Technology-aided cheating … here are the ways:

1. Impersonation. The student can go to an online service that offers to make assignments or write papers and then pass of the work as his.
2. Search engine and plagiarism duo. The very easy to do cut-and-paste method without citation.
3. Unauthorized intellectual networking. Posting of previous content or coursework from those who have taken the course so others in the network can benefit.
4. Unauthorized technology exploitation. While taking an online test on the official desktop computer, the student has a tablet computer or other mobile device at hand to google answers. More tech-savvy students can actually do course hacking.
5. Unlawful distribution. Students borrow previous submissions or assignments from others who have taken the course. They revise these a little and submit them as their own. They assume the teacher doesn’t read it anyway and will be unable to tell them apart.
6. Deceit and manipulation. Student misrepresents one’s status or situation to buy time or cheat. The student may say he was unable to complete an assignment because a relative died or she got pregnant.

Fr. Ravasco offers the following suggestions to help prevent cheating on ODeL courses:

1. Policies and requirements. There must be clear guidelines and consequences for academically-inappropriate behavior. Assignments must require creativity so that students cannot just cut and paste.
2. Interaction and communication. Students are less likely to cheat if there is frequent feedback from the teacher.
3. Design of assessment. Randomize items in the question pool. Conduct oral exams via live web chats. Perform assessments in a secure web browser.
4. Monitoring and evaluation. Do online proctoring using screen viewers.

Fr. Ravasco says we probably need to do more studies on online cheating as there is limited literature since ODeL is relatively new. Got any more cheating examples not cited here? Drop me a line at isiptan@endocrine-witch.net.

So I sat down today and googled away … Here’s a short presentation on Slideshare.net from Ed Bennett, Director, Web & Communications Technology of the University of Maryland Medical System:

Welcome to the Post Liver Transplant Support Group online patient support community on Facebook. This group is restricted to current and former patients treated at the University of Maryland Medical Center. It is intended for you to share your experiences and connect with others who have a similar diagnosis.

This group is not intended for personal communication between you and your health care provider, or for seeking urgent medical attention. If you have an urgent medical need, please call your doctor or the nearest emergency room immediately.

This group has been set up as a private Facebook group accessible only to approved patients, caregivers and health care providers. Confidentiality of discussions shared in this forum is expected; however, it cannot be guaranteed. Private groups are subject to Facebook corporate policies. In addition, posts to the group are viewable by all group members. As with any online communication, be aware that anything posted has the potential to become public and only post information you are comfortable sharing with others in the patient support community.

By joining this private patient support group, you are indicating that you agree to the terms and conditions listed above.

I’m downloading the free app as I write this post! It has page templates to get one started. There is a drag and drop interface for Pages documents – nice. Multi-touch widgets look interesting – have to learn how to use those. And aha, you can submit your book to iBookstore for purchase or free download, that’s neat! The book can also be shared on iTunes U.

Interesting stuff going on as well with the all-new iTunes U! With the iTunes U app on the iPad, iPhone or iPod touch, one can not only get access to course materials in one place but push notification is also possible when the teacher posts a new message or creates an assignment. I’ve used Moodle for the past few years in our endocrinology course and students find the interface somewhat too staid. It would be interesting to see how we can add some magic with these new offerings from Apple. I notice that quite a number of my students have at least one of these portable Apple devices.

I know I’m gushing but this is NOT a paid advertisement from Apple Let you know once I get cracking with iBooks Author!

http://jetpack.me/annual-report/28741494/2011/

The predicted third generation of the World Wide Web, usually conjectured to include semantic tagging of content.

What does that mean? Semantics is the study of meaning – a Web with more meaning? Tim Berners-Lee, the inventor of the World Wide Web was quoted by Wikipedia as having said this -

I have a dream for the Web [in which computers] become capable of analyzing all the data on the Web – the content, links, and transactions between people and computers. A ‘Semantic Web’, which should make this possible, has yet to emerge, but when it does, the day-to-day mechanisms of trade, bureaucracy and our daily lives will be handled by machines talking to machines. The ‘intelligent agents’ people have touted for ages will finally materialize.

