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Abstract

A revolution is underway in the fields of education and health practice. Social media are now considered by the new generations of students, doctors and patients as a useful tool for learning and for doctor–doctor, doctor–patient and patient–patient communications. However, should we be excited by this revolution or afraid of it? Advantages and challenges of such new tools for medicine in general and rheumatology in particular are discussed in this Perspectives.

Introduction

15 years ago, communication between patients, doctors, students, researchers, pharmaceutical companies and health authorities relied on face-to-face discussions in consultations, lectures and meetings, as well as interactions via scientific and medical publications, newspapers, postal mails, telephone calls and fax. Today, some of these communication methods are in decline (such as postal mail or fax) and a new world of online communication has been created. Numerous, instant emails have replaced the few regular postal mails we used to receive, Google is now the first 'professor of medicine' for the majority of medical students, and Facebook has become another confidant of many patients, along with the clergy and the family doctor. Social media are rapidly encroaching on personal and professional lives of the medical community. So, what happened in only 15 years? Should we be excited by this evolution or afraid? How will the world of communication in the field of medicine evolve in the next 10 years? In practice, how should we use these new tools for optimal usage in medicine? In this Perspectives, I will try to address some of these questions.

Definition of social media

The first email was sent in 1971 by researchers at the Advanced Research Projects Agency via the World Wide Web (a system of interlinked hypertext documents accessed via the internet).1 For the first time, one could view web pages that might contain text, images, videos and other multimedia, and navigate between them with a web browser. In 1994, Justin Hall, a college student, became the first blogger, meaning the first to launch a website in which the objective was to communicate with the outside world. In 1997, AOL launched the first Instant Messenger application. However, the first tangible social media date back only to 2003–2004 with the launch of Friendster and Myspace. Since 2004, however, Facebook (originally a way of connecting US college students) has been revolutionizing the field by connecting 1 billion active users worldwide to date. Many additional social media platforms have since been successfully launched such as YouTube in 2005, Twitter in 2006 or Google+ in 2011. This expansion of new platforms is due, at least in part, to the rapid evolution of the way people access social media thanks to the development of mobile phone technology. Today, among internet users aged 18–29 years, 86% are actively engaged in social networking compared with 61% of users 30–49 years, 47% of users 50–64 years, and 26% of users over 65 years (all statistics from the Pew Research Center2).

Defining social media is more complex than predicted.3 The consensual definition of social media is services based on platforms that integrate participation, communication, user-centeredness, collaboration and openness. In other words, social media can be defined as the means of interactions among people in which they create, share and exchange information and ideas in virtual communities and networks. These services that are relevant to primary health care for both patient and clinician include social networking websites, blogs (enabling individuals to post on the web, even without specialized HTML code knowledge), microblogging websites and wikis (a type of content management system).

Social media: an educational tool

One of the major advances as a result of social media has been the developments in the use of social media in medical education, for students, practitioners or patients.

Education for medical students

Learning medicine in the digital age seems to be a more exciting prospect than previously.4 Thanks to social media technologies, social-media-based student–student and student–teacher interactions should enhance skills and learning capacities. Outside the classroom, students who participate in social media demonstrate higher engagement and stronger connection to their institutions and campus communities, leading to higher achievement in exams, retention on the academic courses and eventual degree attainment.4 Students who utilize social media are more involved in offline activities (studying, face-to-face interaction) and have stronger connection to their institutions.5Inside the classrooms, increasing numbers of teachers now request that their students watch lectures online (usually via YouTube) before the course starts to ensure that students are suitably prepared to challenge themselves and their teachers and other students during learning. In my experience, these teachers argue that they gain time to discuss concepts that are most challenging for students, increasing their attention. Some universities use social media in a number of ways: blogs as a pedagogical strategy; Twitter to create live notices of commencement of education programmes, class events and live chat sessions; blogs, podcasts and webcasts to share the work of current and former students; and dissemination of information to visiting scholars across the broader world. Interventions using social media tools are associated with improved knowledge (exam scores), attitudes (for example, empathy) and skills. Learner engagement, feedback and collaboration development are the most reported prospects related to incorporating social media tools. A study on Twitter's influence on both engagement and academic performance showed positive effects on grades and traditional measures of engagement.6

Moreover, a new revolution in medical education is evolving as a result of high-quality, open-access online courses. Massive Open Online Courses (MOOCs) are based on websites integrating social media platforms and have been launched by start-up companies and nonprofit organizations separate from universities with the aim to reach millions of students worldwide without any barriers (open access for unlimited participation).7 This type of massive learning could improve education, especially to those who would not afford to pay the fees for, or who have no access to, universities for geographical and economic reasons. That their potential deleterious consequences on universities organizations are currently 'frightening' the professors is noteworthy.8 In the future, will university boards prefer to hire fewer professors to save on the budget? Indeed, if the flow of students turns towards these independent organizations then the necessity for recruiting professors and administrative staffs would decline.

