Anyone who has been following my blog for a while now will know that when I have my mind on something, I usually need to chew on the thoughts for a little while before writing them down and plugging them into a coherent article. The topic of today’s rant/ramble/post (hopefully an articulate one) is no different. This week, I’m chatting about an issue that has been bothering me for a long time, but has been especially on my mind since starting my Masters in Public Health and Nutrition last September. I also began to reflect on it more as I began to receive more and more direct messages (DMs, I believe we call them) on Instagram from followers asking for medical advice for various symptoms or queries they had. Needless to say (I hope!), my reply to these messages is always that I don’t give out medical advice online as its entirely unethical and (although these lines may be blurred to some) illegal in my book and in the Code of Ethics we follow as doctors in Ireland.
So what is this ‘issue’? Well, if my last sentence didn’t give you a hint, here it is – the rise in use of Dr. Google and social media as a substitute for clinical contact with healthcare professionals. This bothers me a LOT, for a number of reasons, but I’m going to try and summarise the problems I see with this into 3. I think it’s important to write about it because we know technology isn’t going away, and in fact will only become increasingly advanced and intrusive in our lives every year. I’ve heard discussions and read many an article at this stage describing how ‘tele-healthcare‘ is on the rise (which, to be fair, has many benefits for sure, so I’m not dissing tele-medicine as a concept, just to make that clear), which it is – there’s also a lot of work going on in Ireland regarding ‘eHealth‘ as a major part and drive of the way forward for our healthcare system. Again, not something I’m focusing on in this article – I spent five weeks as a final year medical student at Johns Hopkins Hospital which was entirely run on an online system, so I’ve seen the efficiency and effectiveness of eHealth firsthand. Online prescribing for in-patients, integration of hospital and community data – all of these things can and will improve healthcare, if managed appropriately and sensitively and in keeping with the relevant data protection regulations (I doubt there is anyone reading this who hasn’t heard of GDPR by now!)
What I’m talking about in this article is different, and it’s a toxic yet frustratingly pervasive issue. I’m going to share 3 points with examples to illustrate it, and I hope it will make sense to you guys and help you see why it concerns me so much as a doctor.
1. Sliding into a healthcare professional’s DMs does not replace clinical contact.
I’ll start with this one, not because it worries me the most (all 3 do equally!) but because it’s the one that I have been the most affected by. This point isn’t to call out anyone who has slid into my DMs previously asking for advice – it’s usually someone genuinely just looking for a bit of help and I do understand how easy it can seem to just ask the person whose content you trust following online. It’s like a digital extension of having a friend who is a dermatologist and asking their advice over coffee about a skin spot you have (my friend Ciara knows this drive-by question well!) or asking a friend who is a physiotherapist their ‘quick advice’ about a niggle you’ve had, or even, as I know well, being the doctor in your family who is asked ‘What do you think about this symptom I’ve had…’. I’ve had DMs asking me for dietary advice, exercise advice, weight loss advice, menstrual cycle advice, fertility advice, advice about irritable bowel syndrome, polycystic ovarian syndrome – and many more. To each person looking for personalised advice, my answer is the same, to thank the person for following my content but that I can’t give such advice for legal and ethical reasons as a doctor, and equally because it’s against my own moral values. As well as that, many of those issues need specialist medical advice (especially topics like fertility), not a few ‘tips to improve’ shared online.
As doctors, the two most important skills we learn during our medical training are history-taking and clinical examination. Meeting a patient (in person, whether in the hospital or community setting), taking a careful history of why they’ve presented to us, their symptoms, and all of their past medical, surgical, personal and family history, as well asking about as their medications if any. A clinical examination follows depending on what the patient has told us, and what our train of thought is in terms of a differential diagnosis, where we may elicit clinical signs that help us with our diagnosis. Using what we have deduced from both our history and exam, we use our brains, perhaps peer and senior support from colleagues and relevant investigations (e.g. blood tests, imaging, etc) to work out what we think is going on and causing the patient’s presentation. Following that, we form a plan of management/treatment and discuss that with our patient.
