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 In the new draft guidance on social media the only additional emphasis is on the impact of embedded information such as GPS co-ordinates that would allow us to know from where a tweet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.