Author Archive
Although I sometimes flatter myself that patients actually look forward to seeing me for their appointments, the reality is that for most, attending doctor appointments can be a bit of a chore.
Medical appointments themselves don’t take that long but the process of getting there often does. There’s the time off work or childcare to consider, finding a hospital car parking space, or the demands of negotiating a journey with the additional demands of the symptoms of a chronic illness. The consolation of a waiting room which allows unlimited access to vintage copies of Hello magazine or Homes and Gardens isn’t always enough…
Thats why I was fascinated to demo a system that might allow patients to experience the benefits of a medical consultation, from the comfort of their own home or workplace.
Facetalk is a new, secure, hi definition video consultation system developed by the Radboud REshape & Innovation Center the Netherlands. The Facetalk tagline is ’Your Virtual Consultation Room’.
Lucien Engelen, the director of the centre showed me how it worked.
Our ‘appointment’ took place during the evening when I was at home and Lucien (whom I expect works longer hours than most doctors) was still at work. The email invitation I received to the appointment included a link which prompted me to download a piece of software to my iPad (the platform can be viewed on PC, Mac, iPad, iPhone and Android).
Once installed (pausing only briefly to settle an argument between two of my kids and put the rubbish out), I was then ready to ‘attend’.
And there was Lucien. All three of him. In order to show me how easy it was to have a number of people connected simultaneously, Lucien had connected toFacetalk using three devices simultaneously; his PC, iPadmini and iPhone. Lucien, as the “doctor” in the consultation, was able to share his desktop with me show me xray, clinical images or videos (in hi definition). He explained how up to 10 people can attend a meeting simultaneously (eg a patient, attendee of their choice, GP, Hospital doctor physiotherapist etc). A hard feat to pull off in real life in a busy outpatient clinic.
I was able to attend my meeting with Lucien from my office but also – because I was using a tablet device – from my kitchen or even (theoretically, but lets not go there) my downstairs toilet.
Facetalk has already been piloted to facilitate a diagnosis of skin cancer, out patient neurology appointments, paediatric urology consultations, palliative care consultations, TPN prescribing and and cleft palate.
The advantages of Facetalk are, according to Lucien, that it is secure (neither Skype nor Google Hangouts are secure for Healthcare use), doesn’t require any fancy hardware, works on all systems (except Blackberry), and that is does not require Flash (use of Flash video can pose additional security issues – not to mention, viewing problems on Apple mobile devices). Facetalk has also incorporated a workflow solution for healthcare without the additional hassle of security codes and does not require registration at the patients’ end.
It works over a regular home broadband connection and also works over 3G connections (think ‘Youtube’ over 3G).
I think it is likely that Facetalk will also add value for doctors. It will allow us to collaborate with specialists without the need for travel, might reduce the amount of time necessary for a consultation, and potentially reduce the need for office space and secretarial staff where there are less patients are physically present.
I’m decided to offer it to a group of my patients who are interested in using it in place of their regular appointment. I feel its probably going to lend itself better to patients who I know reasonably well, who have conditions where perhaps a thorough physical examination may not be necessary on every visit; eg Ankylosing Spondylitis, stable psoriatic arthritis or fibromyalgia. I’ll let you know how I get on.
Would anyone like to buy some old copies of Hello magazine?
I was a junior doctor when I experienced my first episode. The strange thing is, that despite my medical training (I may have bunked off a few of the relevant lectures in medical school), I didn’t recognise the symptoms.
I had lost my appetite and had lost weight. I wasn’t sleeping and was irritable, angry and tired most of the time. Most disturbing to me was a feeling (despite being surrounded by work colleagues and friends most of the time) was that I felt emotionally cut off and removed from people. I had also become cynical and decidedly detached from my work responsibilities and, truth be told, had lost all empathy with my patients. Not a good combination for someone working in healthcare.
It took a conversation over coffee with a good friend of mine who is a psychiatrist to make me realise that I was depressed.
Although of course it is obvious to me in retrospect, I had no idea I was depressed at the time. Like many people, I had no clear sense of my mood on a day to day basis. Like most other doctors I just kept on going.
For the last 20 years, I’ve been on the receiving end of medical care from GP’s, psychiatrists and psychologists. I’ve learnt a lot about mental illness, its treatment and how to look after myself better.
I have also learned a lot about the stigma of mental illness in medicine and how to cope with it. Largely, it has to be said, by keeping quiet about it.
