What I have learnt about blogging

I blog... by alamodestuff

So if you have known me on Twitter or elsewhere for a while you will know that I am a big fan of blogging and I encourage everyone to start keeping one. Why? You will learn a lot and you will help others learn too!

I started my blog just over 4 years ago. Sometimes I will write a few posts in a week and at other times I leave it for a month or two. How often you write is up to you. It shouldn't feel like a chore.Write when you have something to share, a question to ask.

Blogging is public writing. Think about who your audience is. For me a massive strength is that all kinds of people read and comment here. This means that I can learn about many more different perspectives than if I was to walk down the corridor and ask my colleagues at work thought of the random idea I'd just had. But sometimes people won't understand what you say, the language you use or where you are coming from. That's OK. Just as in any communication, if someone doesn't understand you then don't get angry, just try and explain in a different way.

Writing helps me to develop my thoughts and get someway to understanding what has been perplexing me. And usually I ask a question at the end so that people who read the blog know that I didn't just want a soap box but that I am really interested in what they added. If no one comments on your blog, and you have wanted them to, then maybe people who were reading didn't know what kind of response you wanted. Questions really help with this. If you are writing the post because you are developing an idea that arose out of a conversation somewhere else then make sure that you let the other people involved know so that you can continue the conversation there. And if there is someone whose insight you would really like then email them or send them a tweet with the link and ask them to leave a comment. And get into the habit of commenting on other people's blogs too. They will appreciate your feedback.

Sometimes people ask about ethics. Are there any particular ethical concerns? If you were writing for a journal or a magazine you would most likely have an editor who would tell you if what you were writing was really off for some reason. But you don't have an editor on a blog so you do have to take a bit more care and consider what you are writing. My own rules are that I don't mention a patient on my blog without asking their explicit consent. In fact, I don't often write about anything relating to my clinical work on this blog. If I am teaching and I realise that I would like to write a blog post about something which has come up then I would let the students know when I was with them. Sometimes, I don't realise at the time that I want to write about the episode but I always try to make sure that I at least let anyone involved know that I have written the post later. So I don't think there is anything particularly ethically troublesome about blogging, but if you have any doubts then don't be afraid to pass what you are going to write by someone else first.

Should you blog in your own name? I do. That doesn't mean that you have to. But I think that writing in your own name leads to a richer experience because you can make stronger links between your online and offline worlds.

And some practical tips? You can set your blog up on any number of sites. This is on Blogger, which is owned by Google and is really very easy to use and rarely down. Lots of other people choose Tumblr or Wordpress. Have a look around and see what you think will suit you.

Do make sure that you enable sharing buttons on your blog so that people can easily share it with others. And let people subscribe by email too.

I usually add a picture to my posts because it brightens them up and hopefully helps with understanding too.

I allow anonymous comments here but I moderate all comments, mainly to stop spam getting through. It's easier than deleting.

And you'll hear people say every now and again that blogging is dead. But that's nonsense. How could it be when you have just started? Enjoy!

Digital divide, health records access and online security

Oxford Internet Survey 2011

The 'digital divide' is very real. The Oxford Internet study is conducted every two years and the above chart is from their most recent survey in 2011. Level of income here relates to household income rather than individual outcome. If you live in a household with an income above £40K it is almost guaranteed that you will have online access. If you live in a poor household with an income of less that £12.5K it is most likely that you won't. There are also stark divisions related to age and educational levels described here.

I've just been having an interesting discussion with Amir Hannan, a GP who is a very strong advocate of patient access to their own health records, about how the digital divide means that those who are most likely to have health problems are least likely to be online... bringing us in the direction of a digital 'inverse care law'.

So if you are a GP and are encouraging patients to access their records online what would you say to those who lack the means to be online? Amir said that patients who are not yet online are directed to a course run by the local library which helps to get people online. But what if you can not afford to have your own access at home, should patients be encouraged to access their medical records from public places such as libraries or internet cafes? What are the risks? Or what about using a computer at the house of friends or family?

Of course, it's not only those who don't have their own computers at home who may use other computerss that they do not own themselves. What issues should you be concerned about if accessing your records from a computer that is also shared with your family or from your work place? Or a hotel lobby when on holiday?

A quick search does not reveal guidance about these issues for people in the UK. Here is the log-in page for the EMIS general practice records access. There is no link to information about online security. Contrast this with information which is available from online banking websites on what to look out for when using their services, for example here is a page on online security from Intelligent Finance.

If there are issues around the online security of accessing health records online, then those who don't have their own internet access at home, are more likely to be at risk. Do you have any examples of links to information in easy to understand forms which will help people to understand and address these issues? Or is it not an issue at all?

EDIT: some great guidance from BCS on accessing records http://www.bcs.org/upload/pdf/social-care-records.pdf <- they state if possible not to access from public computers, but if you do to clear browsing history.*** note this guidance is draft and NOT FOR CIRCULATION but I found it through Google ;-) ***

Renal #meded on Twitter

Twitter for a/e triage?

Ethical responsibilities of leaders of tweetchats?

That way by justinbaeder
Over a year a go, Natalie Lafferty and I hosted the first #meded chat on Twitter. Ours was between 9-10pm UK time, and 5 hours later a similar chat was held for participants in the US.

We had some really great and very wide-ranging discussions. In the UK we had a lot of participation from students and doctors in training. This made for particularly rich and informative debates, for example on portfolios and competency. Over the summer we wound the chats down and didn't get them started again, although the US chat has kept running. But thanks to some calls on Twitter we have got some momentum building again and it looks as if our first session will be announced soon.

