Renal #meded on Twitter

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 In the new draft guidance on social media the only additional emphasis is on the impact of embedded information such as GPS co-ordinates that would allow us to know from where a tweet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

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?

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.

Crowd Sourcing Medical Education

Today I received the following tweet from a Maltese medical student, @karambinu :
" i need help in finding web tools for medical education....do you have any ideas I could start off with?"

So how can we find and share the best resources for medical education online? There are lots of great curation tools emerging like scoop.it but where to find the best content to put there?

A database might be useful. But how to crowdsource it? Below is  a google form which I've just set-up. You can see the results here. And here is a scoop.it for cardiology in #meded which shows how you might want to use the results.  This is only a start. What would be a better way of doing this? If you have any ideas please leave a comment. And if you use the spreadsheet to curate leave a link. And don't be afraid to publicise your won work!

Digital professionalism... if only it were that easy

Image: Doctor reading articles by rosefirerising

The longer I am online and the more I become immersed in being online the more complex this existence seems.

I want to talk about some principles for "Digital Professionalism" which have been put forward by Rachel Ellaway in the journal Medical Teacher last year. The journal is paywalled so I am going to give the principles here.
The 7 principles are:

Principle #1: establish and sustain an on online professional presence that befits your responsibilities while representing your interests. Be selective in which channels and places you establish a profile.

Principle #2: use privacy controls to manage more personal aspects of your online profile and do not make anything public that you would not be comfortable defending as professionally appropriate in a court of law.

Principle #3: think carefully and critically about how what you say or do will be perceived by others and act with appropriate restraint in online communications.

Principle #4: think carefully and critically about how what you say or do reflects on others, both individuals and organizations, and act accordingly.

Principle #5: think carefully and critically about how what you say or do will be perceived in years to come; consider every action online as permanent.

Principle #6: be aware of the potential for attack or impersonation, and know how to protect your online reputation and what steps to take when it is under attack.

Principle #7: an online community is still a community and you are still a professional within it. The call for ‘is there a doctor. . .’ may come online as well as on a ‘plane or in a theatre’.

 To me these are good starting points, but as someone active in the space, I can see that these principles only take me so far. I'll write more in my next post but I wonder what you think of them now. Please comment.

Talking to medical students about social media and medicine

This afternoon I had a short session with about 25 medical students talking about social media and medicine.We had a general chat and discussion around twitter and blogs and I also used this short presentation.

Policing YouTube: Medical Students, Social Media and Digita Identity

View more presentations from Anne Marie Cunningham

A few snippets from the discussion:
-all students had a Facebook account
-most had adjusted privacy settings, some hadn't because they didn't know how or weren't worried as they rarely used
-some had heard about FB profiles being checked by recruitment firms but were unsure if that happened in medicine
-all thought it was inappropriate to become friends with a patient on FB.
-there was a lot of discussion about how or why we might keep different aspects of our identity separate from our professional identity, eg being political
-no students used Twitter
-we thought that @shazmo showed great ingenuity in using her Twitter learning network, as described here.
-there was surprise that doctors sharing pictures of the 'lying down' game on FB had made it to the press, but were not surprised that they were 'let off'.
-there was a feeling that students did not need guidance about how to use FB for example. This was 'common sense' and there was a feeling that guidelines may represent the more general encroachment of medical education in to apsects of life outside medicine, in the same was as other discussions of 'professionalism'.
- thinking about the paper of Farnan et. al, there was surprise that the medical school changed its mind over what was appropriate. We thought this reflected general ambiguity over how to use social media.
-they wondered what it was like to be a medical student before the internet. I told them about Index Medicus.
-we wondered how technology would affect our work in the future. Would we be skyping with patients. This was thought to be unlikely but it was thought that when with a patient we might use video-calling to access a sepcialist opinion for a patient.
-the main reasons for not thinking that telemedicine would be useful were: duplication (time spent discussing remotely and then face-to-face), not being able to examine the patient, and why bother as doctors and patients are local so why not benefit from richness of face-to-face communication
-there was mention of this New Scientist article on 'digital souls'
-the TV series Junior Doctors told a story, as all media do. The difference is that with social media you might be able to tell your own story.

A big thank you to the group. I learnt a lot from you. If I've forgotten anything- let me know!

