Filtering Helps E-patients, per MIT Media Lab

For those interested in a contrasting viewpoint – because there are always at least 2 ways to look at an issue – to my recent post about the potential effect of the “filter bubble,” I am using this post to present the other side of filtering. Filtering – in layman’s terms – is the way by which companies  like Google and Facebook (“gatekeepers”) determine what your search results will be, using algorithms that incorporate data from your prior search habits. Ian Eslick recently sent me a link to an article that explains the positive aspects of filtering. Eslick is a PhD candidate at MIT Media Laboratory and is studying how filters apply to healthcare information on the web. Here’s an excerpt from that article:

In an era of increasing information overload, the filter is a necessary and valuable tool and we’re only at the beginning of the technology curve.  In the context of health, filters are critical to improving the effectiveness of the rising class of e-patients.

This is a fascinating topic that is not new, but that I have recently discovered. I certainly don’t claim to be an expert, which is why I am posting the MIT Media Lab’s perspective, as well.

Do any of you out there have thoughts on the topic? How about filtering as it relates to healthcare information? Did you know about the concept of the “filter bubble” or personalized search results or is this also the first you have heard of it? Do you see other pros and cons to it? Does this topic even matter to you?

The Internet and Delusional Thinking: A Take on the Effect of the “Filter Bubble”

Some suggest that social media is full of illusions. Real life people creating an alternate reality through the web and social media is not unfamiliar. Sometimes the alternate reality becomes so infamous it creates real danger and harm, as in the case of Kiki Kannibal.

But there may be a greater collective societal harm in our use of social media and the individualized way we in which interact with the internet and other people. We’ve created a sort of “selective hearing” with the introduction of DVR, Facebook friending (and de-friending), RSS feeds, podcasts, and Twitter. Even if we are not creating a fake image of ourselves, we are living in a world designed around our own self-interests.

Long gone are people telling us things we don’t want to hear. We can tune them out and tune in messages from like-minded people. If I believed in life on Mars, I can “program” my inputs from various channels to be heavy on that topic by selectively following those with similar interests, searching for corroborating articles on the web, and highly rating similar topics on DVD.

The internet and our current technological advances do more than just encourage us to create illusions. For a much larger percentage of us, if not all of us, they help us create and maintain our own delusions (I am not referring to the actual medical term here). Delusions are technically defined as false beliefs, but in the tweeted words of Jan Henderson, there is “no one right conclusion that stands the test of time indefinitely.” So I would argue that we are delusional if we only look at the world from a singular or narrow perspective, being unwilling to accept or selectively avoiding other opinions/ realities.

As I was pondering the above in recent weeks, I come across a video that, quite frankly, sent slight chills up my spine. It was a video of a TED talk given by Eli Pariser, author of his new book, The Filter Bubble, which deals with the notion that the major players in the internet world (like Netflix, Google, and Facebook) are tailoring your searches based on your previous online behavior. They acquire data regarding your pattern of clicking, your location, etc., to personalize your results. “You actually start to have – without you really knowing it – your own views fed back to you,” Pariser said in a recent radio talkshow. Why? To increase the likelihood you will click on the links presented. “You can make more money if you can show people stuff that they’re going to like.”

He explains this more clearly in the video (well worth watching for the 8-min duration)…. By the way, after watching the video, you get the sense that you have inadvertently sold your soul by engaging in a technology that, without which you would be considered obsolete and nonfunctional.

What are the implications of “the filter bubble” for healthcare? Potentially huge. People are now “researching” online for their healthcare information. And this is only going to increase over time. If I have a tendency to click on naturopathic medicine links and I get diagnosed with breast cancer, the first two pages of my google search regarding treatment might be related to alternative approaches because “personalized media is showing you the things… it thinks you want to see.” This type of filtering may affect my decision on who I call first and thus my treatment plan. It doesn’t take into account that I may have changed my mind about which approach to treatment I would prefer.

It is concerning to think that internet companies “have a lot of power to shape what you see and don’t see.” The web will assume our preferences for us, feeding us the information that substantiates our underlying tendencies. Even outside of the specifics of healthcare, there is potential for our biases become more deeply entrenched with personalized media. And I suspect that would not be good for the evolution of human consciousness. I personally feel fairly reassured because I believe I have a critical way of searching on the web. But other people (with less formal experience researching information) may feel they are just as objective, but in actuality, have less discernment. (This is exemplified in the case of a sensational article circulated on the internet recently.)