In advance of this I wanted to clarify what someone who participates in these chats could expect. I am not so interested in etiquette. We didn't really have any problems before, and participants seemed to be relatively sophisticated users of Twitter, so saying 'be nice' would seem to be a bit superfluous, and a little prissy.

But there are some other issues that I think we should address. The first is the issue of archiving. Anyone can archive anything on Twitter, but I think we should be clear with users that we ourselves will be archiving tweets and the implications of that. Up to now we had been using Symplur's archiving tool but we need to check whether individual tweets can be removed if they breached the confidentiality of patients or others. Again this did not arise before, but it is a serious enough governance issue that I think we should draw attention to it.

Next is the issue of research. As we are forming a community with the participants we would not consider researching the community without making participants aware. However, others outside our community might make us an object of research without making us aware. We can not do anything to stop that but we can make participants aware at least.

So given all that, here is a first draft. It is a fully editable document so please leave a comment here or directly on the document. What else do you think we need to add?

For students, can any social platform compete with Facebook?

Facebook like button by Sean McEntee

At #amee2012 last week Facebook was talked about a lot. It came up in the excellent  social media workshop that was lead by students and in several posters and short communications. Search this 500+ page book of abstracts to see how often!

But as might be expected there was not agreement on whether Facebook should have any place in medical education. Whilst there were reports of it being used to support student learning in informal and formal ways Imperial College, London, other students and faculty argued that Facebook is a social space and not a learning space. In the past any mention of Facebook at a medical education conference usually concerned being unprofessional, so the fact that people were starting to consider the possibility that it might be educational platform was very interesting in itself.

It was also suggested (including by me) that we might have responsibility to provide  safe spaces for students and faculty to model and develop digital professionalism. Quite a few of the issues I heard discussed were raised in the comments of two blog  posts I had written last April.

This post is also a  follw-up to a discussion on our LinkedIn group 6 months ago. It was started by Bernadette John asking if any medical schools were looking into developing  and supporting social platforms for students. King's had just started a project with Elgg but was also thinking about Mahara. Why would a medical school want to do this? Some suggested that the VLE should support social learning interactions. But they don't. Blackboard does not feel social, certainly not social like Facebook.

Today a colleague told me that the University of Wales, Newport (who don't have a medical school) had started using NING , a 'social community tool', in 2008 to support first year students. How might we use something like NING in a medical school? What value would it have? My thoughts are that it would be useful to have a space where students and staff could get to know each other in a semi-formal way. Most of the NHS staff who our students meet do not have profiles on the university site, but it might be useful for students to know some more about what their special interests are clinically, and in research. And vice versa, it would be excellent if teachers could know more about the students they meet on placements.

But later I found out that Newport had stopped using the NING. It was only used by students in the first few weeks of the course to make contacts with each other before they migrated to their own Facebook groups. And if you can't beat 'em, join 'em!! This year Newport is setting up a Facebook page for students to like and post to throughout their university careers.I imagine that even if activity does tail off over the next few months this might still be quite a good channel for the university to communicate with students through.

So can any social platform compete with Facebook? Is there any merit in trying to encourage students to use another 'social learning' platform? A separate platform would mean that students are at less risk of being accused of digital unprofessionalism because they minimise their contact with faculty there *although I would rather see a re-calibration of what is considered unprofessional in the first place- if my ears did not deceive me I think I even heard a medical student volunteer that they were urged not to like a One Direction page on Facebook for fear that it may be seen as unprofessional*.

A separate platform would also mean that faculty with Facebook antibodies could avoid it. Other faculty might be just as concerned as students about mixing personal and professional presences online. There was some talk of dual profiles at AMEE but that is against Facebook terms and conditions. Facebook would rather see professionals create 'pages' to project their work-relate personae.

So some questions. Would students or staff see value in a social platform? For more ideas on how that might work see this post on location and learning.  If yes, could that platform ever be Facebook?

(Edit: Here's an interesting post by Donald Clark in January, "7 reasons why Facebook is front runner in social media learning"

You have a Twitter account... now what?

So you have a Twitter account. Great!  But what's next? Maybe you've had this account for months or years and you haven't figured out what to do with it. Here are a few quick tips to enhance your experience!

1. Update your profile. 

Say who you are and why you are using Twitter. If you have a blog or a webpage somewhere that explains more about who you are then link to this. It will help people to know who you are and to have a context for what you say. And add a picture. It doesn't have to be you, it could be something abstract, but it will give people a sense of who you are.

2. Follow people. 

Who? Well, it depends on your interests but if you are interested in medical education then I can recommend a few ways to find people to follow. I have pulled together a list of people who tweet quite a lot about medical education. You can find it here. And with a slightly different flavour you can find another list by Jonny Tomlinson here. Jonny is a GP in London who is passionate about inequalities in health, and helping others to understand their impact on the lives of the patients in his practice. He tweets as @mellojonny and I recommend following him strongly.

How I decide who to follow? I look at their recent tweets and if they are saying interesting things or sharing interesting content then I follow them. And then I will often share what I see them saying. The simplest way to do that is to click on the 'retweet' button which then rebroadcasts that tweet so that people who are following you will see it. There are other ways to retweet. You can copy and paste what the other person has said into a tweet. But it is expected that you will try to attribute thoughts and ideas to those who they came from so it is customary to see 'RT' for retweet added to the tweet. There are a few other variations of this... MT for modified tweet, if you change what the first person has said by deleting part for example. And HT for 'had tip' or 'heard through'. It's a way of thanking someone else for bringing you some information. Don't worry if that is confusing. You can just use the RT button and everything will be taken care off.

