Doctors should be advocating against patients' digital exclusion, not scare-mongering.

This post in an edited version of my comment on KevinMD's post on "Patients using internet health information without physician guidance".
...........................
I’m a doctor. I’m a GP (family doctor) in Wales, UK and I teach medical students. I work in a deprived area and I wish that many more of my patients, rather than less, accessed information that could help them be more healthy. But many of my patients do not have easy access to the internet. This impacts on their health in many ways. One that is less often considered is that digital exclusion leads to reduced income.

Recently there was a post on StoryTellERdoc about “Grim Google”. This related the story of a young, healthy man who presented in ER with bright, red rectal bleeding convinced he had bowel carcinoma because he had googled his symptoms and saw that this was a possibility. The story itself and most of the comments are quite scathing. But is this the appropriate response to this episode?

In the UK we know that despite universal access to healthcare we still have differences in cancer survival rates between areas, with patients in well-off areas living longer. This may partly be due to delay in diagnosis.

With regards to late-stage diagnosis of colorectal cancer, research in 1996 in the US showed that patients living in areas of low socio-economic status (SES) were significantly more likely to be diagnosed at a late stage compared to those living in areas of high SES. You may think that times have changed, but more recent research in Denmark- covering 1996-2004- shows that older, wealthier patients, and younger more highly educated patients are less likely to be diagnosed with rectal cancer at a late stage.

So a simple story that seems to illustrate the fallacy of patients trying to diagnose themselves online, may instead represent the awareness and health behaviours which mean that those with the know-how feel empowered to seek care for what could be life-threatening symptoms.

We should be encouraging more of our patients to access health information, especially those who will find access harder. In fact we should be advocating against digital exclusion because its influence as a cause of health inequalities may increase in coming years.

When are Influential Blog Posts published? And what makes one anyway?

I was really surprised when I noticed last month that Sarah Stewart had nominated me for an Edublog Award for Most Influential Blog Post. Actually, I was more than surprised I was shocked! The post in question was written a few weeks after I broke my wrist and was in response to an online BBC news article, with the title "Tech Addiction 'Harms Learning'". You can read the blog post here. It is about poor research and poor journalism. I'm not so sure how influential the article was, as none of the authors, the universities involved, or the publishers responded to my emails seeking clarification on the research.
I discovered later that the BBC were not the only people to publish the story. Most of the main UK newspapers had also picked up on it. So as google-sidewiki appeared at the same time I went around leaving links to my blog post anywhere that I could not leave a comment directly.
Paul Bradshaw did manage to get a response from the BBC after he picked the story up on his blog. Well done Paul! But not such a great response from the editor.

I am not so sure that the blog really was influential, or how anyone judges what an influential blog post is. But I am very happy that Sarah nominated me, and that the Edublog Awards team agreed it should be shortlisted.

Still, this post starts with a chart. There are 30 blog posts short listed in the Most Influential Blog Post category and I noticed that several of them, like mine seemed to be posted in the latter half of the year. So, why is September such a good month for blogs? Are we all well rested after the summer and keen to get back to blogging?  Or are memories just short, and when nominating posts we tend to remember best what we have read most recently?

What do you think?

Edublog awards 2009

My nominations for the Edublog awards 2009 are:

Best individual blog : Science of the Invisible
Best new blog : Dundee Chest
Best teacher blog : Dundee Chest 
Best librarian / library blog: Laika's MedLibLog
Best educational use of a social networking service ELESIG Ning

I'm sorry that I am not writing why I am nominating these (because it is later!) but if you have a look, it will be self-evident! A special mention has to go to Dundee Chest which is an outstanding example of going beyond the walls of the VLE to connect with medical students and the world.

UPDATE: I checked yesterday to see if my nominations had made the final list. It looked like they hadn't. And then I realised that I hadn't followed correct procedure by emailing in the nomination as well as just linking. Sorry to the great people I nominated. Next year!

What happens when you invite students to collaborate on a google doc....

Confused Sign
Originally uploaded by kudaker

..... and you use their university email address?

I've had a gmail account for years. I've used google documents with others for years. I've presumed that when I sent invites to universith colleagues to access a timetable in a google doc spreadsheet and fill in their availability etc, that this was quite an easy task to respond to. Although I had noticed that few people tended to actually add anything to the spreadsheet and emailed me back instead.

A few weeks ago, I invited the 7 students who I am working with on an audit project over the next year to collaborate on google documents. I used their university emails. Some of them could access the initial brainstorming document but they seemed to be denied access to to edit. Others couldn't even see the document. And a few 'asked permission' to edit, which I agreed to, although it seemed to be to the same email address which already had permission to edit! I was confused. They were confused.

So I decided to try it out for myself. I gave access to myself through my Cardiff Uni address to see how the process worked. This is what happened by way of my explanation to students:
"1. I received an email with a link which showed me the document and asked me to sign in with a google acount.
2. I didn't have a google account for Cardiff Uni address so I had to click to set one up.
3. I entered in Cardiff Uni email address and selected a password.
4. After a few minutes I received an email asking me to confirm that I had set up an account. When I clicked on this/logged in and clicked on docs, it looked as if the account was completely empty. There were no documents there.
5. I went back to the email with the link to the document. I clicked it and this time instead of being brought through to see the document I was told that I have been invited to share a document and I could click to accept or decline.
6. I accepted and was then able to go in and edit the document and invite others, and send all of you a mesage!
So if you are having trouble could you please follow these steps."

What have I learned? 1. If you invite someone to collaborate on a document and they don't already have a google account in that email address they might find the process more difficult that you think. It might be a good idea to instruct them to start by creating the google account.

2. I am so familiar with google accounts and documents that I assumed the process would be more striaghtforward to others than it was.

So, now for the question. What has been your experience of collaborating with students, or another group, who are unfamiliar with gdocs? What tips do you have?

Thanks!

Medical mistake

Medical mistake
Originally uploaded by Lobke van Aar

What does this image mean to you?

Why I think I am a patient and not a consumer.

In August I was having a great time at the Greenman festival in South Wales when I slipped and fell backwards when dancing. I broke my radius (and my ulnar styloid process). The fracture needed internal fixation with k wires and I had to spend two nights in hospital.