Mental illness is, for many affected doctors, a shameful secret. One that can affect how other doctors perceive your reliability as a clinician and also one which could affect your career. To admit to not coping in medicine is to be weak, to somehow let your community down, and to go against the macho code of invincibility that we have imposed on ourselves.
What’s ironic about the code of silence is that a significant proportion of doctors have experienced mental health problems. Up to a quarter of doctors will meet the criteria for a depressive illness by the end of their first year in training and other studies suggest that up to 51% of (female) doctors have a lifetime history of depression. Substance and alcohol abuse are common, burnout is common and suicide rates are higher than in other professions. Medicine is not as glamorous as it sounds.
At present, thanks to the medical care and advice I’ve received and the support of family I’m doing well. Most of the time. I’m more mindful of my own moods and more forgiving of myself when I make mistakes. I recognise the warning signs of an imminent crash and feel better equipped to deal with the symptoms when they come. I have learned to say no (and not feel guilty about it) and also to give myself the odd pat on the back and remind myself that I’m doing some good.
However awful I sometimes feel, I know that it will pass eventually. I also know, that on my worst day, I’m still a conscienscious and caring physician.
I also firmly believe that my experience of dealing with depression has made me a better doctor; It has helped me understand the healthcare system from a patient’s perspective and also helped me empathise more deeply with patients (as another patient) and to be a more compassionate.
It has made me much more attuned to psychiatric symptoms in my patients (even when may not be aware of them themselves) and to develop a language that allows me to engage them in discussions about their mental health in a non-threatening way. Although I have a better understanding of how an illness like depression can colour and skew patient perceptions of certain physical symptoms, I think I am also less likely to over-diagnose psychiatric illness in a patient who’s symptoms don’t easily fit into a neat medical model.
There. I’ve said it. Whats your story?
Have you ever wondered what it would be like to sit in on a doctors appointment with a patient with a similar illness to yours? Wouldn’t it be interesting to listen in to see how they approach discussions with their (your) doctor, whether they’ve got the same concerns and side effects as you’re experiencing?
Can you actually imagine it happening though? Sharing your appointment with another patient may seem unlikely in todays health care environment where the assumption always has been that patient privacy is sacrosanct. But this commonly held assumption may be wrong…
In this months’ Harvard Business Review a novel approach to appointment scheduling which allows appointment sharing between patients. Not just one other patient – up to 11 other patients to share a single appointment. Patient satisfaction with the system is about 98%. So how does it work?
Dr. Amy Tucker is a cardiologist at the University of Virginia Health System where they have originated the concept (known as Club Red). At the clinic, patients are given a choice between a one on one appointment with their specialist, and a 90 minute shared appointment where they are seen by their doctor in a group. The patients don’t sit in a waiting room either. They all gather in a meeting room where they will complete some paperwork, have a few basic measurements taken and chat informally with other patients. The doctor then goes through the patients one at a time, addressing their concerns, orders tests, discusses progress and sets further treatment plans for each patient. Any physical examinations are done privately by the doctor outside the group.
These discussions all take place openly within the group. Although the consultation is private within the group (patients sign a confidentiality agreement), it is not private in the traditional sense.
According to the clinics’ website, many patients think of the shared appointment as a seminar or class because of the wealth of information they obtain and the length of time spent at an appointment. The patient advantages of a shared medical appointment are that patients get to spend more time with their physician, no waiting room time, faster access to their doctor, and having the help and support of other patients who have similar health issues. They also leave with more information and answers to questions they never even though to ask themselves.
The advantages to the doctors are clear; In 90 minutes, they can see 10-12 patients rather than the usual 3 to 5, providing obvious efficiencies in terms of physician time. Whereas one might assume that the process lessened the patient connection with their clinician, the article suggests that ‘counterintuitively, Club Red members develop a stronger connection with the doctor, largely because they observe his or her expertise and empathy in dealing with patients’. Although I’d like to see some published information on this process, it does seem to challenge a number of commonly held assumptions – something we need to do more of in healthcare.
Whereas I’m unsure as the applicability of this process to my own specialty, I’d love to know what patients (and colleagues think). How would you feel about sharing your clinic appointment with a group of other patients with a similar disease? Would you feel comfortable talking about your own health care problems with other patients present?
Here’s Sharon Jones and Marcia Johnson, two shared appointment participants describing who it all works….
