especially when the edits come from occasional editors.

This is more or less in line with an earlier finding [9] showing that Wikipedia members feel more comfortable expressing themselves on the net than off-line and scored lower on agreeableness and openness compared to non-Wikipedians, a finding that was interpreted as consistent with the possibility that contributing to Wikipedia serves mainly egocentric motives.

Image representing Medpedia as depicted in Cru...
Image via CrunchBase

Encouraging students, doctors and scientists (provisional)

One way of improving content, is to encourage experts to write. To achieve that the information on Wikipedia is of the highest quality and up-to-date, the NIH is encouraging its scientists and science writers to edit and even initiate Wikipedia articles in their fields [36]. It joined with the Wikimedia Foundation, to host  a training session on the tools and rules of wiki culture, at NIH headquarters in Bethesda.

A less noncommital approach is the demand to “Publish in Wikipedia or perish”, as described in Nature News [9]. Anyone submitting to a section of the journal RNA Biology will, in the future, be required to also submit a Wikipedia page that summarizes the work. The journal will then peer review the page before publishing it in Wikipedia.” The project is described in detail here [10] and the wiki can be viewed here

Wiki’s for experts.

One possible solution is that scientist and medica experts contribute to wiki’s other than the Wikipedia. One such wiki is the wiki-surgery [5]. PubDrugRxWiki , WikiProteins [11] and Gene Wiki [12] are other examples. In general, scientists are more inclined to contribute to these specialists wiki’s, that have oversight and formal contributions by fellow practitioners (this is also true for the RNA-wiki)

A medical Wikipedia

Yet another solution is a medical wikipedia, such as Ganfyd or Medpedia . Ganfyd is written by medical professionals. To qualify to edit or contribute to the main content of Medpedia approved editors must have an M.D., D.O., or Ph.D. in a biomedical field. Others, however, may contribute by writing in suggestions for changes to the site using the “Make a suggestion” link at the top of each page. Suggestions are reviewed by approved editors. Whether these medical wikipedias will succeed will depend on the input of experts and their popularity: to what extent will they be consulted by people with health questions?

I would like to end with a quote from Berci during twitterview (link in Wikipedia):

@Berci : @diariomedico And as Wikipedians say, Wikipedia is the best source to start with in your research, but should never be the last one. #DM1 9 months ago

REFERENCES

ResearchBlogging.orgScientific Articles

  1. Laurent, M., & Vickers, T. (2009). Seeking Health Information Online: Does Wikipedia Matter? Journal of the American Medical Informatics Association, 16 (4), 471-479 DOI: 10.1197/jamia.M3059
  2. Hughes, B., Joshi, I., Lemonde, H., & Wareham, J. (2009). Junior physician’s use of Web 2.0 for information seeking and medical education: A qualitative study International Journal of Medical Informatics, 78 (10), 645-655 DOI: 10.1016/j.ijmedinf.2009.04.008
  3. Lee, C., Teo, C., & Low, A. (2009). Fulminant dengue myocarditis masquerading as acute myocardial infarction International Journal of Cardiology, 136 (3) DOI: 10.1016/j.ijcard.2008.05.023
  4. Halavais, A., & Lackaff, D. (2008). An Analysis of Topical Coverage of Wikipedia Journal of Computer-Mediated Communication, 13 (2), 429-440 DOI: 10.1111/j.1083-6101.2008.00403.x
  5. Devgan, L., Powe, N., Blakey, B., & Makary, M. (2007). Wiki-Surgery? Internal validity of Wikipedia as a medical and surgical reference Journal of the American College of Surgeons, 205 (3) DOI: 10.1016/j.jamcollsurg.2007.06.190
  6. Clauson, K., Polen, H., Boulos, M., & Dzenowagis, J. (2008). Scope, Completeness, and Accuracy of Drug Information in Wikipedia Annals of Pharmacotherapy, 42 (12), 1814-1821 DOI: 10.1345/aph.1L474 (free full text)
  7. Mühlhauser I, & Oser F (2008). [Does WIKIPEDIA provide evidence-based health care information? A content analysis] Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen, 102 (7), 441-8 PMID: 19209572
  8. Amichai–Hamburger, Y., Lamdan, N., Madiel, R., & Hayat, T. (2008). Personality Characteristics of Wikipedia Members CyberPsychology & Behavior, 11 (6), 679-681 DOI: 10.1089/cpb.2007.0225
  9. Butler, D. (2008). Publish in Wikipedia or perish Nature DOI: 10.1038/news.2008.1312
  10. Daub, J., Gardner, P., Tate, J., Ramskold, D., Manske, M., Scott, W., Weinberg, Z., Griffiths-Jones, S., & Bateman, A. (2008). The RNA WikiProject: Community annotation of RNA families RNA, 14 (12), 2462-2464 DOI: 10.1261/rna.1200508
  11. Mons, B., Ashburner, M., Chichester, C., van Mulligen, E., Weeber, M., den Dunnen, J., van Ommen, G., Musen, M., Cockerill, M., Hermjakob, H., Mons, A., Packer, A., Pacheco, R., Lewis, S., Berkeley, A., Melton, W., Barris, N., Wales, J., Meijssen, G., Moeller, E., Roes, P., Borner, K., & Bairoch, A. (2008). Calling on a million minds for community annotation in WikiProteins Genome Biology, 9 (5) DOI: 10.1186/gb-2008-9-5-r89
  12. Huss, J., Orozco, C., Goodale, J., Wu, C., Batalov, S., Vickers, T., Valafar, F., & Su, A. (2008). A Gene Wiki for Community Annotation of Gene Function PLoS Biology, 6 (7) DOI: 10.1371/journal.pbio.0060175
    Other Publications, blogposts
    (numbers in text need to be adapted)

