Tuesday, 23 December 2008

Patient narrative- leading to transformation

Last week I came across two great papers by Arno Kumagai. He is an associate professor in the department of internal medicine in the University of Michigan. There they have a programme for first and second year medical students, the Family Centred Experience, which is similar to Cardiff''s Family Case Study.

The first paper " A Conceptual Framework for the Use of Illness Narratives in Medical Education" recognises that learning through patient narratives is often marginalised and considered 'soft' in medical school curricula. This was a point that I attempted to make recently.

He introduces a conceptual framenwork, whereby narratives are seen to help contribute to transformative learning. This is a wonderfully powerful idea where " The doctor-patient relationship changes from subject-to-object communication to intersubjective communication and action: the patient is no longer reified as an object to be worked on but an active subject to be worked with."

Unfortunately I read Arno's paper after my post on online narratives, so I emailed him to ask him his opinion.

"Dear Arno,
I just wanted to say how much I enjoyed this paper and the more recent one on patent narratives in diabetes. I wish I had read them before I wrote the following blog post! http://wishfulthinkinginmedicaleducation.blogspot.com/2008/12/patient-narratives-in-medical-education.html
I was wondering if you have any thoughts about how we could incorporate online patients voices into medical education. The world of health 2.0 is getting bigger and possibly better. It means that we can let students have access to many more experiences than in the past... particularly with regards to under-researched topics, or particularly stigmatising conditions.
I am sure you are very busy but if you have time to drop me a line I would be very grateful.
Happy Christmas,
Anne Marie"

He was very kind and replied at length:

"Hi Anne Marie:
Many thanks for your kind note and apologies for my delayed response. With the upcoming holidays, it has been a bit difficult to find time to quietly chew over your thoughtful insights and question. While I completely agree with you that the patient voice needs much more prominence in medical education, I often wonder whether there are limitations to use of on-line resources to introduce this perspective. I truly believe that there is something fundamental and powerful about going to someone's home, getting to know them and listening to their stories of loss and struggle (and triumph). There is something very old and very human about sitting in the physical presence of the storyteller and bearing witness, not only to their oral history, but also to them as individuals--their non-verbal queues, gestures, and emotions. While words are powerful tools (as a former student of comparative literature, I'm acutely aware of this), there is something in personal interaction which, I believe, may enhance perspective-taking and empathy. In addition, the fact that the students get to know a specific individual and his/her family over the course of 1-2 years makes the interactions--and consequences--highly personal, individual, and contextualized within a specific place and time. As a result, their understanding of chronic illness is different than, and complementary to, that they acquire through formal biomedical readings and lectures. I recently published a paper on this specifically in reference to diabetes (attached).
I fully realize, however, that to do this as a required activity is prohibitive for many institutions--I was just discussing this the other day with my associate dean. At Michigan, the program has 340 students (170 per class), 170 volunteer families, 30 small group instructors and 30 small groups. The amount of time and cost this requires is mind-boggling--as well as being a bit of a burn-out (I've been doing this for 6 years and hit a wall of exhaustion last year; fortunately, got a "second wind" and have been going strong since then.
I don't, by ANY means, want to discourage you from pursuing on-line approaches. In fact, one of the volunteers in the FCE with recently diagnosed type 1 diabetes has his own on-line blog, and I've referred many of my patients to it. The address is http://www.diabetesselfmanagement.com/blog/Eric_Lagergren/. Words ARE powerful tools and should be used in the service of the patients and of justice. One thought: since storytelling can take the form of movies/songs/videos, the use of video interviews or monologues may be a great way to give presence to the patients' voice. As a matter of fact, I'm working on a video project right now with a delightful young woman with sickle cell disease with this approach in mind.
Hope that's at least a little helpful. I'd be delighted to continue this conversation. Please feel free to post this to your blog if you wish."

I am very grateful to Arno for taking the time to respond and I agree with him that the level of interaction achieved by actually sitting with a patient in their own space can not be replicated in any other way. This is intrinsic to our Family Case Study and we would not want it to be removed or downgraded in anyway.

But I do think that it may be possible to supplement these very meaningful interactions. In other parts of the course, for example when studying surgery or gynaecology, we could make use of existing patient accounts on the internet to increase the insights of students. When patients talk to each other online they may speak with a candour which they find harder to use with health professionals. These authentic accounts may be a greater assistance to students developing empathy than fictional narratives, no matter how creative or well articulated.

I agree with Arno, that audio and visual accounts could be particularly rich. In the next few years patients more patients may start documenting their illness journeys on YouTube. Of course these patients may not reflect the entire patient population. The digital divide may mean that the stories of empowered patients get much more airplay from students than those of their disadvantaged neighbours. We need to think of ways of redressing the balance, so that our students will be equipped to move forward in partnership with all their patients.

Thursday, 18 December 2008

More networking options...