3. Tweet!

Time to get going! What should you say? Don't think about it too much. Just share what you think will be useful to others.  Have you read something interesting to day? What are your thoughts about it? Don't under-estimate how knowing that you think a certain paper is worth having a look at is valuable to others. There is a lot of information out there and your efforts to highlight some of the best bits will be appreciated by others.

Should you tweet about matters that are not about your work or study? That's up to you. My personal choice is to share only very limited information about my personal life. I like to have my privacy. But sometimes I will mention the music I am listening to, or a holiday snap. I have no hard and fast rules about this. But I do have a very clear rule that I never tweet about my clinical work. I don't even say if I am working in the practice on a given day. This works well for me.

If you have any questions or tips for others, please post them in the comments. I've written this quickly so I might not have been clear and I might have left some important topics out.

Remember it is fun. If it's not then step away from the computer (or the smart phone!)

Clinical Key and #OER

Clinical Key is a new product from Elsevier which will search 700 textbooks and 400 journals for clinical content.

I came across Clinical Key today by a tweet in #tipsfornewdocs

#tipsfornewdocs If you're at UCL, @ClinicalKey is being trialled until 28 September bit.ly/QD7q9i
— Breda Corish (@BredaCorish) July 25, 2012

I then found a YouTube about the 'Presentation Maker' in Clinical Key which allows images to be imported into Powerpoint with all the copyright information embedded. Sounds good.

But going forward we would like to make our educational materials open educational resources which with could easily share with others. Would this be possible with Clinical Key?


I asked the Twitter account and got the following response:

@amcunningham Sharing within an LMS of subscribing institutions, no problem. The content on @ClinicalKey is copyrighted material, so no OER.
— ClinicalKey (@ClinicalKey) July 25, 2012

In the mean time I had missed a tweet from Brenda directing me to the Presentation Maker Terms and Conditions. These specify that "Authorized users for ClinicalKey have permission to use content from the site in presenations for noncommercial use.  You must keep intact all copyright and other proprietary notices"


But producing an OER is a noncommercial use. I would have thought that using Elsevier images in a presentation with their copyright respected would be a great way of advertising what might be a very useful service.


Maybe Clinical Key will rethink this.

I'm thinking about Twitter but....

This is a follow-up to my recent presentation at #asme2012 where I tried to convince anyone who was at the conference, and therefore interested in medical education, that they had something to gain from Twitter. These were my 10  reasons, more fully explained here. At the end I asked, "What is stopping you?". Here are some of the queries, and I'll add others as they arise and hopefully you can contribute some questions and answers too.

I'm already swamped by email, etc etc - how would I manage Twitter?

Email swamps us because it is hard to discern the messages that we do need to reply to from the junk that we shouldn't have received in the first place. But Twitter is an opt-in service. If you feel swamped by getting a newspaper at the weekend then perhaps this is not for you. You will choose who to follow and how often you want to check if something interesting is waiting there for you to discover, or respond to. But if you don't have time then you can ignore it. No one will be annoyed or upset. If someone really wants to get your attention they probably have other ways of contacting you than by a tweet (the dreaded email!) but you will very likely be surprised by how liberating you find 140 characters. Brevity is your friend!

And if like me you want to explore Twitter for your professional development then you can make some choices. What do you currently do for CPD? Why don't you swap 10% of that time to Twitter and see what return you get on your time investment? (I can make that challenge quite confidently!)

Should I have a personal and a professional account?

I have one account. It makes life easy. I don't feel that I share very much of my personal life but you probably will get a very good sense of what I will be like if you meet me at a conference from my tweets. You won't know how I interact with my family but I don't imagine you are very interested in that. Despite leading quite a public life I like my privacy. I feel that I have reached a happy balance.

Is it a problem that tweets are archived?

This question surprised me a little. If my tweets are professional then it is good that they are archived surely? Often the first thing I do when I attend a conference is check if the tweets are archived and if not then set up an archive. Or I try to curate tweets into stories myself using tools like storify. So archiving is not the enemy, it is our friend. I think the questioner was concerned that I was through my limited personal tweets I was exposing personal data. But this happens every time I use my mobile phone, my Visa card, and with CCTV cameras in the UK, often just walking down the street. We are all trading privacy for convenience to a certain extent. Again I am happy with my current balance?

I hope to do another follow-up post about how to get the most out of Twitter, but in the meantime, what are the questions that people raise when you talk to them about social media?

Why does a twittering doctor tweet?- note from ASME 2012

Why does a twittering doctor tweet? from Anne Marie Cunningham

"My very first tweet was made in May 2008.

preparing for a seminar on medicine and the media- thinking about health 3.0
— AnneMarie Cunningham (@amcunningham) May 27, 2008

 I was invited to join Twitter by a friend who works in IT. It just happens that at the time I was still at work thinking about a teaching session so my first tweet has quite a strong medical education flavour. Like many people I wasn't sure what to actually make of Twitter after this and I left it for several months until I went to two medical education conferences and decided that social media could serve a purpose for me.