The next day after discharge my husband and I returned briefly to the festival... well, we had to pack up the tent! In the picture above I am sitting in a near empty comedy tent in between acts. This was my first few hours back in the real world. It was a Sunday evening and I had to let my doctor colleagues know that I would not be coming in to the practice. I was figuring out how I would cope with not being able to drive for several weeks. Soon after I went on holiday to Co. Kerry and watched on as the rest of my family set off for a day hike up Ireland's highest mountain.

My wrist got more painful and my next hospital check showed that the wires were pressing on my skin. Moving my thumb became very painful and I worried that I had ruptured my extensor pollicis longis tendon (a rare complication of Colles fracture) and was glad to be reassured that I hadn't. I googled to see if I could find an explanation for the pain in academic literature, or in the blogs and forums of others who had had a fracture like mine. But I didn't find anything. One night the pain in my arm woke me from sleep and I lay for a while half-crying before I remembered that the solution was to take more painkillers.

I wondered if I should return to the clinic early but I knew that I had been told that the wires couldn't really be removed before four weeks so I just had to wait it out. Two weeks after that the cast was removed and I could start exercising to conquer the stiffness that immobilisation had produced. I am still under the care of some excellent hand therapists. Tomorrow morning we will document how successful I have been in getting back to normal.

Whilst my arm was in the cast I did not see patients. I worked in the university but I felt too much of a patient myself to act as a doctor. But what do I mean by patient? I hadn't really thought about the term too much myself until I started seeing people use it in a way that I didn't recognise.

Last week the E-patients Connections 2009 (#epatcon) conference took place. Although it used the word e-patient in the title, the strapline made clear that this was about how to "reach, engage, educate today's digital health consumers". Consumers not patients. There were patients speaking there. ePatient Dave talked about how companies wanting to connect with patients should be authentic. Kerri Sparling (from Sixuntilme- a fantastic blog about her experiences of living with diabetes) wrote "It's a strange dance, watching people who are living with different health conditions in the same room as marketing teams and pharma companies and people who might view us as "consumers.""

The day after #epatcon I lamented that the only consideration of epatients at the conference had been as a consumers, and that perhaps there was no-one to fund a conference to look at the "real experience of patients". Jonathan Richman replied "I don't get it. What's the diff between 'consumers' & 'real patients'. They're the same ppl, just a diff word."

So is the word important? I have been recommending a book by a Dutch philosopher Annemarie Mol, " The Logic of Care: Health and the Problem of Patient Choice" in the past few months. Some of it is available here on Google books if you want to look before you buy (and you can read a great post by Ken Bottles on his thoughts about this book here). She describes how the response to the medical paternalism was an undue focus on patient choice as part of a consumerist model of healthcare. She is not opposed to patient choice and neither am I when it is appropriate but it is not sensible for it to be the focus of all interactions in health. It also implies that there may be a choice when there is not. Mol's study is of patients and professionals working with diabetes and some of her points resonate with another recent post by Kerri on Sixuntilme. Kerri talks about the guilt that is inflicted on those with Type 1 diabetes when they are made to feel that any deterioration in their illness is due to bad choices that they have made, and not to the disease itself. As the prologue of Mol's book states, she concludes that "good care is not a matter of making well-argued individual choices but is something that grows out of collaborative and continuing attempts to attune knowledge and technologies to diseased bodies and complex lives". Diseased bodies and complex lives.

So if consumer is not a good word to describe the experience of someone living and dealing day to day with a disease or disability, is patient any better? Patient as an adjective is defined as "bearing or enduring pain, difficulty, provocation or annoyance with calmness. It is only perhaps the "with calmness" part which is not appropriate. I often felt not very calm as a patient for a number of reasons. But this definition captures more of the root of the word "to endure" than does the most common definition of the noun "one who receives medical care, attention or treatment". When patients go online today to tell their story they don't just talk about their experiences of healthcare. That is just one part of dealing with an illness. There is another whole world outside of the hospital, doctor's clinic and medicine cabinet that must be negotiated. And that is what epatients tell us about. It is what I wanted to learn about when I searched for the stories of others who had endured a Colles fracture like me.

Some think that other terms such as survivor are more appropriate. I feel that I endured my wrist fracture rather than survived it, and I feel the same about other experiences of patienthood which I will not share here. Epatients tell us about how to endure and survive illness, how to collaborate with the professionals who care for us, and how to actively participate. The don't tell us about how to consume.

How do you feel about being a patient? Do the words matter at all?

Information Literacy Teaching- Sabotage!

Today in a tutorial I met one of the students I spoke to last summer when doing the first year portfolio reviews. I mentioned that I had blogged about how he and other students used social media, including YouTube and Wikipedia.

He then told me a story about a teaching session they had on information literacy. They had been asked to compare an article on Wikipedia with a review paper on the same topic from an academic journal. The session aimed to show the inaccuracies of Wikipedia and how it could not be trusted. But this student sabotaged the exercise. He demonstrated that the essential quality of Wikipedia is that it can be edited. Before most students had got round to the piece of work, he went into the Wikipedia article and improved its quality by updating the content and referencing the article!

He says that the organisers were not too happy, but I'm sure they were. He had demonstrated:

• Wikipedia is always changing
• It can and often is a good source of information if we all contribute
• Medical students CAN be Wikipedia editors.

Well done!

The BBC responds.

A week had gone by and there was no response from BBC Education News to my email informing them of my blog post "Tech addiction 'harms learning' .....really??? $24.99 and I am no wiser". I probably would have left it at that.

The post was about an alarmingly titled BBC online news story on a study set in an English secondary school, that could only be accessed by spending $24.99. I did buy it and I used this blog to inform others who were interested but didn't purchase it. My finding was that this was a piece of poor research, done by people without backgrounds in education, and presented in a way that suggested that any peer-review process it had been near was 'light touch' in approach. In short, this Sigel Press "Special Report" didn't live up to the publisher's claim that it would contain "groundbreaking information", be "written by global experts", and be an "indispensible resource[s] to keep you up to speed in your field." For the record, my field is not secondary school education. I am a doctor and a university teacher and researcher. I maintain this blog as a way of connecting with others in the wider education community. Several of my past posts have criticised the methodology of peer-reviewed research on the use of new media in medicine; research which has been more or less reported in a positive way. I make it clear on this blog that I don't support the use of technology "for the sake of it", to the extent that I have on occasion gained the moniker "web 2.0 skeptic". And if there was evidence that the use of the internet or other tech really did harm learning, I would want to know about it. I'm not a push-over.