I am coming round to the idea that we need to leave as many traces as possible for people to find us. So to that end I want to mention a few of the places you can find the medical education community online at present. If you know more then please let me know:

First I found Deirdre Bonnycastle's Medical Education wiki.
And then the Medical Evolution NING.

By the end of October I was starting to use Twitter but I still had not made many medical educational contacts. Now there is a Twitter Medical Education Group which acts as a database.

In the meantime Natalie in Dundee started blogging too. We started discussing how we were using delicious and up came the diigo Medical Education group.

So where else might people be searching for a medical education community? Facebook was always a possibility so I have set up a group there too. And then I was reading about networking opportunities on AJ Cann's blog, and I thought that FriendFeed might be a good place to leave a trace as well. So I started a Medical Education room there too!

So that is a few bases covered. Where else do you think we should leave traces?

Tuesday, 16 December 2008

Medical Education on Diigo- more social bookmarking

After my last post, and some twitter discussion, Natalie and I decided that it was worth giving Diigo a go. It would allow us somewhere to form a medical education community, where we could have discussion, and talk to each other outside blogs. So here it is.

I'll be honest and say that as a social bookmarking tool I am finding it is taking me a little bit longer to find my way around. But it would be good if you check in and give us some feedback. We are living and learning!

Wednesday, 10 December 2008

Social bookmarking isn't quite social enough for me

I've had limited success in finding delicious doctors. Well, I might have found some and I don't know. I have certainly come across a few people who are very good at tagging sites relevant to me. But it is a little bit frustrating that I can not get in contact with these people, who are interested in the same things as me, to find out who they are and what they do. They might even be part of the elusive medical education community!

There is no way to directly contact another user in delicious if they do not have a website or email address listed. So I have to resort to other methods to make contact. I can join them to my network, send them a link and add a hello message to the note I tag, but I can't just send them a message.

Maybe there are good reasons for this. Maybe it prevents spam. But maybe it is just because delicious don't think it is very relevant. On their help page they state that your network might consist of "even new people you run across while exploring Delicious" so it doesn't seem to be considered a primary purpose of the site. Anyway, I have contacted them to find out and will let you know. I'll also tell you if anyone has responded to my strange hello notes!

Tuesday, 9 December 2008

The tag cloud of clinical uncertainty :-)

The tag cloud of clinical uncertainty is a graphical representation of the areas of medical research where we still don't have the answers that would help us day to day as practitioners. It is part of the new TripAnswers website, which takes a clinical question answering approach but allows comments from other users. At the moment the site does not seem to be fully functional, but I think it is a great idea.

And for some reason the Tag Cloud of Clinical Uncertainty makes me think of Bill Bailey. I hope that doesn't seem too irreverent ;-)

Patient narratives in medical education.... where are they?

Since my post about students learning from patient narratives in online forums I have been thinking a lot about how much emphasis we place on patient narratives in medical education.

When talking to individual patients we ask students to consider and explore the patient's experience of their illness along with the history of when symptoms developed and how they have responded to treatment. The exercise I blogged about asks students to compare the narratives of one family with that of others in the course and beyond.

But how often are the findings of qualitative research, which is in a sense about bringing together patient narratives, contributing to medical education? For example, there are several qualitative research studies (here and here for example) on heart failure finding that patients want to know more about prognosis from their physicians. But are we teaching students this? Does the Oxford Textbook of Clinical Medicine discuss the experience of being diagnosed with diabetes or heart failure? Well, I can't find it.

Is it time that we stopped seeing patient narratives as an add-on and started moving it to centre-stage in medical education?

Monday, 8 December 2008

Del.ic.ious doctors!

I've been using del.ic.ious now for a few weeks, but I have bookmarked very little that is relevant to my other life as a GP. By searching for tags such as appendicitis, bts (for british thoracic society), and rosuvastatin I am establishing that there are few tagging clinicians out there.

It may be hard to convince medical students that social bookmarking will be relevant to their lives unless there are a few examples of early adopter clinicians using it well.

Are there clinicians out there using social bookmarking? I'd be interested to find you. And if there aren't, why not?

Thursday, 4 December 2008

Students learning from the patient's online voice

I've been thinking about how students can learn from accessing online communities which are publicly available.

I lead a project where students visit families who are hopefully in reasonably good health. The students are early in the course and we want their learning to be around individuals and families negotiating the choices (or lack of choice) they make with regards to their health and interaction with health services.

The assessment includes a 1500 word essay where they focus on a topic that particularly interested them when they were getting to know the families. The topics can be diverse as how social housing is managed in Cardiff, antenatal screening, or the impact of growing up in a multilingual environment. They are encouraged to compare the experience of the family to accounts in the literature, quantitative and qualitative, and to other families who are participating in the project who have had similar experiences. Students can ask their colleagues about the families they are visiting through a discussion board. As there are only 150 families in the project quite often students will come across issues which no other families have been through. I have suggested to students that they might look at publicly accessible community forums and see if the topics are being discussed there.

