Category: Blog

Bill Gardner writing on The Incidental Economist examines two studies in Health Affairs that look at “Treatment as Prevention: The Value of Early Treatment of HIV Infection” 

Compared to people who initiated cART late…, those who initiated treatment early (with a CD4 count of 350–500) could expect to live 6.1 years longer, and the earliest initiators (with a CD4 count of more than 500) could expect an extra 9.0 years of life.

cART is expensive, but it turns out that

[t]he total value of life expectancy gains to the early and earliest initiators of treatment was $80 billion, with each life-year valued at $150,000… The value of the survival gains was more than double the increase in drug manufacturers’ revenues from early cART initiation.

Clearly more studies similar to this are needed for other diseases. What are the benefits for life and what are the economic benefits. 

Renner, Kimmerie, et. al publishing in JMIR “Web-Based Apps for Reflection: A Longitudinal Study With Hospital Staff” examines how a web based app can improve reflection which is a key component of learning and aids us our ability to apply new knowledge to previous experiences in order to create new learning. Reflection does not just happen since it is complex and demands the learner develop skills on reflection. 

One area where reflection and reflective thinking are broadly researched topics is in the health care sector. A special focus of previous research has been on the education of nurses and physicians. In hospitals, reflection helps the staff combine theory and practice and enables them to turn experiences into learning opportunities. In this way, reflection and reflective work behavior foster continuing professional development. Research findings in this field suggest, however, that reflectivity is indeed not an easily applied skill. Instead, guidance and support are needed to achieve higher levels of reflection.

The study had 167 employees from a hospital participated. They were involved in user studies and workshops to better understand reflective behavior and the needs of the hospital staff. Each was provided with devices and apps. The apps they were given were DocTrain, CLinIC-The Virtual Tutor, and Talk Reflection. 

The primary findings to test whether the introduction of apps that support reflection would affect staffs actual reflection behavior at work. 

As expected, there was a positive relationship between reflection behavior and job satisfaction, indicating that higher levels of collaborative reflection processes go along with enhanced job satisfaction among participants in the hospital. This further supports the findings of other authors regarding a relationship between informal learning and job satisfaction as introduced above. The content of our collaborative reflection scale suggests that being provided with sufficient time to reflect, reflecting collaboratively in a team, and discussing work with a supervisor go along with a higher level of job satisfaction.

This is an excelelnt read but more importantly it offers a way to help medical student and all HCP improve their ability to apply what they’ve learned to their experiences to produce new knowledge that improves care. 

At Science Blogs Respectful Insolence introduces me to Dunning-Kruger Disease “Pediatricians versus the Dunning-Kruger effect on vaccines.”

It’s the phenomenon whereby people who are unknowledgeable or incompetent about a topic have a falsely elevated estimate of their own knowledge base. In the antivaccine movement, the D-K phenomenon tends to take the form of parents who think that their University of Google knowledge trumps the knowledge of physicians and scientists who have dedicated large swaths of their lives to the rigorous study of conditions such as autism and the question of how vaccines work.

We get a look inside a wine and cheese event where non-vaccinating parents share their adventures in turning science and health back to the dark ages while lifting their behavior to the highest level of self-delusion.

This is well worth the read and it’s shock value to science and what happens when a patient is fired by a pediatrician. 

Dr. Vartabedian writing on his blog 33 Charts offered the following post “When Hospitals Engage by Megaphone” His point which is brilliantly stated…

And so organizations learn to engage by megaphone. Volume, it seems, is the greatest metric of success.  And as long as unidirectional output can be formatted as a graph on a Powerpoint slide, the beat goes on.

As it turns out, no one listens.  People care about themselves, not minimally invasive surgical centers.

Put in my terms adults will only learn when they are seeking solutions to problems. They do not want to be sold to or shouted at. Know what I need to learn and serve it up. 

JMIR just published a paper “Are Public Health Organizations Tweeting to the Choir? Understanding Local Health Department Twitter Followership” by Harris, Choucair, Maier, et. al. The authors note that only 61% of local health departments meet standards for information and educating constituents. There is a gap in current and best practices. The objective of this study was to examine local health departments Twitter followers and their relationship with local health departments and their followers characteristics. The sample size was 4,779 Twitter followers from 59 random health departments. 

Results, local health department Twitter accounts were followed by organizations in greater numbers and were health focused located out of state. They most comprised education, government, and non-profits. Surprising was the finding that individuals were more likely to be local and not health focused. And when the health department has a public information officer on staff and tweeting they were likely to have higher percentage of local followers. 

The gross anatomy of this study is that we tend to talk to ourselves. This can be seen in Twitter chats such as #hcsm #dwdchat. Generally participation are made up of the same faces. Though the discussions provide great new information it remains in the echo chamber and is not driving greater participation or broad based learning though I will say the outside chats posts using the # are many times retwitted and reach a wider audience but still limited to those who share similar characteristics. 