From W3C at http://www.w3.org/2001/sw/

The Semantic Web is about two things. It is about common formats for integration and combination of data drawn from diverse sources, where on the original Web mainly concentrated on the interchange of documents. It is also about language for recording how the data relates to real world objects. That allows a person, or a machine, to start off in one database, and then move through an unending set of databases which are connected not by wires but by being about the same thing.

Imagine the possibilities for health! The Semantic Web will make it easier to find relevant health information online. I thought about the Semantic Web when I came across this article, Google Users Will Get More Personalized Results in Searches by Brian Womack on Bloomberg.com. According to the article, Google will for the first time bring personal content into the results page by tapping photos, news and comments posted on Google+. Womack says that, “If someone searches for a dog, for instance, pictures of friends’ dogs might show up first in the search results.” Now is that cool or eerie?!

As of today, I have 626 FB friends and gulp, 82 friend requests. Most of my FB friends are from PGH or UP, some are my grade school/high school classmates, a few are my students (mostly sorority sisters) and a handful are from the pharma industry. I like that on FB I am reminded to greet even that grade school classmate I haven’t seen in decades, a happy birthday. I like how I am able to catch up with friends who are abroad. But how deep are these friendships exactly if we don’t meet up offline?

Blogger Linzee was also confused about FB friendships when she wrote on the Etsy blog-

Did these folks really fit my definition of “friend”? Why would they want to read my day-to-day prattle? How did I know them and why should we stay in touch?

How can we define friendship? Watch this short YouTube video by Notebook Babies entitled “What is a Friend?”

The video defines a friend thus -

1. A friend is someone who will compliment you.
2. A friend will cheer you up when you’re sad.
3. A friend will let you win sometimes.
4. A friend will remember your birthday.
5. A friend is fun to be with.
6. And a friend will make you smile.

I think you can do all of these on Facebook, except No. 5. How important is no. 5? Does online chatting count as “being with”?

In the same post, Linzee talks about a photographer named Tanja Hollander who has embarked on “Are You Really My Friend? The Facebook Portrait Project.” Tanja has set out to meet up with all her 626 FB friends and take their photos “in intimate settings – gathered around kitchen tables and lounging on living room sofas.” I suppose this is her way to make the friendship real! Tanya’s work will be on exhibit at the Portland Museum of Art in 2012 – that should be interesting.

Finally in this article, “Friendship, Facebook-style,” Aditya Chakrabortty recounts how on Christmas Day, a certain Simone Back posted what was essentially a suicide note on her Facebook wall – “Took all my pills be dead soon so bye bye every one.” Sadly, not one of her 1,048 FB friends checked up on her. How can that be real friendship? Very disturbing indeed. Something to think about with Christmas only a few days away.

““[Most doctors] really do like to think they have ALL the answers. This will never change, I am afraid.”

Quote from a Patient in the Pew Internet Project e-Patient Survey

 Are you an internet-friendly or an internet-hostile doctor? Does it make you uncomfortable that patients will seek a “second opinion” online? Do you feel offended by the patients’ attempts to learn more online? I hope not.

Like it or not, patients are now more likely than ever to search for health information online. I try my best to be as internet-friendly as I can in my endocrine practice. I often find myself giving internet prescriptions for uncommon endocrine disorders:

1. www.pituitary.org – This is the website of the Pituitary Network Association. It has a very helpful FAQ section for the different pituitary disorders.
2. www.hormone.org - This is the website of the Hormone Foundation, an affiliate of the Endocrine Society. It has very useful Fact Sheets and Patient Guides.

In my lecture at the Philippine College of Physicians annual convention, I highlighted the following more general websites:

1. MedlinePlus – It not only has good articles on the different medical conditions but has a section on Drugs, Herbs and Supplements.
2. Mayo Clinic – The site has a Symptom Checker and information on how different tests and procedures are done so patients can be prepared properly.

During the clinic encounter, the opposite also happens where the patients recommend that you read this or that website so you can inform them if the website is accurate or not. Since obviously I may be too busy to check it out, I usually just reply by asking them to look for the HON (Health on the Net) Code seal on the website.

“HON was founded to encourage the dissemination of quality health information for patients and professionals and the general public, and to facilitate access to the latest and most relevant medical data through the use of the internet.”

