A picture is worth a thousand words: comic books for medical and patient education

Patient communicationThe BMJ has just published an interesting feature about comics in medicine – the history, the approaches, and their use in medical and patient education.

The authors Michael J Green and Kimberly R Myers call such comics “graphic pathographies”: illness narratives in graphic form. “These graphic pathographies can be helpful to patients wanting to learn more about their illness and find a community of similarly affected people,” they say. “Graphic pathographies also provide doctors with new insights into the personal experience of illness and misconceptions about disease and treatment that could affect compliance and prognosis.”

Mom's cancerThe two examples they discuss are Marisa Acocella Marchetto’s Cancer Vixen, in which Marchetto describes her experiences as “a shoe-crazy, lipstick-obsessed, wine-swilling, pasta-slurping, fashion-fanatic big-city girl cartoonist” with breast cancer, and Brain Fies’ Mom’s Cancer, which documents Fies’ mother’s metastatic lung cancer. Both provide actually quite moving and at times subtle personal accounts of illness, and in a more succinct and engaging way than the same tale in prose form.

Medikidz diabetesMedical comics are proving particularly useful in patient education, both to promote public awareness and to help patients and their families understand what to expect from a disease. Apparently, combining pictures and text enhances understanding because reading and viewing activate different information processing systems within the brain. “This combination also fosters connections between new information and existing knowledge,” say the authors, “thereby increasing recall of health information, especially among those with low literacy.”

The series Medikidz is a prime example of the latter approach. Medikidz comics provide quite complex medical information for kids about a variety of different diseases, such as osteosarcoma, scoliosis, and type 1 diabetes.

The “Medikidz” are a group of five larger-than-life superheroes who journey around Mediland, a planet shaped like the human body. These heroes battle against villainous characters representing aspects of disease. For example, Chi is the Medikidz lungs specialist whose secret power is hypnotic relaxation, whereas her nemesis is Anna Phalaxis.

Comics can also be used to educate medical students and doctors. For example, personal patient stories in comic book form could reinforce to junior doctors that fact that healing a patient entails more than treating a body. Also, as the authors point out, “In keeping with research in medical education showing that visual art improves students’ diagnostic skills, reading graphic stories may likewise enhance students’ observational and interpretive abilities.”

I find these comic fun to read, and they certainly seem a novel and creative way to communicate patients experiences and information about diseases.

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Improving communication of medication risks and benefits in direct-to-consumer ads

A new study published in Annals of Internal Medicine has shown that adding a simple fact box to adverts for prescription drugs considerably improves consumer awareness of the risks and benefits of the medication.  In this study, people who examined an advert with a drug fact box were more likely to choose the most efficacious drug than were participants who assessed an advert with an in-depth summary of the drug characteristics.

The FDA requires that direct-to-consumer adverts include a ‘brief summary’ of all the risks listed in the drug’s FDA-approved prescribing information. This summary can amount to more than a page of dense text, however, and although companies are supposed to use easy-to-understand language, the text can seem pretty impenetrable.  Writing of the current system, the study authors Schwartz et al. say that “the U.S. public currently lacks accessible and accurate information about prescription drug efficacy and side effects. Instead, people are exposed to billions of dollars in marketing designed to generate enthusiasm for new products, leaving them vulnerable to persuasive marketing techniques and selective presentations of information”.

Drugs fact box

Schwartz et al. assessed whether using a ‘drug facts box’ – a 1-page round-up of a drug’s benefits and side effects, with key information on the chance of various outcomes provided in a table – improved knowledge of the risks and benefits associated with a medication and helped patients make informed treatment choices.

This study was split into two randomised trials that assessed two types of fact box: one box on how a drug treats current symptoms and one on how a drug prevents the onset of symptoms.

