The use of smartphones amongst health care professionals is now estimated to be in excess of 85%, with Apple's iPhone currently being the most popular platform. There is a wealth of information (from popular blogs, to formal journals) that demonstrate the potential of smartphone apps (and technology in general) to improve healthcare. However, despite widespread use of smartphones, proper application of the software at our disposal has been arguably poor. The latest mobile Apple operating system 'iOS 8', may be the start of a long-awaited overhaul of the current health apps available.
The App Store - as it stands
The Apple app store boasts many hundreds of what it describes as 'medical' apps. A review of the 'Top 200' medical apps conducted in 2012 by this author revealed that 49% were in fact general health or lifestyle applications aimed at the general public. The same process was repeated this year (2014) and demonstrated that this percentage has increased to 54%. This increase in apps aimed at the general public suggests that Apple do not differentiate between 'medical apps' and 'health and lifestyle' apps. This could negatively affect health care professionals' perception of the otherwise high-quality medical apps that are available. In addition, of the remaining percentage of apps aimed at healthcare professionals, only 5.56% were deemed to be of clinical benefit (an increased from 3% in 2012). The overwhelming majority of 'medical' apps aimed at medical professionals are actually educational in content and usually focus on the learning of anatomy.
Current health apps
Much like the 'medical' apps, only a limited selection of the health apps that are aimed at the public/patient are deemed to be high-quality. Prominent examples include the blood glucose monitors that record data in to a smartphone and similarly, the blood pressure and pain diaries. These examples focus on people with medical conditions, but it is important to note the potential of apps in preventative medicine too (i.e. promoting general health). Typical high-quality apps in this category include RunKeeper and Map My Ride. These apps allow everyone to become their own personal trainer and keep an accurate record of their physical activity. Smartphones will even send reminders to the user that a workout is due, and the option is present to share your stats and 'compete' with friends/family via social media. These features highlight the absolute vanguard of what could potentially come in terms of technology influencing healthy living.
A current criticism of health apps is that most (if not all) are individual enterprises with very little information shared between them. The metaphor of 'silos' is used to represent these large vessels of information that sit adjacent to one another whilst never benefiting from the contents of one another. The iOS 8 operating system hopes to ameliorate this current issue with its new Health app and HealthKit, which will enable developers and their apps to pull data from several health related apps into one streamlined app. It is envisaged that this app will be able to feed (with the appropriate permissions of course) health related information to your family physician for health monitoring purposes. This could have impressive effects in community blood pressure management and blood glucose management (just to name the obvious ones).
There are scattered anecdotal reports of users being wary of centralised health information and as always Data Protection is a major concern (whether it is warranted or not).
In addition, whilst a large percentage of the population may have a smartphone many may still opt not to use health related apps. Poor uptake will obviously limit the perception of this medium as a method of health monitoring.
Smartphone usage is high and many healthcare related apps are already available either to serve as medical tools to healthcare professionals or health monitoring devices for the public. Currently, Apple does not seem to differentiate between medical and lifestyle apps on its app store and many lower quality apps seem to appear in 'medical' searches. Also, Current apps do not share information. However, with iOS 8 it seems that Apple seems to be addressing several key issues surrounding the use of the iPhone as a health monitoring device. For the moment it seems that healthcare professionals will have to harness this patient-held approach. Perhaps direct improvements to the medical aspect of the Apple app store and the quality and originality of apps aimed at doctors is still a little way off.
“You’re a boring whore! Fix it.” The barked criticism came like a slap in the face. The director of Les Miserables was right, though. I was a boring whore.
Actors need to immerse themselves in their roles, shed inhibitions and squelch embarrassment. I was not managing to do this while rehearsing the Lovely Ladies prostitute scene. My performance was overly self-conscious and restrained.
Three days later I found myself at a medical education conference, attending a session discussing learning plans. A popular tool in adult education generally, and a training requirement for all GP registrars, learning plans are actively disliked by many. Done purposely and thoughtfully, they can be of great benefit; completed hastily or reluctantly because they are compulsory, they are next to useless.
