Learning neurology is a very visual and hands-on affair. Neurological assessments are complex and steeped in ritual. Tomes have been written about the best way to take a neurological history. A lot of ink has been spilt in describing great eponymous neurological signs. But nothing comes close to learning from the masters. Observation and apprenticeship have been key to transmitting neurological skills since the time of Charcot.
There is no doubt that neurological disorders are mushrooming, and the skills required to master them are becoming more intricate. But this has flamed rather than dampened the desire of learners to acquire them…by all means possible. But only the privileged can witness the artistry on display at the grand rounds of Queen’s Square; the exhibition of finesse in the teaching halls of the Pitié-Salpêtrière; or the sublime virtuosity evident on the wards of The Brigham.
What then to do in the digital age? Online videos of course. These are now playing a major, perhaps unconventional, teaching role in neurology.
The Neurology Lounge has already reviewed the changing terrain of neurology, throwing a light on the increasing role of social media, online video sites, and online databases, all competing and complementing the classroom and the clinic. Our previous posts on this subject include:
Youtube remains the clear leader when it comes to videos. Buried among the cat and dog snippets, hiding behind the crazy stunts and funny clips, and camouflaged by the ubiquitous vlogs, are many enlightening neurological stuff. And of the many neurology videos on Youtube, some have attracted more attention than others. Is there a secret? There’s only one way to find out!
Here then are the top 10 most viewed neurology videos on Youtube:
If there is any lesson here, it’s all about the simple things. No complicated syndromes, no convoluted guidelines. In some cases, no master at all! Viewers just want to see the complex simplified!
PS. To widen the variety of video sources, I have restricted each source to one video.
A few months ago, Neurochecklists set out to discover how people go about searching for neurology information. We therefore carried out an online survey of neurology information users. We asked 10 critical questions about the who, what, where, why, and how of neurology information quest.
We asked these question specifically to guide a major Neurochecklistsupgrade. This knowledge is, after all, critical for a website which has set out to be the best source of clear, concise, and comprehensive neurology information. But we needed help to know whatreally matters to people when they go foraging for neurology. What do they really want, and how do they go about satisfying their need?
The response we got was heart-warming; about 190 people answered our online questions. Below are the questions along with the insights we gained from the answers.
Who searches for neurology information?
More than 50% of our responders were consultant neurologists, and about 15% were medical consultants. Neurology trainees constituted about 7%. The range of users is however quite broad, including nurses, surgeons, medical students, and patients! See the breakdown in the pie chart below:
Insight: There are diverse neurology information seekers!
How often do we forage for neurology information?
Neurology information is in high demand, with >50% of responders seeking information at least once a day, and >80% at least once a week. Below is the breakdown:
Insight: There is a huge craving for neurology information!
Where do we go when we need neurology information?
Online websites are by far the most popular source of quick neurology information, accounting for >50% of responses. This is followed by journals which account for just over 25% of responses. Very few responders access textbooks, handbooks, downloadable apps or online videos. Below is the breakdown:
Insight: Neurology source information is now mainly online
Where are we when we most crave neurology information?
In a question which allowed multiple answers, the clinic was by far the most common setting for looking up neurology information. We however also have a strong urge for neurology on the ward, and at home! Below is the breakdown:
Insight: The need for neurology information has no boundaries
Why do we access neurology information?
The most frequent reasons responders access neurology information were to answer clinical questions and for personal study. Other reasons were to aid discussions with patients, and to look for relevant references.
Insight: the checklist approach is the best solution
What devices do we use to access neurology information?
In another multiple answer question, responders most often use their phones to access online neurology information. Laptops and desktops are also favoured, but tablets much less so.
Insight: neurology information must be device-compatible
What features do we most favour in an online neurology database?
We asked what features responders most desire in an online neurology database, and the front-runners here are accuracy and currency of information, followed by conciseness, adequacy, ease of navigation, and link to references.
Insight: Neurochecklists is on the right track
We wish to extend our thanks to everybody who took part in the survey, including the many who attempted it after the closing date! We have taken all the responses on board, and we have been working night and day to provide an enhancedNeurochecklists. Watch out for our next blog post to find out the changes we will be launching soon. Neurology seekers, watch this space!
