For students, can any social platform compete with Facebook?

Facebook like button by Sean McEntee

At #amee2012 last week Facebook was talked about a lot. It came up in the excellent  social media workshop that was lead by students and in several posters and short communications. Search this 500+ page book of abstracts to see how often!

But as might be expected there was not agreement on whether Facebook should have any place in medical education. Whilst there were reports of it being used to support student learning in informal and formal ways Imperial College, London, other students and faculty argued that Facebook is a social space and not a learning space. In the past any mention of Facebook at a medical education conference usually concerned being unprofessional, so the fact that people were starting to consider the possibility that it might be educational platform was very interesting in itself.

It was also suggested (including by me) that we might have responsibility to provide  safe spaces for students and faculty to model and develop digital professionalism. Quite a few of the issues I heard discussed were raised in the comments of two blog  posts I had written last April.

This post is also a  follw-up to a discussion on our LinkedIn group 6 months ago. It was started by Bernadette John asking if any medical schools were looking into developing  and supporting social platforms for students. King's had just started a project with Elgg but was also thinking about Mahara. Why would a medical school want to do this? Some suggested that the VLE should support social learning interactions. But they don't. Blackboard does not feel social, certainly not social like Facebook.

Today a colleague told me that the University of Wales, Newport (who don't have a medical school) had started using NING , a 'social community tool', in 2008 to support first year students. How might we use something like NING in a medical school? What value would it have? My thoughts are that it would be useful to have a space where students and staff could get to know each other in a semi-formal way. Most of the NHS staff who our students meet do not have profiles on the university site, but it might be useful for students to know some more about what their special interests are clinically, and in research. And vice versa, it would be excellent if teachers could know more about the students they meet on placements.

But later I found out that Newport had stopped using the NING. It was only used by students in the first few weeks of the course to make contacts with each other before they migrated to their own Facebook groups. And if you can't beat 'em, join 'em!! This year Newport is setting up a Facebook page for students to like and post to throughout their university careers.I imagine that even if activity does tail off over the next few months this might still be quite a good channel for the university to communicate with students through.

So can any social platform compete with Facebook? Is there any merit in trying to encourage students to use another 'social learning' platform? A separate platform would mean that students are at less risk of being accused of digital unprofessionalism because they minimise their contact with faculty there *although I would rather see a re-calibration of what is considered unprofessional in the first place- if my ears did not deceive me I think I even heard a medical student volunteer that they were urged not to like a One Direction page on Facebook for fear that it may be seen as unprofessional*.

A separate platform would also mean that faculty with Facebook antibodies could avoid it. Other faculty might be just as concerned as students about mixing personal and professional presences online. There was some talk of dual profiles at AMEE but that is against Facebook terms and conditions. Facebook would rather see professionals create 'pages' to project their work-relate personae.

So some questions. Would students or staff see value in a social platform? For more ideas on how that might work see this post on location and learning.  If yes, could that platform ever be Facebook?

(Edit: Here's an interesting post by Donald Clark in January, "7 reasons why Facebook is front runner in social media learning"

I'm thinking about Twitter but....

This is a follow-up to my recent presentation at #asme2012 where I tried to convince anyone who was at the conference, and therefore interested in medical education, that they had something to gain from Twitter. These were my 10  reasons, more fully explained here. At the end I asked, "What is stopping you?". Here are some of the queries, and I'll add others as they arise and hopefully you can contribute some questions and answers too.

I'm already swamped by email, etc etc - how would I manage Twitter?

Email swamps us because it is hard to discern the messages that we do need to reply to from the junk that we shouldn't have received in the first place. But Twitter is an opt-in service. If you feel swamped by getting a newspaper at the weekend then perhaps this is not for you. You will choose who to follow and how often you want to check if something interesting is waiting there for you to discover, or respond to. But if you don't have time then you can ignore it. No one will be annoyed or upset. If someone really wants to get your attention they probably have other ways of contacting you than by a tweet (the dreaded email!) but you will very likely be surprised by how liberating you find 140 characters. Brevity is your friend!

And if like me you want to explore Twitter for your professional development then you can make some choices. What do you currently do for CPD? Why don't you swap 10% of that time to Twitter and see what return you get on your time investment? (I can make that challenge quite confidently!)

Should I have a personal and a professional account?

