A twitter conversation with UK medical students about empathy

Antidepressant prescribing in England: variation may not be as great as Guardian map suggests.

The Guardian published a story on March 5th, 2011, showing that the crude rate of anti-depressant prescribing in some areas of England was more than 3 times higher than in others.The highest rate of prescriptions was in Blackpool, and the lowest in Kensington and Chelsea.
The data was from publicly available sources and is linked to from the Guardian website. The journalists give this description of their method :
"How did we arrive at our figures? First, we gathered prescription data from the online database managed by the NHS Information Centre.

This quarterly information was compiled to get annual numbers covering 1 April 2009 to 31 March 2010 – the most recent full year with available data. In order to make the numbers comparable, we then linked the raw prescription numbers to the ONS mid-year population estimates.

This allowed us to calculate the prescriptions per 100,000 figure in the data below, which controls for the different sizes of PCTs, if not their different levels of wealth, employment and general illness."

The data is also not age standardised. In the comments section some have suggested that in areas with low numbers of prescriptions doctors may be prescribing several months prescriptions at one time. I have looked at the most recent data set available (July-August 2010). Data is available on the total cost of the prescriptions as well as the number of prescriptions and these are plotted below.


This shows a clear correlation between number of prescriptions and cost. However when one looks at individual PCTs the average cost of an antidepressant prescription in Kensington and Chelsea PCT is £7.01, whilst in Blackpool PCT it is £3.48. This does suggest that either more expensive antidepressants are being prescribed in Kensington and Chelsea, or more months prescriptions are being given at one time. Since the absolute number of prescriptions in Kensington and Chelsea is so much lower than in Blackpool, it may be that more antidepressants are being prescribed in each prescription. 


When looking at datasets it's good to make use of all that is available.


You can find my spreadsheet here.


EDIT 4.20pm 6/3/11 I've calculated a rate of prescribing of antidepressants per 1000 of population over 19. (This is not ideal as some teenagers may be prescribed antidepressants, but more accurate than using the total population including children). This has been plotted against average cost of antidepressant prescription. This shows that Blackpool and Kensington and Chelsea are outliers. 

There is not a strong relationship between cost of prescriptions and number of prescriptions. This may explain some of the variation between north and south of England, but the long-established relationships between deprivation and depression are likely to have greater explanatory power.


Here is a link to some papers on that relationship and a very interesting report (via @coxar) on the relationship between antidepressant prescribing, poisoning by antidepressants and deprivation.

If something is shared do you value it less?

Image: Sharing the juice by zummersweet

If you listened only to those I know online, who are interested in learning, you would think that the world believed in trying to make and share educational content as easily as possible. But that is not always true.  I have participated in discussions where it has been suggested that students might think that a course has less value if the content is freely available. The usual response is that  a student should sense more value in participating in a course,  than that which can be derived from easily shared online content. There should be more to it than a few lectures.

This morning I saw a tweet about a lecture on health inequities in the London School of Hygiene and Tropical Medicine. My immediate thought, which I tweeted back, was that it was a pity that the lecture wasn't more widely available (recorded, shared and able to be embedded in a blog) since the topic is so important. The things is that I've started getting a little spoiled. Last week I was able to watch sessions from the Foundation for Informed Medical Decision Making (FIMDM) conference in Washington DC here, live as they were being streamed, and for free. Last year, I watched many of the sessions in a 2 day conference on "Innovation in the Age of Reform" and you can too now, because those sessions are still available here. That conference was organised by Swedish . I had never heard of them before but I have now and so have you.

Lecture capture is becoming so easy to do that most universities have started already. And if you have the lecture then why not share it? Many are. iTunesU is one way of  sharing your content freely with others. Cambridge, Oxford, Harvard and Yale are some of the universities already sharing with iTunesU. MIT have a whole website devoted to sharing 2000 of their courses. So all of these institutions have decided that there is something to be gained from making some of their content freely available. Maybe they believe that it is morally right to share, or that is will garner them positive coverage, or attract future students.

Anyway, the doctor I was speaking to thought that it wouldn't be appropriate to share material from a post-graduate course that someone was paying for. I asked if she thought it would devalue the course and she said yes. So, away from the echo chamber that I seem to inhabit more often I wanted to ask how you would feel about paying to attend a course where some of the materials were made freely available to others. Would it put you off? Would you feel proud that others could see the high standard of teaching you were receiving? Would you feel glad that your fees were helping to share knowledge around the world? Or would you feel cheated?

Intimate examinations without consent- it's still happening.