Despite the widespread use of social media in teaching, little is known about the potential downsides of its use. The most commonly cited challenges are technical issues, variable learner participation, and privacy and/or security concerns.9 An obvious and popular worry is that students spend too much time on extra-academic activities on social media that would limit their time for studying. The capacity of social media to provide useful information and resources is also challenged by many teachers. The findings from a wide range of studies suggest that outcomes can vary depending on the ways in which students engage with the social media. In one study, social media negatively affected student academic achievement.4 Some studies have found social media use to have no effect on academic performance in college.4 Overall, two recent systematic literature reviews on the use of social-networking sites in medical education demonstrate no solid evidence-based support that social networking is equally or more effective than other media available for educational purposes.9, 10

Education for patients

That a patient with a chronic disease has better outcomes if their disease-specific knowledge is improved is well known, owing to improved self-management, increased adherence to treatments, and help in coping with and driving lifestyle change.11 This finding is true for a number of chronic diseases, and well-demonstrated in patients with arthritis.12 Unfortunately, the implementation of educational programmes usually faces some challenges. The absence of flexibility with regards to the timing or the location for such sessions is frequently evoked by patients who did not attend.13Self-management programmes integrating social media technologies enable asynchronous communications that should suit subgroups of dispersed or severely disabled patients. Social media, if available and accessible at any time, might allow patients greater access to the self-management tools proven to improve their health, enabling patients some choice to decide when, where and how they interact. In other words, social media in self-management programmes should foster support, information sharing and empowerment, all objectives that are critical for improving care for chronic conditions such as arthritis.14, 15 A study published in 2012 that investigated the effects of an online chronic pain management programme in addition to standard therapy showed statistically significant improvements in pain severity, pain-related interference and perceived disability in this patient group compared with standard treatment alone.16 Experiences of text-messaging exchanges for sending educational targeted messages according to the disease and to their profile to isolated patients showed effective outcomes.17 However, whether social media use in patients with arthritis should be facilitated demands more evidence-based studies with strong outcomes as comparators.18 Another potential caveat could be unequal access to social media owing to socioeconomic disparities.

E-health application platforms can be used by patients to manage their chronic disease; biosensors monitor vital signs (the data being directly transmitted to their doctors), optimizing the time between diagnosis and a therapeutic decision.19 Such an experience has been tested in patients with rheumatoid arthritis to increase adherence.20 Each incident patient with early rheumatoid arthritis was given access to a digital web application. Every 2 weeks during the following 6 months, the software automatically sent a text message to the mobile phones of 137 patients with advice about medication and adverse events, and patients answered by one push on their phone's keypad. If the patient's answer indicated problems, then a nurse automatically received an email for her to call the patient. This study showed that, thanks to this procedure, most patients achieved the predefined treatment target. One-third of the patients were assessed via this method before regular appointments.