I have one account. It makes life easy. I don't feel that I share very much of my personal life but you probably will get a very good sense of what I will be like if you meet me at a conference from my tweets. You won't know how I interact with my family but I don't imagine you are very interested in that. Despite leading quite a public life I like my privacy. I feel that I have reached a happy balance.

Is it a problem that tweets are archived?

This question surprised me a little. If my tweets are professional then it is good that they are archived surely? Often the first thing I do when I attend a conference is check if the tweets are archived and if not then set up an archive. Or I try to curate tweets into stories myself using tools like storify. So archiving is not the enemy, it is our friend. I think the questioner was concerned that I was through my limited personal tweets I was exposing personal data. But this happens every time I use my mobile phone, my Visa card, and with CCTV cameras in the UK, often just walking down the street. We are all trading privacy for convenience to a certain extent. Again I am happy with my current balance?

I hope to do another follow-up post about how to get the most out of Twitter, but in the meantime, what are the questions that people raise when you talk to them about social media?

Why does a twittering doctor tweet?- note from ASME 2012

Why does a twittering doctor tweet? from Anne Marie Cunningham

"My very first tweet was made in May 2008.

preparing for a seminar on medicine and the media- thinking about health 3.0
— AnneMarie Cunningham (@amcunningham) May 27, 2008

 I was invited to join Twitter by a friend who works in IT. It just happens that at the time I was still at work thinking about a teaching session so my first tweet has quite a strong medical education flavour. Like many people I wasn't sure what to actually make of Twitter after this and I left it for several months until I went to two medical education conferences and decided that social media could serve a purpose for me.

 But I'm not a techno-evangelist. I believe we have to be very careful about how we use technology and to consider how it impacts on relationships. If you google web 2 (a term for newer social technologies including social media) sceptic then the top result is actually about me, because I have disputed with other doctors in the past that these technologies are having any impact on our clinical practice. And I am still uncertain about this. However I am certain, and have decided that I can allow myself to be evangelical, about the benefits that can be had for anyone who is at this conference and is therefore interested in improving medical education.I started becoming aware of this a short while after starting my own blog in October 2008 which is why in 2009 I gave a presentation at ASME about how social media and networks could develop and support scholarship in medical education. However, this did not lead to the expected paradigm shift in scholarly communication. So I have decided that I might need to be a little more direct with you this time. And this is why I am going to give you 10 reasons why you should be on Twitter now.

1. To connect

The first is my own initial reason- to develop a network with other researchers, educators and practitioners. This works and it can happen.

2. To engage

The second reason is something I didn't expect. Beyond simple connection you can have meaningful engagement with those whose voices you might not usually hear- students, junior doctors and patients, or the wider public. For me this has been tremendously powerful.

3. To inform

Third, is to inform. I'll use as an example the hashtag of this conference #asme2012. In the past few days more than 1000 tweets have been made by more than 100 participants and reached thousands of people who are mainly not at this conference. But what does that mean? Well, it means that ASME has a higher profile in the global education community. If your mission is to spread the word, then you should be using Twitter.

4. To reflect

Fourth, is to reflect. To illustrate this I've chosen a tweet by a doctor in the US raising the topic of the fall in empathy levels of medical students during the medical course.

UK med students- is this true? RT @drmintz:Process by which we train our students sucks the empathy out of them #meded
— AnneMarie Cunningham (@amcunningham) March 9, 2011

 It’s something that we often hear discussed at conferences. I decided to share, or retweet his thoughts, and to ask our UK medical students what their experience was of this phenomenon. I don't have time to show you all the responses (storified here) , but believe me that there was a rich discussion on what was wrong and what we might do better. So if you want to consider how you could make your practice better you could be helped by being on Twitter.

5. To share

The fifth reason is to share things that are important and meaningful to you. To do this best you need a space where you can write more than 140 characters and I would recommend that to get the most out of Twitter you also start a blog. But don't worry if you want to just stick to Twitter for now. In Twitter you can easily share links to content that is online; be that a research paper, or a blog post about your research or someone else's research or just a story that you think needs to be told. But remember you have no editor here. You have to be your own self-censor, but it doesn't matter if you make the odd mistake. Don’t let this fear stop you saying anything at all. The community is forgiving.

6. To be challenged

 But sixth, when you share your thoughts and ideas don't expect everyone to agree with you. Sometimes it is said that people online talk to those who are just like themselves. It can seem as if we are indeed sheep, so much that I have added to my twitter biography that I am determined NOT to be one of the sheep. Near the end of ASME 2011, Professor Trudie Roberts even warned against the ‘filter bubble’. But just as here at this conference we are prepared to defend our point of view, be prepared to be challenged about what you think online. This is a good thing. Don't be surprised if it happens. Enjoy and relish it.