"I'm sorry to have to tell you this...."

Empathy by The Shopping Sherpa

Another Sunday morning, another stimulating conversation about medical education on Twitter.

It started with a tweet from Dr. Jonathon Tomlinson “To say you cannot learn insight and empathy is like saying you cannot learn science or a new language. Possibly true, but very sad.”

So can we teach empathy? What do we mean by empathy? A good review of the complexities was published earlier this year by some researchers from the University of East Anglia. They suggest that we might be better to step away from the concept of empathy and instead just focus on etiquette. It's a provocative read.

I wonder if teaching empathy isn't like teaching clinical reasoning. We need to first think of empathy as a disposition before concentrating on the skills. The following quote comes from a just-published study on how physicians think about clinical reasoning in students, is it an ability or a disposition? : "The ability-disposition distinction highlights the difference between teaching knowledge and skills, referred to as teaching-as-transmission, versus teaching attitudes, modifying personality and changing behaviour, referred to as teaching-as-enculturation."

So how can we transmit what we think is important to others about empathy? A few years ago,  I blogged about a communication skills session that I was teaching. I was aware of how this session on "breaking bad news" had to some become formulaic. But an interesting discussion did occur and we all questioned our thoughts and approaches to the topic.

Just as Krupat et. al suggest that in order to develop clinical reasoning we need to focus on  "encouraging self-awareness and mindfulness, modelling open discussion and inquiry, accepting doubt and uncertainty", I'd suggest that the same is true of developing empathy.

What we do not want is for students to leave thinking that empathy is just a set of behaviours. As this doctor tweeted: ""Empathy by rote" is a ridiculous concept. It's like teaching somebody to be "happy". Faked empathy is insulting."

Another doctor replied that to his mind one of the worst examples of this was: “ to score on 'empathy' student said 'sorry it has to be me to tell you this'”. The doctor was shocked as he saw this as the student putting “professional discomfort before patient distress”. It’s this kind of situation that we exactly need to tease out when talking to students about empathy and communication.

In a comment on a blog post by a doctor about breaking bad news, a patient writes of her feeling when she was told she had a serious condition. She explains how the doctor “As he spoke, he began to sip little bits of air in between his lips. This suggested to me he was feeling emotions as well. It made him more human and incredibly compassionate. I loved him for that.”

For some patients showing that we are human and have emotions to will be right. For others it might be seen selfish. They might want us to have ‘professional distance’, to just get on with the job. How with someone that we don’t know well can we figure out how to be? Do we have to accept that sometimes we will just get it wrong and that etiquette is the best we can aim for?

I don’t expect to reach the answers to those questions through this blog. But they are the kind of issues we should discuss with students when we are in real-life situations, so that we can help them to start developing their sensitivity to communication and their inclination to becoming good communicators.

More tweets can be seen in the storify here.
Regina Holliday tells the powerful story of a doctor who seems to lack all empathy here.
Excellent post on empathy by oncologist, Robert Miller, here.
Previous posts on medical students' thoughts about teaching and learning about empathy:
A medical student's thoughts on empathy and #meded
A twitter conversation with UK medical students about empathy

Reflection and Portfolios

Do you agree with these medical students and young doctors?

Location and Learning

Image: SP Nurse on the Job by dharder9475
In the last few weeks I've been thinking about how we can support the learning that takes place when medical students are on placement. We know that entering wards can be a daunting experience for students. They don't feel part of a team. They don't know who everyone is. They don't understand what is happening. They don't want to interrupt nurses attending to patients or junior doctors catching up with paperwork at desks.They see other members of the team wandering in and out of the ward but they don't know what their role is. They don't recognose the social worker or the pharmacist or the OT.   They might not even know what their own role is. They miss out on opportunities to attend meetings and teaching sessions because they don't know they are happening. In fact they spend too long waiting around for someone else to turn up to teach them, and on activities that have little educational value. They generally have a haphazard learning experience.

But placements are very rich environments with many unique opportunities to learn.

So what can we do?