After 5 years of data gathering and sorting, neurochecklists launches today. This is a web-based application which covers the spectrum of neurological practice. I was prompted by Atul Gawande‘s call to physicians to develop checklist-driven medicine, as I discussed in my previous blog post, What is the value of checklists in medical practice? Conceived in libraries and coffee shops, lay-bys and terminals, neurochecklists is the culmination of a vision to commit the whole of neurology to checklists.
What exactly is neurochecklists?
Neurochecklists is a comprehensive and easy-to-search database consisting of thousands of checklists. It is conceived as a mobile resource to aid all cadres of medical professionals. It has 18 categories, each consisting of chapters divided into topics. All checklists are brief and divided into sub-checklists as required. Users may explore topics either through the search boxes available on all webpages, or via the Index. Each checklist is fully referenced, and all articles are hyperlinked to theirPubMed abstracts, and books to their Amazon.com page.
How can neurochecklists help neurological practice?
1. By quickly checking up a topic in the clinic or on a ward round
2. By helping the preparation of presentations or teachings
3. By making reading for examinationsand researchinga topic easier
4. By complementing the search for relevant and up-to-date references
5. Facilitating neurology discussions with patients
What exactly does neurochecklists contain?
Neurochecklists is extensive, covering all the core neurological subspecialties:
Disorders of Cranial Nerves
Disorders of Cognition
Disorders of Consciousness
Neurological Infections and Toxicity
Non-Parkinsonian Movement Disorders
Anterior Horn Cell Disorders
Peripheral Nerve and Radicular Disorders
Neuromuscular Junction and Muscle Diseases
Nervous System Tumours
Spinal Cord Disorders
Autoimmune and Metabolic Disorders
Neurochecklists also addresses the range of allied neurological specialities such as:
These diseases are all reviewed from diverse perspectives:
How reliable are neurochecklists?
In developing neurochecklists, I took into consideration the challenges of such a project as discussed in my previous blog, What are the obstacles to creating reliable neurology checklists?Neurochecklists has also gone through a beta-testing stage, and the feedback has influenced the final version. This is however the beginning of the journey to maintain and improve the database. This on-going challenge will require feedback from users which will be invaluable in advancing the app to higher levels.
What will it cost to access neurochecklists?
Neurochecklists comes with two levels of access. There is a free version which entitles users to 15 free searches a month. There is therefore no excuse not to have a neurochecklists account! To get the maximum benefit of neurochecklists, a premium account is required, and this comes at the equivalent cost of a coffee and cake a month, and even less with an annual subscription.
The reason for paid subscriptions is to help offset the heavy financial cost of app development and future improvement and enhancement plans. One such plan is to develop android and ios platforms. I am however open to suggestions to make this a completely free resource.
Who helped to develop neurochecklists?
Neurochecklists is the result of a collaborative effort in many ways. My wife Zainab has been invaluable in encouraging and supporting me throughout the journey. To Jafaru Dori for invaluable guidance, support and connections. To the bright young men at Studio 14, Stephen, Tobi and Timi for their great imagination and passion for the project. My gratitude to my work colleagues and the hundreds of social media friends who share so much knowledge, much of which has found its way into neurochecklists. And finally my apologies to Aminah, Safiyyah, Ja’far, and Maryam for not having their dad’s full attention for so long. Hopefully it’s been worth the while.
How to get to neurochecklists?
If you have so far resisted the dozen opportunities to click on neurochecklists, go on now and click on the image or text below to check it out! Don’t forget to leave your feedback.
We all know how important checklists are in our day-to-day lives. We cannot survive the day without a to-do list reminding us of the tasks that make our lives go round. It is clearly not an exaggeration to say we live by the checklist.
But checklists perform far more important roles than reminding us to buy the milk, or to pick junior after football practice. Checklists are central to the maintenance of safe practice in many industries. Checklists are best celebrated in aviation where they are indispensable to airlinesafety.
The Checklist Manifesto
Despite their recognised value, checklists are not applied widely enough in medicine. One person who has passionately addressed this shortcoming is Atul Gawande in his highly acclaimed book, The Checklist Manifesto. In this book, the author explored the positive impact of checklists based on his own research into surgical safety. His view of checklists is quite instructive, for example when he says:
Checklists translate knowledge into a simple, usable, and systematic form
Checklists are quick and simple tools aimed to buttress the skills of expert professionals.