Education for doctors

Doctors are increasing their skills by using these new social media technologies.21 Up-to-date applications on their mobile phone enable them to receive disease-specific tools for patient diagnosis, evaluation of prognosis and management. The industry of so-called mHealth, the medical and public health practice supported by mobile devices, patient monitoring devices and other wireless devices, is dramatically expanding.22 Twitter is a targeted method to get live news about things that affect your practice and patients, and increase interactions with people. For instance, organizations such as the FDA (@US_FDA) use their Twitter feeds to announce real-time updates on topics such as disease pandemics, emergencies and drug approvals.23 Pharmaceutical companies increasingly use social media to interact with patients and doctors. Although restricted by stringent regulatory rules, in this way pharmaceutical companies can disseminate news and information on their company informally, increasing their visibility, transparency and conviviality for doctors and patients. The majority of rheumatological and orthopaedic professional societies and journals are on Twitter, tweeting about matters such as annual meetings, publication of major studies and member-related news.24 Scientific rheumatology meetings are now covered by attendees who tweet live during the lectures as to what they consider as the most interesting speakers' messages for their followers. By adding the specific conference hashtag at the end of each message, any individual on Twitter can find all the tweets sent during the meeting (for example, “#ACR13” or “#EULAR2013” were used in 2013 for the annual meetings of the ACR and EULAR, respectively). Most of the rheumatology-related Twitter users discuss, comment and share articles with hyperlinks for disseminating information to rheumatologists, patients or the general public, and also to help with networking with professionals outside the community (Supplementary Table 1). A specific hashtag “#rheumedu” has been created by Ronan Kavanagh (an Irish Rheumatologist who is well-known in the rheumatology community on Twitter; @RonanTKavanagh) to facilitate the search for educational tweets in the field of rheumatology. When used in this way, Twitter can serve as highly personalized, continuously updating news feed of a physician's most valued interests. In the same objective, a Google+ community devoted to rheumatologists has been launched called “Rheumatology World”.25 Blogs and Facebook pages are other opportunities for rheumatologists and hospital departments to spread and discuss with readers their personal view on different aspects of their profession, to highlight articles from the medical literature that bloggers consider as breakthroughs, to critically analyze hot topics from the media, and so on. Rheumatologists are also producing their own podcasts to share information with one another (an example being the 'The Rheumatology Podcast';26 launched by M. Laccheo, P. Sufka and S. Bhana).

Overall, social media platforms could help implement a medical or scientific society's recommendations on disease management to practitioners, health-care professionals and patients. Another positive aspect of such technologies is their great potential for increasing and improving communication and collaboration among primary health-care professionals, doctors and patients.27This feature is particularly true for those who are located in rural and remote areas.28 Efforts to create virtual conferences on social media platforms are ongoing in some medical societies; for instance, the Radiological Society of North America has an option to 'attend' their annual meeting virtually.29 Popular social media platforms have been launched (such as Sermo and Doximity) in which doctors can upload their unresolved clinical cases and others connected to the platform can give their opinion on and discuss these cases online to enable the diagnosis and treatment options to be refined. However, the absence of dedicated moderators in some of these platforms might compromise accuracy and credibility. For instance, vaccination advice is a frequent request from patients on social media, but anti-vaccine activists have opportunistically launched anti-vaccine websites to influence individuals' choice30 for those who are browsing specific keywords related to vaccines on forums.

A major drawback to the use of social media by health-care professionals and medical students relates to the challenge of confidentiality.31 Doctors have already been dismissed by their hospital for the posting of confidential patient information online. Even when the patient's name is not cited, enough information could be included that enables others to identify the patient. Posting on the internet is more public than simply discussing a topic in person—anything posted on the internet is permanent and traceable. This public aspect to the internet brings many issues (including misconduct such as internet prescribing without an established clinical relationship with patients) to the forefront. To avoid these types of misconduct amongst physicians, experts and professional organizations have now launched recommendations for the use of social media by clinicians32, 33,34, 35 (Box 1). However, some active users of social media consider that, in practice, these recommendations are impossible to implement and instead advocate self-regulation by always asking if it is appropriate for a public space or not.36 Because of these critical concerns, many doctors are limiting the usage of social media, considering that the risk of a legal issue outweighs the supposed benefits.

Box 1: Examples of guidelines for use of social media by doctors and medical students

• American College of Physicians and the Federation of State Medical Boards:http://annals.org/article.aspx?articleid=1675927

• Mayo Clinic, Rochester, USA: http://network.socialmedia.mayoclinic.org/2012/03/07/guiding-principles-for-physician-use-of-social-media/

• American Medical Assocation: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9124.page

• Washington University School of Medicine in St Louis, USA:http://medschool.wustl.edu/policies/social_media_guidelines

• Icahn School of Medicine at Mount Sinai, USA: http://icahn.mssm.edu/about-us/services-and-resources/faculty-resources/handbooks-and-policies/faculty-handbook/institutional-policies/social-media-guidelines

• General Medical Council, UK: http://www.gmc-uk.org/Doctors__use_of_social_media.pdf_51448306.pdf