Imagine instead that before coming to the ward the students had access to a network which let them find the profiles of all the staff who worked on that ward. They could see the timetables for teaching. They could even see what the last students who had been on this placement had seen and learnt. They can select what they would they would particularly like to gain from the placement, and this will become part of their profile which will also be available to all the staff on the ward. The network will also contain links to information about initiatives that are happening in the ward to address patient safety and quality improvement. They students can see if there are opportunities for them to get involved in this work and learn about the input their colleagues have had in the past.

When they turn up on the ward the students check in. They can see the profiles of the staff who are working there and when they should be finishing, when they will be on call and what clinics or theatre sessions they will be doing that week. Their calendar updates with activities that are happening that day that they should know about.

The network that they are tapping into is the same one that all the staff in the hospital use to keep themselves up to date. The students can record their learning and their thoughts about how the ward works. Their input is valued by the staff on the ward and their fellow students from other disciplines.

Do you think this will happen soon? Why hasn't it happened already? And how could patients use this network?

A medical student's thoughts on empathy and #meded

Patient + Wife a photo by polaroid667 on Flickr.

Today during the twitter conversation Gautam went back to one of my old blog posts on empathy and left a comment that I think deserves its own post, so I have posted it below. Much of what he writes strikes me as very true and accurate. What is the solution?

"I think the crux of the problem is the practitioners that medical students train with. I'm a final year in Sheffield and even though we have 12 weeks of general practice over two separate sessions, that leaves around 2.75 YEARS of training in hospital.

My own opinion is that in-hospital practitioners are less empathic because the prevailing attitude is that patients are problems to be solved. The 'House MD' way of looking at things still prevails amongst many practitioners - particularly surgeons but equally amongst medical physicians. Students are 'taught' empathy but equally, are (not overtly) dissuaded from feeling it, talking about it and dealing with it. The pressure is to deal with the 'real' problems - the broken leg, the tweaking of medication doses - and ignore the 'BS' - the trauma of losing a child or partner (unless they can be referred for CBT).

Contrasting hospital care to general practice, the existence of a lasting relationship between doctor and patient means that these concerns have to be taken more seriously simply because the patient is a recurring figure in the doctor's professional life. In other words, it makes sense to deal with these patients as people, rather than as problems.

Now, this theory of mine (as weakly-backed by evidence as it is!) holds some water, I feel, since patients who are seen in clinic regularly are treated differently by consultants. These patients' problems are listened to, their concerns are heard and dealt with as much as is possible. Time constraints exist with patients on the ward, as well, but for some reason, (perhaps worries about confidentiality and privacy?) they are not covered as completely.

Medical students can be taught to reflect and encouraged to empathise by the medical schools as much as possible. But while they are taught as apprentices by overworked and jaded physicians and surgeons who may not have time to empathise as much as they'd like to, true empathy remains out of reach."

Thank you, Gautam.

Intimate examinations without consent- it's still happening.

Image: Exam Room by Maggie Osterburg

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

Press Release from University of Dundee.

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

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

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

"Don't Lecture Me"- but do watch Donald Clark

Donald Clark gave this highly engaging lecture on why we should not be using lectures at the ALT-C (Association for Learning Technology Conference) 2010. Many medical schools in the UK, at least, have moved away, or are moving away, from the lecture format. But just in case we forget why that is a good idea, Donald Clark gives us a few good reasons.

My experience using social bookmarking with medical students: #fail?

Experience with Delicious...
I have about 300 second year medical students independently researching topics related to families who they are visiting. 2 years I ago I started using Delicious to share resources with them- often forums where patients were discussing topics such as living with diabetes or being a parent.The advantage was that Delicious was public. It made it easy to share a group of links in Blackboard. I encouraged students to sign up and share their own links so that they could develop ideas about curating and sharing, but this was a secondary aim.  I was aware of 15 students who actually signed up to Delicious, and about half of those saved at least one bookmark. But they didn't really understand tagging and obviously didn't find use in it for themselves as they haven't done so again.  I was also a little frustrated that I couldn't comment on or discuss with students why they had identified a particular source.

Interestingly I have showed Delicious to two of my personal tutees and they have continued to use it. But I introduced this to them in a one-to-one meeting. How can I manage to show the benefits of social bookmarking to 300 students in a lecture (in 5-10 minutes)?