Image: Exam Room by Maggie Osterburg

Having an intimate examination can be uncomfortable enough, but the thought that a medical student might be examining you without your clear consent is hard to accept in 2011.Although Canada only introduced guidance that explicit consent from patients was needed for pelvic examinations  less than six months ago (and following much dissent in the press), in the UK and Australia this has been established policy for many years. But researchers from Cardiff and Dundee universities who were exploring UK and Australian  medical students 'professionalism dilemmas' found that the students often told stories of performing intimate examinations without consent. Sometimes they challenged being asked to perform an examination by a doctor-tutor, but more often the stories were of going along with requests despite knowing it was against their school's policy.
The researchers conclude that having a policy is not enough to change the behaviour of doctors who request students to practice examinations of patients without consent despite clear guidance which says this is wrong.
So where next? To try and quantify how common some of the professionalism dilemmas such as this are, the researchers are now carrying out a survey of all medical students in the UK which can be found here, and have set up a Facebook group to support the research. They also hope to study why the policies have not had the impact on doctor-tutors that would be expected.

Press Release from University of Dundee.

EDIT: Annabel Bentley has suggested that action needs to be taken. What do you think?

Rees CE, & Monrouxe LV (2011). Medical students learning intimate examinations without valid consent: a multicentre study. Medical education PMID: 21251051

You can see some of the discussion about this on twitter via @storify here. 

What I have learnt about Twitter.

Image:  Greenfinch singing - Carduelis chloris by Rob Baldwin


A week or so ago I was listed in a BMJ Careers article as a "health professional to follow". That's quite an honour, so I thought I should write a short post to share my Twitter learning.


My first tweet is recorded here. It was on 27th May 2008 and was "preparing for a seminar on medicine and the media- thinking about health 3.0". I had just received an invitation to Twitter from a friend who works in IT. He has never quite got the twitter bug and I didn't for a few more months either.


Twitter was just one of the strategies that I chose to use to try and find (and develop) a community of people interested in medical education online. I had been to two medical education conferences in the summer of 2008 and I wanted to keep talking and sharing. My first move was to start this blog back in October 2008.(Lesson no1:  If you want to get the most out of twitter then start a blog. It doesn't matter if you don't write anything for months, you will have somewhere that allows you to share your ideas in a longer form. Twitter lets you find people but for real conversations and learning you need something that allows for  discussion and that is a blog.)


I started following two distinct groups on Twitter- those interested in learning and education, and those interested in health - much wider areas than the narrow field of medical education that I was first searching for. This has been a "good thing". Having a network which is diverse by interest and geography has maximised what I have got out of twitter. (Lesson no2: Don't just follow people like yourself on twitter. Diversify your network.)


I have tweeted a lot! But there are some things that I don't tweet about, namely anything that could break the confidentiality of the students I teach or the patients I care for. Now and again I mention something personal but rarely. I am aware that my tweets are there forever and I want to be comfortable with anyone from my mother to my boss reading them. (Lesson no3: Twitter is always public).


Lastly, twitter is good for bite-sized conversation. Don't try to make it do more than that. Tweet chats like #nhssm (NHS and social media) are good for finding people but unwieldy for learning. If you find yourself getting into a long conversation on twitter then you probably need to write a blog post instead! Then you will have the record of your thoughts and those who comment forever. Tweets can be hard to archive and find again. (Lesson no4: Twitter has limitations)

I hope that is helpful. Do you have any questions about how I use Twitter or anything you would like to share?

Sharing hashtags for upcoming medical/health conferences.

Earlier Annabel Bentley, @doctorblogs, was wondering if it was possible to find a list of upcoming medical or health conferences- and more importantly the hashtags that would be used to cover them on twitter.

Anyone got recommendations for following medical conferences on Twitter? My eg: follow #ev2010 1-2Nov! http://bit.ly/afFXVF @bmj_latestless than a minute ago via webannabel bentley
doctorblogs

I'm not aware of a solution yet so I made this google form and spreadsheet. Get sharing! Oh- and if a better resource exists already,  then share that too!

EDIT: 16/11/10 I've just been shown Lanyrd by @helenpullen - it's the perfect solution!

Should the NHS be on Yahoo Answers?

Last week Leigh Blackall and I agreed that patients needed access to high quality information on the internet but we disagreed on how that would happen. He mentioned Yahoo Answers and I and many of those I know on twitter responded sceptically. Why would ANYONE look to Yahoo Answers??!! But my experience of looking for information online is most often centred around knowing the diagnosis. If you are trying to make sense of your symptoms then it is a whole different ballgame. So I decided to make a short screencast to show what the experience might be like.
What should we do about this? Make the existing NHS websites more user-friendly when checking symptoms? Develop better tools for symptom sorting? Make sure that the relevant NHS pages are serach optimised? Or should the NHS be patrolling Yahoo Answers?
I'd love to know your thoughts and feel free to share any stories. But remember this is a public site and others will be able to read it after you!
EDIT: After Fi's comment below I feel I should add that I think it is unlikely that patients will find a diagnosis online but they should in a sense get good triage information. Is this a serious symptom that I need to go to the doctor with, or can I leave it for a few months to see if it goes away?
I've blogged about fear of Dr Google before. We should be helping Dr Google to perform better, and we should be able to give guidance to patients on where they can get sensible information online.