• The College of Physicians and Surgeons of Ontario, Canada:http://www.cpso.on.ca/policies/positions/default.aspx?id=7874

• Royal College of General Practitioners: http://www.rcgp.org.uk/social-media

• Canadian Medical Association: http://www.cma.ca/advocacy/social-media-canadian-physicians

• Indiana University School of Medicine, USA:http://msa.medicine.iu.edu/files/7113/2648/2858/OnlineProfessionalism.pdf

• Australian Medical Association: https://ama.com.au/social-media-and-medical-profession

Patient–doctor relationship

With the use of social media by patients, the relationship between the doctor and his or her patient, as well as the behaviour of the patients, has profoundly changed37 (Figure 1). Before the consultation, it is now common that the patient browses the internet to obtain information on diagnosis, prognosis and treatments. During the consultation, the patient then compares what the doctor is telling him or her with the information that they found on the internet and judges whether it matches or not. After the consultation, the patient often browses the internet again to understand the potential discrepancies between the information from the internet with that from the doctor, as well as to obtain information about the drugs prescribed. In this way, the patient can incidentally encounter online forums in which patients with the same disease can exchange their experience on prognosis and treatments. Names of experts are sometimes suggested, leading to a new consultation to cross-compare their diagnosis and treatments. In other words, the patient is becoming an 'e-patient', enabling them to empower themselves and become more autonomous and more engaged in his or her health-care journey.38 The use of social media by patients is considered as an added value compared with discovering online information only. The important element that social media adds is social networking: not only do patients now look online for information, but, by using appropriate social networks, information on social media is now being perceived as trusted information because of the source.

An exciting field in which social media will be expanding in the near future concerns medical research. Increasing numbers of patients submit substantial amounts of personal data on social media platforms, with dedicated websites designed to facilitate their upload. In this way, patients can share their own experience and might then feel less isolated when they see that many others are sharing the same symptoms and the same problems. Moreover, patients can compare their own treatments with other patients with the same condition. The first website of that kind was by patientslikeme® (Patientslikeme, USA),39 in which patients can describe their conditions, treatment history, adverse effects from drugs, hospitalizations, symptoms, disease-specific functional scores, weight, mood, quality of life and more on an ongoing basis. Moreover, the patients have immediate access to the ongoing clinical trials for patients with their condition (the information being obtained from ClinicalTrials.gov40). Furthermore, the endless wealth of such information can be used by pharmaceutical companies, device developers and consumers to optimize their strategies. The data are aggregated by the developers to constitute cohorts of patients and then sold to interested stakeholders. A scientific team of international experts has now been created to propose innovative epidemiological studies based on these databases.41 Epidemiologists are also keen to use social media as a source of information; i-Share, a French cohort study on students' health, is recruiting individuals on Facebook. A couple of years ago, developers at Google found that certain search terms could be used as indicators of influenza activity. They then launched “Google Flu Trends” that uses aggregated Google search data to estimate influenza activity worldwide in near real-time.42 The potential of such 'infodemiology' research is high.43, 44 In 2009, millions of H1N1 (influenza A virus subtype H1N1)-related tweets were surveyed and became a valuable source of opinions and experiences.45 In this way, health authorities can adapt their reports and disease prevention strategies according to real-time public concerns.46 However, aggregating multiple, disparate and unstructured streams of data is challenging because it requires new sophisticated tools and needs a cultural shift in methods of acquiring and disseminating information.47 Given the fact that social media are now integrated into everyday life, and because of the fairly low cost for such research, the potential of social-media-based research is tremendously strong.

Measuring influence

Motivations for using social media are different from one individual to another (self-promotion, altruism, interest in technology, and so on), but people would like to know whether their activities on social media eventually have influence on others in general. For this aim, exposure, engagement and influence on social media must be accurately measured, but the tools currently available are still in their infancy. The main challenge is to define the key performance indicators according to the user's profile and objectives. Alternative metrics (altmetrics) are in development to measure the influence of doctors or researchers in social media not commonly recorded by the usual tools (such as the citation index or the h-index for researchers). However, consensus guidelines for the choice of key performance indicators for assessing the influence of social media in science and medicine are still expected by the community, and by the academic authorities in particular, before using these altmetrics as tools for selecting their future professors or researchers.48