Good checklists could become as important for doctors and nurses as good stethoscopes
The WHO surgical safety checklist
Gawande’s major contribution to patient safety is the development of the acclaimed WHO Surgical Safety Checklist. This simple tool is now a key component of surgical operating procedures globally.
Gawande’s own experience of using the checklist shows how important this tool is. He says:
I have yet to get through a week in surgery without the checklist’s leading us to catch something we would have missed
With the checklist in place, we have caught unrecognized drug allergies, equipment problems, confusion about medications, mistakes on labels for biopsy specimens
We have made better plans and been better prepared for patients
Beyond the operating room
Atul Gawande made the important observation that checklists have potential applications “beyond the operating room“. He said “…there are hundreds, perhaps thousands, of things doctors do that are as dangerous and prone to error as surgery“. He gave several examples of these such as the evaluation of headache, chest pain, lung nodules and breast lumps. He also pointed to the treatment of heart attacks, strokes, drug overdoses, pneumonias, kidney failures, seizures, and headache.
Addressing Gawande’s challenge
Gawande appreciates that all medical activities involve risk, uncertainty, and complexity. His simple recommendation is to commit them all to checklists. He urges the medical fraternity to seize the opportunity and do this. Apart from Anaesthesia which is probably ahead of the curve, there are only few medical checklists such as:
Gawande’s vision of a checklist-led approach to medicine, encompassing the spectrum of clinical practice, is indeed challenging. As a neurologist who is keen on patient safety, I was intrigued by this perspective, and I wondered if it was possible to commit the whole of neurology to checklists. In taking up the challenge, I imagined a neurology checklist application that is practical, comprehensive, easy to search, evidence-based, and up-to-date. After five years of collecting and distilling articles, reviews and guidelines, and after months of engagement with software developers, the dream is becoming reality. In my next blog post I will describe the outcome of the journey and discuss how simple checklists may unlock excellent neurological practice.
It is no exaggeration to say our lives revolve around apps. These handy devices bring knowledge to our fingertips at the tap of the finger, or the click of a mouse . They promise easy access to a world of information, often digested to size. Some offer tools to simplify our practice. Neurology is, or should be, no exception.
So what are the tools out there making neurological practice easier and handier? What are these practical shortcuts making clinical work more efficient? I browsed the web to and found some useful neurology applications and have grouped them as below.
Clinical management apps
StrokePad™is an electronic patient record for stroke care
FAST Test to evaluate stroke risk using the FAST mnemonic
5-minute Neurology Consult. The blurb on google play says Neurology Consult ‘provides instant access to comprehensive, clinically-oriented, must-have information on all disorders of the nervous system’.
This is a follow up on my post, what is the state of neurology on the blogosphere. Social media is growing and pulling in professionals at a breath-taking pace. This phenomenon, which many have previously turned there noses up at, is now becoming an indispensable part of our personal and professional lives.
Social networks are important, and in today’s world, overwhelmingly digital. The importance of social networks is stressed in some books such as Linked and Connected. So what are the important social networks relevant to neurologists?
The social network medium most professionals prefer is LinkedIn. It is probably the extreme lone-wolf who could afford not to have a presence on LinkedIn today. There are so many neurologists on LinkedIn, and it is a good medium to establish and broaden professional connections. These connections are almost impossible otherwise. There are quite a few valuable professional Neurology LinkedIn groups such as:
Twitter is a multipurpose and open social medium which gives professionals an invaluable platform to do practically whatever they like. It is however very rapid fire, relying on quick and short messages, limited to 140 characters. These messages, called tweets, may be educative or inspirational, amusing or controversial. Anyone may follow you, but you may also block nuisance followers. You may unfollow anyone you wish, and sometimes this happens at an alarming pace. Many professionals use Twitter to circulate interesting and breaking research work or articles they come across. It is a veritable way of keeping abreast of developments across your patch, but you have to check your twitter feed frequently; unfortunately old tweets tend to fade away. Here is a list of active neurology Twitter accounts.
This is probably the most popular social network platform, perhaps considered less academically rigorous. Many Facebook accounts combine social and professional activities, but you may decide to make parts of your account private. There are some interesting Neurology Groups on Facebook worth following such as
ReseacrhGate is a social medium entirely focussed on research output. It links professionals and researchers to others with similar interests. You could keep track of what your collaborators are doing (or up to), and you may follow the research output in your areas of interest. ResearchGate also has an interactive service where you could ask the experts. Indispensable.
