The right tools for the job....what to say where and why.

I've been meaning to write a post about how I see different kinds of social networks fitting together and was thinking about how to structure it when lo and behold Harold Jarche linked to this post on his own blog this morning. I've posted his model above.

When I started blogging and tweeting in 2008 my aim was to find other people interested in medical education to connect with. I found some but from the start my external networks have been much more diverse and therefore fruitful that if they were just made up of people interested in people interested in medical education. These are the yellow networks in the diagram above.

Since I was appointed academic lead for eLearning in the medical school in Cardiff University, I have felt the need to try and develop a community of practice with those in similar positions in medical schools acoss the UK. So I started a LinkedIn group called eLearning in Medical Education- not very original! I knew that many of the people who I wanted to join this group were not yet on Twitter or blogging. And I thought that we needed a space that would allow threaded conversation. A few years ago I might have set up a Ning - but this would now cost me £36/year and I don't think it is a format that people are very familiar with in any case. On the other hand, LinkedIn is a social network which those who are aware of it know is work related. So far there are more than 50 members of the group with a reasonable representation of medical schools across the UK. A few medical students have also joined and made some great contributions. I set up a few polls eg Which VLE are you using in your medical school so that newcomers had very non-threatening ways of joining in. And so far the group has been very useful to me at least! It is too early to say that it is a community of practice but it is developing.

And then there are the tools that I use the project teams I am part of within the university. In Cardiff University we have access to IBM connections, a social business solution. The latest version is about to be rolled out. I am going to attempt to use this to share task, project management, information, ideas and developments with all those throughout the university, and in the medical school in particular, who are interested in how we are using technology in the existing course and as we approach a new curriculum.

There has been a lot written recently about the failure of internal networking platforms. A post in the Harvard Business Review last week suggested there is no simple explanation for the poor uptake of internal social networking platforms compared to informal social networking like Twitter and Facebook. A multitude of factors might be responsible including "investing in technology with no clear intent or use in mind" (but who knew why they were signing up to Facebook or Twitter when they fist did? and do all of those corporate accounts know why they are there?). The comments are also well worth reading. One of my favourite comments is the first one "Information flow among desk-sized fiefdoms is usually not free. Attempts to lower the price are almost always met with resistance." The reason that people don't attempt new ways of working is because the cultures of the organisations that they are working within do not give them messages that this is supported and valued. But this intransigence is being challenged by an increasing emphasis on social approaches external to the organisation, and the realisation that to be, as Lee Bryant says, 'social on the outside' also needs good connections and the free flow of information on the inside.

What does 'social on the outside' mean for a university? Who should we be relating to externally as an organisation and as individuals, and as a medical school specifically? Most of the posts on this blog,and the links here, are about me relating externally to other researchers, educators, medical students and patients and a public across the UK and the world. If as educators we are to help students develop digital literacies then we need to consider how these literacies fit with our own identities as researcher and academics and health professionals. And internal social networking platforms may be a safe place to explore identity and utility.

If health organisations also actively engage with 'social on the inside' solutions then perhaps this may impact on how the NHS engages with the use of social media externally. Perhaps.

Do the organisations that you work within provide you with the spaces you need to work with others effectively? Do you think that internal social networking platforms are a waste of time? And is social over-hyped?

EDIT: 24/2/3012 It is really work checking out this post by lecturer in digital media Dr Kelly Page, a colleague in Cardiff  University, on "Social Ways of Working in Higher Education".

Are medical schools abusing 'fitness to practice'?

In 2005 the GMC introduced guidance on 'Professional values and fitness to practice' for medical students. Some have said the notion that a student could be 'fit to practice' is nonsensical....as they aren't licensed until after graduation. But the case has been made that medical students are placed in a position of trust with regards to patients and public as students so they should be held to higher standards than other students.

However, a conversation on Twitter today suggests that some medical students feel that medical schools are abusing their responsibility to ensure students 'fitness to practice' by threatening to carry out FTP procedures for what students perceive as minor misdemeanours  such as missing a day on placement.

You can find the fitness to practice guidance of many medical schools online. They specify serious and severe health and professional issues, but often have a line which says 'and any other matter which may call into question a student's fitness to practice'. This ambiguity is retained in a lot of professional guidance because it is impossible to specify every single circumstance that may mean that concerns would be justified, but it may be that this alarms students as they feel that the guidance then leaves too much leeway to the medical school and potential for abuse as suggested.