I emailed BBC Education News because I thought that anyone who had the report in their hands would have reached the same conclusions as me. I emailed Cranfield University PR department as well, and they thanked me and said they would pass my comments to the authors immediately. I didn't really expect to get any responses.



But Paul Bradshaw wasn't happy. He is a senior lecturer in journalism at Birmingham City University. He had emailed the BBC Education department as well and today he started chasing for a response. On the off chance I emailed the BBC again and 30 minutes later there was a reply to the email sent a week earlier. This is from Gary Eason, the BBC News website education editor:

"Hi Anne Marie
Thank you for your thoughts. The author of the article did have the whole report in front of her and interviewed one of the authors. I do not agree that our headline is "sensationalist".
best wishes
GE"

OK, we can agree to disagree I suppose. But then I saw Paul's blog post about the matter. His interaction with Mr. Eason was considerably longer and contains the following quote:

"It seems to me the results don’t fit her world view so she sets about rubbishing them. Is she seriously arguing that ‘cut-and-paste plagiarism’ is not a problem?”

Spot the logical fallacies. This study was not good science and should not have been reported by the BBC. My worldview has nothing to do with it and is simply a red herring. In any case as I have pointed out above, I am not dogmatic about the place of technology in education. I look for evidence to inform me about what we should be doing.

Next , we have the straw-man attempt to rubbish my blog post. I made no comment at all on whether plagiarism is a problem. All of us working in education know that this can be an issue if assessments are designed badly. But my argument was that this research told us nothing about the relationship between learning and 'addiction to technology'. It possibly could have done as the researchers had data which could have been analysed to tell us something about this. But they didn't. Yes, it was a small study with a dubious response rate but they failed to make the best of the data they had.

Tom Morris comments on Paul Bradshaw's blog that this is a "perfect example of a glaring editorial problem". I think I agree. What do you think?

Email to BBC News Education Re: Tech Addiction "Harms Learning"

Dear BBC

I was disappointed when I read this article as I
could immediately see that the research was likely not to be of good quality.
But I was more concerned that you had managed to construct a sensationalist
title to go along with it. A cross-sectional study could never establish the
kind of causative relationship that your title infers.

I paid $24.99 to download the full report and my suspicions of poor
standards in research were supported. Did the author of this article actually
read the report or simply base their story on a press release from Cranfield
University?

Since this report is not freely available to the public, I think that the
BBC, a publicly funded body, has an even greater onus to ensue high
quality reporting of such 'research'.

Here is my blog
response.

Yours faithfully,

Anne Marie Cunningham

.......................................................

So how do we go about starting a campaign for decent science journalism on the BBC?

Tech addiction 'harms learning' .....really??? $24.99 and I am no wiser

EDIT 11/12/09 This post has been nominated for an Edublog Award for "Most Influential Blog Post" You can vote here. Thank you to Sarah Stewart for her nomination.

Last night, I started noticing tweets about this BBC News Education story in my twitter stream. Researchers at Cranfield University had published a report "Techno Addicts: Young Person Addiction to Technology" about a study they had conducted where 267 secondary school pupils completed a written questionnaire about their mobile phone and internet use. Included in the BBC story is the statistic that 63% of respondents 'felt addicted' to the internet and 53% 'felt addicted' to their mobile phoneThe BBC headline ("Tech addiction 'harms learning'") suggests that the researchers have established a relationship between this feeling of addiction and poor learning. In fact, the headline suggests a causal relationship which a cross-sectional study could not establish, but the body of the text doesn't really support any relationship between addiction and learning.

I wanted to know more so I set out to find and read the report. Googling the full title pulled up a link to the Sigel Press site where the report could be purchased for $24.99. And a press release from Cranfield university confirmed that this was the only way to get my hands on it. It also was clear that none of the authors had an education background. The 2 main authors, Nadia and Andrew Kakabadse, have a blog showcasing their many interests but education doesn't feature amongst them. They descibe themselves as "experts in top team and board consulting, training and development". I bought the report.

I expected the report by university academics to follow a standard format but it doesn't. It is 24 pages long and contains no references and no appendices. The survey instrument is not included.

Mainly it consists of charts illustrating question responses. Unfortunately it contains some typos and poor grammar.

No response rate is given, although we are told that the single school contained 1277 students and that there were 267 respondents, so it may have been as low as 21%.

With regards to 'tech addiction' this seems to have been a self-assessment based on response to the question: How addicted are you to the internet or your mobile phone? The proportions given in the BBC report are those who stated they were 'quite' or 'very' addicted. Of course, we don't know what the students meant by 'addicted'.

With regards to this addiction harming learning, there is no analysis relating the perception of being addicted to outcomes in learning. In fact very few of the questions are related in any way to learning.

It is hard to understand several sections of the report because of lack of access to the questionnaire. For example, with regards to plagiarism the authors state that "A high proportion of students (84.3%) openly admitted that they inserted information from the Internet into their homework or projects on a number of occasions." The tone of this sentence reflects some of the bias which is found throughout the work. The authors don't seem to be aware that if referenced it is acceptable to insert information from the internet into work, so the students would have no reason to be ashamed and fear 'openly admitting' this. The finding that 59.2% of students have inserted information into work without reading it is more concerning. It is also reported that 28.5% of students "feel it acceptable to insert information from the Internet straight into schoolwork without editing or making adjustment, recognising that such behaviour is considered plagiarism." It would help a lot to see how that question was actually worded in the survey, as in the figure it is simply represented as "Ok to “insert” information from the Internet straight
into schoolwork- Yes/no". That's not quite the same!

But there is no analysis relating amount of time spent online (or perception of addiction) and likelihood to insert internet contents into work without reading it. It may be that those who spend less time online, have less skills in information literacy and are more likely to plagiarise.