...then Diigo....
Last year I decided to try Diigo. This was because it had richer features and would allow discussion around a topic. I am perhaps over-protective of students, but because this task was around the families they were visiting, I was keen to make this a private community so that if they did inadvertently break patient confidentiality then less harm was done. I've written more here about the the process of setting up the group and some of the hiccups along the way. Towards the end (after 3 months) some students (three!) did start saving bookmarks (one saved 7 to his diigo account, and shared 3 of these with the group, the other two only saved one bookmark each).
58 students signed up to Diigo - and these are the only ones who could access the 187 items that had been saved to the group- mostly by me. If I shared a link like this http://groups.diigo.com/group/familycasestudy/content/tag/breastfeeding on Blackboard I was guaranteed to get a response from students saying that they couldn't access Diigo as they weren't a member. The process to join a closed group made it all more onerous.

Lessons learnt

• The rich features of Diigo including the ability to use an avatar were not used by students.
• A closed group makes things very much more complicated- and there was no evidence that students used the site in an inappropriate way- so open is better.
• Few students saved links themselves, but it is very useful for me to be able to easily share materials with them.

This year?

I need to be clear about why I am introducing social bookmarking to students. This is not (yet) part of a programme in digital literacy. I started using Delicious in the course simply because it was an easy way for me to share information with students. My expectations then started increasing which was why I chose to use Diigo in a much more complex way the next year. I don't think that I can say that the use of Diigo was a success. I don't actually use it myself very much despite these rich features so it is hard to recommend to others.

Should I go back to using Delicious. Yes- students will need to set up a Yahoo account in order to save links- and the features are not as rich.

Or, I continue to use Diigo but open it up- it might take off this year.

Or, I try out using Scholar, a social-bookmarking tool which is built into our VLE. So far I don't understand it which means I am unlikely to use it. (Why did they pick a name so close to Google Scholar which is completely different??)

It is perhaps harsh to call this a failure. I didn't set out with the deliberate aim of teaching students about social bookmarking. If I was then I would probably force them to set up accounts and to save and comment on others links.But, I would like students to understand what social bookmarking is about- and to see that it might be useful to them. 

In this situation what would you do? I will report back!

EDIT: Martin Weller writes about similar issues in encouraging researchers to adopt social media here http://www.typepad.com/services/trackback/6a00d8341c0c0e53ef0133f47b6207970b

What is more important: behaving badly or being seen to behave badly?

Doctors behaving badly
Yesterday, CNN carried a story ("Photos of drinking, grinning aid mission doctors cause uproar")
that doctors from Puerto Rico, volunteers in Haiti, may be disciplined because pictures of them holding soldiers' guns, drinking alcohol and with patients (possibly without their consent) have been posted on Facebook. The comments on the story are interesting, as some say the doctors are being treated too harshly. They may be traumatised by events and should be allowed to relax. Others who have seen all of the photos are in no doubt that the activities of the doctors are unprofessional. But in nearly all cases, commenters are talking about the act of taking the photo, rather than the sharing of the photo in social media.I have not read all 1411 comments but there does not seem to be anyone advocating that the photos could be OK in private, but inappropriate in public.


Medical students behaving badly
The conduct of medical students in social networking sites has been recieving increasing press. In September 2009,  Chrieten et al. published the reults of a survey in JAMA which found that the majority of US medical schools has had to take disciplinary action against some students because of their activities on social networking sites. And in November 2009, Farnen et al. described a case where first-year medical students posted a sketch from a medical talent show on YouTube. The sketch was of a hip-hop song accompanied by medical students playing  with plastic skeletons and  body bags. It was removed when a more senior student complained that it portrayed the medical school poorly, although there was student resistance to that action as the video had been very popular with students. The author's state:
" Our students' video has become our digital liaison. Prospective medical school applicants often comment on viewing it before their interview day. Alumni and senior faculty responded with significant concerns about the video's representation of the medical profession and how patients may react to this depiction of physicians' training. " (my emphasis) Students do not seem to have been disciplined for any unprofessional conduct in the production of the video,instead it is the sharing of the activity through social media which is the focus of the article. This seems to suggest that activities may be acceptable in private but not in public. In a further response to letters on their work, Chrieten et al. state "the medical profession is responsible for maintaining the public's trust. It is necessary to understand how online behavior is viewed by the public and how that affects trust in the medical profession."
Hayter (2006) has wrote about the medical student show. He says that it has various functions including "the collective ventilation of emotional reactions to the process of becoming a doctor". There are links to some of the skits from these shows in this Slate article. What we do not know is how the general public views these shows. Did they know of them? Did they think the conduct was appropriate? Since medical faculty often participate, and attend, they may be seen to approve of the content. If this is the case then why is it not appropriate to share the content publicly.