I have long said we need to understand who we are speaking with and what are their characteristics to better target them. The authors note 

…we identified the characteristics (eg, jurisdiction population size, employing a public information officer) and practices (eg, tweet frequency) associated with local health department Twitter follower characteristics. This information could inform strategic planning for local health departments using or considering using Twitter. For example, if a goal of a local health department is to reach greater numbers of individuals rather than organizations, their Twitter strategy could include a regular daily or weekly tweeting schedule.

Second, understanding who the Twitter followers are could help local health departments better target tweets to diverse audiences. For example, local media and policymakers may be important followers for a local health department. Standard strategies (eg, tweeting more, developing an easy-to-find user profile ) for increasing the number of followers may bring in more media and policymakers. However, additional research into how media and policymakers on Twitter select specific information sources may help to identify strategies for local health departments in increasing the presence of these followers. As another example, out-of-state organizations are less likely to be interested in tweets focused at the individual, as well as locally focused or locally relevant tweets about health and health-related events. However, these followers may be interested in learning about innovative or successful local health department programs and best practices. Local health departments wishing to connect and engage more with this existing audience might program their Twitter accounts as dissemination platforms to reach these organizations with relevant information about successful strategies and programs.

Bottom line, we need to use social media the way we’ve always approached communications, advertising, marketing, and sales. Know our audience, know where they are, know what they want to learn, and speak to them frequently. They want to solve their healthcare problems. Know what those problems are specific to their learning needs. 

Muench, Stolk-Cooke, Morgenstern, et. al. out of the Department of Psychiatry at Columbia University College of Physicians & Surgeons have published an original paper “Understanding Messaging Preferences to Inform Development of Mobile Goal-Directed Behavioral Interventions”.

The goal of this study was to determine what if any were global messaging preferences existed for various types of language content. In other words do readers of text messages prefer certain words and linguistic style when seeking to achieve a personal goal.

Results of this study indicate that there are clear user preferences for certain types of message characteristics over others, underscoring the importance of attention to message structure, linguistic content, and overall tone in the development of messages for goal-directed behaviors.

Participants indicated an overwhelming preference for messages that were accurately spelled and grammatically correct over messages that included textese or contained grammatical errors.

The more we know about the why people search and use the Internet for healthcare and understand how these same individuals respond to new information the better we can be at delivering knowledge and guiding learning. Which in the end is what healthcare is about transferring HCP knowledge to the patients in order to drive behavioral changes and improve outcomes. 

Batenbury and Das out of VU University Amsterdam have an original paper in JMIR “Emotional Coping Differences Among Breast Cancer Patients From an Online Support Group: A Cross-Sectional Study”. The authors had 184 Dutch breast cancer patients complete a questionnaire examining activity in peer online support community. They wanted to determine if the effects of online support group participation is driven by patients’ ability to cope or not with their reflection on the disease. 

The conclusion: breast cancer patients individual coping style drove their participation in online communities. Those who coped less actively had a lower sense of psychological well-being then patients who were actively coping. 

A potential explanation for the negative relation between the intensity of online participation and breast cancer-related concerns among patients with a more avoidant coping style is that these patients may be less able to cope with the negative content on online forums; they may be overwhelmed by the sad and frightening stories from patients in the same conditio

This fits with my first time experience as a caregiver for Donna going online through a local organization. I signed up and went to the lung cancer group. I nearly lost my dinner. The stories and posting about the horrific nature of the disease and treatment left me cold and broken. Subsequently when I was working with a counselor I was told nearly word for word what is above. I’m pleased to see the data supporting the anecdotal reporting. 

Romane Millia Schook, MD out of BU University Medical Center in Amsterdam published “Why Do Patients and Caregivers Seek Answers From the Internet and Online Lung Specialists? A Qualitative Study” in JMIR. The goal of the study was to determine the reasons why lung cancer patients and caregivers search the Internet for information and ask lung specialists questions on the Dutch Lung Cancer Information Center.

This was a qualitative study via telephone interviews about medical information seeking of 5 lung cancer patients and 20 caregivers who posted questions on the web site.

The diagnosis of lung cancer drove the behavior to seek information and ask questions of experts. The need for knowledge was critical. It is worth noting that these participants were email, banking, and information seeking individuals prior to the diagnosis. So online activities were not new. 

Information was sought during chemo, when there were changes in symptoms, disease progression, or needing to choose between two treatment options. The authors noted patients and caregivers would seek information once they had time to rest and think about what they were told or forgot what they heard. They sought to learn when they had to find a solution to a problem. Which matches why adults learn. 

Respondents searched for information related to lung cancer yet specific to their situation, to better understand the disease, prepare for future visits, become aware of the disease course and trajectory. Additionally they sought answers to questions that were directly answered by their physician. To confirm and learn. 

The author noted the differences between patients and caregivers which fit with our general understanding from various studies done by PEW etc. Patients searched for a minimal amount of information directed at symptoms and therapy and practical information regarding disease. Patients stayed away from end of life information. Finally patients sought hope in the form of others and support regarding disease management and care.

Caregivers were little information vacuums collecting copious amounts of knowledge. Though caregivers noted the need to be better informed about the disease it conflicted with the fact most information was difficult to understand or understanding it correctly. This group also sought information more frequently and specific to end of life and prognosis.