 But I'm not a techno-evangelist. I believe we have to be very careful about how we use technology and to consider how it impacts on relationships. If you google web 2 (a term for newer social technologies including social media) sceptic then the top result is actually about me, because I have disputed with other doctors in the past that these technologies are having any impact on our clinical practice. And I am still uncertain about this. However I am certain, and have decided that I can allow myself to be evangelical, about the benefits that can be had for anyone who is at this conference and is therefore interested in improving medical education.I started becoming aware of this a short while after starting my own blog in October 2008 which is why in 2009 I gave a presentation at ASME about how social media and networks could develop and support scholarship in medical education. However, this did not lead to the expected paradigm shift in scholarly communication. So I have decided that I might need to be a little more direct with you this time. And this is why I am going to give you 10 reasons why you should be on Twitter now.

1. To connect

The first is my own initial reason- to develop a network with other researchers, educators and practitioners. This works and it can happen.

2. To engage

The second reason is something I didn't expect. Beyond simple connection you can have meaningful engagement with those whose voices you might not usually hear- students, junior doctors and patients, or the wider public. For me this has been tremendously powerful.

3. To inform

Third, is to inform. I'll use as an example the hashtag of this conference #asme2012. In the past few days more than 1000 tweets have been made by more than 100 participants and reached thousands of people who are mainly not at this conference. But what does that mean? Well, it means that ASME has a higher profile in the global education community. If your mission is to spread the word, then you should be using Twitter.

4. To reflect

Fourth, is to reflect. To illustrate this I've chosen a tweet by a doctor in the US raising the topic of the fall in empathy levels of medical students during the medical course.

UK med students- is this true? RT @drmintz:Process by which we train our students sucks the empathy out of them #meded
— AnneMarie Cunningham (@amcunningham) March 9, 2011

 It’s something that we often hear discussed at conferences. I decided to share, or retweet his thoughts, and to ask our UK medical students what their experience was of this phenomenon. I don't have time to show you all the responses (storified here) , but believe me that there was a rich discussion on what was wrong and what we might do better. So if you want to consider how you could make your practice better you could be helped by being on Twitter.

5. To share

The fifth reason is to share things that are important and meaningful to you. To do this best you need a space where you can write more than 140 characters and I would recommend that to get the most out of Twitter you also start a blog. But don't worry if you want to just stick to Twitter for now. In Twitter you can easily share links to content that is online; be that a research paper, or a blog post about your research or someone else's research or just a story that you think needs to be told. But remember you have no editor here. You have to be your own self-censor, but it doesn't matter if you make the odd mistake. Don’t let this fear stop you saying anything at all. The community is forgiving.

6. To be challenged

 But sixth, when you share your thoughts and ideas don't expect everyone to agree with you. Sometimes it is said that people online talk to those who are just like themselves. It can seem as if we are indeed sheep, so much that I have added to my twitter biography that I am determined NOT to be one of the sheep. Near the end of ASME 2011, Professor Trudie Roberts even warned against the ‘filter bubble’. But just as here at this conference we are prepared to defend our point of view, be prepared to be challenged about what you think online. This is a good thing. Don't be surprised if it happens. Enjoy and relish it.

7. To be supported

 But also expect support from your colleagues. My seventh point is illustrated by the development of a list of women healthcare academics by Prof Trisha Greenhalgh. She is someone who I really hoped would join Twitter after she attended AMEE last year, and then she did. If you want to see how a productive academic can get a lot out of Twitter then follow her. This list was started because we were aware that often women are less visible online. It started as a list of 50 but very quickly rose to more than 100 and is still growing. 

8. To lead

Trisha Greenhalgh was exhibiting leadership and if you are interested in leading your community you should be on Twitter. This is my colleague Natalie Lafferty from Dundee who many of you might know. Last year we held a series of discussions on Thursday nights called #meded chat. We picked the topic in discussion with our community and supported the chats with blog posts which helped pull together the learning. One week we discussed how students and trainees felt about the use of the portfolios to assess competency. We knew that this could be an explosive topic and it was. In advance of the discussion 25 people commented on a blog post with detailed descriptions of their own experience of the use of portolios. Many more participated in the chat. A year later a junior doctor has started a blog NHS eportfolio revolution which is bringing the voices of trainees directly to the AoRMC. If you are involved or want to be involved in the development of policy and you want to connect with your community then one way that you can lead is by being on Twitter.

9. To learn

Getting near the end, my 9th point is that you will learn. When you have worked at developing a network, you will have the benefit of other people curating the best of comment, news and research and directing it towards you. Priceless! 

10. To inspire

And lastly, you can inspire others. Do you know this amazingly busy, and productive man? 

Image: Atul Gawande Video Shoot by stevegarfield


It's Atul Gawande- surgeon, author and researcher. The eloquent Atul Gawande can teach you about how to use Twitter. Last year, I spotted this tweet one Sunday afternoon.

And then Djokovic's confidence evaporated... The rest of the way is a test of who's mentally toughest. Epic.#wimbledonfinal
— Atul Gawande (@Atul_Gawande) July 3, 2011

 Two minutes later I had made my reply to him.

@Atul_Gawandedo you know that Twitter Journal Club is discussing the surgical checklist tonight at 7pm GMT? Please join! #twitjc
— AnneMarie Cunningham (@amcunningham) July 3, 2011

 I invited him to participate in a discussion of his paper in the Twitter Journal Club, a twice monthly discussion of a paper on Twitter, started by a medical student, Fi Douglas, and Natalie Silvey, a junior doctor. This was too good an opportunity to miss. What do you think happened? Well- the discussion started and there was no sign of Atul Gawande. People were making some of the usual complaints about the original surgical checklist paper. It didn't apply to the developed world etc etc. But then he joined in. He started commenting on the discussion. And if you have any doubt about how 140 characters can be used to communicate anything useful watch and learn from this master.