7. To be supported

 But also expect support from your colleagues. My seventh point is illustrated by the development of a list of women healthcare academics by Prof Trisha Greenhalgh. She is someone who I really hoped would join Twitter after she attended AMEE last year, and then she did. If you want to see how a productive academic can get a lot out of Twitter then follow her. This list was started because we were aware that often women are less visible online. It started as a list of 50 but very quickly rose to more than 100 and is still growing. 

8. To lead

Trisha Greenhalgh was exhibiting leadership and if you are interested in leading your community you should be on Twitter. This is my colleague Natalie Lafferty from Dundee who many of you might know. Last year we held a series of discussions on Thursday nights called #meded chat. We picked the topic in discussion with our community and supported the chats with blog posts which helped pull together the learning. One week we discussed how students and trainees felt about the use of the portfolios to assess competency. We knew that this could be an explosive topic and it was. In advance of the discussion 25 people commented on a blog post with detailed descriptions of their own experience of the use of portolios. Many more participated in the chat. A year later a junior doctor has started a blog NHS eportfolio revolution which is bringing the voices of trainees directly to the AoRMC. If you are involved or want to be involved in the development of policy and you want to connect with your community then one way that you can lead is by being on Twitter.

9. To learn

Getting near the end, my 9th point is that you will learn. When you have worked at developing a network, you will have the benefit of other people curating the best of comment, news and research and directing it towards you. Priceless! 

10. To inspire

And lastly, you can inspire others. Do you know this amazingly busy, and productive man? 

Image: Atul Gawande Video Shoot by stevegarfield


It's Atul Gawande- surgeon, author and researcher. The eloquent Atul Gawande can teach you about how to use Twitter. Last year, I spotted this tweet one Sunday afternoon.

And then Djokovic's confidence evaporated... The rest of the way is a test of who's mentally toughest. Epic.#wimbledonfinal
— Atul Gawande (@Atul_Gawande) July 3, 2011

 Two minutes later I had made my reply to him.

@Atul_Gawandedo you know that Twitter Journal Club is discussing the surgical checklist tonight at 7pm GMT? Please join! #twitjc
— AnneMarie Cunningham (@amcunningham) July 3, 2011

 I invited him to participate in a discussion of his paper in the Twitter Journal Club, a twice monthly discussion of a paper on Twitter, started by a medical student, Fi Douglas, and Natalie Silvey, a junior doctor. This was too good an opportunity to miss. What do you think happened? Well- the discussion started and there was no sign of Atul Gawande. People were making some of the usual complaints about the original surgical checklist paper. It didn't apply to the developed world etc etc. But then he joined in. He started commenting on the discussion. And if you have any doubt about how 140 characters can be used to communicate anything useful watch and learn from this master.

VA surgery study in 74 hsptls scaled checklist thru training. Electronic data & good ctrls. JAMA: Deaths cut 11%+. No Hawthorne. #twitjc
— Atul Gawande (@Atul_Gawande) July 3, 2011

What was the reaction? People were thrilled and informed. Atul Gawande was on vacation with his family but he was able to share his expertise with students and others who asked him questions about his work. He was inspiring. Do you want to inspire others? So this is only a short 10 minute race through how you might be able to contribute through Twitter to the development of the medical education community. Every voice is legitimate from students, to professors. So now I will take questions, but my question to you is what is stopping you from joining this conversation? "

Follow up:

some good introductory blogposts :

A gentle introduction to Twitter for the apprehensive academic by @deevybee

Why should medical students tweet by @fastbleep

Why should trainee doctors tweet by @elaineleung

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?

Doctors’ use of social media - some thoughts prior to publication of GMC guidance

This is taken from the GMC website. The GMC have published draft guidance on social media here. Take part in the consultation here.

This month, Dr Anne-Marie Cunningham (@amcunningham), a GP and Clinical Lecturer at Cardiff University, writes on the role of social media in doctors’ lives.

More than half the UK population now use Facebook. And more new users are over 50 rather than under 50. The dominance of Facebook means that if you are not there you are likely to miss out on what is happening with your family or friends. For most of us our use of Facebook has nothing to do with being a doctor. It is about being a mother, nephew, or friend. And it is because we want to protect these people that we care about, and ourselves, that we check our privacy settings and make sure that we are not publishing photos of our nearest and dearest to the world.