I have to confess that, as a registrar, my own learning plans were dashed off with little thought, submitted and then promptly forgotten. I’d never thought this technique would work for me.
At the conference, the attending educators were instructed to each write a learning plan that addressed an aspect of their non-medical lives. We were asked to choose something that we genuinely wanted to improve. I instantly knew what I’d write about, and completed the task with seriousness and sincerity.
The facilitator randomly picked a few participants to read out their learning plans. The topics were predictable: “I want to exercise each morning”, “I want to get at least seven hours of sleep a night” and the like. Yes, you can see where this is leading ...
I should have anticipated being called upon, but when the “We have time for one more, how about you?” came, along with direct eye contact and a kindly smile, I momentarily panicked.
Surveying the room of mostly middle-aged, male faces, many of whom I didn’t know, I considered making something up on the spot. Instead, I stood up, took a deep breath and read out: “I want to be a more exciting whore.”
I then outlined my proposed methods for achieving this objective and how I intended to measure my progress. Without explanation, I then sat down.
Silence. Not a sound. Most eyes were glued to me, the others looking anywhere but. The atmosphere was thick with shock, amusement, confusion, suspense and fascination.
I didn’t leave them hanging for too long. After my disclosure as to why I chose the topic and the context in which I was “whoring”, there were audible sighs of relief and a sprinkling of laughter throughout the room.
It was memorable for those present. Four years later, I still get the occasional question about my “whoring” when I run into certain educators at conferences.
I am pleased to report that my learning plan well and truly achieved its aim. I enacted my plan exactly as written and practised diligently. I knew I had been successful when the director instructed me to “Tone it down a bit. This is a family show, you know!”
I now feel a lot more comfortable extolling the benefits of learning plans to unconvinced registrars. I tell them: “I used to think that I wasn’t a learning plan-type person either but I’ve discovered that if you choose a relevant and important objective and spend time and effort working out how to achieve it, the technique can really work.”
I tend to leave out: “It didn’t do much for my medicine, but it turned me into a fabulous whore.”
This blog post has been adapted from a column first published in Australian Doctor.
Dr Genevieve Yates is an Australian GP, medical educator, medico-legal presenter and writer. You can read more of her work at http://genevieveyates.com/
Storylines on popular TV dramas are a great way of raising the public's awareness of a disease. They're almost as effective as a celebrity contracting an illness.
For example, when Wiggles member Greg Page quit the group because of postural orthostatic tachycardia syndrome, I had a spate of patients, mostly young and female, coming in with self-diagnosed "Wiggles Disease". A 30% increase in the number of mammograms in the under-40s was attributed to Kylie Minogue's breast cancer diagnosis. The list goes on.
Thanks to a storyline on the TV drama Desperate Housewives, I received questions about male postnatal depression from local housewives desperate for information:
"Does it really exist?"
"I thought postnatal depression was to do with hormones, so how can males get it?"
"First it's male menopause, now it's male postnatal depression. Why can't they keep their grubby mitts off our conditions?"
"It's like that politically correct crap about a 'couple' being pregnant. 'We' weren't pregnant, 'I' was. His contribution was five seconds of ecstasy and I was landed with nine months of morning sickness, tiredness, stretch marks and sore boobs!"
One of my patients, a retired hospital matron now in her 90s, had quite a few words to say on the subject.
"Male postnatal depression -- what rot! The women's liberation movement started insisting on equality and now the men are getting their revenge. You know, dear, it all began going downhill for women when they started letting fathers into the labour wards. How can a man look at his wife in the same way if he has seen a blood-and-muck-covered baby come out of her … you know? Men don't really want to be there. They just think they should -- it's a modern expectation. Poor things have no real choice."
Before I had the chance to express my paucity of empathy she continued to pontificate.
"Modern women just don't understand men. They are going about it the wrong way. Take young couples who live with each other out of wedlock and share all kind of intimacies. I'm not talking about sex; no, things more intimate than that, like bathroom activities, make-up removal, shaving, and so on."
Her voice dropped to a horrified whisper. "And I'm told that some young women don't even shut the door when they're toileting. No wonder they can't get their de facto boyfriends to marry them. Foolish girls.
Men need some mystery. Even when you're married, toileting should definitely be kept private."
I have mixed feelings about male postnatal depression. I have no doubt that males can develop depression after the arrival of a newborn into the household; however, labelling it "postnatal depression" doesn't sit all that comfortably with me. I'm all for equality, but the simple fact of the matter is that males and females are biologically different, especially in the reproductive arena, and no amount of political correctness or male sharing-and-caring can alter that. Depressed fathers need to be identified, supported and treated, that goes without saying, but how about we leave the "postnatal" tag to the ladies?
As one of my female patients said: "We are the ones who go through the 'natal'. When the boys start giving birth, then they can be prenatal, postnatal or any kind of natal they want!"
(This blog post has been adapted from a column first published in Australian Doctor http://bit.ly/1aKdvMM)
During our antibiotics teaching at medical school we were told that a recent survey of junior doctors had revealed that a significant proportion didn't realise that augmentin, tazocin, and carbopenems were penicillins and as such should not be given to those with known allergies. I devised a "mind-map" summarising the main antibiotics in use using information from the BNF and my own lecture notes. For me, seeing the information laid out in this manner, pinned above my desk as I work, helps me remember the major classes, their relationships with one another, and their major side-effects.
I have recently spent a few days following around registrars on military ward rounds. It has been a fantastic experience for learning about trauma care and rehab, but more importantly it has shown me just how vital team spirit is to modern health care! The military ward round is done once a week. It starts with a huge MDT of almost 40 people, including nurses, physios, registrars and consultants from all of the specialities involved in trauma and rehab. The main trauma ward round team then go to speak to all of the patients in the hospital. The team normally consists of at least one T+O consultant, one plastics, two physios, two nurses, 3 registrars and a few others. This ward round team is huge, unweildly and probably very costly, but those military patients receive a phenomenal level of care that is very quick and efficient.
Having then compared this level of care with what I have experience on my 4th year speciality medicine placement, I now feel the NHS has a lot to learn about team work.
I am sure that everyone working in healthcare can relate to situations where patients have been admitted under the care of one team, who don’t really know what to do with the patient but struggle on bravely until they are really lost and then look around to see who they can beg for help. The patient then gets ping-ponged around for a few days while management plans are made separately. All of the junior doctors are stressed because they keep having to contact multiple teams to ask what should be done next. The patient is left feeling that their care wasn’t handled very well and is probably less than happy with the delay to their definite treatment. The patient, thankfully, normally ends up getting the correct treatment eventually, but there is often a massive prolongation of their stay in hospital. These prolonged stays are not good for the patient due to increasing risks of complications, side effects, hospital acquired infections etc. They are not good for the health care staff, who get stressed that their patients aren’t receiving the optimum care. The delays are very bad for the NHS managers, who might miss targerts, lose funding and have to juggle beds even more than normal. Finally, it is not good for the NHS as a hole, which has to stump up the very expensive fees these delays cause (approximately £500 a night).
There is a simple solution to this which would save a huge amount of time, energy and money. TEAM WORK!
Every upper-GI ward round should be done with the consultant surgeon team and a gastroenterologist (even a trainee would probably do) and vice versa, every Gastroenterology ward round should have a surgeon attached.
Every orthopaedic ward round should be done with an elderly care physician, physio/rehab specialist and a social worker.
Every diabetic foot clinic should have a diabetologist, podiatrist, vascular surgeon and/or orthopaedic surgeon (even trainees).
Etc. etc. etc.
A more multi-disciplinary team approach will make patient care quicker, more appropriate and less stressful for everyone involved. It would benefit the patients, the staff and the NHS. To begin with it might not seem like an easy situation to arrange. Everyone is over worked, no one has free time, no one has much of a spare budget and everyone has an ego. But...
Team work will be essential to improving the NHS. Many MDTs already exist as meetings. MDTs already exist as ED trauma teams, ED resus teams and Military trauma teams. There is no reason why lessons can’t be learnt from these examples and applied to every other field of medicine.