Health on the Net Foundation

According to the HON website, the HON code is stamped on more than 10 million pages covering 102 countries. A website is given HON certification if it adheres to the following principles:

1. Authority – gives qualification of authors
2. Complementarity – information to support, not to replace
3. Confidentiality – respect the privacy of site users
4. Attribution – cite the sources and dates of medical information
5. Justifiability – justification of claims/ balanced and objective claims
6. Transparency – accessibility, provide valid contact details
7. Financial disclosure – provide details of funding
8. Advertising – clearly distinguish advertising from editorial content

The Health on the Net Foundation does have a disclaimer though -

“HON cannot guarantee the accuracy of medical information presented by a site and its completeness at any given time, but possession of the HONcode seal allows a site to demonstrate its intention to contribute to quality medical information through the publishment of objective and transparent information.”

 

Finally, some thoughts to ponder from a white paper:  Tom Ferguson, MD & the e-Patients Scholars Working Group (2007), “e-patients: How They Can Help Us Heal Healthcare.” First, do not underestimate the patient’s ability to provide useful online resources. The paper points out that some of the best health-related websites have been made by patients! These websites often offer helpful information that physicians may think less important to discuss i.e. tips for coping and living with the disease. And secondly, do not overestimate the hazards of imperfect online information. The paper cites the Database of Adverse Events Related to Internet Use (DAERI) which reported only a single case of possible fatality as of 2004, in its four years of existence. This project which offered a fifty-euro reward for each case reported was eventually shelved for lack of cases reported.

Image credit: http://www.flickr.com/photos/caricaturesbynelson/2031107541/

In my last post, I talked about how access to health information online is transforming the physician-patient relationship. Apparently, the impact of online health information is determined by the severity of the patient’s medical condition and the patient’s attitude towards his physician. This is according to a Vital Signs report (E-Health in the United States, Boston Consulting Group, 2003) by Carina Von Knoop, Deborah Lovich, Martin B. Silverstein MD and Michael Tutty from which I got this figure below:

The Vital Signs report categorizes the online patient population into the following segments:

1. The Accepting (“doctor-dependent and uninformed”) – These patients rarely go online to seek health information even if they have Internet access, as they are comfortable with a paternalistic relationship with their doctor. Most of my patients fall in this group, though I often wish that they become more involved in decision-making. It can become quite frustrating when after I patiently explain all the options, the patient says, “Kung ano po ang sa tingin ninyo ang mabuti Dok.” Translated, “Whatever you think will be best, Doctor.”
2. The Informed (“doctor-dependent but informed”) – This group still depends on the doctor to make decisions but they are likely to seek more information online before or after a clinic visit. I encourage this by giving “Internet prescriptions” – a list of websites that patients can visit. My dream is for the Philippine Society of Endocrinology & Metabolism (PSEM) website (www.endo-society.org.ph) to be the leading resource for Filipino endocrine patients. Malayo pa
3. The Involved (“junior medical partners”) – These patients are fairly well-informed and somewhat involved. They visit websites and discuss these actively with their physician. While they prefer to make joint decisions, they usually defer to the doctor. These patients respond well to Internet prescriptions.
4. The In-Control (“autonomous patients”) – These patients seek online information to be able to diagnose their condition and decide the treatment for themselves. They may even attempt to update their doctors on the latest treatments or studies. They may be active members of online patient communities and contribute to blogs.

As can be seen from the figure, the more severe the medical condition is, the more involved the patient becomes in his care and the doctor’s role is lessened from being Godlike to becoming merely a supplier of information and/or treatment. I know this from my experience when I diagnosed myself as having a prolactin-secreting pituitary adenoma last 2000. The prevailing treatment then was surgery but I reviewed all the literature (did an extensive MEDLINE search) and decided on medical therapy, despite the advice of consultants in both endocrinology and neurosurgery (I was only a medical resident then).

I must confess I feel more comfortable with The Involved. I’ve met a few of The In-Control and the encounters have been particularly stressful. I guess it’s because these autonomous patients most often show their distrust (often a result of previous encounters with other physicians before they come to see me ). I then have to demonstrate to these patients that they can trust me, more than or maybe just as much as what they read online.