As it is, to be open to new ideas and evolve into broad-minded human beings requires much attentiveness and deliberateness, which can easily get lost in our fast-paced lives. The internet is now making it that much harder.

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Dear Electronic Medical Record

Dear EMR (Electronic Medical Record),

Where to start? When we first met, I was enamored. We were both young and much less jaded back then. Things were simple. You knew what I needed and I knew what you needed. And it worked. But a lot has changed over the years. Our initially simple relationship has gotten messy and much more complicated. I still want you in my life because I believe in you and your potential. Your intention is definitely good, but as I’ve gotten to know you over the past few years, it’s gotten hard to tease out the real you from all the other stresses. You are constantly pre-occupied with the finances and have become more demanding. I am willing to forgive you for hanging out with the girls in billing and the lady lawyers in their fancy high heels. I won’t leave you, and, anyway, we’re practically inseparable at this point. But I do keep vacillating between just working around the idiosyncrasies you’ve developed and trying to change you back to your previous self. But, we both know that won’t happen, don’t we? We won’t ever be that simple or young again. But let’s not forget for whom we should really exist… each other.

Image: Simon Howden /

Social Media to the (Timely) Rescue

Yesterday, I read an e-mail from someone who wanted my thoughts on an article entitled, “Scientists cure cancer, but no one takes notice” The article published on  (which, by the way, “Helps Everyday Experts Publish & Earn”) was scientifically unsound, poorly written, and painful for me to read. It proposes that that dichloroacetate is a simple wonder drug for cancer but is so inexpensive that no one cares to study it further. I looked into it and it turns out that the original research that led to this article was done in 2007 – a long time ago in the field of medicine!

Of course, I tried to find out whether there were any more recent references to dichloroacetate. I won’t say I actually researched it, though. (After all, “googling” is to “research” as watching TV drug ads is to getting a pharmacist degree.) Interestingly, the very same day that I read my friend’s e-mail, this was posted on Twitter by Gary Schwitzer, Publisher,

Science blogger @pzmyers deflates sensationalism of “Scientists cure cancer, but no one takes notice” story –

It turns out that this is a resurrection of a sort of “conspiracy theory” on the web, one that was circulated a few years prior. “Science blogger,” PZ Myers, is a biologist and an associate professor at the University of Minnesota, Morris. His post, published online just two days ago begins with this sentence:

So many people have sent me this sensationalistic article, “Scientists cure cancer, but no one takes notice”, that I guess I have to respond.

Well, thank you, Dr. Myers for your timely response. Mostly, though, thank you for responding in a way that not only points out the sensationalism of the popular article, but also teaches your readers about the mechanism of how dichloroacetate works, its potential, and the issues surrounding research of it. Thank you for providing a link that I could forward to others who ask about it (because the “written” word seems to carry more weight than the spoken word). And I also hope that your article, which currently has 1,698 “Likes” on Facebook, eventually supercedes the number of “Likes” of the article, which happens to be a mere 362,000, and counting….

Eyes in the Exam Room

Scientific American published an article earlier this month that revealed the results of a study corroborating the idea that “we tend to be on our best behavior when we know that we are being observed.” The researchers actually demonstrated that posters of staring human eyes were enough to change people’s behavior.

 …During periods when the posters of eyes, instead of flowers, overlooked the diners, twice as many people cleaned up after themselves.

The article goes on to hypothesize how or why this effect occurs, citing evolutionary reasons (“detecting lurking enemies”). It is then suggested that images of staring eyes could prevent theft and other bad behavior.

Looking around my exam rooms, bare but for the essentials, I think there might be some use for some “art” in the form of staring eyes. Would patients be more honest or forthcoming about their recreational activities? Would my diabetic patient be more inclined to admit that he has been eating ice cream and cake every night for the past few nights?

Or… it might even keep me in check. Not that I’m dishonest. But it might help me stay consistent with my values surrounding practicing medicine when days get harried or stressful. Hey, I may be a doctor, but I’m human, too. A little subtle evolutionarily-based trick can’t hurt.