VA surgery study in 74 hsptls scaled checklist thru training. Electronic data & good ctrls. JAMA: Deaths cut 11%+. No Hawthorne. #twitjc
— Atul Gawande (@Atul_Gawande) July 3, 2011

What was the reaction? People were thrilled and informed. Atul Gawande was on vacation with his family but he was able to share his expertise with students and others who asked him questions about his work. He was inspiring. Do you want to inspire others? So this is only a short 10 minute race through how you might be able to contribute through Twitter to the development of the medical education community. Every voice is legitimate from students, to professors. So now I will take questions, but my question to you is what is stopping you from joining this conversation? "

Follow up:

some good introductory blogposts :

A gentle introduction to Twitter for the apprehensive academic by @deevybee

Why should medical students tweet by @fastbleep

Why should trainee doctors tweet by @elaineleung

Case discussion on Twitter: how can we make best practice explicit?

Image by quinn.anya

It's great to see the growth of discussion in medical education on Twitter. Recently I have seen a few really interesting cases being discussed (and a lot being learned), but there have also been some questions about how we together can think about what is best practice in leading these discussions.

Case discussions have always been a very important way of learning in medicine. And as one doctor said, junior staff are still encouraged to submit cases to journals, but it can take many months for a case submitted to a journal to reach publication. In the meantime, social media removes those barriers to publication. We can all self-publish. But we have to be responsible too. I think that all of the people currently involved in leading discussions are being responsible, but how do we make clear to others what best practices we are following? I think that it is important to consider this for a few reasons. First, we have an obligation to all patients to make these discussions safe. Second, we are modelling how to share these cases to other students and professionals.

We also need to think about whether the existing guidance, which in the UK is from the GMC, is sufficient to guide us.

So a few questions....

What should we tell patients about sharing their story? Do we need their consent if the story is not recognisable to others?
When the GMC discuss confidentiality the emphasis is on not sharing information (without consent) that would allow another to recognise a patient or someone close to them. In the new draft guidance on social media the only additional emphasis is on the impact of embedded information such as GPS co-ordinates that would allow us to know from where a tweet was made, or an image taken. 

My own practice is that if I want to share a story about a patient that might allow them to recognise themselves then I ask permission, and I record that when sharing the story. So far this has only happened once and it was in a blog post. How could it be conveyed that a patient was aware and happy that their story was being shared on Twitter? If this is done in a separate tweet then those following the tweets may miss it and wonder if permission has been given. Is this something we need to be concerned about?

What about sharing images routinely made as part of care?


In 2011 the GMC gave additional guidance on the audio-visual recordings. For some images made as part of routine care, such as pathology slides, internal images of organs, and xrays,  then no specific consent to take the images is needed. It is presumed that if the patient gives consent to the procedure then they give consent to the image being recorded. The guidances says that attempts should be made to make patients aware that they may be shared in an anonymised form, but there is no need to ask permission before doing this. This includes for publication in widely-accessible media such as press, print and internet. We can presume this includes Twitter!  

The draft social media guidance makes no additional comment on this so sharing an anonymised image on Twitter for teaching purposes seems acceptable. But images are rarely of much value without an accompanying story. So we are back to the situation above. How much permission is it good practice to obtain before sharing a story? And we have to remember that the real-time nature of social media means that a story about a patient might be shared as it is happening, rather than six months later, so that it is more likely that people may recognise themselves or others.

Other images that are made as part of routine care, but are not part of a procedure, such as an image of the outside of the body, do need specific consent to be given. And again patients should be made aware that these images may be used for teaching or research, but specific consent does not have to be given for them to be shared for this purpose as long as they are anonymised and all identifying details are removed. However, the guidance states that if the image is to be shared in widely accessible media (eg Twitter or a blog) then if the image is identifiable consent must be obtained. If the image has been anonymised then good practice is that consent should also be obtained but," if it is not practicable to do so, you may publish the recording, bearing in mind that it may be difficult to ensure that all features of a recording that could identify the patient to any member of the public have been removed."

What about recording an image to share in an educational discussion on social media?


The GMC guidance which applies here is the section on "recordings for use in widely accessible public media". Here, even if the patient is not identifiable, and has been anonymised, consent must be given explicitly. Paragraph 37 states:
"You must get the patient's consent, which should usually be in writing, to make a recording that will be used in widely accessible public media, whether or not you consider the patient will be identifiable from the recording"
We are also obliged to check with our employers what their policies are. Some trusts prohibit the use of mobile phone cameras by staff to protect patient confidentiality.

If consent has been obtained from patients to share their non-identifiable images online, how can we share that information in a tweet? Can we presume that if we see an image shared on Twitter then the person sharing it has followed the correct policies, just as when we see an image in a journal we might presume that the correct policies have been followed? Should those leading case discussions develop their own policies and make these accessible from their Twitter profile?

Medical education on Twitter is fantastic. There are no professional or geopgraphic boundaries to discussions. And no boundaries to patients participating either! I want to see all that is happening already continue and also for more people to get involved. I think that by considering these issues and showing how we can be safe and transparent we can take these discussions to a new level of participation.

CPD and clinical discussion on Twitter

What do you think might be the risks and benefits of clinical discussion on Twitter? Would you be happy to take part in a discussion like this?

#hcsm review- the global edition

For this week’s edition of #hcsm review I asked for posts from around the world to show us how social media is being use in healthcare, and in relation to health more generally. I received a wonderful selection of posts from all over the world.