In summary this report tells us very little about internet addiction or learning. Do you think that someone writing for the BBC website actually read the report? Many of those who tweeted about the BBC article thought there were no suprises in the findings, and that perhaps it suggested that teaching methods needed to change.

This evening Ben Goldacre and Lord Drayson were debating the state of science journalism in the UK. I wonder why do the BBC give space to research which is so poor? How did they manage to concoct such an alarming headline? And why do people believe it? Is it because as one person responded to me last night, there is the perception that "U may fault methodology, results true".

And the quotes from the authors are not even results, just their thoughts which may chime with readers. But it's definitely not science.

Image: "Playing with the new baby cell phone" http://www.flickr.com/photos/cwinters/2150107228/



EDIT: You can read the BBC response to this blog post here.

Apologies for quietness

It's 2 months to the day since my last post. First there were holidays and then I broke my wrist. I was whirling round in a dance tent at the Green Man festival and then suddenly I wasn't. I was rushing backwards towards the ground and put my left hand out to save myself.

I think a broken wrist is a pretty good excuse for a blogging hiatus, though my story is not quite as dramatic as Stephen Fry's.

Supporting Scholarship in Medical Education: The Role of Social Media and Networks

Supporting Scholarship in Medical Education: The Role of Social Media and Networks

This is the presentation I am shortly going to give at #asme09.
I will make more notes soon and update on feedback.

Web 2.0 tools and medical education - more sceptical comments

Last week, @drves described me as a web2.0 skeptic. Those who know me in 'real-life' would certainly agree that I ask many questions, and may doubt received wisdom. Now it seems this facet of my personality is more apparent in the online world too!



Lemley, T., & Burnham, J. (2009). Web 2.0 tools in medical and nursing school curricula*EC Journal of the Medical Library Association : JMLA, 97 (1), 50-52 DOI: 10.3163/1536-5050.97.1.010

The above paper was published in January 2009. It has been talked about a lot on twitter today because it was mentioned in a student BMJ article, which was then picked up in a blog post by Dr Ves. The finding that '45% of medical schools use Web 2.0 tools in their curricula' is that most often cited in twitter and elsewhere. So what does this mean and how did the authors draw their conclusions?

Method
A survey was conducted using Survey Monkey. Participants were identified by emailing a link to the survey to 3 different email lists:
DR-ED (for those involved in medical education) 1383 subscribers
AACN (for those involved in nursing education) 150 subscribers
AAHSL (for academic health librarians- who were asked to forward the survey to those responsible for curricula in their institution) 146 subscribers

The questionnaire is given in an appendix.Although the title and background to the article talk about web 2.0, the first questions asks about use of the following 'web 2.o/social networking tools':

• Blog
  
• Del.icio.us or some type of social bookmarking resource
  
• Flickr or some type of photo-sharing resource
  
• Moodle
  
• MySpace, Facebook, or some type of online community
  
• Podcasts
  
• Videocasts
  
• Wiki
  
• YouTube or some type of video-sharing resource

I don't know why Moodle, which is an open-source,and flexible learning management system (LMS) or virtual learning environment (VLE) is included as a web 2.0 or social networking tool. Moodle does support the use of web 2.0 tools, but so can other VLEs, so it is unclear why it is listed here.

Results

There was no way of tracking how those who responded to the survey found it, ie did they find it on a list themselves, or was it passed to them by a librarian? In any case there were responses from 36 individuals involved in medical school education, and 19 individuals involved in nursing school education.

The response rate from the medical school list is no higher than 36/1383 or 2.6%, amd possibly lower if some of the responses came via the librarians' list.

Several responses may have came from individuals in the same medical or nursing school as responses were anonymous.

Despite this the authors go on to report results as the percentage of medical schools which are engaging in the use of web 2.0 tools, rather than the percentage of medical educator respondents. The individuals who responded that they did not use these tools may work in institutions where many others do, and the individuals who responded positively may be the sole educators in the institution to use the tools out of several hundred or more.

The questionnaire did contain a question ("Please briefly describe how these tools are incorporated into your instruction.") which allowed free-text response and could have provided some information for a qualitative data analysis, but no results are given.

My conclusion

Does this paper tell us anything about the use of web 2.0 tools in medical and nursing schools in the US? No.


Is the author's justification of validity despite low response rate, because the study is "to gain insight into an issue", appropriate? No, because exclusively quantitative results are published.

This paper is short. It is open-access. I think that with a cursory look, most people would have reached similar conclusions to me. So why were so many people referring to this paper today without any criticism of the severe weaknesses in methodology?

Thanks to @drcolinmitchell for drawing my attention to this research.
He has also published a great post about this paper.

Where do junior doctors look things up?

A short time after my post on where medical students look things up, @drcolinmitchell tweeted about a paper on where junior doctors look things up.
Hughes, B., Joshi, I., Lemonde, H., & Wareham, J. (2009). Junior physician’s use of Web 2.0 for information seeking and medical education: A qualitative study International Journal of Medical Informatics DOI: 10.1016/j.ijmedinf.2009.04.008
I have to admit that when I first glanced at this paper I thought the methodology was good. There is talk of triangulation and inter-coder reliability etc. But when it is read more deeply much of it simply does not make sense because key concepts are so loosely defined. In the past few days I have seen this paper mentioned several times on twitter and in blogs, but there has been little or no mention of the poor quality of this study. Therefore I thought I should add my thoughts to the debate.

Method

The study took place in the NHS in England. The subjects were junior doctors. 55 were identified through a stratified sample (of 10 different specialties) from 300 graduating from a London medical school. 50 of these agreed to participate but only 35 completed all three stages. More demographic data on the participants would have been useful.

Next, they were given a questionnaire, used in previous research on this topic, and asked to keep a diary over at least 5 days of every website they accessed for work. Finally each participant was interviewed although themes were saturated after 20 interviews.

Results

From the survey data, 32 of 35 said they used web2.0 sites and of these 28 used wikis (read the content, only one doctor contributed to wikis). Next, looking at the diary data, confusingly, google.com is now referred to as web2.0 content, whilst in the survey it was not. 80% (28/35) of physicians used google during the five days. 25/35 reported using wikipedia. Smaller percentages used yahoo.com, doctors.net.uk and Facebook. This data is presented in chart form with percentages of physicians accessing each site (eg google, wikipedia, NICE). Presentation in tabular form with absolute numbers of accesses would have given more information.