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* Salvatore Vuono

The Right Way to Solve a Workplace Conflict

One day, in the first few months of my second year of residency, I was called into the office of one of my superiors in the Graduate Medical Education Department. I didn’t know why I was summoned or whether it was a good thing or bad, but I was not prepared for what I was about to hear.

Paraphrasing (because it was some time ago):

Superior: “Did Dr. So-and-so talk to you?”
Me: “No.”
Superior: “Dr. So-and-so didn’t talk to you about a patient interaction recently?”
Me: “No.”
Superior: “I got a call from Dr. So-and-so and he told me you were rude to a patient. That you said something that upset the patient.”

At this point, my heart was racing and my mind was spinning. I was grasping in the realm of my short-term memory…. Probably turning as pale as a person like me can get, I said,

“I don’t know what you are talking about.”

Superior: “Dr. So-and-so said that you went to a patient’s room and said that the patient got you in trouble.”

Me: “That never happened. I don’t understand what he is talking about.”

Superior: “So, you’re saying this didn’t happen?”

At some point in the conversation he revealed when it happened, and it was on a day that I was not even working. I pointed this out to him and was utterly confused about why I was being accused of something completely out of my character.

Superior: “Well, I don’t need to get in the middle of this then.” (This part is verbatim, unforgettable).

“That’s it? ” I thought. “You tell me about something fictional that damages my reputation and character and then leave it for me to lose sleep over? You are already in the middle of it.”

I was shaking inside as I left that room. I felt completely helpless. All the hard work of proving myself over the past year as a trustworthy, reliable, diligent, consistent and attentive physician who took good care of patients was thrown out the window with an unfounded accusation. Lest you think I was overreacting, let me point out that Dr. So-and-so was very highly regarded in the institution and the head of his particular department, which happened to be a field I was strongly considering for fellowship. That dream was over with this event.

Several days went by and with time there grew a constant, queasy feeling in the pit of my stomach. I started to realize that if Dr. So-and-so believed this about me, word would travel to all the attendings on staff in the hospital. Perhaps some residents could brush something like this off. (I wished I could be just as nonchalant.) Perhaps others could just let it brew. (I was already taking that route). However, my integrity was in question, and neither approach seemed right.

I got more and more uncomfortable with the knowledge that I had to work in this institution for another year-and-a-half and would be interacting with everyone in Dr. So-and-so’s department. I mentioned my situation to a few trusted residents, who were just as aghast. Sympathetic, but solution-less, they were. Even my Superior, whom I felt should have had my best interest in mind, offered me no advice whatsoever.

Once resolved to end this issue once-and-for all, I looked up which section meetings that Dr. So-and-so was expected to attend at the end of the day. I picked one and waited outside the door until it was over. When I approached him and asked if he had a minute to talk privately, I could see he was hesitant. But he agreed.

I am going to be completely honest about my feelings here, as it is crucial to the story. You, the reader, may have been able to accomplish the following with ease. But for me (in my twenties) to approach this well-regarded physician (probably in his 50s) who held significant clout and a stand-offish temperament was a psychological and emotional challenge. Telling patients that they had cancer was an easier task for me. And that is very difficult.

Dr. So-and-so and I went to a private room and I told him my side of the story. (Did I even have a side? I wasn’t there!). I am sure my voice was feeble. I am sure I looked meek. Together, this probably made me look guilty. The expression on his face showed that he was disengaged. My heart sank and I started to believe this approach was useless.

Dr. So-and-so didn’t interrupt, however, as I laid out the facts of the matter and that I really had no idea what the issue was about. He then told me his side of the story. His patient had told a nurse that a female resident with dark hair reprimanded him for something and it upset him. The nurse identified me as one of the residents working with the patient, so she told Dr. So-and-so that I had caused the patient’s distress. I had not been the only one with dark hair working with this patient, I pointed out to Dr. So-and-so. Furthermore, other details of the story just didn’t add up to prove any culpability on my part.

Dr. So-and-so’s expression softened (as much as it could for him) and he acknowledged my point. Maybe he said he was sorry. Maybe he didn’t. I don’t remember. But I was able to complete the rest of my training with some dignity and without defamation of my character.

There are a few lessons here, the personal ones so obvious I won’t write more about them. Firstly,

The decline of face-to-face resolution of conflicts as we develop advanced technological ways to communicate is lamentable. For example, I know an employer who received lengthy e-mails about grievances from an employee even when he was working side-by-side with that person daily, as if the issue didn’t exist except in cyberspace. One might say intimidation is a factor. I can relate to that (see above story).

