“Are You The F**king Doctor?” A review

 

Farrell   “Cometh the hour, cometh the man.”

It would be the very height of pretentiousness to apply this phrase to Dr. Liam Farrell, an author and former family physician from Rostrevor, Co. Down, Ireland and I am sure he would be the last person to do so.

But at a time when family medicine seems to be at its lowest ebb, if not globally then very much here in Canada, there is much to be said for having a physician who can so eloquently write about both the rigors and the joys of general practice – and using erudite quotations and references to do so.

I would argue that Dr. Farrell does this in “Are You The F**king Doctor? Tales from the Bleeding Edge of Medicine” – a collection of his columns, blogs and short stories published over more than 20 years in publications such as the BMJ.

This is not necessarily an easy book to read, filled as it is with a juxtaposition of not just blood but all manner of unpleasant bodily fluids ,and anecdotes which are usually brief – sometimes too brief to absorb either the story or the message contained therein. Dr. Farrell combines these descriptions with a degree of learning and knowledge that one takes for granted with a well-educated physician.

Take for instance this description of his office (aka ‘surgery’)

“The surgery had the spiritual ambience of a monastery chapel, and if C.S. Lewis and J.R.R. Tolkien had walked in twittering gently on about morality and suspiciously androgynous fairies, I wouldn’t have been surprised.”

All of this, mind you, in a short piece describing a woman bringing him a sample of one of her husband’s bowel movements.

If some of this book is not easy to read or comprehend, that challenge surely begins in the very first chapter where Dr. Farrell writes with grim realism about his own battle with morphine addiction. Once past this however, one finds oneself immersed in stories which are often very funny yet which deal with  issues of life and death that family doctors must face every day.

Dr. Farrell talks about family medicine in a manner that would resonate with those Ontario family doctors currently tweeting in despair about the future of the profession:

“… it is not a specialty, but rather a generality, with all the burdens and privileges that this role confers, demanding skills that reach across the divide, not just of a dissonant phalanx of fragmented medical specialties, but of that deep romantic chasm between science and art …

Or:

“Real medicine is the process of making decisions among diverse influences. It involves discussion, calm deliberation and the capacity to balance valid but competing interests.

In this era of Choosing Wisely Dr. Farrell also writes from the trenches about patients who insistent on antibiotics to treat colds or x-rays for sprains.

Whether we are dealing with truth or Dr. Farrell’s feverish imagination is often hard to distinguish.

As he writes in a piece defending a much-maligned column involving trying to drive over a cat and instead hitting a young fox, Dr. Farrell states “I write by stream of consciousness; the caprice, the knights-move thought, the harsh imagery, something to grab the reader and want them to read on and assimilate the message.”

I have had the pleasure of meeting Dr. Farrell in person (the photo accompanying this article in no way reflects our interactions) and there are many others who know him as the gracious host of #Irishmed, one of the most successful regular tweet chats still dedicated to matters medical.

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As a non-physician I can recommend this book to anyone who enjoys a good turn of phrase. But I would particularly recommend it to the family physicians who feel nobody understands them or the value of what they do – it’s not CME but the book may prompt more than a chuckle or two.

 

 

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MyHealthNS – A perplexing patient portal poser

MyHealthNS

“Most QI (Quality Improvement) programs don’t incrementally ascend, but often fail. Many QI projects never work out at all and of those that do, almost all have real failures, along the way. But failure is not bad and contains within it the seeds for future improvement.”

Dr. Joshua Tepper, former president and CEO of Health                                                             Quality Ontario and now CEO of North York General Hospital

Those committed to bringing a patient portal to the residents of Nova Scotia should take heart from these recent remarks by Dr. Tepper. While he was talking about quality improvement initiatives, the comment speaks directly to the Nova Scotia situation and is probably more relevant than people would acknowledge to all aspects of digital health and health technology innovation.

Surely, nothing seemed better set up for success than the MyHealthNS portal intended to allow patients to communicate with their physician virtually, receive laboratory results, book appointments, and allow physicians access to Econsultations and Ereferrals. Canadians have overwhelmingly indicated that this – in some ways more than anything else – is what they want from digital health.

Yet despite government backing and strong early support, MyHealthNS has enrolled only a small number of Nova Scotians. And while the initiative is by no means dead it must, to date, surely be judged a failure.

The reasons behind this are informative and speak volumes about the importance of local variables and the challenges of bringing change to a complex system such as health care.

The MyHealthNS story was told recently by Dr. Stewart Cameron, a family physician and advocate of the portal, at the Canada Health Infoway (@Infoway) 2018 partnership conference in Montreal. A very, very abridged version of that follows:

MyHealthNS was piloted in 2012 with about 30 family physicians and 6,000 patients. Results were overwhelmingly positive and a full provincial roll-out of the portal was initiated in 2016 (and again in 2018 and again in?).

Two important points:

  • Enrollment in MyHealthNS is done through family physician offices which made it easy to authenticate patient identities but has had negative consequences leading people to question whether this is the right model.
  • Physicians involved in the pilot project noted that the portal must be integrated with their EMRs to be successful and that a payment model was needed to remunerate physicians for using the portal. In fact, one physician involved in the pilot saw their income drop as a result of participation.

Fast forward to this year.

In February 2018, only 13,782 patients were registered with the portal out of a provincial population of approximately 1 million people (that figure is now up to about 20,000, according to Dr. Cameron). Of these only 10% had accessed the portal at all in the month prior the evaluation in February. Additionally, only 250 practitioners had registered with the portal and of these only 35% were using the portal actively.

The reasons behind these poor numbers can be traced to two key reasons:

  • Payment for physicians for enrolling patients or using the portal is still not part of the master fee agreement although physicians can now receive a stipend for involvement.
  • While the portal is now integrated with most EMRs in the province, one major system is not integrated directly. Further, many physicians are currently migrating to different EMRs and are reluctant to take on the extra burden of enrolling patients in the portal during this time.

Of course, with physicians acting as the gatekeeper for patient enrollment it is obvious their reluctance to be support this initiative actively is a huge barrier to success. At a time when family physicians are under increasing stress and many suffer from burnout, embarking on such an initiative must produce tangible, immediate benefits to attract them.

Not only are family physicians reluctant to enrol their patients (which must be done face to face or by phone) but many residents of the province currently lack a family physician and so have nobody to sign them up.

What must have been a source of frustration for Nova Scotia delegates to the Infoway meeting was that the same meeting heard how Quebec has already signed up 300,000 people to their portal in a short time using a direct enrollment model.

MyHealthNS has failed to date but that is no indicator of future failure as long as those involved with the project learn from their experiences to date. In the words of Dr. Cameron: “This is going to happen. It’s inevitable.”

(Image courtesy, the Government of Nova Scotia)

 

Patients at #HIMSSEurope18: From ‘a’ to ‘the’

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To have the patient voice presented articulately from the podium isn’t all that unusual at medical and health conferences these days.

However the fact that this occurred at a major digital and health information technology conference – until recently the domain of companies and organizations wanting to do things to and for patients (often for money) rather than with them – is worth noting.

To its credit, the HIMSSEurope/Health 2.0 meeting in Sitges, Spain did not just have prominent patient advocates such as Marie Ennis-O’Connor (@JBBC) and Anne-Miek Vroom (@annemiekvroom) speaking at plenary sessions but throughout it also reflected a new paradigm of providing health care services and products that patients want, delivered where and when they want them.

Although some feel more can be done: “The most powerful force in health care innovation (the patient) is yet to be unleashed,” said Ennis-O’Connor.

“To me, empowerment is not just having an app with all your health care information, it is about being part of the system,” said Miquel Bru, VP of business development for Made of Genes, during a session on precision medicine. As Vroom pointed out in her address, you don’t need a program or project to work with patients, just ask their opinion and incorporate them into the workflow.

It was Vroom who also pointed out that while virtual care, mobile apps, and telemedicine innovation are all being applauded as breakthroughs for patient care they do not automatically improve the patient experience and can still be challenging for those with disabilities.

In his keynote address, Dr. Robert Wachter, chair of the University of California, San Francisco department of medicine and oft-time critic of electronic records and their impact on physicians, noted that the “perfect patient” ready, willing and able to adopt digital tools to manage their care is not common. Instead, he said, digital tools and information will have to be customized to accommodate patient preferences and knowledge levels.

“There is no such thing as a ‘one size fits all’ patient,” said Ennis O’Connor who also noted there is some concern about the growing gap between digitally literate and engaged ‘super patients’ and those who are not.

While the conference was filled with speakers discussing tailoring their digital solutions to what patients really wanted, Ennis O’Connor challenged people to act on truly involving patients in their work. She said that patient engagement has become a leading theme at conferences (including this one) but said there has been no significant movement to change this rhetoric into a tangible reality.

However, Lucien Engelen (@lucienengelen), a global digital health strategist and patient engagement champion, who served as master of ceremonies for the Sitges meeting said he perceived the tendency to involve ‘token’ patient has been decreasing while meaningful involvement of patients at conferences has been increasing.

And while the yardstick may not have moved as much as patient advocates may wish there was a definite sense here that digital health innovators, policy makers, and providers are starting to view patients as partners and not simply subjects for the next shiny new digital healthcare toy.

Something is happening here … #HIMSSEurope18

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You try so hard but you don’t understand
Just what you will say when you get home
Because something is happening here but you don’t know what it is
Do you, Mr. Jones?

                                             Ballad of a Thin Man: Bob Dylan

The problem with a Health Information Management Systems Society (HIMSS) meeting – any HIMSS meeting – is that there is so much going on at one time that it is impossible to craft it into one coherent narrative.

That is the challenge with HIMSS Europe 18 currently underway here in Sitges near Barcelona, Spain as hundreds gather to discuss the latest in digital health and health information technology and to network, network, network. And it’s doubly challenging as this meeting is being held in conjunction with Health 2.0, the health innovation conference recently purchased by HIMSS.

(Now wait a minute, wait a minute you say – you get to go all the way to a resort hotel in Spain, with a clothing optional beach within 5 minutes walk, where they serve wine at the some conference buffet luncheons, only to cop out and say you can’t write coherently about it. Patience please).

As a social media ambassador here and lively live tweeter I can supply you with an endless number of insightful tweets or sound bites from just the first 24 hours. For example:

“We have gone from a paper world to a digital world in a short period of time”: Dr. Robert Wachter

“There is a lot of tokenism in health(care) innovation, and some think you can change or even fix health(care) overnight. It is not about technology, nor about the process, it is about changing the culture of an organization”: Lucien Engelen

“Pay patients and value them as the experts that they are”: Marie Ennis-O’Connor

But while I think these tweets provide a useful running commentary of the meeting they – and even the twin meeting hashtags #HIMSSEurope18 and #health2con – provide only a partial and episodic picture of what is going on.

Individual presentations or sessions are also noteworthy. For instance I have never heard as passionate a presentation supporting the role of nurses in the future digital world as that given by Angelien Seiben and Shawna Butler from Radboud University Medical Center. And Dr. Jordi Sorreno Pons a GP and CEO of the Universal Doctor app jammed so many ideas into his 8 minute presentation on future developments in medical innovation that it was almost incomprehensible.

The big subject areas – patient engagement, big data, artificial intelligence – are all given their own sessions or streams here.  But in the time available they tend to focus on specific projects or regional initiatives.

Certain things have changed from HIMSS or eHealth meetings held 15 or 20 years ago. The digitization of patient records is now a reality and not a vision and patients are not only discussed but included (#patientsincluded) as presenters in their own right.

But as to what all of this means for the future of digital health in Europe or worldwide – we are too much in the moment to have a clear picture given the complex nature of health systems and the endless number of variables that impact such systems.

For the numerous people here with an start-up to promote or an niche application to profile the meeting is a far simpler place.

(This is the first of what we hope will be a series of posts from Sitges)

A parliament of medicine no more: @CMA_Docs changes its governance

 

CMA

The Canadian Medical Association (@CMA_Docs) is not immune to the dramatic changes in governance impacting governments and organizations around the world.

At its annual gathering this August in Winnipeg, the CMA’s General Council will cease to exist as “the parliament of medicine” and a major policy making body, and will be substituted with a healthcare summit aimed at attracting a much more diverse audience to advance the debate about health care in Canada.

For those who have sat through decades of often intense debate by physician representatives from across the country, on issues as important as abortion, physician aid in dying, and the future of medicare, this is a dramatic change. But, frankly it is not a surprising one as the CMA has been transitioning its policy-making processes for a few years now.

While CMA General Council often made great theatre and was guaranteed to attract front-page news for the organization, the issues discussed where often not within the strategic framework of where the organization wanted to head. The CMA has been clear it wants to broaden the funnel for collecting new policy ideas from a council of 200 plus selected representatives from its provincial and territorial associations, to the membership as a whole.

The elimination of General Council will be perhaps the most obvious but, given various announcements on the association’s cma.ca website, certainly not the only governance change being planned by the organization and voted on this year.

For instance in order to better align the CMA with its new mission statement as “empowering and caring for patients”, the CMA Board of Directors wants to add a non-physician to bring the patient representative to its Board of Directors. While a radical step for the CMA, this is in keeping with what many other medical organizations are doing.

That’s not the only change envisaged for the Board. Rather than allocating numbers of Board representatives based by number of physicians in a jurisdiction each province and territory would have just one Board member. This would shrink the size of the Board from the current size of 26 to 18 or 19 members including ongoing representation from students and residents.

The annual general meeting which was always held in conjunction with General Council will continue to expand its role for ratifying business decisions and after this year will move from August to the spring in 2019.

Those who will remember the extensive CMA governance review process that culminated in 2008 with arguably minor changes to governance will appreciate just how much and how fast the world is changing, to see what CMA will be doing this year.

Sir Charles Tupper may not be rolling over in his grave but it will be very interesting to see how CMA members do in keeping up to the speed at which their organization is moving.

Radiology and AI: An algorithm took my job

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Radiologists and those who love them sometimes seem to be some of the most insecure people around and radiology seems consistently voted the specialty most likely to be made defunct by modern technology.

In Canada, this perception has been voiced repeatedly over the past decade or two, first with the perceived threat of radiologists on the other side of the world working during our night to interpret scans and provide results when Canadian radiologists are sleeping, and now with the widespread attention given to artificial intelligence (AI) and deep learning and its potential uses in health care.

At last year’s annual meeting of the Canadian Association of Radiologists (@CARadiologists) I pondered whether this year’s meeting of that organization would be leaving it too late to discuss the significant issues revolving around AI and radiology (see my post “(A) I, Radiologist”) given the speed with which the field is advancing.

I need not have worried.

Last week the CAR released a white paper on the role of AI in radiology in advance of its annual meeting this year to be held April 26-29 on the theme of AI in radiology with the learning objectives including: discussing the recent changes that have occurred in imaging as a result of the implementation of artificial intelligence, deep learning, and machine learning in imaging workflows and; discussing the opportunities of big data and artificial intelligence to improve on the diagnostic performance and predictive value of imaging.

As an extensive overview of the topic, the CAR document squarely confronts the main issue at hand, namely that “recent breakthroughs in image recognition introduced by deep learning techniques have been equated in the media with the imminent demise of radiologists.” The authors go on to state rightly that the work of radiologists goes far beyond that of just correctly interpreting images.