  13. Envision Solutions, LLC. Diving Deeper Into Online Health Search – Examining Why People Trust Internet Content & The Impact Of User-Generated Media (2007) http://www.envisionsolutionsnow.com/pdf/Studies/Online_Health_Search.pdf Accessed August 2009 (CC)
  14. New data available of the the Pew Internet & American Life Project are available here)
  15. http://www.thegooglecache.com/white-hat-seo/966-of-wikipedia-pages-rank-in-googles-top-10/
  16. http://www.seoptimise.com/blog/2008/05/why-wikipedias-google-rankings-are-a-joke.html
  17. http://wishfulthinkinginmedicaleducation.blogspot.com/2009/06/where-do-first-year-medical-students.html
  18. http://www.newscientist.com/article/mg20327185.500-should-you-trust-health-advice-from-the-web.html?page=1
  19. http://wishfulthinkinginmedicaleducation.blogspot.com/2009/07/where-do-junior-doctors-look-things-up.html
  20. http://www.shockmd.com/2009/07/06/how-and-why-junior-physicians-use-web-20/
  21. http://sandnsurf.medbrains.net/2009/07/how-and-why-junior-docs-use-web-20/
  22. Wikipedia used by 70% of junior physicians, dominates search results for health queries (casesblog.blogspot.com)
  23. http://scienceroll.com/2009/07/06/junior-physicians-and-web-2-0-call-for-action/
  24. http://scienceroll.com/2009/08/03/rorschach-test-scandal-on-wikipedia-poll/
  25. http://www.nytimes.com/2009/07/29/technology/internet/29inkblot.html (Rorschach)
  26. http://www.pcworld.com/article/170874/the_15_biggest_wikipedia_blunders.html
  27. http://www.futureofthebook.org/blog/archives/2006/07/reuters_notices_wikipedia_revi.html
  28. http://en.wikipedia.org/w/index.php?diff=prev&oldid=144007397
  29. http://business.timesonline.co.uk/tol/business/industry_sectors/media/article2264150.ece
  30. http://blogs.wsj.com/health/2007/08/30/abbott-labs-in-house-wikipedia-editor/
  31. http://www.brandweeknrx.com/2007/08/abbott-caught-a.html
  32. http://www.kevinmd.com/blog/2009/08/op-ed-wikipedia-isnt-really-the-patients-friend.html
  33. http://www.businessweek.com/technology/content/dec2005/tc20051214_441708.htm?campaign_id=topStories_ssi_5
  34. http://asc-parc.blogspot.com/2009/08/part-2-more-details-of-changing-editor.html
  35. http://www.guardian.co.uk/technology/2009/aug/12/wikipedia-deletionist-inclusionist
  36. http://www.washingtonpost.com/wp-dyn/content/article/2009/07/27/AR2009072701912.html
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Appropriate bedside manners

14 05 2008

Do you prefer a doctor that is crying at the bedside or rather one that stays calm and keeps at a professional distance???