In fact, I was reminded of this story when I read a recent New York Times article about an unpleasant interaction between a nurse and a doctor. The nurse, who wrote the piece, details this incident and goes on to describe the types of bullying physicians perpetrate towards nurses and potential solutions to stop it. It would have been interesting to learn whether she reported her specific incident, what channels there were for reporting such behavior, and whether her hospital’s administration (which tends to affect the tone of the working environment) did anything to help resolve the issue. In addition, any attempt to address the issue directly with the physician is not mentioned in the article, except for the fact that she says, “As we walked out of the patient’s room I asked the doctor if I could quote him in an article.” An article that was published months later. To correct a wrong, timeliness and directness is most effective.

Secondly, if you are involved in medical education as an attending, program director, assistant program director, or chief resident, do not forget that, in addition to teaching the scientific knowledge of medicine and the nuances of doctor-patient relationship and the importance of work-hour restrictions, etc, you are helping to mold these new physicians. You are important examples and should be mentors for the betterment of their professional and personal development. In some ways, you are family for these residents, who live, eat, sleep, and breathe with you more than they do their own families. In my opinion, the duties of a physician in a teaching institution go beyond getting them to pass the boards. It is to also guide them in being able to handle difficult ethical and moral situations and to advocate for what is right. This will serve them and their patients well in the future.

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What You Should “Pack” if You Are a Nomadic Healthcare User


Are you a nomadic healthcare user?


no·mad noun \ˈnō-ˌmad, British also ˈnä-\
: a member of a people who have no fixed residence but move from place to place usually seasonally and within a well-defined territory
: an individual who roams about
— nomad adjective
— no·mad·ism noun

Origin of NOMAD

Latin nomad-, nomas member of a wandering pastoral people, from Greek, from nemein
First Known Use: 1579

Synonyms: drifter, gadabout, gypsy, knockabout,maunderer, rambler, roamer, rover, stroller, vagabond,wanderer, wayfarer, bird of passage

*Modified from Merriam Webster online


A nomadic healthcare user – if there is such a term – is an individual who gets his healthcare from multiple places (different clinics/states/cities/etc). There are various reasons for this type of healthcare utilization that I have come across since I started practicing as a primary care internist.

Some reasons are obviously geographical:

  • a move (to another city or state)
  • travelling for long periods of time after retirement (ex: RV’ing )
  • Wintering in other states

Other reasons are less obvious, but frequent, and still occur despite living in the same location:

  • a job change (new insurance)
  • doctors changing or closing practices
  • an employer changing insurance, thus forcing a change in PCP due to cost (My pet peeve. This seems rarely cited as a contributing factor to fragmented healthcare/increased healthcare costs and can occur each year for some patients!)
  • using the healthcare system “prn” (only as needed, calling up doctor’s offices as needed, going to the first local doc that has an appointment available)
  • “doctor shopping” (going from doctor to doctor, searching for one that you agree with)
  • second, third, and fourth opinions.

In the U.S., particularly in bigger cities, an individual’s healthcare can be quite fragmented due to all of these factors.

The result:

  • Expensive care (primarily through repeated tests and scans that have already been done)
  • Confusion among patients and their doctors
  • Over- or under-immunizing

If you find yourself in any of the above “nomadic” situations, there are some things you can do to keep as much continuity as possible in your healthcare. If you need to switch primary care doctors, get records from the last one. It may cost you money, but it can be invaluable to the next doc and perhaps to the healthcare system as a whole by reducing redundancy of testing. They are your own records and you should have them. They may not be retrievable if the clinic went out of business.

Let’s say there was a fire in your doctor’s office and all the documents disappeared, the computer system was inaccessible, and you came to see me for the first time. These are the records that I would hope you have:

  • Complete immunization record
  • Labs from the last 2 years
  • Medication list (exact dosages and frequency)
  • Allergy list (reactions)
  • Primary care notes from the last 2 years
  • The last colonoscopy report + pathology report (if there was a polyp)
  • MRI and CT reports within the past 5 years
  • Specialist notes from the past 2 years (this one is more optional)

 As a side note, it would be curious to see how the “medical home” concept fits into some of this nomadic behavior. They seem antithetical by definition .

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