I know that as medical students (and probably every other health care student) the theory of how MDTs should work is rammed down our throats time after time, but I personally still think the NHS has a long way to go to live up to the whole team work ethos and that we as the younger, idealist generation of future healthcare professionals should make this one of our key aims for our future careers. When we finally become senior health care professionals we should try our best to make all clinical encounters an MDT approach.
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This field of medicine requires much more physiological and pathophysiological knowledge than most people give it credit for. Psychiatric illness DO have physical manifestations of symptoms; in fact those symptoms help form the main criteria for differential diagnoses. For example, key physical symptoms of depression, besides having a low mood for more than two weeks (yes, two weeks is all it takes to be classified as 'depressed'), include fatigue, change in appetite, unexplained aches/pains, changes in menstrual cycle if you're a female, altered bowel habits, abnormal sleep, etc. Aside from this, studies suggest that psychiatric illnesses put you at higher risk for physical conditions including heart disease, osteoarthritis, etc. (the list really does go on)
Although some mental health conditions, like cognitive impairments, still do not have very effective treatment options; most psychiatric medications work very well, and are necessary for treating the patient. The stigma surrounding them by the public causes a huge problem for doctors. Many patients are reluctant to comply with medications because they are not as widely accepted as the ones for non-mental health conditions. A psychiatrist holds a huge responsibility for patient education. It can be tough to teach your patients about their medication, when many of them refuse to belief there is anything wrong with them (this is also because of stigma).
Contrary to my previous beliefs, psychiatrists DO NOT sit around talking about feelings all day. The stereotypical image of someone lying down on a couch talking about their thoughts/feelings while the doctor holds up ink blots, is done more in 'cognitive behavioural therapy.' While this is a vital healthcare service, it's not really what a psychiatrist does. Taking a psychiatric history is just like taking a regular, structured medical history; except you have to ask further questions about their personal history (their relationships, professional life, significant life events, etc), forensic history, substance misuse history (if applicable), and childhood/developmental history. Taking a psychiatric history for a new patient usually takes at least an hour.
The interesting thing about about treating a psychiatric patient is that the best guidelines you have for making them healthy is their personality before the symptoms started (this is called 'pre-morbid personality'). This can be difficult to establish, and can often be an ambiguous goal for a doctor to reach. Of course, there is structure/protocol for each illness, but each patient will be unique. This is a challenge because personalities constantly evolve, healthy or not, and the human mind is perpetual.
On top of this, whether mental or physical, a serious illness usually significally impacts a person's personality.
Most psychiatric conditions, while being very treatable, will affect the patient will struggle with for their whole life. This leaves the psychiatrist with a large portion of the responsibility for the patient's quality of life and well-being; this can be vey rewarding and challenging. The state of a person's mind is a perpetual thing, choosing the right medication is not enough.
Before I had done this rotation, I was quite sure that this was a field I was not interested in. I still don't know if it is something I would pursue, but I'm definitely more open-minded to it now!
PS: It has also taught me some valuable life lessons; most of the patients I met were just ordinary people who were pushed a little too far by the unfortunate combination/sequence of circumstances in their life. Even the ones who have committed crimes or were capable of doing awful things.. It could happen to anyone, and just because I have been lucky enough to not experience the things those people have, does not mean I am a better person for not behaving the same way as them.
So you're sitting in a bus when you see a baby smile sunnily and gurgle at his mother. Your automatic response? You smile too. You're jogging in the park, when you see a guy trip over his shoelaces and fall while running. Your knee jerk reaction? You wince. Even though you're completely fine and unscathed yourself. Or, to give a more dramatic example; you're watching Titanic for the umpteenth time and as you witness Jack and Rose's final moments together, you automatically reach for a tissue and wipe your tears in whole hearted sympathy ( and maybe blow your nose loudly, if you're an unattractive crier like yours truly).
And here the question arises- why? Why do we experience the above mentioned responses to situations that have nothing to do with us directly? As mere passive observers, what makes us respond at gut level to someone else's happiness or pain, delight or excitement, disgust or fear? In other words, where is this instinctive response to other people's feelings and actions that we call empathy coming from?
Science believes it may have discovered the answer- mirror neurons.
