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: