Wednesday, September 30, 2009

How to talk back to your doctor?

When was the last time you visited your doctor? What was it like? What happened? How did you communicate? Were you listened to? Were you able to develop, or deepen, your therapeutic relationship with them? Who else was part of the consultation? Was your doctor using a computer during the consultation? And if so, for what purpose?

There are a number of factors that are known to strengthen the therapeutic relationship that you have with your doctor, and they all fall under the broad heading of “patient empowerment”. There is a truism in healthcare that “knowledge is power” and that this is a key component of any good relationship. The capacity to make choices based on correct information, whether it is from your doctor, or the Internet, or elsewhere, is crucial. Another factor is responsibility – patients have to be aware of what is expected of them in the relationship, just as is the case for doctors – with any treatment program being designed to make the patient independent and able to take charge of their own lives and any future treatment programs. Finally patients need to know what are the expectations of their treatment program, who else might need to be involved (such as family, interpreters or other doctors), how can second opinions be arranged.

All of these matters are related to knowledge and information, and all can be improved by working with your doctor and the Internet to help yourself better. 38% of patients in a recent study from the Pew Foundation reported being able to email their doctors in 2008, compared with only 6% of patients in 2003, but over 80% of patients said they would like this ability. The same study estimated that over 8 million Americans use the Internet to search for health information every single day. This works out at over 140 million Americans each year. We all know the importance of communication, and doctors and patients are now increasingly communicating by using the Internet and email.

Think about all these questions. Have you, like many others, seen your doctor in the presence of a third “person” – a computer linked to the Internet? Most doctors have rapidly computerized their practices over the past decade. They are very aware of the extraordinary amount of health information on the Internet, and most are fluent users of email, and many other software packages. Doctors have taken to the Internet like ducks to water, and use many aspects of the Internet for their own lives just like most other people in the USA. They use it to manage their practices, and many now also communicate regularly with patients on email. This is not surprising. Most doctors will use any useful innovation or new technology that presents itself to allow them to provide better care. They are very aware that this is the Information Age, and that they and their patients can greatly benefit from the amazing amount of healthcare information that is now at their finger tips, and from the astonishing access that they have to this information.

It is national US health policy for all patients to have an electronic health record within a few years time, so many doctors and hospitals are implementing such records to hold patient information. Large health systems are forming partnerships with commercial companies such as Microsoft and Google to make health information more available to patients in the form of personal health records – another way for patients to see, and contribute to, their own health information. And another way for patients to learn more about themselves, and hence communicate better with their doctors.

So what happened when you saw your doctor? How did he or she then involve this “third person” in the consultation? How did you feel about it, and did it help you? Were you able to find and use the amazing amount of health information available online, to work with your doctor, to collaboratively become the winning team that is necessary to keep you healthy, happy, and fully productive in as many aspects of your life as possible. To teach you how to talk back to your doctor, to be heard, and to be empowered to improve your health.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

Monday, September 14, 2009

Virtual Reality in Medicine - many evolving uses and advantages

Virtual reality techniques, involving three-dimensional imaging and surround sound, are increasingly being used in diagnosis, treatment, and medical education. Initial applications of virtual reality in medicine involved visualization of the complex data sets generated by computed tomography (CT) and magnetic resonance imaging (MRI) scans. A recent application of these techniques for diagnostic purposes has been the “virtual colonoscopy,” in which data from a contrast-enhanced abdominal CT scan is used to make a “fly-through” of the colon. Radiologists then use this fly-through for colon cancer screening. Recent improvements in methodology have brought the sensitivity and specificity of this technique closer to the levels of optical colonoscopy, and patients prefer the technique to the traditional method.

Virtual reality has also been used extensively to treat phobias (such as a fear of heights, flying and spiders) and post-traumatic stress disorder. This type of therapy has been shown to be effective in the academic setting, and several commercial entities now offer it to patients. In one of my projects using the multi-user virtual reality environment offered by Second Life, one of several easily available online virtual reality environments, we have used a virtual psychosis environment to teach medical students about the auditory and visual hallucinations suffered by patients with schizophrenia.

Virtual reality has been used to provide medical education about healthcare responses to emergencies such as earthquakes, plane crashes and fires. While the primary advantage in phobia treatment is a “safe environment” which patients can explore, the primary advantage in emergency preparedness is simulation of events that are either too rare or too dangerous for effective real-world training. The immersive nature of the virtual reality experience helps to recreate the sense of urgency or panic associated with these events.

Virtual reality programs have also been used for a variety of medical emergency, mass casualty, and disaster response training sessions for medical and public health professionals. One study developed a protocol for training physicians to treat victims of chemical-origin mass casualties as well as victims of biological agents using simulated patients. Although it was found that using standardized patients for such training was more realistic, the computer-based simulations afforded a number of advantages over the live training. These included increased cost effectiveness, the opportunity to conduct the same training sessions over and over to improve skills, and the ability to use “just-in-time” learning techniques and experience the training session at any time and location, while adjusting the type and level of expertise required to use the training for various emergency response professionals. Others have explored the potential for training emergency responders for major health emergencies using virtual reality. Their objective was to increase exposure to life-like emergency situations to improve decision-making and performance and reduce psychological distress in a real health emergency.

Experience with recent natural disasters and terrorist acts has shown that good communication and coordination between responders is vital to an effective response. In my work using Second Life to develop a virtual mass disaster emergency clinic to hand out antibiotics to the population following a massive anthrax bioterrorism attack, we have found a number of important advantages of the virtual world, over the real world, for training first responders.

Responders to such events come from many different organizations, including fire, police, military, and hospital personnel. There are three major difficulties in training and evaluating these first responders in the real world:
They have little or no chance to train together before the event occurs and hence lack teamwork skills.
What training they may have had comes at great cost, in large part due to the effort and need to transport so many people to a specific training site at a specific time.
The training sites frequently cannot be the most common targets – for example, one cannot shut down the Golden Gate Bridge during rush hour to train for an earthquake or terror scenario.

Virtual reality offers some intriguing advantages over the real world for these aspects of first responder training, as all of the above difficulties can be overcome. Virtual reality systems can support multiple simultaneous users, each connecting to the system using standard office personal computers and broadband Internet access. Lifelike models of buildings, roads, bridges, and other natural and man-made structures where the users can interact can be constructed. Finally, the whole scenario can be digitally preserved and a full workflow analysis can be performed retrospectively. Public health officials and first-responders can work through the scenarios as many times as they like to familiarize themselves with the workflow and emergency protocols, without encumbering the time and expense of organizing a mock emergency in real life.

Virtual Reality treatments are rapidly becoming more available. They are currently being used to treat post-traumatic stress disorders caused by wartime experiences, and US servicemen are now increasingly being offered such programs. Rather than the traditional method of confronting old nightmares, online technology is able to deliver treatment in a far more therapeutic and humane way. Patients are “transported” to the battlefront and fears and traumas are resolved in virtual place and real time. Virtual Reality is here to stay, and will increasingly be used widely in a number of areas of healthcare.

Peter Yellowlees MD blogs at and has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

Virtual Reality Medical Education in Second Life

Increasing numbers of people are using the Internet for the provision of all sorts of health services, from prescribing, through consulting to setting up automated self-treatment programs. But what about using it for education and therapy? After all, in theory, the ultimate form of cognitive behavioral therapy should be “virtual reality therapy.” By simply wearing your wrap-around sound and vision multimedia headset you can be instantly transported to a cliff edge, soar in a plane thousands of feet above the ground or be surrounded by a gathering of thousands of spiders - depending on your phobia. And the ultimate form of online education should be fully interactive, case based and student driven, all of which I now use in my teaching in Second Life.

The phrase “virtual reality” was coined by Jaron Lanier in 1989 to describe computer simulations of physical environments. Since the mid-1990s, the video game industry and 3D graphics card manufacturers have driven forward the state of personal computer graphics, advancing it far beyond the needs of most business users. These systems range in capability from simple displays of 3D objects to entire virtual cities. Virtual reality systems are now being routinely implemented on personal computers for a variety of activities. One of the most popular virtual reality programs is Second Life, produced by Linden Lab, Inc. Second Life is a general-purpose virtual world accessible through any Internet-connected personal computer. In order to interact in Second Life, users create “avatars”, or animated characters, to represent themselves. Individuals use these avatars to maneuver through various “worlds”, complete with buildings, geographical features, and other avatars. While the system borrows heavily from video game technology, it is not a game – there are no points, no levels, no missions, and nothing to win. It is simply a platform by which people can create virtual communities, model geological, meteorological, or behavioral phenomena, or rehearse events. I have been working in Second Life for several years now.

Users of Second Life include a variety of education organizations, from Harvard Law School to the American Cancer Society. There are currently areas of the virtual world that provide such disparate services as teaching heart sounds and auscultation technique, providing social support for individuals with Asperger's Syndrome, and modeling the effects of tsunami on coastal towns. The system has over 10 million account holders from all over the world, most of them with free basic accounts. Approximately 800,000 of those users are active, with over 80,000 of them connected to the system at any time. Virtual reality programs such as Second Life are increasingly being used for educational purposes in a variety of fields, including medical training and disaster preparedness. Linden Lab currently operates the Second Life Education Wiki which functions as a source of information for educators and trainers in a variety of fields who wish to use Second Life for distance learning or large-scale training purposes. A number of government agencies, including the Department of Homeland Security, the Centers for Disease Control, the National Institutes of Health, and the National Science Foundation, have begun using Second Life to hold meetings, conduct training sessions, and explore ways to make access to information more readily available around the world. A recent comprehensive survey intended to gather information on the activities, attitudes, and interests of educators active in Second Life conducted by New Media Consortium reported that the majority used it for educational purposes such as teaching and taking classes as well as for faculty training and development.

I have been using Second Life as a teaching and learning environment for several years now. With colleagues I have created a "virtual hallucinations" environment, which demonstrates the lived experience of psychosis and allows participants who travel through the environment to experience both visual and auditory hallucinations; visions and voices. We used this environment to teach this experience to our medical and psychology students. With the California Department of Health and other colleagues I have created a virtual bioterrorism crisis clinic to train health workers, and more recently, as part of our Health Informatics Certificate Program, with University of California Davis Extension, we have taught informatics students in a virtual conference center on our own private island; Davis Island. Students find the environment straightforward to learn to navigate, and within a week of our informatics students being introduced to the environment they were able to travel and tour around Second Life with the rest of us with ease.

Second Life and similar multi-user environments offer enormous possibilities in the medical educational world, where such applications are now called "serious games" rather than social or fun software. Students of the future will adapt to them very easily, and it is clear that applications such as Second Life have a great educational future before them. I look forward to continuing to teach classes of medical and graduate students "inworld".

Peter Yellowlees MD blogs at and has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online