How much of that can be done online? Minimal, in my opinion. Sure, a doctor can take a history online, I won’t dispute that. But I don’t think it even comes close to being the same or as valuable as speaking to and connecting with a patient. And you certainly can’t physically examine someone via social media. Technology isn’t that crazy yet – so far, Alexa is just a virtual voice, as far as I’m aware! Plus, and most importantly, there is a whole other intangible and precious element to the doctor-patient relationship that can’t really be taught in medical school, and can only be learnt by experience. What is it? Well, it’s hard to put a name on it, but it’s the unique interaction you have with each individual patient, using communication skills, body language, compassion – a blend of all of these things. I would love to be able to put a name on it, because it’s one of the best things about being a doctor, the fact that we can meet (in person) and hopefully help every person who needs it in a unique way, meeting them where they are at. In my book, and I think you’ll agree, it’s pretty hard to achieve that connection through a digital interaction. I often think being a doctor in a way, is sort of like driving a car – you cannot and should not ever take from granted the responsibility that comes with jumping behind the wheel – the doctor equivalent being, for example, surgical tools or a prescription pad.
2. Media myths have and continue to cause real world harm to human health.
Get ready gang, I’ve leapt onto my soapbox for this one and I won’t be jumping down anytime soon. There is one particular example I’m going to share with you that I know will illustrate my point on this (vaccination), although there are also nutritional media myths that I’ve found quite worrying too (particularly around dairy and meat, but there are lots of worrying examples of specific diets promoted online as ‘cancer cures’) but I’ll use that example in my third and final point.
Let’s chat vaccinations. My Masters in Public Health and Nutrition has taught me many MANY important things thus far, but in particular, I have become increasingly aware of and alarmed by the power of the media (including social media) when used to a) spread myths about specific health issues and b) report health-related research (which generally it does poorly). The Andrew Wakefield MMR-Autism controversy for example (if you haven’t heard about this, check out this great British Medical Journal summary and critique article here) led to major reductions in the rates of uptake of the MMR (measles, mumps and rubella, all vaccine-preventable diseases) vaccine for years afterwards. Unfortunately, despite Wakefield’s claims being totally discredited and a huge amount of work by public health officials and our health sector to dispel the myths and claims about the MMR vaccine and assure people of the vaccine’s efficacy and safety over the past 2 decades, we still see anti-vaccination movements online leading to public confusion about whether to vaccinate their children. What’s even more scary is that we are now, in Ireland and other European countries, seeing the direct effect of the less than optimal vaccination uptake rates on children and adolescents, with ongoing measles outbreaks over the last year especially. More recently, in Ireland we have seen several mumps outbreaks among university students in particular. These are diseases that we can PREVENT with (as recommended by the World Health Organisation) vaccine uptake rates of 95% and above – not diseases we should be using valuable healthcare resources to investigate outbreaks of and contain spread as a result of suboptimal vaccine uptake. The pertussis and influenza vaccines are also examples I could touch on, but I’m going to stick to the MMR and HPV vaccines for this post (I want to hold your attention, so stick with me!)
Example number two. HPV. HPV stands for Human Papilloma Virus, which is the virus identified as the cause of cervical cancer. Most women will have a HPV infection at some point in their lives, usually acquired via sexual contact – but most will clear this infection. In some women it may persist (which may be more likely to occur in the presence of other cervical cancer risk factors, such as smoking) and cause abnormal cell changes in the cervix, which can over time lead to cervical cancer. So by vaccinating young girls (in first year of school in Ireland, as we want to give the vaccine before girls become sexually active) against the subtypes of HPV that can cause these cancerous cell changes, we are giving them the best shot at cervical cancer prevention. First of all, I’m going to give you this excellent website by our Irish Health Service here which has a lot of frequently asked questions about the vaccine, details on the schools vaccination programme in Ireland, and the vaccine safety and efficacy information too. In Ireland, we administer a vaccine called ‘Gardasil’ which protects against 4 sub-types of HPV – 2 that cause 70% of cervical cancer (16 and 18) and 2 that cause 90% of genital warts (6 and 11). We run a schools vaccination programme that administers the HPV vaccine to girls in first year of secondary school (2 doses in total if under 15 years old, and 3 if over 15). Giving this vaccine is what is called ‘primary prevention’ in public health lingo. We give it in first year of secondary school because, as I’ve said, its most effective if given at this age of a young woman’s life. Each year in Ireland approximately 300 women get cervical cancer, and 90 die from this disease – so given that we have such a powerful prevention strategy to reduce this numbers, why wouldn’t we use it?!