Let’s start in the United Kingdom. As I write this the #nhssm discussion is going on. This was started in 2010 by Alex Talbott and a few others and is about how social media might be (and is being used) in relation to NHS services.Here on Alex's own blog he discusses some of the practical lessons being learnt by those using social media in healthcare organisation. And from a different angle, in this storify he describes the concerned response on Twitter of several doctors to the launch of a government campaign to increase awareness that an unexplained cough may be a symptom of lung cancer. Another GP, Martin Brunet, has used his practice blog to explain the background of the campaign to patients and that 'common sense' is needed when interpreting symptoms. If you are launching a public campaign have a good read at these posts.

How else is social media being used in the UK? Vanguard Health are trying to encourage us to look at the systems in healthcare. Here Mark Cannon blogs about what he has got out of the use of social media over the past year, although he ends with the reminder that nothing trumps face-to-face relationships. Thinking more broadly than just healthcare, here @ermintrude2, a social worker who blogs under a pseudonymn, explains why she thinks social care also needs social media, and vice versa. Mental health nurse turned manager, Sarah Amani, tells how she started using social media because her professor in an MSc in health care mangement told her it was the best way to stay up to date with research in the field. She describes some of the many benefits blogging and tweeting have had for her.

Let's look at a few posts by Dr. Mark Newbold, a medically qualified doctor, who is now Chief Executive of one of the largest NHS trusts in England. Here on his personal blog he gives 10 reasons why healthcare CEOs should use Twitter. You will be interested in what happened when his trust decided to have a Twitter Open Day. Who do you think would engage with a chief executive if he said he would reply to all and sundry? The expectation was that the interaction would mainly be from those using the service, but it wasn't. Instead most tweets came from staff, and this has lead to changes which can be implemented quickly. Who do you think would respond if you ran an activity like this?

But what about the voices of those using the services? Victoria Betton is doing a PhD on the use of social media in mental health services. She has just posted an interview with Mark Brown, a mental health campaigner, in 3 posts on her blog. Read all of them, but if you only have time for one read this: Is the NHS rubbish with social media? If you are fed-up of the rhetoric about the use of social media in healthcare then read this now. Do!

But if you only have time to read one blog post from this entire review then read this post about patient and disability activist, Sue Marsh. At the time of writing this post has 63 comments. It describes an incident that took place last weekend and was watched by thousands on Twitter. After surgery Sue discovered she had been given analgesia which she was allergic too. She tweeted about her distress and this resulted in the columnist for a national newspaper, the Daily Mail, contacting the hospital and asking for a senior nurse to review her case immediately. This happened. Last weekend, the Guardian newspaper, suggested you should complain on Twitter for an instant response from companies. This blog post describes how patients may also use social media to get help when they are in acute distress within a hospital. This may be something you have not considered before which is why you should read this post.


Of course, we can't leave out the United States, the more usual home of the #hcsm review. Here is a lovely post by patient turned healthcare advocate, AfternoonNapper, describing what you might get out of becoming an activist: much more than you put in. I think the patient activists I have linked to above would probably agree.
Also from the US, lawyer and HSCM review co-founder. David Harlow, casts his critical eye over the decision by Facebook to start tracking organ donor status. I have to say that I too was slightly cynical when I read about this. David suggests that monetization as much as medicine might lie behind the decision, but he would like to see Facebook throwing their weight behind a presumed consent law.

And now two posts from the other side of the world, Australia. First up, Mike Cadogan, an emergency physician, updates the 2009 analysis to show social media is being used by hospitals in Australia. This is an incredibly detailed post linking to the YouTube, Facebook and Twitter presence of all hospitals there. But Mike is disappointed. Private hospitals are about 10 times as likely to have a social media presence as public hospitals. A bigger question is does this matter? Tim Senior, a GP with a special interest in Aboriginal health and medical education (who I first met through his citeulike presence) reminds us that the digital divide is a reality when he writes asking us to "look in the rear view mirror occasionally". The people who get left behind because they can't or don't access social media, might be those who need healthcare more than any other group.

For a truly global perspective catch this post by Christopher Purdy about the use of social media around the world to promote sexual health.  Here he describes initiatives in Mozambique, Ethiopia, Brazil and Indonesia amongst others.
Closer to (my) home is the upcoming Doctors 2.0 conference in Paris later this year. Joan Justice, HCSMreview co-founder, writes about it here, whilst organiser Denise Silber interviews a physician and marketing specialist from Italy on the future of mHealth in the EU.





Last but not least, a post from Ireland (I'm from the 1/3 of the way down the Eastern coast, just beside the Mourne mountains). Dr, Ronan Kavanagh is a rheumatologist who writes here about why he is a convert to the use of Twitter at conferences. Read and learn about his experiences at the world's biggest rheumatology meeting.

And so concludes this round-up of how social media is being used in healthcare around the world. Tune in next time!

Photo credits :
UK Love by Doug88888
USA flag by FreefotoUK
Ireland by Nasa Goddard Photo and Video
Australia's flag looking like canvas by Chrisser

Your posts please for the global #hcsm review!

So what is #hcsm? The hashtag, #hcsm, has been used for a few years now. It means 'health care social media' and is about the use of social media in relation to health care. Tweets tagged with #hcsm tend to have a US focus, but other areas have started using their own tags too. So there is #hcsmca (Canada), #hscmanz (Australia and New Zealand), #hcsmeu (Europe), and #nhssm (social media in the UK's national health service).