The participants were asked to state for each of the 444 events where they accessed information online whether this was on a wed2.0 or user-generated content site, or hybrid, or traditional content site. The doctors said that on 235 occasions they were accessing web 2.0 content. However, the authors have classed the 142 uses of google and 115 uses of wikipedia (total 257) as web 2.0 content. No absolute numbers for the access of yahoo, facebook and doctors.net are given so the agreement between the authors and participants over what constitutes web 2.0 is not clear.

The authors then present themes from the interview data. Here "using the internet" is confusingly equated with web2.0 content. There is mention that doctors look things up online because it is easily accessible, and up to date, but at times they are uncertain about the quality or usefulness of the information found. The authors introduce a taxonomy of information needs from the interviews which they then use to analyse the information needs addressed inthe diaries, categorising 237 out of 444 internet accesses/information needs:

1. "to solve an immediate defined problem" "to advance an immediate task in the clinical context and forms a closed question with a specific answer" "closed questions" 107 of total information needs, of which 90 addressed through use of "hybrid or best evidence tools" (these tools are not specified)
2. "background reading on a subject" 130 information needs, of which 107 addressed through the use of "web 2.0"
   

It is not clear why 207 web accesses were not classified, or which sites were accessed in those diary entries.

Futher information is given on the way that doctors used google. 21 out of 35 mentioned using google as a way of navigating between trusted sites. It is not stated if these trusted sites were named in the diary.

There is then some discussion of how these (web 2.0) sites could be better used in clinical contexts. Doctors mentioned :

• patient education- comment is made of patient use of wikipedia and need to educate patients on different sites
• physician education- awareness of "web2.0 sites" as difficulty is in finding out about sites(wikipedia and google? or were they referring to some other web 2.0 sites? or to trusted web 1.0 sites?) , not much training necessary as sites so easy to use.
  
• remove blocks to web2.0 sites - it is reported that google is blocked in

I am not commenting on the discussion of the paper because I found the method and results section quite perplexing. No clear definition of web 2.0 content is given. It is not clear why the use of google is considered use of web 2.0. As Mark Hawker has pointed out google is a web 1.0 application. (Data is indexed by computers and pulled by humans. The content is not in any way user-generated or social. ) Previous researchers such as Sandars and Schroter, who this paper cite, did not consider google to be a web 2.0 application.

Because the authors did not use a clear definition of web 2.0 content this work can tell us very little about doctors use of web 2.0 content. It is possible that most doctors are using the same trusted websites that they have always uesd. They use wikipedia because it is easily accessible (free and no passwords needed) and is equivalent to an online textbook. The user-generated content of Wikipedia is not a factor for most doctors. Credibility of user-generated content for physicians did not emerge as a theme in the qualitative work. Instead they were concerned about how patients might use the same websites that they use.

Overall, I found the study very disappointing. We need debate and discussion on how best to address the informational needs of clinical staff. To me, the best description of these needs still seems to be Richard Smith's BMJ review in 1996. Now we should be asking, have the information needs of doctors changed in the last 13 years? How are these needs best addressed by current technologies and what tools should we be trying to develop.

What do you think? Am I being too harsh? Why did you like this paper?

Metaphors of Medicine... and implications for medical education

Just a short post. Last week I saw Annemarie Mol speak at COMET09 about the 'messiness' of clinical practice. Today I received an email from a colleague where we were discussiing the fact that many aspects of medicine do not "offer a script". And then through Rakesh Biswas I came across this blog of Shashikiran Umakanth, a physician and associate professor in India. His former student comments that "no patient comes in a neatly packed diagnostic disease".

So these metaphors of medicine are about its complexity and unpredictability. But do we acknowlege this in our medical courses?

What are your metaphors for medicine and how do they inform the way we prepare students to become doctors?

Tweeting from a conference.

If you are following me on twitter you will have noticed many #comet09 tweets in the last two days. There will be more tomorrow as the conference finishes in the afternoon. So what was it about? COMET is an interdisciplinary conference in communication, medicine and ethics. It moves around the world and this year was on my doorstep in Cardiff so too good an opportunity to miss.

I decided to tweet because I thought the content would be interesting to quite a few of the people I know on Twitter. And it was. Some of the things that happened:

• @jrbtrip found out what an old colleague was up to
• @hadleybeeman and I had a discussion about whether patients had the right to not engage in partnership with their GP in their care
• @mrhyde found out about some research on how people who are obese access information on the internet.
• @vmontori who was a co-author of some work that my colleague presented was kept up to date although he was still on the other side of the Atlantic.
• @casesnetwork kept up to date with Brian Huritz's lecture.

And after seeing a presentation about using multiple modalities in drug patient information leaflets I remembered that I had seen a lightning talk about this last week at Health Camp but couldn't remember who. I tweeted and had the answer before the speaker had finished her presentation.

I do seem to have been the only person tweeting from COMET 09, but I predict that come COMET 10 in Boston there will be a few more. This was not about providing a backchannel to the conference, but simply about bringing the contents of interesting dialogues to a wider audience. So if you are listening to someone stimulating, think about tweeting. The chances are that someone you know will be glad that you have made the effort to share.

Where do first year medical students look things up?

In the last two days I have spoken to 31 first year medical students about their early clinical attachments in primary and seconday care. I asked them where they looked up unfamiliar clinical topics. These are some of the responses:

• Wikipedia
• Google
  
• Kumar and Clark
• Medical dictionary
  
• YouTube (especially to find out more about operations)
• NHS Direct/Choices
• Oxford Handbook of Clinical Medicine
• I didn't look anything up.

Wikipedia was definitely the most common choice. Many students said 'I know I shouldn't but....' and then qualified that they used Wikipedia first because it was easy to understand, they felt it was reasonably reliable, and accessible. One student used it to search directly from her phone when on placement.