So if most of our social media use is about who we are when we are not at work do we need guidance from the GMC? What does using social media have to do with being a doctor at all?

Useful guidance or ‘moral panic’?

Some might think that the development of this guidance is a response to a near moral panic about what may be seen as the portrayal of unprofessional behaviour by doctors and medical students in their use of Facebook and other social networking sites. Breaking patient confidentiality is always wrong but these days what does it take to reduce trust in ourselves or the medical profession? Research seems to indicate that the main determinant of trust in doctors is their interaction with patients in consultations. Patients value doctors who listen to them and take their concerns seriously. They trust them. So are we worrying excessively about how the public may respond to the depiction of minor misdemeanours and hijinx which may not reflect how well an individual will carry out their professional role?

Blurred boundaries

In the past, the private life of a doctor living in a small community may have been well known to her patients. Social media facilitates this same kind of blurring of boundaries. We all have to consider how much of our private and personal lives should be revealed to the public and patients. Will ‘professional distance’ be a meaningful or helpful term in the 21st century? Medical decision making is no longer seen as objective and the role of the doctor, but as a shared task with the patient which acknowledges their values and subjectivities. Might this process be helped or hindered if patients understood our values and subjectivities too?

Doctors may also choose to use new technologies to interact with patients. What then are our responsibilities? As we have a duty to protect patients’ confidentiality we must assure ourselves of the appropriateness of any communications platform. If there are risks then we must make these clear to patients.

The importance of maintaining trust

We might also use social media to connect with other professionals. There can be many benefits to opening up the flow of knowledge within networks. Again, discussing the details of any clinical case should be done with patient consent. In the past when considering if a patient may be identifiable we tended to focus on whether others would be able to recognise the individual concerned. But if discussing a case in near real-time in a public space we have to consider whether the patient will be able to identify themselves even if no one else can. Without their explicit permission, this in itself may reduce trust in us as practitioners.

Looking forward

Will social media have a major impact on the practice of medicine? We do not know yet, but the pace of change is rapid. It took 100 years from invention of the telephone for it to reach 50% of UK households in the mid-1970s. Has the telephone radically changed medical practice? Facebook reached 50% of the UK population in 5 years. Will it be a more powerful disruptor?

When discussing technological change we have to remember that social divides also exist. Julian Tudor Hart coined the phrase the ‘inverse care law’ for his observation that those who most need good medical or social care are least likely to get it. The digital divide describes inequalities in access to information and communication technologies. In 2011, 99% of those with a household income above £40,000 had internet access, whilst only 43% of those with household income below £12,500 did. The gaps are narrowing, but if we change our practices we need to consider how the digital divide will impact on access for the poorest, and most vulnerable.

So do we need guidance on the use of social media and networks? If the publication gives us cause to reflect on how use of these technologies fit with our professional roles and our professional practice then this can only be a good thing.

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

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

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

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

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

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

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

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

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

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

Would you block your patient on Twitter?

Road Block, a photo by PSP Photos on Flickr.

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

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

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

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

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

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

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

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

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

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

On being public : How social media reshapes professional identity.

This was my presentation at ALT-C (conference of the Association for Learning Technology) earlier this year. It sums up in 20 minutes a lot of the thoughts and ideas that are covered in this blog. But of course it raises more questions than answers- I hope!

Social Media Monitoring in Healthcare

Search Privacy by Mushon

One year ago a story was shared on the nhssm (NHS social media) blog. The story was about what happened when St. George's trust in London started monitoring Twitter for mention of their name. Social media monitoring is a practice that is becoming increasingly common for businesses and it is not surprising that there is increasing discussion about this in healthcare.

Generally talk about the use of social media in the NHS tends to be driven by people who work in communications teams. This is evident from the programme of the first joint conference between NHSSM and Guardian healthcare, Social Media in Healthcare. None of the presenters are from a clinical background although I believe that another conference is possibly being planned. It is my belief that clinicians (doctors, nurses and other health professionals) and patients should be involved in developing social media strategies for any healthcare organisation.

Back to the St. George's story. When the team started monitoring they came across tweets from a patient who had recently had a renal transplant. Something in his tweets concerned the communications team and because no policy had been devised on how to handle a situation like this they were uncertain what next steps to take. Eventually the patient's clinical team were made aware of the patient's tweets. The patient only became aware of all of this when his consultant mentioned the tweets to him in a consultation.