The physician-patient relationship in the Philippines remains mostly paternalistic but I think that the time will come when more patients will become empowered by the health information available online and become active partners in medical decision making. Gerber BS and Eiser AR (The Patient-Physician Relationship in the Internet Age: Future Prospects and the Research Agenda J Med Internet Res 2001;3(2):e15) describe this change in the physician-patient relationship:

“Until recently, in the clinical visit the physician had the sole responsibility for medical knowledge, whereas the patient was only accountable for his or her own preferences. Now, by more easily obtaining medical information prior to seeing their doctors, patients potentially have a different position in the decision-making process; possessing both preferences and knowledge prior to any physician contact.”

And so I ask, are doctors threatened by the Internet savvy patient? Certainly, there is a “leveling effect” since patients can now have access to health information previously made available only as their doctors saw fit to disclose to them. Interestingly,  Geiber & Eiser had this to say in their paper -

“Paradoxically, a patient’s interest in knowledge may not always accompany an interest in the medical decision-making process.“

Aha!

Geiber and Eiser then go on to discuss two kinds of patient-physician encounters:

1. The Physician & the Informed Decision Maker – The patient has done a Web search prior to the clinic visit and is equipped to weigh the alternatives the doctor offers and decide on treatment. Pros: There is truly an informed consent. Time can be wisely spent on an in-depth discussion during the clinic visit since the basics have already been researched and understood by the patient. Cons: Physician may need to spend more time with the patient debunking alternative or complementary treatments and/or correcting wrong information.
2. The Physician & the Knowledge Acquirer – The patient discusses his values and beliefs with the physician who then is able to decide more ably for the patient. The patient may then browse the Web after the clinic visit, which serves to reinforce the medical decision that has been made by his physician. In this situation, Geiber & Eiser describe the physician-patient encounter as having a “priming effect” on the patient’s behavioral response to subsequent information provided by the Internet.

In my endocrine practice, I find that for the less common hormonal disorders such as those involving the adrenal or pituitary glands, patients need to read up after the clinic visit to fully understand the concepts I’ve explained during the encounter. I then find myself recommending websites to the patients or their more internet savvy relatives. This is what is called an Internet prescription. More about this in a future post.

Photo credit: http://www.flickr.com/photos/dannysullivan/273838692/

Before the Internet, physicians served as the main source of health information for patients. NOT anymore! In the clinic encounter, it has become more and more common to see patients bringing information gathered from the Internet. Gunther Eysenbach in Medicine 2.0: Social Networking, Collaboration, Participation, Apomediation, and Openness (J Med Internet Res 2008;10(3):e22), describes this shift:

The first possible approach is to use intermediaries (ie, middlemen or “gatekeepers”), for example health professionals giving “relevant” information to a patient. Trusted Web portals containing only information vetted by experts can also be seen as an intermediary. The second possibility is to bypass “middlemen” completely, which is commonly referred to as disintermediation. Examples are patients searching for information on the web, or travelers booking their flights directly on the booking system of an airline, bypassing travel agents. The third way, prevalent in the age of Web 2.0, is a special form of disintermediation: an information seeking strategy where people rely less on traditional experts and authorities as gatekeepers, but instead receive “guidance” from apomediaries, ie, networked collaborative filtering processes.

 

I worry about disintermediation – patients directly accessing information on the Web! It is possible for patients to get lost in the sea of information the Internet provides. I also worry about apomediation – crowdsourcing health information! Eysenbach’s examples of apomediation (where agents “stand by” rather than “in between” as in intermediaries) include ratings on Digg, amazon.com or epinion.com.  Can we apply the same strategy for finding information about good deals, the best hotels or destinations to health care?

Mary Cain et al. in their report Health e-People: The Online Consumer Experience (written for the California HealthCare Foundation Aug 2000) classifies online health information consumers into 3 groups:

1. The Well – around 60% of online health consumers who occasionally browse for general health and wellness information
2. The Newly Diagnosed – a small group (~5%) that understandably searches widely for information following their diagnosis
3. The Chronically Ill and Their Caregivers – actively manage their illness daily and seek information regarding management online (~35%). The report identifies this group as having the most potential to be affected by health information on the Internet.

Which of these three groups have you met in your practice? I’ve met some of the newly-diagnosed clutching their web print-outs and have patiently answered queries regarding the veracity of online health information from a few caregivers of the chronically ill. What to do? More in my next post.

 Photo credit: Person: question http://www.sxc.hu/photo/1124847