There’s a little boy inside me that still titters at a particular type of smutty British seaside postcard. The range of postcards, popular in the 1950’s, featured double entendre gags illustrated by cartoons of buxom bathing ladies, naughty vicars, randy milkmen and hen pecked husbands
One of my favourites features an exchange between a younger female patient and doctor stereotype chap in a white coat and a bow tie.
‘Where shall I put my clothes doctor?’ she asks she undresses.
‘Just over there in the corner Mrs Smith. On top of mine.’
I like it because it pokes fun at a moment of potential awkwardness that we all recognise. The cartoon also highlights the intimacy of the doctor patient relationship, the vulnerability of patients in that situation and of course, what can go wrong if certain boundaries are not adhered to.
At the risk of being struck off, I’d also like to point out that this cartoon refers to one of my favourite parts of the doctor patient encounter.
I am referring to the few moments after I ask a patient to undress butbefore I examine them. I should add that as this occurs, I am sitting, fully clothed at my desk on the other side of the examination curtain.
This few second pause marks the mid point in the consultation (in terms of time spent), but in my specialty most of the hard work will have already been done. Although physical examination is an important part of the diagnostic process, by the time I get to it, I will have usually come up with a probable diagnosis, a list of confirmatory investigations and likely treatment options. At this point, I can usually take a short breather.
These moments also signal a pause after what can sometimes be the most intense part of the consultation. The idea of sharing very personal information with a total stranger within minutes of meeting them has very few parallels in life. The environment of trust that allows this to happen comes about from creating an atmosphere where a patient is instantly put at ease, and where they feel as though they are being listened to with empathy. Although it is always worth it, it takes energy, patience and time.
The short time it takes for my patient to undress allows me brief respite where I can temporarily disengage, breathe and to snap back into myself. Although its important for me to be able to take an ‘emotional breather’ it is also important for my patients that I do.
No matter how much we desire to help our patients, effective care demands a degree of objective and emotional remove from them. Sometimes (as a mentor of mine once said), ‘we need to care less to care more’.
Although this point doesn’t signify a total emotional disengagement, it allows me to step back a little into my professional self from the initial intensity of engagement to ready myself for the part that follows.
Galway hosted Irelands’ first Performing Arts Medicine Conference in October of this year.
The theme of our inaugural conference was the health of musicians. Our panel of speakers included health care practitioners from diverse specialty backgrounds such as Neurology, Psychiatry, Rheumatology, Primary care, Psychology, Anatomy, Occupational Medicine, Occupational therapy, Osteopathy and of course, our patient experts.
I have included a selection of those presentations from the day which focused on the musicians hand.
I hope you enjoy them.
Dr. Fiona Molloy, Consultant Neurophysiologist (Beaumont Hospital) speaks about Hand Dystonia in Musicians.
Katherine Butler, Hand therapist (London Hand Therapy Clinic) speaks about rehabilitation of the musicians hand (with some emphasis on hand dystonia).
Mr Ian Winspur, Consultant Hand surgeon (London) talks about his 25 years experience of surgical aspects of managing the Musicians Hand
Here’s the panel discussion with all 3 experts, chaired by Dr. Juliet Bressan, Director of the Dublin Performing Arts Centre.
Panel Discussion on The Musicians Hand from Ronan Kavanagh on Vimeo.
Are you a health care professional who has a commerical idea involving technology that could improve health but don’t know where to start ?
Undoubtedly inspired by the enthusiasm (and success) of the entrepreneurs presenting, this was one of the hot topics of discussion at the .Med medical innovation meeting in Dublin this month. Here’s a few of the suggestions that were made by our panel of speakers and from the audience that might help you bring your idea to fruition.
Healthfounders is a a company founded by the inimitable Australian Dr. Johnny Walker. Johnny is a radiologist and successful medical entrepreneur who has built and sold a successful global diagnostics company. He wants to leverage Health Informatics to create compelling personalised digital and mobile solutions for the stakeholders of the wider Healthcare ecosystem. Johnny wants to ‘pour petrol’ on the ideas of medical and health entrepreneurs and ignite their energies.
If you have an idea for a technology that disrupts health, you could do a lot worse than go and have a cup of coffee with Johnny in the Hermitage Clinic.
HealthXL is an accelerator program specifically designed for helping people with ideas for disrupting health with breakthrough technology. They bring people with ideas together with the people who have the necessary expertise to help them ‘accelerate’ those ideas to a point where they are likely to attract investors and customers. The whole programme takes three months.