My previous post on Etiquette Based Medicine also dealt with ‘correct’ attitudes of doctors towards their patients. Here I quoted Dr. Khan who believes that “patients may care less about whether their doctors are reflective and empathic than whether they are respectful and attentive”. His opinion is shared by many, but certainly not by all. I allready cited a British Journal of General Practice issue on doctor-patient communication, where different viewes were presented. Well, the debate is still ongoing. In the NY Times of 22nd April was a interesting piece about physicians crying at the bedside: At Bedside, Stay Stoic or Display Emotions? [*requires registration].

Some excerpts:

“A young doctor sat down with a terminal lung cancer patient and her husband to discuss the woman’s gloomy prognosis. The patient began to cry. Then the doctor did, too.

At a recent meeting of the Society of General Internal Medicine, Dr. Anthony D. Sung of Harvard Medical School and colleagues reported that 69 percent of medical students and 74 percent of interns said they had cried at least once.

In the 1988 PBS documentary “Can We Make a Better Doctor?” a Harvard medical student, Jane Liebschutz, sees her patient unexpectedly die during a cardiac bypass operation. She suddenly bursts into tears and wanders away from her colleagues until the chief surgeon, who has witnessed what happened, assures her that her response was natural.

Dr. Benita Burke, skipped lunch to spend extra time with her cancer patients. They dubbed this time “mental health rounds,” during which they could address issues that were not strictly medical. Many times, Dr. Burke would wind up in tears or giving an embrace.

The comments in the NY Times and at two blogs (DB’s Medical Rants and Clinical Cases and Images) are also worth reading. These responses illustrate that there is not one truth. Whether strong emotions like crying are appropriate depends on the doctor, the patient, the situation and where and how emotions are expressed. Most patients do not seem to appreciate outright crying at their bedside as it makes them insecure. A crying doctor might also feel like a final verdict: no hope is left. But nobody would blame an intern for crying with his or her mates. And a doctor who cries in front of the patient’s family when sharing information about a serious medical error might help to accept what happened.

So, what kind of doctor would you prefer?

I agree with Dr Hiram Cody, cited in the NY Times, who cautions against excess emotions. Although Dr. Cody emphasizes the need for doctors “to understand, to sympathize, to empathize and to reassure,” he says his job “is not to be emotional and/or cry with his patients for two reasons: It is not therapeutic for the patient, and it will cause “emotional burnout”. (although I’m not sure about the latter)

Personally I prefer a doctor with great knowledge, but openminded to other ideas, attentive and empathic, but without loosing a certain distance, a good listener, explaining disease and treatment options, ….. but no crying, please, never! Never when I’m around. Not when I’m the patient.

****************************************************

NL flagToevallig kwam ik in mijn Feed-Reader een bericht tegen uit de New York Times van 22 april, dat perfect aansluit op mijn vorige post over Etiquette Based Medicine: At Bedside, Stay Stoic or Display Emotions? [*registratie vereist].

Dit stuk bespreekt de voor en tegens van een dokter die zich “laat gaan”.

Enkele citaten:

A young doctor sat down with a terminal lung cancer patient and her husband to discuss the woman’s gloomy prognosis. The patient began to cry. Then the doctor did, too.

At a recent meeting of the Society of General Internal Medicine, Dr. Anthony D. Sung of Harvard Medical School and colleagues reported that 69 percent of medical students and 74 percent of interns said they had cried at least once.

In the 1988 PBS documentary “Can We Make a Better Doctor?” a Harvard medical student, Jane Liebschutz, sees her patient unexpectedly die during a cardiac bypass operation. She suddenly bursts into tears and wanders away from her colleagues until the chief surgeon, who has witnessed what happened, assures her that her response was natural.

Dr. Benita Burke, skipped lunch to spend extra time with her cancer patients. They dubbed this time “mental health rounds,” during which they could address issues that were not strictly medical. Many times, Dr. Burke would wind up in tears or giving an embrace.

Behalve dit stuk zijn ook de commentaren in de NY-times zelf en op 2 blogs (DB’s Medical Rants en Clinical Cases and Images) de moeite van het lezen waard. Diverse meningen passeren de revue, zowel die van dokters als patiënten of familie. Hieruit blijkt dat er niet één waarheid is. Of het uiten van heel sterke emoties kàn, hangt erg af van de dokter, de patient, hun relatie en de situatie. De meeste patienten vinden het uiten van emoties wél belangrijk (“een dokter moet geen robot zijn”), maar velen vinden te sterke emoties zoals het in huilen uitbarsten waar de patient bijstaat niet prettig, omdat ze juist willen dat ze op hun arts kunnen steunen. Gaat het om een heel slechte boodschap (kanker bijvoorbeeld) dan kan de patient het ook ervaren dat hij opgegeven is: de arts neemt alle hoop dan in een keer weg. Maar als een co-assistent bij het overlijden van zijn/haar “eerste” patient bij haar vrienden uithuilt kan iedereen dat begrijpen. Als een dokter huilt wanneer hij slecht nieuws brengt over een dierbare ten gevolge van een medische fout, dan kan dat bij de verwerking helpen.