The story provoked a lot of discussion with 39 responses and a follow up post by Dr. Dan O'Connor on the ethics of social media monitoring in healthcare. I urge you to read both of these posts and have a look at the comments. I've made several comments on both.

Generally I have not come across a lot more discussion of this topic in the last year. I'm not sure if many NHS organisations have developed policies on social media monitoring and I'm not sure how many have involved clinical staff or patients in developing these policies. In fact, I might not have thought a lot more about this if I hadn't attended a breakfast meeting at Evidence 2011 by Ben Breeze of Dell. He talked about how individual members of staff, outside the comms team as far as I understand, were being trained to represent the organisation.

So I am wondering what you think about this. What would be gained from an NHS organisation monitoring social media for mention of their name? Who should be involved in developing policies? How should clinical staff be involved? What are the risks and benefits?

Social media, black humour and professionals...

Last week I presented at #altc2011 (the Association for Learning Technology Conference). My topic was "On being public.... how social media reshapes professional identity". One of my main points was that social media almost necessitates a reflexivity which we can get by without in face to face encounters. The pace of interaction is fast, we're dealing with people we may not otherwise come across, and norms are still being established. In fact we may never even get to the stage of having 'social norms'. Probably the only way to operate in these spaces is by having internalised your own values, but also being able to step outside of those values and to see what has shaped who you are and what you think, and to afford the same courtesy to others.


A few days later I came across a discussion between several male doctors on twitter which caused me to reflect on this very topic. The doctors were using slang, which I have not come across before, to refer to the wards in which they might have been working. The terms used were 'labia ward' and 'birthing sheds' to refer to the delivery suite where women give birth, and "cabbage patch" to refer to the intensive care ward where many patients are unconscious. 


I was shocked at this and angry and did query the doctors about some of the other things they said, but I felt I couldn't challenge them directly at that time about this language. One of the doctors referred to midwifes as 'madwives' and was challenged by a medical student to justify this position. In the meantime I pulled together the tweets using a curation tool and informed the doctors involved that I had done this. I did not tweet the link publicly and did not endeavour to have a conversation in public about this. However I did feel the need to check with others how they felt about this exchange so I sent them a link to the collated tweets by private message. I wanted to find out if my own shock and revulsion was  typical and also to gain some advice on what to do about this.  


Almost all replies stated that they found the discussion insensitive. Doctors seemed to be as likely to be offended as non-doctors. Some thought that this was risky behaviour because regulators may take action. I personally think this is very unlikely and do not consider these tweets a disciplinary offence.

But what happened in public? A few others (mainly other doctors) did challenge the use of this language. The protagonists explained that they thought their tweets should be interpreted as a conversation between medical professionals. One expressed that he did not want to cause offence and that he perhaps had misjudged sending the tweet.


How did I feel?
I was surprised at the strength of my reaction to this. I wanted to let it pass but I also felt that this was not appropriate. I felt that the language objectified women and was misogynistic. I privately told one of the doctors this and asked that he removed the tweets but he refused to do so and suggested that my feelings of offence were my problem.


Some doctors have thought that I am concerned that this kind of talk will 'bring the profession into disrepute'.  But I am not. I believe that patients make assessments of us as individuals. I don't believe that the public will think less of doctors after this. As has been pointed out, programmes like "Cardiac Arrest" have portrayed doctors as cold and callous individuals. But there has been no corresponding fall in trust in the "profession". 


The doctors involved in the initial discussion have suggested that my views to their use of slang are atypical. Only a very small number of their followers have raised any kind of objection to their use of this language. Perhaps inside more women are offended but they feel that they can not speak up because to have your views dismissed publicly is humiliating. I don't know. But I don't think that this is an issue of numbers. 


My account of this episode, so far,  has been very personal. But I also want to place this story  in a wider context within the medical education literature on professionalism and black humour.  Is the use of derogatory humour or slang by medical professionals inappropriate? Berk thinks that ;
"Simply put, derogatory and cynical humour as displayed by medical personnel are forms of verbal abuse, disrespect and the dehumanisation of their patients and themselves. Those individuals who are the most vulnerable and powerlessin the clinical environment – students, patients and patients’ families – have become the targets of the abuse. Such humour is indefensible, whether the target is within hearing range or not; it cannot be justified as a socially acceptable release valve or as a coping mechanism for stress and exhaustion."