I was intrigued by one student who was very keen to distinguish 'learning' which was what he did for exams... spotting questions on past papers and reviewing lecture notes... from 'experience', when he would access YouTube or Wikipedia to find out more about something that really interested him. His reluctance to call this learning reminded me of a third year student I spoke to earlier in the year. We were talking about how she would continue learning for the rest of her life. "That's so depressing", she said. In her mind learning was bound up with exams and assessment.

Should we worry about students turning to Wikipedia so often? Which other resources are just as user-friendly and comprehensive?

I think that NHS Choices is a good place to start.

EDIT: Just to make clear, the first year students I am referring to here are in an undergraduate 5 year course. The first few years of the course are pre-clinical but these early clinical attachements are to give them some initial insights into the world of clinical medicine. Some medical schools in the UK have no distinction between the pre-clinical and clinical parts of the course.

Facilitating a network

I am hoping to establish a network between those leading programmes in which medical students have the opportunity for contact early in the course with patients in their own homes or in the community. I think we will benefit from sharing motivations, materials and ideas on assessment. So I am wondering how I could support this. We could simply have an email list. Or a google group. Or a NING.

What would you use?

EDIT: This is to be a network with my peers- fellow medical educators- not with students.

Are you a digitially competent doctor? Do you need to be?

I was talking to a colleague in the last few days about digital competencies. He wondered if we should be exploring developing a set of competencies for medical students.

I started this blog more than 6 months ago as part of my learning journey on the use of web 2.0 (or whatever term you prefer) technologies and to meet other people who were on the same journey in medical education. I know that I could not yet say what the competencies needed for medicine are. I work with and know many good doctors providing good quality care and they do not blog, or use social networks, or collaborate online in wikis, or use rss feeds, or save or share links in social bookmarking tools. Would they be better doctors if they did?

And if I am not competent yet myself how could I decide that these, or others, are areas which students need to be competent in. How could I assess if they are competent?

Yesterday I was co-ordinating 3rd year exams assessing students skills in clinical examinations. Competency in clinical examination has been regarded as essential for doctors for many years. Maybe in the future it will be irrelevant. But for the moment we, as a profession, hold that it is important.

Will we ever have the same agreement about digital competency?

In praise of the walled garden (VLE)....

I have to start this by saying I am not a techy. I struggled a few nights ago to install MS Office on a netbook. But I am interested in how new technology can improve the way that we do things.

Back in 2004 I was invited to go on a Blackboard training session as there were plans that the medical school would use the VLE " increasingly to deliver course information and material". But when I went to the training session it wasn't this that got me excited but the discussion boards. I immediately thought that this would be a good way for me to communicate with and facilitate communication between 300 2nd year students undertaking a course I co-ordinated over 9 months. They were not even based in the same building as me. I've posted more about this here.

This year I used discussion boards, wikis and a course blog. Participation is voluntary. I don't assess contributions to the boards but students seem to find them a good way of accessing me and sharing with each other. The connections that they make through the discussion boards should help them to do better in the assessed written work.

So in my experience VLEs can work.

But many people do not like VLEs, or the way they are used or what they stand for (large, monollithic companies which I don't like either).

Martin Weller said the VLE is dead or dying back in 2007.Instead we will using "Loosely Coupled Teaching"... lots of different, freely available websites pulled together. Yes, that could mean lots of different log-ins and getting to grips with different websites but learning how to use wikis and discussion boards and blogs takes time no matter where they are, and tools such as openID, and facebook connect, might get past the log-in problems.

In 2009, Mike Bogle wrote about Distributed Online Learning Frameworks, now possibly including twitter, and was inspired by the experience of David M Silver.

But talk about moving away from VLEs is not just that they are big and cumbersome and slow, there is also a sense among many that it is the walled garden that is the problem. Access is restricted to those within the course within the institution. It is anti-edupunk and anti-connectivism. Mike Johnston thinks the VLE might be 'killing connections' for the institution's benefit.

But might there not be advantages to a walled garden? Can't students benefit from being able to talk and share in a private place where they can make a mistake and ask or say something stupid. We know the Cisco Fatty story. We're learning about digital identities. Is education in public really better? If institutions have any role in education might it not be the provision of a walled garden or safe space?

Emotional perspective taking

Last night my mum phoned to say that Traffic Cops was from Cardiff. Creepers break into houses and steal the keys of cars before stealing the cars. A car was found having rolled over on a road near where I used to work. The driver died. He couldn't be identified as his facial injuries were so severe, and a passenger abandined the car. A liaison office was called to break the news of the drivers death to the family. He called at the house of the owner of the car, to find that the house had been burgled and that the owner was alive and well.
I thought how awful it must be to find out that someone has died in your car, even if it not in any way your fault.
Next we were shown the owner of the car at the police station where he had gone with his father in the middle of the night to make a statement. He said that when he first heard that his car had been stolen and the driver had died in an accident he felt no sympathy. He thought to himself that it was what he deserved, after all he could have came up the stairs and clubbed him to death as these things happen.
I said out loud to my brother who was visiting that his response seemed to be the opposite of mine. My brother said 'maybe you empathise too much'.

So can we empathise too much? What does this mean? And in this case why were my feelings so different to the person who the event had actually happened to?

To read: Empathy Gaps in Emotional Perspective Taking

Empathy, caring, emotion, communication and learning

Oh, a long time since my last post again. Yet, again I have many things going round in my head and holding my attention for variable lengths of time. It is a chaotic narrative an one which may disturb you if I share it in its entirety:) So instead I will mention some parts.

Today, I got news that a colleague and myself have won an ASME small grant to explore how students might learn from the patient's online voice. We're starting with students- what do they think they learn from reading patient narratives in forums and blogs and what do they think of this process. I wonder if reading the way that people talk to each other about health and illness online will help students develop empathy for patients.

There are a lot of questions around empathy that I would like to be able to answer:

• What is empathy?
• How is empathy different to sympathy?
• How do we feel what another is experiencing?
• Is empathy necessary to be a good doctor?
• Is too much empathy bad?
• Can we help students develop empathy? And should we?
• How do others know we feel empathy with them?
• Can we fool others into thinking that we feel empathy for them when we don't?
  
• Can we understand an experience we have not been through?

I used to think I knew the answer to many of these questions but as is the nature of these things when you start reading and thinking more you start having more questions, and you realise that the questions you thought you had answered have not really been dealt with.