Pinterest may appear, at first look, to be less relevant for academic and professional activities. It is however reported, along with Instagram, to be the fastest growing social network. Businesses are reporting its value, and I suspect academics and professionals may soon be. It is a graphic network, as demonstrated by myPinterest page. Posts are called ‘pins‘, and these are place on ‘boards‘. Take a look for example at my Neurology Board on Pinterest.
This is another network focused around pictures. You may want to scoff at Instagram but you would be surprised at how many professionals are posting very interesting and enlightening images. Take a look for example at these posts by neuroradiology. I am very poor both behind and in front of the lens, and this is reflected byMy Instagram page.
This is probably the network your children (and grandchildren?) find most fascinating. But don’t run away yet, there are serious stuff here. You wouldn’t believe, for example, that neuroscience is flourishing on Tumblr. This network allows you to play with unlimited space for photos and text. You may find yourself going there more often than you anticipated, but don’t tell the children you are on it!
Have I missed out an important platform? Please leave a comment.
Neurology is as much a verbal, as it is a visual, specialty. Whilst the history is the bedrock of the neurological diagnosis, some conditions are only diagnosed by observation. Epilepsy and movement disorders are classical examples. Neurologists are therefore trained to observe the subtlenuances that distinguish between many of the diseases they see.
Neurology is however a very broad specialty, and it is unlikely that any neurologist or medical student would have personal experience of the vast number of neurological conditions. For this reason the video is an important contributor to neurological experience and expertise. The video is also a great educational resource for teaching the fairly complex neurological examination, no easy feat.
Where then can we get the best neurological videos? Here is a selection.
YouTube-based video channels
Youtube is the veritable ‘go-to’ site for most videos. Many patients post their own interesting video clips, but there is no guarantee that these clips reflect the diseases attributed to them. YouTube however has a selection of creditable video channels and here are some credible ones.
JAMA Neurology Channel. This is the video channel of the Journal of the American Medical Association. It is an excellent collection of neurological examination videos, very good for basic neurological skills.
Brain Journal Channel. This is the video site of Brain, a foremost neurology journal. It currently has just over 80 subscribers and has its focus on cutting-edge neuroscience.
AAN Channel. This is the video site of the American Academy of Neurology (AAN). This has more than 2,000 subscribers and is fairly regularly updated. It however doesn’t have a lot of clinical material for learning.
Neurology-specific video sites
Clinical Neurology Videos. This site has an extensive library of very interesting educational videos. It covers the wide spectrum of neurology and worth bookmarking.
Utah Medical School Neurology Videos. This large selection of neurology educational videos focuses on the neurological examination. It shows a lot of abnormal cases to augment learning.
The Neuroophthalmology Virtual Education Library (NOVEL). This is a wide collection of educational and experiential neuroophthalmology videos from the Neuroophthalmology Society of North America. It has several sub-collections by different specialists, and it’s a very useful guide to a complex territory.
This is a follow-up to my previous blog post, So what is remarkable about neurology anyway? That post reviewed the challenging tasks neurologists face everyday. How do they go about it? How do they evaluate their patients with suspected neurological disorders?
For the uninitiated, the process of the neurological assessment must seem like an outlandish ritual. Unlike cardiologists who approach patients with the familiar stethoscope, neurologists come armed to the hilt with an arsenal of threatening equipment. Patients are often bewildered, and occasionally irritated, with the neurological exam. Admitted, they sometimes, they sometimes emerge from the assessment feeling battered and bruised-all for a good cause of course!
So what are these bizarre deeds that marks the neurological consultation?
1. Neurologists welcome you with an overly firm handshake
The handshake is a valuable neurological tool. It tells the neurologist right from the beginning if there is any weakness or if there is a form of muscle stiffness called myotonia. Therefore avoid the neurologist’s handshake if you suffer with arthritis or other painful hand conditions.
2. Neurologists make you do the catwalk
The way you walk, the gait, may show the neurologist a variety of clues or signs. There are a variety of abnormal gaits that often point to a diagnosis even before the consultation actually begins. Examples include the shuffling gait in Parkinson’s disease, the hemiparetic gait in Stroke, and the waddling gait in diseases that give rise to hip girdle weakness. More embarrassing for some patients is that the neurologist may actually ask them to do a catwalk, all for the sake of making a diagnosis you must understand!