What does it mean to bring the profession into disrepute?
In the UK, both nursing ("You must uphold the reputation of the profession at all times") and pharmacy (where one should report any circumstances that may "bring the pharmacy professions into disrepute") bodies imply that not upholding the reputation of the profession is in itself something that a member may be disciplined for. For UK doctors, the GMC document "Good Medical Practice", states that "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 it is not clearly stated what conduct may contravene that trust. Older GMC guidance, prior to the first publication of Good Medical Practice in 2005, states that "convictions for drunkenness or other offences arising from misuse of alcohol (such as driving a motor car when under the influence of drink) indicate habits which are discreditable to the profession". Although this terminology is no longer used in Good Medical Practice, when discussing the case of a doctor convicted of driving with a blood alcohol level three times above the upper legal limit, it is stated that, "Public confidence in the medical profession is likely to be undermined by such conduct." The doctor was suspended for three months, in order to "send the right message to the public". In the case of medical students, GMC guidance states that drunk driving and "alcohol consumption that affects clinical work or the work environment" is unacceptable.There is no mention of drunkenness away from patients.


What do patients think?
Research conducted by Mori for the Royal College of Physicians in the UK consistently shows that doctors are the profession thought most likely to be telling the truth. This is routinely reported as "Public Still Trust Doctors". Smith (2001) distinguishes between trust, which exists at the level of individual interaction, and confidence, which relates to abstract systems.  Boudreau et al (2008) asked members of the public about the attributes of the ideal physician. They were reformulating the medical curriculum and wanted patient input. Patients wanted doctors who listened to them and didn't treat them as a 'number'. When asked "If I said to you that a doctor was very professional, what would that mean to you?", some patients responded negatively suggesting that it might mean someone 'stuffy-nosed' or who didn't want to bother with 'menial things'. But generally being professional was associated with behaviours that concerned individual interaction with the patient: bedside manner and interpersonal skills. 
But what of trust (or confidence) in the wider medical profession?  It is understudied. Hall et al.(2002) found, using a new scale, that trust in one's own physician is higher than trust in the physicians generally. They say that might not be a surprise as one might settle with a doctor one trusts, after experience of others who are less good. Calnan and Sanford (2004) in the UK, sudied general trust in the healthcare system rather that trust in the 'medical profession', and found that trust that patients would be provided with patient-centred care, was strongly associated with trust in the system. 


Conclusions
Professional bodies still talk about individuals conducting themselves at all times in a way that does not reduce trust in the profession. But the very limited studies which look at how the public view the medical profession suggest that it is the interactions with individual doctors in the healthcare setting which determine trust. Patients value patient-centred doctors.
Pattison and Wainright (2010) suggest that the ethics of a profession should be determined in conjunction with the wider public. It is not something that a profession can do alone. But I think that after that  behaviour is either unacceptable because it is unprofessional, and therefore should be disciplined, or it is acceptable. If it is acceptable it can be shared through social media.The use of social media is a secondary consideration.


Questions
But what do you think?

1. How do you feel about medical student shows?
2. Are medical student shows appropriate to share online?
3. Would seeing photos or videos of doctors, nurses or pharmacists in a state of drunkenness on Facebook affect your view of the profession as a whole?
4. Would it affect your view of the individuals involved as professionals?
5. What determines your trust of the medical profession as a whole?

Feel free to answer these questions or leave any other comments.


(This post resulted from a rather long discussion with @psweetman, @bitethedust, @drmarcustan and @mtnmd earlier today. I am currently studying for a module on Changing Modes of Professionalism for my EdD course, and writing an essay on deprofessionalisation in medicine. This writing is only tangentially related... as yet!)