So in my next few blog posts I will endeavour to discuss some interesting papers that I have come across in the last few months and I hope that we can discuss them together.

My complex professional identities

We all have complex identities. I am a wife, a daughter, a sister, Irish, from Northern Ireland and more.

But I also have a complex professional identity with several different parts to my job. And sometimes when I come across a paper, a publication, a presentation or a conversation I am not sure which part of my identity is responding. For example, my friend presented about her use of audio-diaries as a method of collecting data for qualitative research this afternoon. I found myself responding to this as a practitioner of medical education, more than as a researcher. The different parts of my professional identity are also valued more or less by colleagues who have more singular identities.

Just some thoughts......

Collaborative learning- some questions

This is a short post.

Why when we talk about collaborative learning do we usually refer to online activities rather than face-to-face small group work?
Why do students see the value of discussing a topic and learning from each other face to face much more than contributing to a wiki?
Why does everyone, including educators, find online collaboration hard?
Does the interaction that wikis produce actually facilitate learning?
Why do we worry so much about assessing online collaboration when we are happy for students to work in small groups in a tutorial without assessing relative contributions?
Doesn't the focus on assessment rubrics mean that we will make the students focus on external motivators for particpation rather than internal?

I have many more questions but it feels good to get these of my chest for now.

Teaching Communication Skills

It's a month since I've last posted on my blog and I am not quite sure why. I've thought about many things and wanted to write about them but I kept thinking that I had to look something more up before I could put fingers to keyboard. And while I do think it would be wonderful if I did have the time to research everything I write and place it within a context, I also think it is good to just get on with sharing reflections on work.

So, I spent this afternoon teaching a 'breaking bad news' session to 3rd year medical students. Our course is undergarduate so these students are in their early 20s. The session is 3 hours long, with 5 students, me and 5 standardized patients(actors) who cycle through the rooms and are with us for about 15-20 minutes.

This is the third of 3 communication skills in 3rd year. I was stepping in for another tutor so had not met the students before and they had bonded quite a lot together as they had been on many placements together not just this class. They were even going out to a pub quiz together.

I want to tell about two of the scenarios we discussed. No. 2 patient/actor has to be told that his long-waited for operation had been cancelled due to emergency admissions. The student psyched herself up because she and the other students had heard on the grapevine that this scenario was particularly confrontational. The others joked that if any of them could cope with this angry man then she could. And so the metaphor of battle for this consultation was set, and it continued throughout. It really did feel that they were on two opposing sides rather than her being there to support the patient. I know from talking to these students that they care deeply about patients, but in this scenario the 'game' of sparring with this actor was too strong. It had been mythologised by previous students and there was little chance for this student to come to it with her own angle. It made me think (again) about who un-natural communication skills teaching can be. I was a bit shocked when I came across this book chapter yesterday.... our exams deconstructed! And I realised that our teaching sessions can be too predictable for students as well. When he had finished acting our actor told how his real-life wife has had an operation cancelled three times in the last month. On the second occasion she had got as far as changing into her gown when she got news it was off. But the news came from the surgeon who left the theatre and came down to sit beside her bed and apologise. It was this story which made the scenario seem real for the students and they thought that perhaps the wrong approach had been taken by their colleague initially. The example of the surgeon who sat alongside his patient, rather than on the other side of the battle lines made sense to them.

We were recovering from this encounter when our next actor/patient arrived. This involved a patient returning for the results of her chest x-ray. It showed an opacity and she was to be referred urgently for a CT scan and to a chest clinic for assessment. She had a high chance of having a lung cancer. I quickly checked with the student if she was prepared as she thought she was going to have another scenario. She made an aside comment about the patient probably going to start crying and I wondered if she was in the right place. I asked her again if she knew what she was going to say and she said yes. The actor/patient was rapping on the door so we moved on. It quickly emerged, to me,that the student after talking about 'shadows' on the scan and the fact that this could mean many things.... but possibly something 'serious', was not going to discuss the possibility of cancer with the patient.

I called time out and asked the student if this was the case. She said it was and said that if the patient asked she would tell them but not otherwise. I said that I didn't think this was the best approach, but the other students said that they thought she was right. It wasn't fair to burden the patient with the possible cancer diagnosis if she didn't want to know. And we had to presume that she didn't want to know if she didn't ask. So they resumed the consultation, and it finished without the patient ever knowing that she was being referred because she might have cancer.

Afterwards the student said that she thought it was the job of the chest clinic to inform her about the possible cancer diagnosis or the actual cancer diagnosis. At the time I was quite strident in my opinion that the patient should have been informed but the students were still not coming round. One did, but just the one.

The next scenario helped us as it was about a young woman presenting with a breast lump. This student mentioned the possibility of breast cancer within her first few sentences. The consultation ran smoothly. The actor shared in the feedback that she felt it was unfair to expect the patient to raise the possibility of cancer and that it was good to get it out in the open. She called it the elephant in the room. We all laughed and told her about our debate with the previous scenario. Some of the others now also started to agree that if the patient was being referred because of the risk of cancer then it was important that they should know and that it was not fair to leave the responsibility of asking to the patients. By the end of the afternoon they all seemed to agree on this.

I framed it in the context of 'informed consent'. Could the patient really give consent to the tests they were to undergo if they didn't know what they were actually checking for?

But I recieved today "The Logic of Care" by Annemarie Mols. I haven't read it yet but I wonder if I will be so sure that I am right when I finish. She compares the logic of choice, which she says is becoming dominant in western healthcare, with the logic of care. Were the students being more caring in wanting to give a woman who has a probable cancer diagnosis her last two weeks without having had cancer overtly referred to, than I with my thoughts of empowering the patient through information? I don't know.

How can we involve (e)patients in medical education?

I have some ideas about this but I would really love to hear from (e)patients.

How do you think you could contribute to medical education? Do you think that students and doctors could learn from reading the blogs of (e)patients or seeing what the hot topics are in discussion forums? How would you feel about letting a medical student take your history in Second Life? How can we help medical students develop the skills to support patients negotiate the online world?

PLEs and Medical Students....