Other bizarre associated tests are walking an imaginary tightrope, standing on one leg, standing on tip toes and then on the heels, and marching in one spot with eyes shut
3. Neurologists stare intently at you
The face often give the neurologist the clue to many diagnoses. Conditions such as Bell’s palsy and Stroke are evident from the face as are Parkinson’s disease, myotonic dystrophy and facio-scapulo-humeral muscular dystrophy (FSHD). There’s no need to blush therefore when the intent gaze seems to go on endlessly.
4. Neurologists come up very close- to peer into your soul
If the eyes are the windows to the soul, then neurologists are second only to ophthalmologists in recognising this nebulous entity. The back of the eye, or retina, holds a variety of valuable clues for many neurological diseases. The neurologist typically looks for signs of increased pressure in the head and this may occur with brain tumours, meningitis, encephalitis, This may also occur without any obvious cause in a condition called idiopathic intracranial hypertension (IIH). Other eye signssuch as cataracts and pigmented retina seen with disorders for example mitochondrial diseases.
To peer into the soul, the neurologist may come very uncomfortably close, (hoping the aftershave isn’t too strong and that the morning deodorant has lasted till then). Don’t hold your breath however, as this gazing into the soul may take longer than you anticipate.
5. Neurologists ask you to roll your eyes-in all sorts of directions
Abnormal eye movements are key pointers to many neurological disorders. There are six muscles that move each eyeball, and these are under the control of three pairs of cranial nerves-the oculomotor, the trochlear, and the abducens nerves. These nerves in turn are coordinated by complex nerve cell bodies or nuclei in the brain stem.The eyelids and pupils are also muscles under control of nerves.
These cranial nuclei coordinate a symphony of unparalleled and unimaginable complexity. This allows us to focus on moving objects without any hinderance. Things may go wrong with this symphony, and this typically results in double vision (diplopia) and droopy eyelids (ptosis). Diseases that cause these symptoms include brain aneurysms,myasthenia gravis (MG), and brainstem stroke. Some diseases may cause the eyeballs to move in uncontrollable and chaotic ways called nystagmus, oscillopsia, and opsoclonus(neurologists love these names!)
Don’t be shocked therefore when your neurologist asks you to look up, look down, look to the right and left; to follow this or the other hand; to look at this fist then at these fingers…. It’s all a helpful game-honest!
6. Neurologists ask you to pretend to brush your teeth
Your neurologist may request you to brush your teeth or hair with an imaginary brush, or ask you to do victory sign or the thumbs-up sign (never thumbs-down mind you). Almost verging on the comedic, this is a serious test because these simple tasks are impaired in many diseases. The difficulty in performing tasks one has previously been proficient at is called dyspraxia, or apraxia if the ability is completely lost. Without any weakness or numbness, people with dyspraxia are unable to use common tools and equipment, reporting that they have no idea how to manipulate them. This could be seen in some forms of stroke and some dementias. Do decline however if she asks you to mimic the great mime Marcel Marceau.
7. Neurologists ask you to wiggle your tongue and poke it out
The tongue is a very important muscle and holds countless clues for the neurologist. It is innervated by the last of the 12 cranial nerves, the hypoglossal nerve. which may be paralysed by a very localised stroke and this is often in the context of a condition called cervical artery dissection. This is a tear in one of the big arteries in the neck which take blood to the brain. The tear may arise from trivial neck movements and manipulations such as look up for a long time or staying too long on the hairdressers couch. A clot then forms at the site of the tear, and this then migrates to block a smaller blood vessel supplying the brainstem where the hypoglossal nerve sets off from…phew! Anyway, when this kind of stroke occurs, the tongue deviates to the the weaker side when it is poked out.
The more general weakness of the tongue is seen in conditions such as motor neurone disease (MND),in which the tongue also quivers at rest-something neurologists call fasciculations. The cheeky neurologist (pun intended) will ask you to push against her finger through your cheek to test its full strength.
Another problem that may affect the tongue is myotonia, a condition in which he tongue and other muscles are stiff and relax very slowly after they are activated. To test this, your neurologist may actually tap on your tongue, and then watches in fascination as it stiffens and then relaxes very slowly. Strong but slow moving tongues may be seen in Parkinson’s disease (PD). So, when next your neurologist says ‘open up’, he really means business.
