My complex professional identities

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

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

Just some thoughts......

Collaborative learning- some questions

This is a short post.

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

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

Teaching Communication Skills

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

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

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

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

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

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

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

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

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

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

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

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

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

PLEs and Medical Students....

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

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

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

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

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

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

Accessing Evidence-Based Medicine

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

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

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

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

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

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

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

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

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

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

Power of social networking....

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



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



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

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

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