The HPV vaccine is recommended by our health service and our National Immunisation Advisory Committee, the World Health Organisation, the International Federation of Obsttrics and Gynaecology, and many more global health organisations.
Is it safe? YES.
The safety of the vaccine has been monitored consistently since it was introduced over 12 years ago – in particular, by the European Medicines Agency, the WHO Global Advisory Committee on Vaccine Safety and the US Centers for Disease Control and Prevention. If you have specific questions about the vaccine side effects, I would highly recommend having a read of this Irish health service webpage on those here, which is informative, easy to read and very clear and details the side effects that are expected based on many many vaccine studies. Unfortunately in Ireland, as we’ve seen with MMR vaccine uptake, anti-vaccination campaigners and claims about unusual vaccine side effects (which are entirely without evidence to back them up, as you’ll see from the consistent safety evaluations by the EMA, WHO and CDC) led to a major drop-off in HPV vaccine uptake. This was as drastic as from 86.9% in 2014-2015 to a record low of 50% in 2016-2017, largely due to anti-vaccination lobby groups who had a large social media platform and unfortunately spread a lot of worry and concern with misinformation. Thankfully, a major response by public health officials in Ireland to this vaccination uptake crisis to dispel myths and address parental concerns has led to improvements in vaccination uptake – for example, in 2017-2018 uptake went up to 61.7%. I would definitely recommend checking out this Lancet publication by the Irish Health Service Executive’s National Immunisation Office detailing this crisis and their response here. Clearly, there has been a LOT done to counter this issue, but also a lot more to do with the ongoing (unregulated) media presence of anti-vaccination groups.
Bottom line: We have vaccinations that save lives, and their maximum potential to do so is not being realised currently due to anti-vaccination groups having an unregulated media presence and as a result a lot of public confusion over vaccine safety. If you have concerns about vaccines either for yourself, or your child, PLEASE speak to your general practitioner/family care physician/provider to address your concerns, and allow them to answer these questions IN PERSON and from an EVIDENCE-based viewpoint. ‘Google said…’ or ‘that group on Twitter said…’ is NOT a valid argument or reason to not vaccinate, and especially not a source of information to quote and tell your friends your views too. As I said with my point about the MMR vaccine, we are seeing the direct result of sub-optimal vaccine uptake with ongoing outbreaks of measles and mumps in Ireland. Let’s do something about it, and trust our doctors and health service.
3. Unchartered digital waters are a breeding ground for unregulated health advice.
This final point flows very nicely on from my last. It’s pretty self-explanatory, but I’ll use my nutritional example of myths around dairy and meat foods to illustrate it. Hands up who watches Netflix? I do on occasion, and I’m sure many of you do too. So lots of people reading this will be familiar with the absolute explosion of Netflix documentaries about food over the last 2-3 years. Cowspiracy, What The Health (don’t get me started on that one), Forks Over Knives – there are many. They weren’t all scare-mongerers (Michael Pollan’s ‘Cooked’ series is fantastic actually), but What The Health was particularly notable for the degree to which it misinformed viewers and made absolutely outrageous claims about certain food groups. Now that I’m 6 months into my Masters and equipped with pretty decent skills to critically appraise research, it’s even more clear to me how absolutely shameful that documentary was. Making ridiculous claims like ‘dairy causes cancer’ and saying that egg and red meat consumption carried the same health risks as smoking – it baffles me that the people behind this documentary thought that cherry-picking studies and making these claims to a global impressionable audience was acceptable. But I digress – you can’t unfortunately apply your own ethical values to others.