In the early 1990s, a group of scientists (I won't bore you with the details of who, when and where) were performing experiments on a bunch of macaque monkeys, using electrodes attached to their brains. Quite by accident, it was discovered that when the monkey saw a scientist holding up a peanut, it fired off the same motor neurons in its brain that would fire when the monkey held up a peanut itself. And that wasn't all. Interestingly, they also found that these motor neurons were very specific in their actions. A mirror neuron that fired when the monkey grasped a peanut would also fire only when the experimenter grasped a peanut, while a neuron that fired when the monkey put a peanut in its mouth would also fire only when the experimenter put a peanut in his own mouth. These motor neurons came to be dubbed as 'mirror neurons'.
It was a small leap from monkeys to humans. And with the discovery of a similar, if not identical mirror neuron system in humans, the studies, hypotheses and theories continue to build. The strange thing is that mirror neurons seem specially designed to respond to actions with clear goals- whether these actions reach us through sight, sound, smell etc, it doesn't matter. A quick example- the same mirror neurons will fire when we hop on one leg, see someone hopping, hear someone hopping or hear or read the word 'hop'. But they will NOT respond to meaningless gestures, random or pointless sounds etc. Instead they may well be understanding the intentions behind the related action. This has led to a very important hypothesis- the 'action understanding' ability of mirror neurons.
Before the discovery of mirror neurons, scientists believed our ability to understand each other, to interpret and respond to another's feeling or actions was the result of a logical thought process and deduction. However, if this 'action understanding' hypothesis is proved right, then it would mean that we respond to each other by feeling, instead of thinking. For instance, if someone smiles at you, it automatically fires up your mirror neurons for smiling. They 'understand the action' and induce the same sensation within you that is associated with smiling. You don't have to think about what the other person intends by this gesture. Your smile flows thoughtlessly and effortlessly in return.
Which brings us to yet another important curve- if mirror neurons are helping us to decode facial expressions and actions, then it stands to reason that those gifted people who are better at such complex social interpretations must be having a more active mirror neuron system.(Imagine your mom's strained smile coupled with the glint in her eye after you've just thrown a temper tantrum in front of a roomful of people...it promises dire retribution my friends. Trust me.)
Then does this mean that people suffering from disorders such as autism (where social interactions are difficult) have a dysfunctional or less than perfect mirror neuron system in some way?
Some scientists believe it to be so. They call it the 'broken mirror hypothesis', where they claim that malfunctioning mirror neurons may be responsible for an autistic individual's inability to understand the intention behind other people's gestures or expressions. Such people may be able to correctly identify an emotion on someone's face, but they wouldn't understand it's significance. From observing other people, they don't know what it feels like to be sad, angry, surprised or scared.
However, the jury is still out on this one folks. The broken mirror hypothesis has been questioned by others who are still skeptical about the very existence of these wonder neurons, or just how it is that these neurons alone suffered such a developmental hit when the rest of the autistic brain is working just dandy? Other scientists argue that while mirror neurons may help your brain to understand a concept, they may not necessarily ENCODE that concept. For instance, babies understand the meaning behind many actions without having the motor ability to perform them. If this is true, then an autistic person's mirror neurons are perfectly fine...they were just never responsible for his lack of empathy in the first place.
Slightly confused? Curious to find out more about these wunderkinds of the human brain? Join the club. Whether you're an passionate believer in these little fellas with their seemingly magical properties or still skeptical, let me add to your growing interest with one parting shot- since imitation appears to be the primary function of mirror neurons, they might well be partly responsible for our cultural evolution! How, you ask? Well, since culture is passed down from one generation to another through sharing, observation followed by imitation, these neurons are at the forefront of our lifelong learning from those around us. Research has found that mirror neurons kick in at birth, with infants just a few minutes old sticking their tongues out at adults doing the same thing.
So do these mirror neurons embody our humanity? Are they responsible for our ability to put ourselves in another person's shoes, to empathize and communicate our fellow human beings? That has yet to be determined. But after decades of research, one thing is for sure-these strange cells haven't yet ceased to amaze and we definitely haven't seen the last of them. To quote Alice in Wonderland, the tale keeps getting "curiouser and curiouser"!
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