Conclusions

The young people who will become senior doctors in a couple of years are already spending on average more than 7 h a day on digital technology.49 For them, a fluid interchange exists between digital and physical experiences. Thus, the next generation of senior rheumatologists will probably include social media in their professional life, as they are currently using these services in the early stages of their careers. The same scenario might well occur in patients too, who will integrate the use of social media as a critical part of his or her care. The relationships between doctors and patients are, therefore, going to be modified dramatically. Whether we should or should not pay attention to these new social media tools is no longer the question, but rather how we should use them in practice. Although adaptation to these new technologies requires time and training in a society in which immediate productivity and efficiency are demanded, social media opens fantastic opportunities for innovation. Let's open our ears and eyes and be pragmatic by testing them in our educational and professional practice.

 

Via Plus91, DundeeChest

A brief introduction to the modern patient

In Tom Ferguson’s e-patient white paper, the authors proclaim a simple truth:

“The principle protagonist of our next-generation health care system will not be a computerized doctor, but a well-wired patient.”

The Internet has changed many parts of our day to day lives. But for patients (particularly acute cases or chronically ill) the Internet is an empowering tool with the power to change lives. It is a bridge between doctors and patients around the world.

Our society has shifted away from an Industrial Age paradigm, in which health professionals were the exclusive source of all medical knowledge and wisdom, into a paradigm that is more appropriate for the Information Age. Ours is a society of knowledge workers; it stands to reason that knowledge workers would transition into the role of the e-patient, a term commonly used to signify a modern patient that is equipped, enabled, empowered, and engaged.

(This is not the only term for this movement, but it is among the most commonly used.)

The Internet has put tools at our fingertips—tools that allow us to prepare for, supplement, and double-check our doctors. As a result, it is no longer necessary or even desirable for a patient to be passive.

We’ll all be patients in the end.

And lots of us become patients at assorted points all along the way. As a patient, you can rely heavily and exclusively on your doctor. Or you can actively participate in your own care, using the Internet as a resource and support mechanism.

When it comes down to it, what kind of patient will you be?

 

Being a patient in the social world

For those who choose to walk the road of the e-patient, benefits abound:

Less dependency on your practitioner, especially for day to day care;Less fear of the unknown—an advantage in the changing landscape of health over a lifetime;More able to ask well-informed questions, which add greatly to the efficacy of regular doctors’ appointments and improve overall quality of self-care;More able to evaluate and provide feedback on the care that is provided;Greater support through online communities both private and public

No one will ever understand what you feel and experience as a patient better than you do. And few doctors can even hope to keep up with half of the afflictions and treatments being researched and discussed today, with the exception of perhaps a small number of top specialists in given conditions.

With the transformation of knowledge worker into e-patient, the Internet has become the centerpiece of a new health ecosystem: a patient-driven hive of sharing and support.

In the new world, individuals have responded to the realities of the world of the modern patient by grouping together with the express interest of sharing information, learning from each other, and building relationships around conditions both common and rare.

These new health ecosystem can take on many forms, from modern social media groups to private websites with forums and bulletin boards to regularly-distributed email lists. They can be public or private, supported by organizations or completely self-arranged by patients.

Our core social networks, which most use quite casually every day, are also become a hub of patient communications and activity. Twitter is one of the leading examples of this community development, centered as it is on short-form public interaction. Why?

The “public” nature of the platform makes it easier for patients to find each other and connect than more privately oriented social networks like Facebook.The short-form nature heavily supports the sharing of links, dialogue around the subjects of the articles, and especially extended conversation through Twitter chats and more general hashtags.

@MightyCasey meets @stales in person for the first time.

The relationships built through brief Twitter conversations then spill out into the rest of the online and offline world, as patients who connect on Twitter will then extend the conversation to venues on Facebook, Google+, LinkedIn, and much of the rest of the Internet. Some patients also make a habit of meeting up at medical conferences or other events of common interest.

I’ve witnessed this myself, a couple of years ago at a patient conference in Kansas City. I watched people who had known each other for years online meet in person for the first time. Twitter came alive that weekend in a big way, and it became clear to me that thanks to social media, geography is no longer a factor when it comes to building relationships.

Those relationships build collaboration.

And collaboration, in the world of the patient, brings healing.

What does the modern patient expect from their health care providers?

“Personal online health networks function as a social version of our body’s immune system.”

So said Dr. Ferguson and his team in the white paper that I mentioned earlier in this post.

