What I have learnt about blogging

I blog... by alamodestuff

So if you have known me on Twitter or elsewhere for a while you will know that I am a big fan of blogging and I encourage everyone to start keeping one. Why? You will learn a lot and you will help others learn too!

I started my blog just over 4 years ago. Sometimes I will write a few posts in a week and at other times I leave it for a month or two. How often you write is up to you. It shouldn't feel like a chore.Write when you have something to share, a question to ask.

Blogging is public writing. Think about who your audience is. For me a massive strength is that all kinds of people read and comment here. This means that I can learn about many more different perspectives than if I was to walk down the corridor and ask my colleagues at work thought of the random idea I'd just had. But sometimes people won't understand what you say, the language you use or where you are coming from. That's OK. Just as in any communication, if someone doesn't understand you then don't get angry, just try and explain in a different way.

Writing helps me to develop my thoughts and get someway to understanding what has been perplexing me. And usually I ask a question at the end so that people who read the blog know that I didn't just want a soap box but that I am really interested in what they added. If no one comments on your blog, and you have wanted them to, then maybe people who were reading didn't know what kind of response you wanted. Questions really help with this. If you are writing the post because you are developing an idea that arose out of a conversation somewhere else then make sure that you let the other people involved know so that you can continue the conversation there. And if there is someone whose insight you would really like then email them or send them a tweet with the link and ask them to leave a comment. And get into the habit of commenting on other people's blogs too. They will appreciate your feedback.

Sometimes people ask about ethics. Are there any particular ethical concerns? If you were writing for a journal or a magazine you would most likely have an editor who would tell you if what you were writing was really off for some reason. But you don't have an editor on a blog so you do have to take a bit more care and consider what you are writing. My own rules are that I don't mention a patient on my blog without asking their explicit consent. In fact, I don't often write about anything relating to my clinical work on this blog. If I am teaching and I realise that I would like to write a blog post about something which has come up then I would let the students know when I was with them. Sometimes, I don't realise at the time that I want to write about the episode but I always try to make sure that I at least let anyone involved know that I have written the post later. So I don't think there is anything particularly ethically troublesome about blogging, but if you have any doubts then don't be afraid to pass what you are going to write by someone else first.

Should you blog in your own name? I do. That doesn't mean that you have to. But I think that writing in your own name leads to a richer experience because you can make stronger links between your online and offline worlds.

And some practical tips? You can set your blog up on any number of sites. This is on Blogger, which is owned by Google and is really very easy to use and rarely down. Lots of other people choose Tumblr or Wordpress. Have a look around and see what you think will suit you.

Do make sure that you enable sharing buttons on your blog so that people can easily share it with others. And let people subscribe by email too.

I usually add a picture to my posts because it brightens them up and hopefully helps with understanding too.

I allow anonymous comments here but I moderate all comments, mainly to stop spam getting through. It's easier than deleting.

And you'll hear people say every now and again that blogging is dead. But that's nonsense. How could it be when you have just started? Enjoy!

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!

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.

ASME Conference 2010

The Association for the Study of Medical Education (ASME) had their conference in Cambridge, UK earlier this week. You can find out more about the conference here. I did tweet thoughout the conference and although I was a rather solitary voice I did have some good interaction with my followers as usual. A transcript of tweets can be found here.

I wish I could link to some of the very interesting presentations I attended but they are not online as far as I am aware. However, one of the keynote addresses was given by John Norcini, from FAIMER (Foundation for Advancement of International Medical Education and Research) using Prezi. I searched the website and found his presentation so can share it here with you.

Although ASME is an international organisation it does have strong UK roots so his presentation on the problems for medical education internationally was an interesting change. I should also point out that the UK does not yet have a national licensing exam. Licensing is carried out by medical schools who are accredited by the GMC (although I did hear some talk at the conference that a national exit exam may be back on the agenda).

One of his most interesting points was that often medical education followed fashion, which was then evaluated. He gave Problem-Based Learning (PBL) as an example of this. But there was evidence during the conference that other aspects such as the use of simulation are also being thought of more critically now. We don't have the evidence to justify widespread use.

I also talked to some other doctoral researchers about the need for a network to share our questions and learning. Watch this space for more about that!

What next for medical education? on Prezi

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