8. Neurologists flex their muscles against yours
OK, she will not literally wrestle you to the ground but it may appear so at times. Pushing against your head, pressing down against your elbows, leaning hard against your leg-she will do everything to show she is stronger than you. Only if she fails will she score your power as grade 5/5-the best you can get. If you do not score full marks however you place the neurologist in a bit of a quagmire; a score between 0-5 is not always easy to allocate, and the obsessive neurologist may get in a bind and may give you marks such as 3+ or 4-. Just for fun let her win, and see her consternation!
9. Neurologists hit you with a hammer-in all sorts of places
The reflex hammer is perhaps the most well-recognised tool of the neurologist. These hammers come in all shapes and sizes, and some are really quite scary. People expect to have their knees tapped and look forward to what they have seen many times on TV-the leg kicking out. Most patients find this amusing. They are however often surprised when the neurologist proceeds to use the hammer on their jaw, elbow, wrist and ankles. The then often bristle at having the soles of their feet stroked by the end of the hammer’s handle, a sharp uncomfortable end it is. All the hammer does is to stretch the tendons of muscles, and this elicits a reflex that causes the muscle to contract or tighten up. This response may be exaggerated (hypereflexia) if there is any problem in the central nervous system. Conversely the reflex response may be diminished (hyporeflexia) with problems of the peripheral nervous system. Stroking the foot is called the Babinski response and gives a similar form of information to the neurologist. But beware the neurologist who then proceeds to stroke the side of your foot or squeeze your shins, all in an effort to get the same information-it is really an unnecessary and uncomfortable duplication of tests.
10. Neurologists prick and prod you with a sharp pin
Now this must take the cake, and quite rightly often comes at the end of the neurological examination. As threatening as this tests appears, this is probably the neurologist at his most acute. Using a sterile pin, the neurologist asks you to respond ‘yes’ if the sensation you perceive is sharp, and ‘no’ if it is dull. He then carefully proceeds to map out areas of reduced sensation or feeling, frowning as he struggles to keep track of your responses in his mind. He tries to establish if you have a glove and stocking pattern of sensory loss seen in peripheral neuropathy (nerve end damage). It may also be a dermatomal pattern seen with radiculopathy (trapped nerve in the spine). Unfortunately for the neurologist however many patients do not understand the rules of the game and give all sorts of unimaginable responses; not surprising when one is under the threat of a sharp pointy object!
These are but a few of the bizarre doings of neurologists. Seeing a neurologist soon? Be prepared-you have been warned!
PS. Images used in this blog post are for illustration purposes only and do not necessary depict the actual equipment used by neurologists. The examination steps described are however a good reflection of actual neurological practice.
The armoury of the neurologist is traditionally a cocktail of tablets and injections. The neurosurgeons and neuroradiologists seem to have all the fancy gadgets. This may however be changing with techniques that are gradually creeping into neurological practice. One such technique is transcranial magnetic stimulation (TMS). This is a non-invasive method of stimulating specific parts of the brainusing a magnetic field generator or coil.
The classical neurological application of TMS is in the treatment and prevention of migraine. The role of TMS in migraine has been fairly well-studied although the impact on symptoms is modest. There is however enough evidence to convince the National Institute of Health and Care Excellence to issue NICE guidelines on TMS. These, as expected, prescribed hope and caution in equal measure.
What of TMS as a cognitive enhancer? I came across the report that TMS may boost memory in Gizmag. OK it’s not a neurology journal but it made a more exciting headline than the original study published in Science under the elusive title targeted enhancement of cortical-hippocampal brain networks and associative memory. In simple language, TMS may enhance the neural networks in the hippocampus, the brains memory hub. Whilst the study was carried out in people with normal memory, there are implications for cognitive disorders such as Alzheimer’s disease if the potential and promise of TMS are realised.
A further surprising application of TMS, potential of course, is in dyslexia. Thisis an emerging field, still under investigation, but imagine the potential this will unleash! There is a helpful review articlein Neuroimmunology and Neuroinflammation whichdiscusses the role of rapid rate TMS in the treatment of dyslexia.
We’re not quite there yet but there is hope for the neurological arsenal; who knows, we may soon dispense with all these difficult to swallow pills and cumbersome to deliver injections!