This program is run by experienced entrepreneurs and backed by leading global health investors, medical professionals and corporates.
I was lucky enough to act as a mentor on the first HealthXL ‘checkup’ weekend where a variety of people (including health care professionals, expert patients, technology startup companies) came along and pitched their ‘raw’ idea to the group. HealthXL is like a combination between the Xfactor (with more nurturing than humiliation although some ‘tough love’ is dispensed) and Dragons den (except the Dragons are nicer). They also serve beer.
HealthXL is funded by a number of sponsors which means that its free of charge to participate in the programme which is based in Trinity development campus.
i360medical is a new, Dublin based, healthcare solutions and medical device innovation company. The principle behind i360medical is to act as an international and national innovation enabler and hub that has the expertise necessary to take new healthcare ideas and medical technologies to market. The company, led by CEO Derek Young, will act as a conduit between healthcare, academic and business, to develop and commercialise new ideas and solutions.
Dr. Philip Gardiner who is a rheumatologist based in Derry was one our speakers. He spoke of how he developed his data glove for rheumatoid arthritis with the assistance of the local translational medicine unit in his local hospital (Altnagelvin Hospital).
Philip says of C-Tric; ‘They are specifically designed to ‘kick-start’ good ideas with funding, facilities and/or to help organise research assistants. They provided some kick start funding to buy our first dataglove (the application for this was really straightforward) – and they have provided advisory support to get us through the various ethics applications. The computing team at UU (Magee) have invested 2 years of PhD work on the project so far which has proved very productive.’ If you have an idea, perhaps one which may require significant clinical research, as well as technological know how and funding, your local translational medicine department may be a good place to start.
If you have an idea for a health related app which could be used by health care professionals, you should speak to Professor Declan Lyons, clinician and founder of Doctot, a technology company which develops ‘mobile tools for health care professionals’. Declan’s company have developed 18 different applications, ranging from tools which allow rapid scoring of clinical outcomes in the clinic. Doctot are very happy to speak to any one working within health who has an idea for mobile health app development.
My father loves to attend the Cheltenham horse racing festival every year. The meeting, which is one of the biggest on the horse racing calendar is a celebration of Irish Horse racing that takes place in the UK and draws a crowd of over 200,000.
As he has got older, the hectic pace of the meeting, the queues for the toilets and the physical toll of socialising have become too much for him. So he now attends the festival virtually, from the comfort of his sitting room - watching it on TV with a few friends at home. He gets to sleep in his own bed, places his bets on the phone and the queue for the toilets is a lot shorter. My mother also ensures that the facilities are better maintained.
We refer to it as ‘Cheltenham in Galway’
This year I’ve decided to do something similar for our big Annual Specialty Meeting as I have decided not travel to Washington. I’m going to do the ‘ACR in Galway’.
Although my main reason for not attending this year relates to work commitments, I’m beginning to wonder about the value of attending the big blockbuster medical meetings in general. There’s too much information (poorly filtered), so many delegates that the social value of the meeting has become diluted, and as I get older I’m less well able to handle jet lag.
Either way, this year I’ll be attending the ACR virtually, in my dressing gown, from the comfort of my home office. I’ll be dipping in and out of the meeting during the day, after the kids have gone to bed in the evening and before I go to work.
I have a copy of the abstract book on my desktop, I have set up a list of all the rheumatologists I know who will be tweeting, following the hashtag for the meeting (#ACR2012) and will be looking at RSS feeds from trade press so I don’t miss anything.
Of course I’ll miss the annual review course, I won’t hear hear experts drill down into their subspecialty areas or meet my rheumatology friends face to face. However, I’m unlikely to miss any of the big news of the meeting. If I’m so inclined, videos of most of the important presentations will be available for review online after the meeting.
Although it is not the same as attending a meeting in person, I’m beginning to get a taste for what it might be like to attend a meeting virtually. Imagine it – less time off work, less cost, no flights, jet lag and all from the comfort of your home / office.
That’s why I was fascinated to see that our colleagues in radiology have been allowing delegates, for a registration fee of $300, to attend the RSNA meeting virtually this year. They offer access to 40 live streaming courses, allow delegates to participate in ‘Cases of the day’ and earn up to 78.5 CME credits.
Here’s hoping that other meeting organisers take note…
Every year plane loads of industry moguls, rising stars, prima donnas, journalists and hangers on make their way across the Atlantic for one of the most hyped events of the year. Hotels and restaurants are booked months in advance, hair dressers and dry cleaners get busy and, unless you’re with industry, it can be hard to get a limo.