Berk was writing this in response to research by Wear and colleagues on medical students and residents attitudes to this kind of humour. It is interesting to note that usually  it is referred to as being performed behind closed doors. Some accounts suggest that it is about establishing insider and outsider groups if performed in public. 


Wear suggests that doctors "throughout academic medicine might begin candid discussions of derogatory and cynical humour in their particular cultures in order to become better aware of their participation in it and their responses to it when they overhear it from others". 


And so I am writing this. Social media- blogs and twitter- are my culture. I want to raise this topic here- in this public space- so that I can think about how I respond to it in the future when I 'overhear' it. The next time I may choose to ignore it. Despite Wear's suggestion that incidents like this  provide 'teachable moments', and should be challenged,  the spaces of social media are much more exposed than a hospital corridor. 


But at the same time my blog is also a relatively safe place for me. I await your thoughts. 

My #altc2011 presentation.

View more presentations from Anne Marie Cunningham

If you view this directly on slideshare the speaker notes might make my points much clearer I hope. When the video of the presentation becomes available I will upload that too.
Enjoy and any questions/comments please post them here!

A story needs a story-teller...

On September 11th 2001 I was working in Bristol as a doctor training in public health, I had arrived in Bristol less than a month before and still hadn't found anywhere to stay. Some friends said I could house-sit for them, whilst they were on holiday.

I watched the tragic events that day on a computer screen at work. I went back to the empty house and felt very alone. I hoped to hear that my friends in the US were OK. I felt powerless.

Today Twitter is full of many sharing their personal reflections of that day. Atul Gawande has been writing about how it was to be a doctor in New York. He is sensitive. But an account @911tenyearson by the Guardian, which was tweeting the  factual series of events 'as it happened' has stopped. There are many tweets describing that stream as "bad taste" and "distasteful", but I think that it is the comment that these tweets were "blunt and faceless" when a "story needs a storyteller" which perhaps gets closest to why so many were annoyed.

Many expect social media presence to show sensitivity today. Many don't want cold hard facts. But others can't see why the stream ended.

Social media, organisations, identity and anonymity- an interview

Steve Wheeler interviewed me at the ALT-C conference on Wednesday just after my presentation on social media and professional identity. I will blog that shortly but here is the interview in the meantime.
Watch live video from jamesclay on Justin.tv

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!

Hello to #asme11!

This is a quick introduction to who I am and why I am interested in the use of technology in medical education, and especially the benefits (and risks) of social media and networks.

I've written a quick post over on the Med Ed Connect blog asking for those coming to our workshop on social media and networks in medical education to leave a quick introduction so that we could start to get to know each other. So here is my own quick introduction. Really looking forward to meeting you.

Blurred boundaries for health professionals online...

The following exchange took place on Thursday night. @celticchickadee isn't my patient, and as far as I know, neither is the person, she is talking about. This exchange is very incomplete compared to how I would have handled this situation offline. I could just have said 'No, I don't respond to medical questions online'. But I didn't. Sooner or later, I'm guessing that a patient in my practice will start following me on Twitter. Perhaps there already are some. Should I interact less with patients than I would with another member of the public? I have a lot more questions about this but I'm interested in your thoughts. I post this as a follow up to my last one.

By the way, I asked @celticchickadee if she minded me blogging about this, as I realise that although our exchange was completely public this would amplify it a lot.

I'm still sceptical about health professionals and social media...

Here's a short video put together to stimulate discussion about the threats and opportunities that social media provides for doctors (and other health professionals). The case is made that we (health professionals) have a responsibility to engage with social media so that we can guide patients to good resources. But does guiding to good content really necessitate the production of content? Does it need tweeting or blogging or just a good website? Do we really need web 2.0 for what is described in this video or wouldn't web 1.0 get us most of the way?
Would I encourage colleagues to set up a blog or a twitter account or a Facebook page with the aim of generating content for their patients? No. I've been in these spaces for a few years and I still wouldn't try this myself. I admire those practitioners who feel they can negotiate the boundaries of privacy, and openness with patients but I don't feel that I am there yet.
So I look forward to continuing the conversation. I've written more on my thoughts about health professionals and social media here, here, here and here. All of those posts have benefited from very rich comments for which I am very grateful.

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.

Health professionals, social media and identity- more thoughts.

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!