“… the complex work performed by radiologists includes many other tasks that require common sense and general intelligence for problem solving–tasks that cannot be achieved through AI. Understanding a case may require integration of medical concepts from different scientific fields (eg, anatomy, physiology, medical physics) and clinical specialties (eg, surgery, pathology, oncology) to provide plausible explanations for imaging findings. Such tasks accomplished by radiologists on a daily basis include consultation, protocoling, review of prior examinations, quality control, identification and dismissal of imaging artifacts, cancer staging, disease monitoring, interventional procedures for diagnostic or therapeutic purpose, reporting, management guidance, expertise in multidisciplinary discussions, and patient reassurance”

However, the white paper’s authors also fully appreciate the potential of AI and state that “to remain current Canadian radiologists will need to follow and contribute to health care AI research and development, embrace the changes in workflow that will be required to support the implementation of clinical AI and adapt to changes in their practice that will improve care of their patients.”

So, while the demise of radiology (again) does not seem imminent, the white paper will bear close reading by Canadian radiologists who wish to remain relevant with some of the most significant and fundamental advances in medicine currently underway.

(Image courtesy of the Canadian Association of Radiologists)

Digital health: A manifesto for the times

Dave_and_Berci

In 2008, Dr. Gunther Eysenbach, editor of the Journal of Medical Internet Research published a paper on the nature of what he termed Medicine 2.0 – and this paper formed the framework for the first World Congress on Social Media, Mobile Apps, Internet/Web 2.0 held in Toronto.

Eysenbach noted that “recent advances in web technologies and user interfaces have greatly changed the design, appearance, stickiness, and pervasiveness of Web applications, and in many cases transformed the way users interact with them. Perhaps equally importantly, it also has changed the expectations of users.” In addition, he said, these advances have coincided with the development of personal health records “with far-reaching consequences for patient involvement, as the gravity shifts away from health care providers as the sole custodian of medical data.”

Eysenbach talked about five major aspects (ideas, themes) emerging from Web 2.0 in health, health care, medicine, and science, which would outlive the specific tools and services offered: social networking, participation, apomediation, collaboration, and openness.

Among the attendees at the 2008 meeting was a Hungarian medical student Bertalan Meskó (@berci) who was to graduate the following year. A year later at the same conference, also held in Toronto, Dave deBronkart (@ePatientDave) gave his first major presentation in Canada around his rallying cry of “Give me my damn data”.

Fast forward a decade: Dave deBronkart, a stage IV cancer survivor, is probably the most high-profile patient advocate there is and Meskó is a medical futurist speaking to audiences worldwide. Together they have just published what they call a Digital Manifesto with six declarations they believe “are essential for correctly understanding what is and isn’t happening in digital health.”

You can read the manifesto yourself – it’s not long and speaks to much that will resonate with those working in digital health or with patient engagement. It talks about behavior change and educated and informed patients working with health care providers to take control of their own health using the manifest new technologies now available.

What I am struck by are the similarities between the Eysenbach piece and the manifesto – despite the gap of 10 years and the very different tone and purpose intended for the documents.

Both reference the significance of new digital tools and platforms and their importance as enablers of change, or in deBronkart and Meskó’s words: “A future where old hierarchies tumble down, the paternalistic patient-doctor relationship is no longer needed and disruptive technologies enable the democratization of care by democratizing knowledge. A future where all these are in place due to cultural transformation facilitated by disruptive technologies.”

The documents and these past 10 years also represent the dedication and common vision shared by many of those who work with digital health – be they patients, providers or researchers. In addition to Meskó and deBronkart, many of those who spoke or participated in the 2008 and 2009 conferences have remained active in digital health research.

“… we could say that medicine 2.0 is what ehealth was supposed to be all along”, Eysenbach wrote 10 years ago. deBronkart and Meskó say “A manifesto can …kindle new thinking among those who do see the light.”