In fact, our communities—our ‘social immune system’—play many key roles in supporting our bodily well-being, from encouraging everyday wellness habits to providing support at the end of a life.

These online communities have become invaluable for patients. In fact, even more than that, they have become a major player when it comes to driving the advancement of health care and the growth of engaged patients.

With participation in online health communities comes education and a greater sense of confidence in dealing with the medical world. Patients’ expectations of their care shift. And so, eventually, the system must shift with it. What might those expectations and subsequent changes look like?

1)      Quality information on the patients’ turf. Doctors once controlled the flow of medical information. They disseminated diagnoses and research to their patients based on their own discretion. Many were qualified and honest, but no doctor can be an expert in every condition, particularly as the population of both people and diseases has increased.

The Internet has opened doors for patients—doors into medical libraries and respected journals, doors into conferences and hospital studies. As a result, many patients and caregivers (especially of chronic illness) become more expert on their condition than their primary care physicians—and even more than all but the top specialists in the field.

2)      High-level collaboration between patients and doctors. Patients have information on their turf, and social media means that they increasingly expect to be able to deal with doctors on that turf too. That means that patients will expect to be able to interact with their doctors via email…via video chat… via forums and social media and blogs. This is already happening, and the usage of technology to connect doctor and patient will only increase.

More important than that, though, is the need for respect for the role of the patient as a medical resource. There are still physicians out there who will be angry or dismissive when faced with a patient who is armed with information from the Internet—even articles from respected medical journals. Rather than dismissing engaged patients, doctors ought to draw them into collaborative dialogue about their care. With the power of online communities, just imagine what would be possible if caring, knowledgeable physicians collaborated with caring, knowledgeable patients in order to improve the quality of care?

3)      Social and logistical support between patients. A new medical diagnosis can be a life-changing moment. And in those life-changing moments, it can be helpful to know that you are not the only one who has dealt with them. Online patient communities meet this need, and many others. Their healing power is the power of relationship.

These relationships form around sharing access to relevant state-of-the-art information and medical referrals to the best doctors and the most caring hospitals. Unlike doctors, who may rotate (especially for those who get most of their care at urgent care clinics), the community will always be there for support, and to humanize medical information.

For people with limited access to professional care or those who are diagnosed with a particularly rare condition, these communities provide tips for day to day illness management, as well as ongoing support for those with an incurable condition.

Collaborative relationships between patients have changed lives. And even saved them.

Through the stories of individual patients and—increasingly—research from official studies, we have begun to see the power of what happens when patients and caregivers flock to the Internet in the face of both medical challenge and everyday medical care.

The Walking Gallery of Healthcare from Eidolon Films on Vimeo.

According to Dr. Ferguson’s research, patients and caregivers who take to the Internet and take control of their own wellness are more likely to both seek physician advice and be prepared for and engaged in appointments with their care providers.

It means that patients can once again be at the heart of their own care.

The Digital Age Health Care Marketplace

The same mindset shift that has occurred among many consumers is now happening more and more in health care environments.

Just as the Internet gave consumers easy access to price comparisons and product information and reviews, it has given patients access to accurate, current data and supportive communities.

Consumers gained the ability to make smarter decisions about the products and services they pursued. Patients gained the ability to take charge of their own care through access to knowledge that was not previously available.

Consumers and patients are now passive only by choice or by circumstance.

Rapid information access and the empowered mentality of social relationships have driven unparalleled collaboration and sharing between patients and caregivers, and their clinicians.

New technologies—ranging from smartphones and tablet computers to wearable devices like Google Glass— make it increasingly easy to access, create, and share data to relevant parties.

From now on, as generations age and seek medical care, there will be new expectations of the relationship between the doctor and the patient. This is not a bad thing. To paraphrase Alan Kay, it is the role of the medical community to lock into what’s best for the patient—not what is most comfortable for them. The transition has already begun.

Clinicians must ask: Am I ready to be a social-age doctor? How will I implement that commitment in my day to day practice and attitude towards patients?

Patients and caregivers must ask: Am I ready to stand up and be a full partner in my own care? What should I do to be a more engaged consumer of care?

The more people who answer the first question affirmatively, the more our system will change. And the more our system adjusts, the more improvements we will be likely to see in patient safety and overall quality of care.

 

Via Plus91