In the symptom drug box trial, the authors tested adverts for a fake proton-pump inhibitor (PPI) – Maxtor – and an imaginary histamine-2 (H2) blocker – Amcid.  These two types of drug are used to treat symptoms of heartburn and have similar adverse effects, but clinical data show that PPIs clearly outperform H2 blockers. All 231 participants received the same ‘ad image page’ (the colorful front page) and then also received either the symptom fact box (drug box group) or a brief summary (control group).

In the prevention drug box trial, the authors used adverts for a statin – Concor – and clopidogrel – Pridclo – for prevention of future cardiovascular events.  Such events are relatively rare, so the drugs have small absolute effects and are, therefore, not appropriate for many individuals. The 219 study participants were randomly assigned to receive either adverts with a brief summary or adverts with a drug box.

In the symptom drug box trial, more participants in the drug box group than in the control group were able to accurately recount the risks of the two heartburn drugs.  In addition, the perceptions of individuals in the drug box group more accurately reflected the actual efficacy of the drugs.  When asked which drug they would prefer to take, 68% of the drug box group chose the PPI – objectively the more effective drug – compared with 31% of the control group.

Participants in the prevention drug box trial who received the drug box adverts were more likely to understand the side effects of the two drugs.  Also,  most of the patients in the drug box group were able to accurately quantify the small reduction in the risk of cardiovascular events provided by the two drugs, whereas more than half of the participants in the control group overestimated the benefits of the drugs by a factor of 10 or more.  Individuals in the drug box group were, therefore, more likely to conclude than the side effects associated with the drugs outweighed the small benefits provided.

The authors write: “Some may wonder whether we simply proved the obvious: one group was provided with the ‘right answers’, whereas the other was not. However, that is precisely the goal of the drug box—it provides the data needed to make informed decisions. Without these data, people can only guess, and their guesses are most likely based on the information that appears in the ads.”

Schwartz LM et al. (2009) Communicating Drug Benefits and Harms With a Drug Facts Box: Two Randomized Trials. Ann Intern Med Early-release article: 17 February 2009

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And while we’re talking about patient privacy…

Today Pulse reports that pharmaceutical companies are directly approaching NHS staff to try to get their grubby paws on patient-identifiable data. The story reports that “two staff members had been approached by a pharmaceutical company while at a conference in London, given access to a website and asked to upload patient-identifiable data”.

A spokesperson for Poole Hospital NHS Foundation Trust went on to say: “For some time the trust has been concerned about the lengths to which pharmaceutical companies, or companies working on their behalf, will go to seemingly bypass the research governance route and encourage staff to release person-identifiable data onto third-party databases. A number of attempts have been thwarted by the trust.” So it seems that for some time pharmaceutical companies have been trying to weasel patient information out of NHS employees.

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Hospital employees fired for posting photos of patients on MySpace

I recently wrote a post about how patient privacy can be threatened in blogs written by doctors. Now a new case illustrates another way that healthcare professionals can violate patient privacy online.

Yesterday the Associated Press reported that two hospital workers in New Mexico had been fired for taking pictures with their mobile phone cameras of patients being treated. Even worse, these pictures – “mainly close-ups of injuries being treated in the Albuquerque hospital’s emergency room over the past few months” – were posted online on MySpace. This all happened despite the fact that hospital employees were banned from taking mobile phones int patient areas.

Unbelievably, this incident doesn’t represent the first time this sort of thing has happened. In May last year the Tri-City Hospital in San Diego confirmed that medical workers in the hospital had been taking photos of patients with their mobile phones, and the Associated Press reports that there have also been similar violations in Arizona and South Dakota. Also, UCLA banned mobile phones and laptops earlier this year after a patient posted group photos of other patients on a social networking website, although I feel this instance is a slightly different issue.

This issue was picked up in the blogosphere (WSJ Health Blog, Kevin, M.D. and Scalpel or Sword to name a few) as bloggers were horrified that hospital employees could do something so stupid. Posting photos of patients online, particularly patients in an emergency room who are may well be unconscious and totally unaware that they are being photographed, is an unbelievable violation of patient privacy. Let’s hope this is the last time this sort of thing happens.

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