So do you think that medical schools are becoming unnecessarily disciplinarian? If so what is driving them to do this? Or are standards slipping? Were higher standards expected of medical students 'in your day'?

UPDATE: Thanks to @jomciver for this link to a very helpful blog post from senior staff in Birmingham medical school on what Fitness to Practice means (and what it doesn't)  and how they are trying to make the process clearer.

Would you block your patient on Twitter?

Road Block, a photo by PSP Photos on Flickr.

@amcunningham I see the logic of not being friends on FB, but if a pt. follows you on Twitter, should you block them?#DifferentPlatform
— WelshGasDoc (@welsh_gas_doc) February 6, 2012

This question came about because I had tweeted a link to some research which had shown that 1/3 of practicising physicians, who responded to a survey (with a 14% response rate)  and said they used Facebook , had been issued with a friend request by a patient or their carer. This was much higher than the level reported in more junior doctors and medical students.

So should doctors refuse friend requests from patients? I have never had a Facebook request from a patient but if I had I would explain that I keep that account for close friends and family. A Facebook request can just be ignored which is an essentially passive act.

But I wouldn't block a patient from following me on Twitter. My Twitter presence is not orientated towards patients but I don't think that they would find anything shocking or surprising in my tweets. It would give them an insight into what I do when I am not in the practice. I consider that patients, or colleagues or students might read everything that I write here or on Twitter or anywhere else publicly online so I wouldn't worry about that.

A few people did think that patients should be blocked however. We discussed that this wouldn't necessarily stop them accessing the tweets as one only has to look at the profile instead. And blocking someone on Twitter is quite a hostile and aggressive act. I think I would find it hard to explain why I was doing that. One doctor said that he had blocked a young, female patient from his Twitter account because he wanted to set clear boundaries.

Another option, as the BMA guidance on the use of social media suggests, is to consider protecting your Twitter account and only allowing approved followers to see Tweets. In my experience the vast majority of doctors in the UK do have public accounts and I don't know if patients accessing tweets is a factor for those who choose to protect their accounts.

And how would I respond to a patient asking me for information on Twitter? Say they asked me where was the best place to find information about diabetes? Well, I would reply and point them to some good sources of information. And what if they were to ask me about their medical condition? If they were following me I would send them a DM advising that I can't give medical advice on Twitter but to get in contact with me in the surgery. I'd also advise them that their tweets are public and that that they might want to be careful about sharing sensitive information so it might be best to delete them. Normally I wouldn't send a DM to someone who I was not following as they would not be able to reply. But I think that in this case it might be the easiest way to deal with the situation. I wouldn't feel comfortable talking to a patient about a medical problem in 140 chtrs even if they were private messages. Essentially, I would treat a patient no differently to any other person I meet on Twitter. And since many people do not use real names on Twitter, and I have no way of remembering the names of all the patients registered with our practice it would be an impossible task to block all patients anyway.

I wouldn't follow my patients on Twitter. But perhaps I will change my mind about this. Perhaps following people from the area could give me better insights into what it is like living in the area and how I might be a better advocate for the community. Have no doubt however that the digital divide is real. A few weeks ago we were having a #nhssm (NHS social media) discussion on using video services such as Skype with patients when Evan Hilton, the executive director of Gofal, the Welsh mental health charity tweeted about the issue of digital in/exlusion in the South Wales valleys. He followed it up with this statistic:

@buzzumi @amcunningham in context of community based mental health services @gofal_ less than 10% of service users on line at home
— Ewan Hilton (@EwanHilton) January 18, 2012

Our patients face many challenges (often beyond their control) in staying health or living with illness. We haven't yet figured out how social media can be best used to help them but perhaps there is a case for not putting more blocks in the road. What do you think?

Doctors getting people back to work

The YouTube video above was shared by the GMC as part of their pre-consultation on updating the guidance on Good Medical Practice(GMP).


Reward to doctors for getting patients back to work is not mentioned in the draft version of Good Medical Practice.  However, for the first time the GMC guidance to doctors includes specific mention of encouraging patients to stay in or to return to employment. I am not aware of the reason why this has been included at this time. The wording is


"51 You must support patients in caring for themselves to empower them to improve and maintain their health. This may include encouraging patients, including those with long-term conditions, to stay in or return to employment or other purposeful activity. You may also advise patients on the effects of their life choices on their health and well-being and the possible outcomes of their treatments."
(my emphasis)


This is specifically raised in the consultation questionnaire:

"At paragraph 51 of this section, we advise doctors that they must support patients in caring for themselves to empower them to improve and maintain their health. This is essentially the same as GMP 2006. But we also now say that such support may include ‘encouraging patients, including those with long term conditions, to stay in or return to employment or other purposeful activity’. 
30 Do you agree this is a reasonable expectation of doctors "


What do you think of this guidance to doctors? The consultation closes on Friday 10th February 2012. Any member of the public can take part.  Find out more here including the link to the e-consultation.



"Doctors to encourage long-term sick to return to work" Daily Mail 1/11/2011
"Who is in charge of doctors and consultants- the DWP?" Twisted News 1/11/2011

"New section of the Department of Health" Jobbing Doctor 1/11/2011

"Work guidance for long-term sick" Guardian 1/11/2011 

More thoughts on doctors' morals

Moral Compass by psd


I wanted to write a quick post to follow-up last week's discussion on the GMC consultation on Good Medical Practice. Several doctors commented that they were concerned that the line which said that they should act "at all times" in a manner that would not reduce trust in themselves or other doctors left them open to possible persecution over lifestyle choices.
For example Ditzy wrote:
"Most of us are up in arms over the ambiguity of what activities, in their private lives, the GMC felt was appropriate for them to regulate. A one off drunken dancing on the tables at the village pub? An affair with a married person? Multiple sexual partners? Frequenting the bookmakers? Falling out of nightclubs every Friday night? There simply is no guidance and any of these actions could, potentially, be said to bring the doctor and the profession into disrepute although none of them are illegal. "


I decided to go back and find out what the reaction was to the introduction of this clause in to the 2006 version of Good Medical Practice. The results of the official consultation are available here. This includes feedback from doctors and the wider public on the 2005 draft document (which unfortunately I can not locate). They note that:
"While honesty and trustworthiness within the doctor-patient relationship are perceived as important by the public, most people no longer appear to expect doctors to demonstrate moral excellence in all aspects of their lives, and it is widely recognised that they are ‘only human’. Some doctors also felt that expectations of probity, as set out in the draft document, are no longer appropriate."


So the GMC recognised in 2006 that the public did not expect 'moral excellence' of doctors. 


But when the guidance was published it was reported in the Guardian, by Sarah Bosely, as being a "tougher ethical code". Why was this? Jane O'Brien, Head of Standards and Ethics for the GMC, is reported as saying that the GMC had been criticised for not giving clear enough guidance to doctors in the past, for example, about how long after a professional relationship ends would it be appropriate to start a sexual relationship with a patient. But Good Medical Practice was not intended to be a rule-book.
"The guidance encourages doctors to think through their behaviour, and is not a set of rigid rules by which they can be judged - which may leave the GMC open to criticism. "We don't think there is a way of making guidance that would provide that absolute boundary," Ms O'Brien said."


An article by the writer Dea Birkett in the Health Services journal, commenting on the 2005 draft policy was very clear that she did not want to know what doctors got up to when they were not at work. Her suspicion was that the guidance had been updated to make it more 'politically correct'.


But what has the reality been? Are doctors being sanctioned for legal sexual activity that might be frowned upon by the public? I haven't reviewed all the Fitness to Practice procedures which are published on the GMC website but there are some accounts in the press. A trainee anaesthetist was suspended for 9 months after accessing (legal) hardcore porn on a hospital computer. Another doctor who had an 'inappropriate' relationship with a patient for several years, and who was cautioned for kerb-crawling, was not suspended.


In the past year, 43 doctors were referred to a GMC hearing  for 'indecent behaviour' but the outcomes are not described. Having reviewed some fitness to practice proceedings it seems likely that these are serious events such as the sexual assault of patients. It seems that it would be very unlikely that having an affair would be deemed 'indecent behaviour'.


In summary, when the current version of Good Medical Practice was introduced there were concerns from the doctors and public that it would involve holding doctors to an exceptional moral standard. However, there is no evidence that doctors are being reprimanded for the types of behaviour which Ditzy has raised in her comment.


Does this reassure anyone? 

"at all times..."

 
The Passage of Time by TonyVC


The GMC, the body which regulates doctors in the UK,  is consulting on the next version of Good Medical Practice. The consultation ends on Friday, 10th February, 2012 and you can learn more here. Since 2005 Good Medical Practice has been the core guidance for doctors on how they should act professionally. In a previous post written almost exactly 2 years ago I discussed the fact that  the guidance states "You must make sure that your conduct at all times justifies your patients' trust in you and the public's trust in the profession." but does not make clear what kind of conduct might be expected to reduce confidence in a doctor or doctors as a whole. It is perhaps deliberately vague.


The last version of Good Medical Practice was issued in 2006. Times have changed since 2006 and in this consultation the GMC have started using social media to spread the word about the consultation and get some informal feedback. They have started a Facebook page and a twitter account, @gooddoctoruk. 


There has been a lot of discussion of the consultation on Twitter, primarily around how much doctor's lives outside their hours working as a doctor should be regulated. Do we have to be professional "at all times"?


To get the debate going Shree Datta, co-chair of the British Medical Association's Junior Doctor's Committee wrote a piece on her thoughts around the current guidance on conduct outside of work. She thinks that in the current guidance there  is "little reassuring detail" about what might be considered appropriate or inappropriate. She says: "The simple fact is that people make mistakes and it is unrealistic to expect doctors alone to remain flawless at all times in every aspect of life. Yet the current guidance suggests that that is what is expected of doctors and arguably does not ringfence our privacy or allow for our personal autonomy."


The GMC then asked the question "Do you think the GMC should regulate doctors lives outside medicine?" This was the response from 1167 people. 94% said No.

The GMC have responded to this saying:

"Most commonly fitness to practise cases citing this paragraph arise where doctors are convicted of criminal offences, accept cautions or equivalent sanctions across the UK. But occasionally we also take action on doctors’ registration as a result of doctors’ behaviour in the public sphere, which while not illegal, may undermine patients’ or public trust in the profession.

The rationale for this has always been that patients need to trust their doctors absolutely. Many patients will be vulnerable when they seek medical care and need to be able to trust doctors implicitly.

For the doctor/patient relationship to be successful, patients must trust doctors to be honest and to act with integrity in their patients’ interests. Patients do not want their doctors to have criminal convictions, particularly for violent or sexual offences, and they may not want to be treated by a doctor whose conduct they find morally repugnant or unacceptable. For example, many people would not want to confide in, or agree to be examined by, a doctor found guilty of crimes relating to child abuse or child pornography, even though there was no evidence that the doctor was clinically incompetent."

The comments that the GMC have shared from people who said No in the poll suggest that they thought that there were being asked about the regulation of activities which would usually be considered legal. But by their response it seems that the GMC think that this question also relates to taking action if a doctor is convicted of illegal activity.

Now we have gotten to the stage of the official consultation. Here is the question that doctors  and others are asked to respond to:

"In September 2011, 1,167 people responded to our online poll asking how far the GMC should go in regulating doctors’ behaviour outside medicine. The vast majority (94%) thought the GMC should not take action against doctors for their conduct outside medical practice. We think that if a doctors’ conduct undermines trust in the profession. It should, in some cases, lead to action on their right to practise medicine. (This approach is also taken by other health regulators in the UK). We therefore think it is important to make this clear in Good Medical Practice (see paragraphs 67–8 of the consultation draft).

Do you agree that the guidance achieves a fair balance in terms of the GMC’s role and remit?

Yes      No      Not sure"

This is section 67-68

67 You must be honest and trustworthy in your professional practice.

68 You must make sure that your conduct at all times justifies your patients’ trust in you and the public’s trust in the profession.

This wording is actually very similar to the current version which can be seen here. 

On Twitter some have suggested that since the GMC "did not get the answer they wanted" in the pre-consultation they have simply asked the question again. The GMC have responded through twitter that the pre-consultation activity was just that; a full consultation was still needed. But it is interesting that the strength of feeling about the question above has made it into the official consultation documents.

So are we experiencing a shift in how doctors think they should be regulated? Do we think that as long as we conduct ourselves appropriately during the working day then it does not matter what we do out of hours?  Should the GMC take any action against those who receive a criminal conviction? What does it mean to be professional in the 21st century? 

It's certain that this topic is going to be discussed for a long time.


By the way, if you look at my old post you'll see that whether patients trust doctors seems to be based on their interactions with them as a professional. We don't know what impact other factors have.


EDIT: Initially this post stated that the poll was of 1167 doctors. This was wrong. The poll was open to anyone and it is not known how many respondents were doctors.

exploring sliderocket

I came across sliderocket today and thought it looked very interesting. I found it browsing chrome extensions and it can be used as a Google app. There is also education licensing. There are interesting features like extensive analytics, feedback and polling allowed in presentations. But ... not in the free version. So this shows some of the more limited features.

What do you think? Any experience with this?