I started this blog with the aim of recording my web 2.0 learning journey and also in the hope that I would find a community of people interested and participating in medical education. Today this bore some fruit as I participated at a distance in an online seminar about these topics.

The presentation by @ajcann, University of Leicester, reported on courses to help students develop skills in the use of web 2.0 and information literacy. The slides and document give a good summary of the findings. Students appeciated tools, like customised google searches and a Pageflakes page, that helped them find resources more quickly. But they did not use the social aspects of tools provided. There was not evidence of the formation of a community of practice.

There was no audio-visual streaming of the seminar, so I could only pick up on the talk in the room through the tweets of those present. You can find them here: #UOLTAN. I am sure that this means that I have missed out on a lot of valuable interaction and responses to the material presented. I commented that I was not surprised that medical students did not use social bookmarking because despite looking for the past few months I have only managed to find one doctor who uses social bookmarking to record sites that are cliically relevant. And if I was looking for information on how to manage stable COPD, see last night's post, my instinct would not be to start searching delicious to see what others in my network had saved.

So what does that tell me? Well, if clinicians are not yet using web 2.0 to help them with their day to day clinical work, is there any point in us worrying about whether or not sudents are interested in developing these skills? I don't mean that only 10% of GPs or hospital doctors are using social bookmarking and blogs to keep up to date. Or even that only 5% are. I doubt that even 1% are. Early adopters of web2.0 tools for clinical practice do not seem to exist yet.

One of the report conclusions reached was that "Students are reluctant to change their habits unless there is a clear tangible benefit to them. If we believe literacy skills are worth developing, we must make them a requirement not an added extra."

I think that before doing that we need to figure out if these tools actually deliver something that is useful to medical students and to doctors. What gap are they actually filling? Medical education can certainly be improved. But we need to describe the problems before we come up with the solutions.

Accessing Evidence-Based Medicine

There is discussion in blogs at the moment about the limits of Evidence-based medicine and how it may be impacted by web2.0 technologies. Laikas, a Dutch librarian, posted about this recently. Sarah Stewart, a midwife from NZ, replied by describing some of the difficulties faced by the public in accessing EBM and the resulting asymmetry of information between doctors and patients.

This reminded me of a You-Tube video I came across last year.

It is an interview Muir Gray, the NHS Chief Knowledge Officer (a post he first floated in 1998 in the BMJ), describes his view of the future of information in the NHS. Resources will be equally available to patients, (or to use his term, citizens) and to professionals. As a clinician and citizen I think this is an enlightened policy. I find much of the content on the NHS choices website very exciting, including Behind the Headlines. BtH gives an evidence-based critique of health stories in the press. I do not like Map of Medicine..... but more about that later:)

To illustrate some of the different sources of EBM available I am going to look at guidance on the management of stable COPD (chronic obstructive pulmonary disease).

First of all here is the page from the BMJ's Clinical Evidence site. I find this very unhelpful. If I wanted to know about one particular treatment and the evidence base, or lack of, for it's use in the management of the condition, this would be useful. But it is not at all useful for a brief synopsis of how to manage the condition.

Next, Clinical Knowledge summaries COPD page. This has many different levels of information and takes quite a lot of clicking around. But it is likely to be useful to a clinician in a surgery. And probably to patients/citizens as well.

GP Notebook is in my experience a favourite of UK GPs. Looking at it's info on the management of stable COPD it is clear that the guidance is related to the NICE guideline on the topic because it references the NICE guidance, and describes different steps for mild/moderate and severe levels of disease. This looks the easiest to access and most clinically relevant so far.

Lastly, we have the Map of Medicine stable COPD page. This annoys me on many levels. For one we are told under 'indications for referral' that this should be considered for severe COPD, but you have to go down to 'follow-up care in severe disease' to find out what the criteria for diagnosing severe COPD is.

What do you use to access EBM? Are different sites useful for different purposes? I'd love to hear your thoughts.

EDIT 11/8/10 I've reviewed the Map of Medicine page (previous link had died- new one is current) and it still does not make diagnosis criteria clear, unfortunately. Time to drop them a tweet!

Power of social networking....

I started this blog a few months ago. Quite rapidly I started learning so much that it was hard to keep documenting my progress. So I find, like all reflective journals, that it is hard to keep it up. But sometimes something happens that really shows the progress you have made so I thought I would tell you a little story about some interactions in the last few hours.



Earlier I was looking at the Health Foundation's webpage. I saved it to my delicious and noticed that someone else had saved it too. The other person had lots of bookmarks interesting to me but no webpage or email address saved. I have been lamenting before about how it is hard to find people on delicious sometimes, but this person had actually twittered about their delicious account so their twitter ID showed up on this page when I googled their delicious ID. Yay! I had found @jranck!



Earlier I had noticed that jranck had bookmarked a blog about developing a communications network using old mobile phones, in a primary health care project in Malawi. The latest post describes analysis of the content of the text messages sent and also included the text of the messages. Somewhere in the last few months I also learned about wordle, and I thought this could do with one so I pasted the text and created a wordle:

I was then able to share my wordle with @jranck and @joshnesbit (the Mobiles in Malawi site creator) through twitter. Within an hour or so my wordle was being bookmarked by other people because of their tweets.

So that is my snapshot of the power of social networking as I see it today:)

information asymmetry

http://en.wikipedia.org/wiki/Information_asymmetry

Posted via email from amcunningham's posterous

Happy New Year....7 things you don't (need to) know about me

Let the frivolity not end yet. I have been tagged by Sarah so here goes:

1. I climbed the highest mountain in Northern Ireland for the first time last week. I grew up a few miles away from it.
2. My first trip outside the British Isles was to Croatia a few weeks after my 21st birthday. I spent the summer working as a volunteer in a refugee camp. I travelled from Belfast to Zagreb by bus.
3. I got a super crew tie-pin for selling 47 quarter pounder with cheese deluxes in one weekend. This was in Belfast's first McDonalds in 1991.
4. In 1998 I stood in the first elections to the Northern Ireland Assembly. I wasn't elected.
5. My mum made and embroidered my Irish dancing costume when I was 8.
6. My husband is great at roasting things.... intentionally, like chicken.
7. I go to bed too late.

Thanks Sarah:)