Next, what is #hcsm review? A few months ago I was asked by David Harlow if I would like to help with curating blog posts related to health care and social media. I agreed and next week, on May 16th, there will be a post on my blog helping you to make sense of the posts publish in the previous few weeks. But to get there I need submissions!

I would particularly like to see posts writing about what social media means for healthcare outside of North America. I think the world of my colleagues on the other side of the Atlantic but I think we can all learn from what is happening around the world.

Any questions just leave a comment. Please submit your post through this form:

Facebook and educators- "There be dragons!"

Do students use Facebook for social learning? YES! 

Yesterday was interesting. I listened to an interview with Jon Scott, a researcher/educator in Cardiff University about the need for social academic platforms- that would support collaborative learning, for example students working on group projects together, annotating documents, question and answer forums. Theoretically VLEs like Blackboard can support this. But either they aren't used this way or attempts to use them this way fail. The discussion that followed on Twitter considered that whatever platform was developed should be like Facebook. It should seem as easy to use. It should be somewhere that students wants to be and were anyway. Afterall as a student your social and academic life do often collide in any case. But then it was suggested that Facebook wasn't that easy to use. Most people didn't understand the privacy settings. They probably were not using it for academic work.

So I wrote a blog post asking students if they 'used' Facebook for learning and lo and behold they do!
The uses cover:
1. Private messages (as an email replacement?)- to ask close friends questions and to work on projects in a groups as documents can be attached.
2. The use of peer-led academic content groups where students can ask each other questions particularly in the run-up to exams.
3. Following pages from BMJ learning, eMedicine, medrevise to help with revision
4.The use of private (even secret) groups to work on group collaborative tasks by sharing documents. The notifications side-bar is particularly useful for letting students know when something new has happened.
5. For sharing information from face-to-face small group activities. There is no additional task to be shared but the content is useful to others.
6. Instant messaging! If VLEs were set up with instant messaging this would be a big win. It is one of the features that students like most about Facebook.

And why are people using Facebook?
-Privacy - this is a space that does not belong to the university so the chances that what is being said will be seen by a member of staff are reduced
-Accessibility- there is a lot less clicking on Facebook than in the VLE and it is faster than the VLE
-People are there- most people go in to Facebook every day. There is every likelihood that you will get a fast response to a query. This is in contrast to asking a question in a discussion forum to support learning on the VLE. As one student said; " if I asked a question on there, it would be as useful as talking to a brick wall as there's no one else on there!"

I also asked students if they felt pressure to be on Facebook in order to be able to keep up with peers. Would students miss out if they didn't have a Facebook account?

One student described how a colleague stopped using Facebook whilst they were in the middle of working on a project. That meant a lot more to-ing and fro-ing for the others in the group. Another student said that they weren't aware of anyone objecting to Facebook but if they did then they could manage as long as someone else kept them in the loop by sharing what was on Facebook.

There was also an interesting point made that some students thought that there university might not approve of the sharing of notes within these communities. The same might go for the sharing of exam questions. This reminded me of a post by Dave White on the Learning Black Market. 

Did students worry about their privacy using Facebook? Some did mention disliking the fact that they had to use Facebook but it worked. It was a trade-off they were prepared to make. 

If students use Facebook for social learning then should educators be there too?

Remember yesterday's blog post had emerged out of a discussion about whether an additional social academic platform was necessary and whether Facebook was already acting as that platform. It appeared that to a certain extent it is. The next question is should educators be there too in order to support the social learning that is taking place?

That conversation had been progressing rapidly in tandem! Alan Cann had started a discussion on google + about my post. His opinion " Allow Facebook to be a student owned space. if you want to set up groups to support learning, do it elsewhere". Now in ways this is a little surprising from Alan. His general mantra is "Build networks, not destinations." In Facebook the network is there! The students are there! Trying to take them to another destination that isn't about their network seems slightly doomed.

I'd come across a post by Cristina Costa titled "Why Facebook and teaching don't go together". She makes a few points here. Her strongest contention is that Facebook is not a pleasant organisation and that we don't know how or can not understand how they are using our data. If students wish to organise themselves there then that is up to them, but if educators have a presence on Facebook then they could be seen as giving tacit approval to Facebook. They might also be seen as encouraging students to set up a Facebook account. 

On the other hand, Natalie Lafferty shared a post that Donald Clark had written earlier this year giving 7 reasons why Facebook was posed to become THE social learning platform. But as Natalie pointed out, in a survey in Dundee University, there was a 50:50 split when students were asked if they wanted an institutional presence on Facebook. So the university held back.

At this stage I'd like to state that my attitude to Facebook is pragmatic. I have an account. It is personal. Nearly everyone that I am friends with are people who I have went to school with, worked with, met on holiday, met at university. Oh and family! We have a secret group where we can share pictures and videos and updates that we don't wan't to share with others.

But I have also used Facebook as an academic. I have been involved in using a Facebook group to help recruitment to a student research project. I've set up a Facebook page in the past to share content that I was already posting to Blackboard. A few hundred students liked the page. No one asked to become by Facebook friend and I didn't ask them to become mine. These uses of Facebook did not seem to present any kind of boundary confusion. It didn't stop students using Facebook to support their learning in the ways that they had already been doing.

"There be dragons!"

My fear is that as educators we have ended up demonising Facebook. And we've done this in a few different ways. 

Particularly in medicine, Facebook has been presented as a place where bad things happen and a challenge to professionalism. Have a look at the references on Pubmed. In the piece I wrote for the GMC in advance of the publication of their social media guidance I made the point that the reactions to Facebook seem to approach moral panic, when in fact most people are using it in very civilised ways.