References
Boudreau JD, Jagosh J, Slee R, Macdonald ME, & Steinert Y (2008). Patients' perspectives on physicians' roles: implications for curricular reform. Academic medicine : journal of the Association of American Medical Colleges, 83 (8), 744-53 PMID: 18667888
Calnan MW, & Sanford E (2004). Public trust in health care: the system or the doctor? Quality & safety in health care, 13 (2), 92-7 PMID: 15069214
Checkland K, Marshall M, & Harrison S (2004). Re-thinking accountability: trust versus confidence in medical practice. Quality & safety in health care, 13 (2), 130-5 PMID: 15069221
Chretien KC, Greysen SR, Chretien JP,  Kind T (2009). Online posting of unprofessional content by medical students. JAMA : the journal of the American Medical Association, 302 (12), 1309-15 PMID: 19773566
Chretien KC, Greysen SR,  Kind T (2010). Medical Students and Unprofessional Online Content—Reply JAMA : the journal of the American Medical Association, 303 (4) 329
Farnan JM, Paro JA, Higa JT, Reddy ST, Humphrey HJ,  Arora VM (2009). Commentary: The relationship status of digital media and professionalism: it's complicated. Academic medicine : journal of the Association of American Medical Colleges, 84 (11), 1479-81 PMID: 19858794
Hall MA, Camacho F, Dugan E, & Balkrishnan R (2002). Trust in the medical profession: conceptual and measurement issues. Health services research, 37 (5), 1419-39 PMID: 12479504
Hayter CR (2006). Medicine's moment of misrule: the medical student show. The Journal of medical humanities, 27 (4), 215-29 PMID: 17123173
Pattison, S., Wainwright, P. (2010). Is the 2008 NMC Code ethical? Nursing Ethics, 17 (1), 9-18 DOI: 10.1177/0969733009349991
Smith, C. (2001). Trust and confidence: possibilities for social work in 'high modernity' British Journal of Social Work, 31 (2), 287-305 DOI: 10.1093/bjsw/31.2.287

Information Literacy Teaching- Sabotage!

Today in a tutorial I met one of the students I spoke to last summer when doing the first year portfolio reviews. I mentioned that I had blogged about how he and other students used social media, including YouTube and Wikipedia.

He then told me a story about a teaching session they had on information literacy. They had been asked to compare an article on Wikipedia with a review paper on the same topic from an academic journal. The session aimed to show the inaccuracies of Wikipedia and how it could not be trusted. But this student sabotaged the exercise. He demonstrated that the essential quality of Wikipedia is that it can be edited. Before most students had got round to the piece of work, he went into the Wikipedia article and improved its quality by updating the content and referencing the article!

He says that the organisers were not too happy, but I'm sure they were. He had demonstrated:

• Wikipedia is always changing
• It can and often is a good source of information if we all contribute
• Medical students CAN be Wikipedia editors.

Well done!

Where do first year medical students look things up?

In the last two days I have spoken to 31 first year medical students about their early clinical attachments in primary and seconday care. I asked them where they looked up unfamiliar clinical topics. These are some of the responses:

• Wikipedia
• Google
  
• Kumar and Clark
• Medical dictionary
  
• YouTube (especially to find out more about operations)
• NHS Direct/Choices
• Oxford Handbook of Clinical Medicine
• I didn't look anything up.

Wikipedia was definitely the most common choice. Many students said 'I know I shouldn't but....' and then qualified that they used Wikipedia first because it was easy to understand, they felt it was reasonably reliable, and accessible. One student used it to search directly from her phone when on placement.

I was intrigued by one student who was very keen to distinguish 'learning' which was what he did for exams... spotting questions on past papers and reviewing lecture notes... from 'experience', when he would access YouTube or Wikipedia to find out more about something that really interested him. His reluctance to call this learning reminded me of a third year student I spoke to earlier in the year. We were talking about how she would continue learning for the rest of her life. "That's so depressing", she said. In her mind learning was bound up with exams and assessment.

Should we worry about students turning to Wikipedia so often? Which other resources are just as user-friendly and comprehensive?

I think that NHS Choices is a good place to start.

EDIT: Just to make clear, the first year students I am referring to here are in an undergraduate 5 year course. The first few years of the course are pre-clinical but these early clinical attachements are to give them some initial insights into the world of clinical medicine. Some medical schools in the UK have no distinction between the pre-clinical and clinical parts of the course.

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.