Maar welke dokter zou jij verkiezen?

Ik ben het in grote lijnen met Dr Hiram Cody eens. In de NY Times waarschuwt hij tegen overmatige emoties. Hij benadrukt weliswaar dat artsen begripvol moeten zijn, moeten meeleven, empathisch moeten zijn en gerust moeten stellen, maar echt emotioneel zijn en huilen raadt hij af omdat het noch de patient noch de arts goed doet.

Persoonlijk verkies ik een arts met een goede kennis van zaken, maar die wel openstaat voor andere opvattingen, die meeleeft en empathisch is wanneer nodig. Hij moet goed kunnen luisteren, mij serieus nemen, goed kunnen uitleggen waarom ik iets heb en welke behandelingsmogelijkheden er zijn (met hun voor-en nadelen). Hij moet eerlijk zijn en als ik het nodig zou hebben is een beetje emotie en een beetje warmte prettig. Maar huilen, nee. Geen huilen waar ik bij ben. Niet wanneer ik de patient ben.





Etiquette-Based Medicine

11 05 2008

Every now and than my collegue Heleen provides me with an interesting paper (a nice web 1.0 way of sharing things). Last Friday I found this paper on my desk: “Etiquette-Based medicine” from Michael W Kahn. The paper in this week’s New England Journal of Medicine is not about the substition of “evidence based medicine” or “eminence-based medicine” by “etiquette-based medicine”. It is about the importance of a good attitude of doctors towards their patients.

When psychiatrist Dr. Khan hears patients complain about doctors, their criticism often has nothing to do with not feeling understood or empathized with. Instead, they object that “he just stared at his computer screen,” “she never smiles,” or “I had no idea who I was talking to”, he writes.
On the contrary, during his own hospitalization he noticed the professional attitude of his European-born surgeon having Old World manners (dress, body language, eye contact etc.).

“The impression this surgeon made was remarkably calming, and it helped to confirm my suspicion that patients may care less about whether their doctors are reflective and empathic than whether they are respectful and attentive”, wrote Dr. Kahn.

Therefore, Khan suggests that medical education and postgraduate training should place more emphasis on “etiquette-based medicine” as it forms the basis of the patient-doctor relationship. One approach would be to introduce a checklist to enforce an etiquette-based approach. A checklist for the first meeting with a patient would for instance cover items like ‘asking permission to enter the room and wait for an answer’, ‘introducing yourselve, showing your ID badge’ and ‘explaining you role on the team’.

This approach bears resemblance to the program introduced at several Academical Medical Centres in the Netherlands. For instance Maas Jan Heineman, nowadays Professor Gynaecology in the Amsterdam Medical Centre (AMC), Amsterdam, helped to introduce such a “etiquette program” in Groningen and in Amsterdam. The competences of the doctors and the integration of knowledge, skills and attitude are now central to the new curricula. As Heineman says it: “What good are doctors who have great knowledge but behave badly. Or vice versa”?! )

These thoughts are (of course) not specifically Dutch (nor European). The entire 2005 January issue of the British Journal of General practice focuses on this subject.

The journal issue ends with a bookreview of a UK-US guide to communicating with patients, consisting of a book ‘Skills for Communicating with Patients’ and a companion volume, ‘Teaching and Learning Communication Skills in Medicine‘, which translates the first book into a framework that can be used in designing and delivering curricula for communications skills teaching in both the academic and clinical setting.

The reviewer, Iain Lawrie, is very positive about the content:

“The layout and language are clear and unambiguous throughout. Important points are emphasised where necessary, and at no time does reading become laborious. Far more importantly, however, the authors have employed an evidence-based approach that moves these titles from the realm of personal opinion and musings to an authoritative work. The frequent use of examples further serves to promote this series as a ‘useable’ guide. (….)
The book gives examples Skills for Communicating with Patients, the authors use a logical approach to analyse the various aspects of communication relevant throughout the consultation process, which are then explored in greater depth over six chapters. They move from the initiation of a consultation (!), through information gathering, structuring, and relationship building, to the often neglected areas of explaining and planning and, finally, closing the encounter.”