It was surprising to learn when respondents were asked why they were reluctant to ask their treatment specialist the same questions they sought answers to online respondents mentioned being ashamed discussing personal matters or indecencies within the office visit. Or they felt their specialists had little or no time between appointments. The convenience of using the Internet and the website was a factor to drive communications. Beyond convenience was a sense of open-mindedness, kindness, and empathy that respondents noted and valued in online communities.

On the down side for Internet usage specific to patients was the reality that there was a vast amount of information and that the greater the amount of information it took focus away from staying positive. (More is not better.) There does exist a tension between the knowledge the caregiver is finding and learning and the patient. That tension tends to focus on sharing too much with a patient and provoking a confrontation. From my caregiving experience I had to walked into that buzz saw when I shared information that did not add to hope. 

The present study adds knowledge to the information-seeking behavior of lung cancer patients and their caregivers during the lung cancer treatment trajectory and their reasons for doing so. Strikingly, the majority of respondents were caregivers. Our findings show the coping strategies of caregivers and patients towards managing lung cancer.

The more we know and learn how patients and caregivers approach knowledge acquisition and how they process it the better we can be in delivering learning to these problem solvers. There uptake of knowledge and its application to their lives will be the driving force in changing healthcare. 

Trevor van Mierlo published and original paper in JMIR “The 1% Rule in Four Digital Health Social Networks: An Observational Study”. We all know there is the 90-9-1 principle (Pareto Principle) for Internet communities. Just to refresh our collective memories, 90% lurk, 9% contribute, and 1% are superusers. Mierlo wanted to know if this rule applies to moderated Digital Health Social Networks (DHSNs) whose mission is to facilitate behavior change (Problem Drinking, Depression, Smoking Cessation, and Panic Disorder). 

Four of DHSNs superusers drove over 74% of the content and generated the vast majority of posts while Lurkers generated limited or no network value. The authors recommend that healthcare organizations should recruit and retain Superusers. Call me old fashion but recruiting Superusers strikes as putting shills at the blackjack tables in Vegas to draw the suckers in. Additionally they note that to really fully understand the Pareto Principle and how it functions within support networks future research should look a how different indications, disease states or actor types behave and what are the demographic and psychographic characteristics. 

The more we can learn about online behaviors and how individuals react and function the better we will be to drive change. We don’t need to make everyone a Superuser as much as understand why some lurk and do they learn from lurking and how do they apply what they’ve learned.

Farhat Yaqub reviews “Deadly Medicines and Organised Crime: How Big Pharma Has Corrupted Healthcare” by Peter C. Gatzsche. Gatzsche points out that there are over 100,000 deaths per year in the US due to drugs, Rx drugs, and another 100,000 deaths due to error.

According to Gøtzsche, “we now suffer from two man-made epidemics, tobacco and prescription drugs, both of which are hugely lethal” and the norm for both industries is a “morally repugnant disregard for human lives”. Furthermore, Gøtzsche claims, the business model of the drug industry is “organised crime”.

Do I, does Gatzsche have your attention? In a word, harsh. In Yaqub’s review he quotes Gatzsche “just like street drug pushers.” referring to big pharma. 

Gatzsche is not a crazy tin foil hat wearing idiot. He worked for pharma as a rep, researcher in clinical trials, physician, lecturer and cofounded the Cochrane Collaboration.

Just take a minute to read the review. I am sure this book will become grist for the mill of attacks on pharma. 

And keeping with the theme Adrian Teal has an article is ever proper Lancet “Quacks and hacks: Georgian medicine and the power of advertising”. He looks at his work as an illustrator and specifically the world of healthcare. He is now writing and illustrating true stories for a spoof 18th-century tabloid “The Gin Lane Gazette”. He sets  this article up by noting there is nothing new under the sun. It seems he’s right.

Quacks were nicknamed “advertising professors”, and many of these hustlers rose to fame and fortune by using the media to their advantage.

I am about to retire my proud title of an AE Account Executive in a healthcare ad agency.

Quacks selling proprietary medicines frequently colluded with newspaper publishers, who not only ran the vendors’ advertisements in their pages, but often sold the remedies on the printers’ premises for a cut of the profits. Another ploy was the “puff”, which was ostensibly an article reporting impartially on the wondrous efficacy of a new drug, but which was actually a kind of “advertorial” paid for by the manufacturer of the remedy.

I read this and think about the Lancet and their publication of Autism and vaccination. Things haven’t changed.

In 1785, Ruspini launched his haemostatic styptic, and published his Concise Relation of the Effects of an Extraordinary Styptic Recently Discovered. One of his newspaper advertisements claimed that the styptic had stopped the bleeding of a sailor’s bullet wound: “[The ball] passed through the man’s cheek, dividing the Vena Jugularis on both sides, which bleeding was immediately stopped by the Styptic, when no other means could give relief. As a result, Sir John Borlase Warren…liberally ordered a quantity to be furnished to each Vessel of his Squadron, for the use of the Seamen, in difficult cases.” There was even a circle printed in the middle of the advertisement that showed the alarming diameter of the bullet.

I love this, showing the diameter of the bullet is such good graphic quality. 

Take a read you won’t be disappointed.