All of this has meant that some, maybe many, students do not trust us to be anywhere near them on Facebook. Jon Hilton has left a great comment which illustrates that the very accessibility that makes Facebook great (2 clicks and you're there!) is also what makes it feel risky. What if a student posts a drunken photo to the wrong group? What if they say something about a lecturer that they wouldn't have said otherwise? Can educators be trusted to respond responsibly to those events? Can we? I would hope that we could. Mistakes are made. People learn. Students and educators both need to learn about digital literacy and digital professionalism, and I think it would be great if we started as we meant to go on and learnt together.

But what about the accusations that it is irresponsible to lead students to Facebook, or to give tacit approval to the organisation. This is a decision that educators need to make themselves. My instinct is that students have decided that they know they are the product. This is a free service and they are paying for it by handing over their information. But it is a trade-off that has value for them. They are prepared to put up with ads for topics they mention in passing. Being off the grid isn't really an option for them. Yes, we don't know how all this information will be tied together and made sense of in the future. 

I also sense that there is a fear amongst educators that their presence on Facebook will be desperately uncool. Private groups that an educator might set up in Facebook might be seen as 'creepy treehouses'. The concept of the creepy treehouse emerged in 2008 just as people were starting to explore the possibilities of social media for learning. But 4 years later how has our understanding shifted? Is it time to explore the opportunities of Facebook in a mature and confident way? Actually, Melanie McBride was arguing that we should do this back then:
"If we do not all venture into these spaces together – as a guided and pedagogically relevant tour – we will become even further disconnected from a student population who are being corporatized at every turn."

We have to be clear to not ask too much of any platform. Can Facebook work with the VLE? Could it be used to support specific pieces of work or just for a big private year group to answer student queries in the way that students are already using it? Any new uses of Facebook by educators shouldn't step on the toes of students who are already doing a great job. 

And because I like to put my money where my mouth is, I decided last night to start a Facebook group to try and learn together with Cardiff University students how we could use technology/elearning better in the course. This could have been done through the VLE. I could have set up different forums for each year group. The students would have been less certain about who was reading their posts. The first thing I posted was the YouTube above which gives quite a very negative view of Facebook. The next item I posted was this screencast about how to check how your timeline looks to members of the public.

Is it time that educators started making timid expeditions into the scary land that is Facebook? What do you think?

Ice, Ice baby- the hidden curriculum around communication skills

A few years ago I wrote a post about the challenges of teaching "communication skills". The YouTube video above is about the Clinical Skills Assessment (CSA)  that doctors training as GPs in the UK take. It emphasised the need to ask patients about their ideas, concerns and expectations (ICE) during a consultation. But it frames the need to do this as a requirement of an exam rather than something that will benefit patients. For example, the first clinical episode described is about a doctor feeling that they have to ask a patient who has symptoms very suggestive of a heart attack about their ideas and expectation of the consultations. This is something that the doctor seems to feel is delaying the patient's care and they may well be right about that.

So what is the take away message? What does this song tell us about how our assessments frame doctors understanding of communication skills?

So students- how do you 'use' Facebook for learning?

facebook business by Sean McEntee

I've been listening to a discussion about whether we need to get more social in learning in higher education. Cardiff University currently uses Blackboard as its VLE (virtual learning environment- we brand it as Learning Central- which is rather aspirational) and like every other VLE there is the potential to be social there. Staff and students can form their own groups and set up their own forums and blogs and wikis. But these social dimensions are not often used.

For staff the university is rolling out the use of an IBM product Connections to encourage us to work in more social ways. And there are some people wondering if there is a place for this to be rolled out to students as well to give them another place to collaborate.

In the past I have tried to integrate the use of web 2 tools into Blackboard- using screencasts social bookmarking - to enhance the functionality of the social tools in Blackboard. You can see a presentation I have about this here. Now, I no longer lead that part of the course and have moved on to thinking about how we can best use technology in the course in general.

But one thing we keep hearing is that students do most of their collaboration in Facebook. So I was wondering if you could tell me about how you use Facebook for learning? Does this really happen? Or is Facebook a place that you organise nights out, and then share the photos afterwards?

Do you feel pressure to participate in Facebook as a student? Or is it just something that is a natural part of your life- you don't even think about it.

Please do comment and share- it would help us all to learn from you.

EDIT: Initial comments are that the social aspects of Facebook, and the fact that it is somewhere that you are already, that make it a clear winner against the VLE. I know this is hypothetical but if the VLE could be like Facebook do you think that might catch on? Or is the fact that Facebook is 'your' space, and that your lecturers are not there, one of the big attractors?

EDIT 2: How would you feel if your lecturers set up a private Facebook group to support an aspect of your course? Would you think that was creepy? That your lecturers were trying to keep an eye on you? Or would you think it was useful?

EDIT 3: I've found this blog post by Cristina Costa saying that Facebook should not be used for teaching. One reason she gives is that we don't know how Facebook uses information so we should be very cautious about encouraging students to use it. She includes this YouTube in her post.

The story of #mysurvey continued

This is the second storify which tells of the background to the twitter survey. Deciding to start the survey was a snap decision. I was probably influenced by conversation the precious Sunday, and the thought that there was no research on this topic. If I had known that there was research would I still have gone ahead? My next post will describe the literature on this topic so far. This is the first survey using social media to look at this topic. Future posts will look at how representative the sample who participated are. If you have any questions or comments please leave them below. Thank you.

The first episode that lead to #mysurvey