‘What to eat’, and increasingly ‘when to eat’ can seem like one of the most confusing questions to answer – especially if you spend too much time online and scrolling social media. There are MANY ‘influencers’ out there who do NOT have qualifications to give dietary advice – and yet, they frequently share posts of their dietary anecdotes as if it were gospel (and sometimes its because there’s a cookbook to plug too). The ‘free-from’ food industry has literally exploded in size and monetary value since the ‘gluten-free’ trend took over a few years ago – and it’s not slowing down. Added to the confusion most recently is the debate around ‘sustainable eating’ and which food groups carry the greatest carbon footprint. I’ve written quite an extensive article on this topic, because it’s an area I do think needs recognition – I’ve linked that for you here. We do know that meat and dairy foods carry the greatest carbon footprint in terms of greenhouse gas emissions, that’s pretty well described by the evidence (due to the methane and nitrous oxide (powerful greenhouse gases) produced by the digestive process of ruminant animals. But, contrary to what you may see on your social media feed, this does not give justification to influencers giving unregulated advice about ‘everyone going vegan’ or confusing environmental motives around food choices with myths.
If someone wants to reduce their meat and dairy intake to eat in a more environmentally sustainable, and does so taking into account the nutritional benefits of those foods and ensuring plant-based alternatives they consume replace those lost, I don’t have an issue. But if someone goes ‘dairy-free’ because they believe it may cause cancer based on a widely discredited Netflix documentary, that’s not okay. I recently attended a ‘Nutrition for Women’s Health’ talk delivered by Associate Professor Clare Corish, which was absolutely fantastic, covering common food questions around dairy, carbohydrates, soy foods and healthy versus unhealthy fats, and it was wonderful to see the lecture theatre packed full of people listening intently and taking all the evidence-based messages on board. The reason I mention this talk is first, because it was brilliant, and second, and what I wanted to highlight to you guys, are the concerns Associate Prof Corish mentioned about women cutting out specific food groups. She discussed the worrying trend of young women cutting out dairy completely for perceived health benefits (as opposed to for personal ethical reasons around eating animal foods) without ensuring they know where to source nutrients lost as a result – for example, 98% of the Irish population consume dairy, and so it provides a large proportion of our daily calcium and iodine intake. Completely cutting out dairy may result in detrimental effects on a woman’s (or man’s, for that matter, it just seems to be a more common trend among women at the moment) bone (which we need calcium for) and thyroid (which we use iodine for) health if she (or he!) don’t know how or where to get enough replacement of those nutrients from plant-based foods. It scares me to think that we may see a rise in low bone density among young women and/or hypothyroidism as a result of (false) perceived health benefits of cutting out dairy. I’m going to link here an absolutely fantastic article by registered dietitian Maeve Hannan (she is @dieteticallyspeaking on Instagram!) who debunked in this article the ten most common myths about dairy by going through the science and examining the evidence (objectively!) for each. Finally, because I’ve gone into such detail on dairy, I’m going to leave you with the link to my Sustainable Diets article again here, which has a section on meat and the science behind the associations between red and processed meat and colorectal cancer, which was was sparked those media headlines a couple of years ago.
Bottom line: Cutting out food groups overnight because a Netflix documentary or a social media influencer or a newspaper headline raised questions in your beliefs about how you eat is NOT okay. First of all, seek professional advice (ideally in person, from a healthcare professional – a dietitian, nutritionist, or your doctor) to question what you’ve read and see if these claims are founded. If not in person (I understand that’s not gonna be feasible for everyone), then at least check out fantastic websites such as that of the Irish Nutrition and Dietetic Institute or the British Dietetic Association for really fantastic online resources. My favourite dietitians to follow on Instagram (these guys objectively discuss nutritional topics in an easy to understand way) are @dieteticallyspeaking, @orlawalshnutrition, @theguthealthdoctor and favourite nutritionists are @rhitrition, @laurathomasphd and @thenutritional_advocate. By favourites I mean that their content is fantastic and pretty much always balanced – I don’t follow them for individualised dietary advice (as I’ve said above, individualised healthcare advice should not be given through the medium of social media).
Okay. I’ll get off the soapbox now. That was a long one, and thank you for bearing with me to read it gang, it means a lot. I would love to hear your feedback on this post – leave a comment, drop me a DM on Instagram (as long as its not one for medial advice!), or catch me on Twitter/Facebook/email! You know where I am – @theirishbalance on Instagram/Twitter/Facebook!
Ciara 🙂 x