Thus it seems that the awareness within the medical community about the necessity of good communication skills is growing. The tools are there, some curricula have already embraced “etiquette based medicine” (although not called by that name) and it seems just a matter of time before “etiquette” becomes an integral part of medical education.

Lets conclude with a quote from the abovementioned book, that also applies to professions other than medical:

‘If you can’t communicate, it doesn’t matter what you know’

*****************************************************************

Van mijn collega Heleen krijg ik af en toe een artikel of een krantenknipsel toegeschoven. Nog geheel op de ouderwetse web 1.0 manier, maar eigenlijk wel zo leuk. Van de week lag er een artikel in mijn postvak getiteld “Etiquette-Based medicine”, geschreven door Michael W Kahn. Ik dacht eerst “weer een zogenaamd alternatief voor “evidence based-“ of “eminence-based medicine”, maar het artikel in het laatste nummer van de New England Journal of Medicine ziet “Etiquette-Based medicine” meer als een aanvulling. Het gaat over het belang van een juiste attitude van de arts tegenover zijn patient.

De klachten die Dr. Khan als psychiater van patiënten over artsen hoort gaan meestal niet over gebrek aan empathie maar veel meer over zaken als: “hij staarde maar naar zijn computerscherm”, “er kan geen lachje af”, “ik had geen idee met wie ik nou te maken had”.

Toen Khan zelf in het ziekenhuis lag had hij precies de tegenovergestelde ervaring. De behandelend chirurg van europese herkomst kwam door zijn zogenaamde ‘Oude-Wereld’ houding (kleding, lichaamstaal, oogcontact) bijzonder professioneel en geruststellend over.

Dit sterkte Khan in zijn idee dat patiënten het veel belangrijker vinden dat hun arts hen met respect en met aandacht bejegent dan dat hij heel erg meelevend is.

Hij stelt daarom dat er in het medisch onderwijs meer aandacht moet komen voor wat hij “etiquette-based medicine” noemt, daar dit de grondslag van een goede patient-doctor relatie vormt. Een checklist zou daarbij kunnen helpen. Als een arts de patient voor het eerst ziet zou hij bijvoorbeeld eerst moeten vragen of hij welkom is en pas als de patiënt akkoord is zou hij naar binnen moeten gaan, een hand moeten geven en zich voor moeten stellen.

Iets dergelijks gebeurt reeds in diverse Nederlandse universitair medische centra. Professor Maas Jan Heineman heeft zo’n “etiquette programma” eerst in het UMCG in Groningen en nu in het AMC te Amsterdam geïnitieerd. In het nieuwe curriculum staan de competenties van de arts centraal en een integratie van kennis, vaardigheden en gedrag. Je hebt tenslotte niets aan een dokter die weliswaar veel weet, maar zich vreselijk gedraagt, of andersom”, aldus Heineman. )

Zo’n benadering is niet specifiek Nederlands, noch Europees. Een heel nummer van het British Journal of General practice (jan 2005) gaat enkel over dit onderwerp.

Het laatste artikel is een boekbespreking van een ‘UK-US gids’ over communicatievaardigheden: ‘Skills for Communicating with Patients” en een begeleidend boekje, Teaching and Learning Communication Skills in Medicine. ]

De recensent Iain Lawrie is erg positief over het boek. Het is helder geschreven en legt de juiste nadrukken. Verder stijgt het werk door de evidence-based benadering boven een opeensomming van feitjes en meningen uit. Het begeleidende boek geeft voorbeelden van hoe te handelen in bepaalde situaties, bijvoorbeeld tijdens het eerste consult. Het boek omvat dus precies wat Khan suggereerde.

Het lijkt er dus op dat men zich binnen de medische wereld steeds meer bewust wordt van de noodzaak van goede communicatievaardigheden. Er zijn al ‘leermethoden’ beschikbaar en in enkele curriculums is etiquette based medicine reeds verweven (zij het onder een andere naam). Het is slechts een kwestie van tijd voordat etiquette een vanzelfsprekend onderdeel van de medische vorming is.

Tot slot een citaat uit het eerder aangehaalde boek (dat eigenlijk op veel meer beroepen van toepassing is):

‘If you can’t communicate, it doesn’t matter what you know.’