Like the Oscars, there’s a certain amount of hype and anticipation to every medical specialty’s Annual Scientific meeting. It can also be hard to remember who featured last year…
Here’s a tongue in cheek look at a few reasons why.
1. Fatigue
Although many of us managed to absorb vast amounts of medical information whilst in a state of constant sleep deprivation as medical students, it is a much harder trick to pull off over the age of 30.
Many of us don’t sleep well in hotels. The combined effect of a noisy air conditioning unit, noisy late night revelers or hotel pillow related problems (one isn’t enough and two too many) can all conspire to interrupt a much needed mights sleep.
By 3.30am on the first day of a US based meeting, the average jet lagged European delegate is wide awake, trying to avoid the temptation to turn on the television, iron some clothes, or risk their lives by going for a jog in their destination city’s deserted streets.
By 5am, they are likely eyeing up the scientific programme, to see which of the (booked out) early morning ‘Meet the professor sessions’ they wish they’d remembered to book, and trying to stave off the urge to congregate (with all of the other Europeans) outside the convention centre before it opens.
By midday, they will begin to feel like they do towards a long day at work; - a certain ennui, fatigue and urgent desire to leave the building will overcome them. Of course this feeling improves over the coming days, only to replaced by conference fatigue (see section 2.).
2. Socialising
The annual scientific meeting can be a unique opportunity to catch up with colleagues, many of whom are old friends. One could argue that a lot of the useful clinical nuggets at meetings are shared in the course of those important social interactions, but it is those same gatherings that can distract us from the important matter of formal learning. Catching up on important family news, medical gossip and political shenanigans with colleagues can be enjoyable, but can sometimes lead to gatherings OUTSIDE the convention centre – in coffee shops or in restaurants. Or even in hotel bars.
3. Shopping
For those of us from overseas to a meeting each conference can also involves at least half a day spent desperately running around shopping malls or outlet stores to purchase items on the family shopping wish list (see section on Guilt below).
4. Guilt
No conference would be complete without the distraction of feelings of guilt that accompanies the average delegate. Apart from the perennial guilt he or she feels from deserting their work colleagues or spouses and kids ( see above section on gifts), the convention is usually held in one of the world’s finest cities with lots to see. When out and about site-seeing a delegate is likely to be feeling guilty that they are not present in the convention centre. When sitting diligently in the convention centre they are also feeling guilty that they are not out sight seeing. Existential angst is not good for concentration and even the moral high ground of medical education cannot always sooth the troubled soul.
What do you think?
This years Musicians’ Health conference took place in Galway on Saturday October 13th. We were lucky enough to hear from a number of patient experts who told of us their experience of living with musicians’ injuries.
I have included presentations from two of these – Enda Scahill (of We Banjo 3) and Johnny Donnelly (formerly of The Sawdoctors). Their unique insight into musicianship and mechanisms of injury was for me, one the best parts of a fascinating and entertaining day.
I will be posting other videos from the conference here over the coming days and weeks. I hope you enjoy them.
I’m on my way to my specialty’s Spring meeting. Its a small gathering with 40-50 specialists attending from all over Ireland and Northern Ireland.
The meeting offers a strictly no choice ‘Table D’hote selection’ of 6-8, hourly sessions, comprising the best of local fayre with an occasional international contribution. As they say in these parts, ‘you’ll eat what you are given’.
We have all been lead to expect, in this era of almost infinite choice, that choice is good. And that even more choice is better. This is reflected in medicines’ obsessions with huge specialty meetings where delegates are presented with a choice of hundreds of presentations and literally thousands of scientific abstracts.
Renata Salecl, in her book ‘The Tyranny of Choice’, points the finger at the ideology of choice as being at the root of a lot of modern discontent. In one of my favourite sections of the book, she describes the crippling anxiety she experiences trying to choose from an overwhelming selection of cheese in a cheesemongers. I know what she means .
At our meeting, there will be no need to spend hours pouring over the programme to choose which ‘meet the professor’ session to prebook. There will be none of the anxiety involved in choosing between conflicting ‘break out sessions’ and no itinerary planner app to be downloaded. We will just turn up, take our seats at the table and tuck in.
I’m looking forward to the meal.
The Irish Society for Rheumatology Spring meeting takes place Friday 22nd March, Royal Marine Hotel Dun Laoghaire, Dublin
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