Since until this year the project only involved visiting families with new babies or young children, and young mothers can be quite active participants in forums such as mumsnet, babycentre and bounty, there has been lots of material for them to access if they wanted to. For example, last week a student said she wanted to explore cholestatis in pregnancy. I've searched and can't find any qualitative literature on the topic, but threads such as this on the bounty forum can give students many insights into how women perceive the investigation and management of the condition and the impact it has on their lives.

Students learn from the narratives of the patients they meet face-to-face in practice. This is central to medical education. It seems that there could be many valuable opportunities for students to learn from online patients as well.

What do you think? What problems could there be with this approach? What are the possibilities?

Tuesday, 2 December 2008

Gout.... what we don't know.

So, I'm exploring RSS feeds and today added BMJ's Clinical Evidence to my Google Reader. I've just got an update on gout. Unfortunately it seems that we really don't know very much about the treatment of gout. So how should I now treat gout? How does this summary help me?

What are the effects of treatments for acute gout?

Unknown effectiveness Unknown effectiveness

What are the effects of treatments to prevent gout in people with prior acute episodes?

Unknown effectiveness Unknown effectiveness

Friday, 28 November 2008

The networked student!

Techticker linked to this great clip earlier. The fact that my teaching involves a project over 6 months, where students work independently, with little face to face teaching, and where I am not co-located with them has forced me to think about engaging new technologies faster than I would if I only taught students in our practice. But I wonder how much this approach should be used in medical courses even if our students are beside us. What does a medical student's personal learning environment look like?

Thursday, 27 November 2008

It's worth it!!!!

Just had a student call in for a chat about his project. I asked if he had seen my course blog. You could have bowled me over when he told me that not only had he found it but he had clicked on the RSS feed tab and now got my updates directly through to his Vista desktop and wished that much more of Blackboard operated like this.
So my course blog is really a blog and students are starting to develop their personal learning environments. Yay!

Networks... can they be designed?

Are useful networks really only emergent? Can we design them? And how does a network emerge?
The NING communities I mentioned last month are not really emerging. Medical Education Evolution hasn't had a post for months. Is it because the function isn't clear enough?

I still haven't really found an online network of medical educators. But maybe it will find me first!

del.ic.ious !

I have to say I am really liking this. It's fascinating to check out the people who tag the same sites as you; especially if there are only a few of you. They might have a blog listed and you learn more. My network is small.... one other person, who intriguingly I don't know. Delicious does not pretend to be many thing but instead does one thing well! Yay!

I'm here.

Wednesday, 26 November 2008

"I don't know how to use a discussion board"

At a meeting this afternoon an academic rep said that quite a few students, including herself, didn't know how to use a discussion board. Discussion boards on Blackboard probably are a less intuitive than others I have used but it was interesting to be reminded that students are not automatically familiar with these technologies. I know this shouldn't be a surprise to me. I've done Gilly Salmon's course on emoderation. I know that 5o out of the 61 people who responded to my surveymonkey questionaire last month had accessed a discussion forum once or never. But sometimes you forget.

Three students turned up to my last minute drop-in session and it was really good to see just three students for an hour and discuss their ideas with them. This is obviously so much richer than what I can achieve online with 300 students. But maybe I can try to translate the conversations we have had into my course blog so that the others can benefit in some way.

I asked the three students if they thought that accessing a discussion board was a problem and they didn't think it was. I know that in past years over 50% of students will access and post on the boards. I'm sure it will happen again. It is still about giving students chances and opportunities.

I also heard about a service to text message students with new information. It occurred to me that I could have sent a text to all the students to announce my drop-in session. But the three who attended told me that when the texts arrive they are prefaced with 'urgent' and can make them panic! They also questioned whether a lecture being cancelled a week in advance really was urgent. So would I.

Earlier I introduced another student to social bookmarking. I set up a Family Case Study account last night on delicious. It would be great to see lots of students signing up and networking.

Tuesday, 25 November 2008

Is it worth it?

My course blog is still running but no students comment so it is a very uni-directional conversation. I'm not even sure that they are reading it.

They have started using the discussion forums again... some of them. If they email me a question directly I encourage them to post on the board instead so that the other students can see my reply.

But would I be better going the 2 miles down the road to where the students live day to day and booking a room for an hour once a fortnight and letting them know that they could come and ask me any questions they wanted?

Well, I've decided to try that too. So I've just booked a room in Biosciences. It was my first experience of using the online room booking system and I was surprised to find that only lecture theatres were available. That is because not only do I live 2 miles away but I am in a whole different school.

Anwyay. let's see who comes along!

Thursday, 20 November 2008

Today I started learning about...

.... intentional networks
.... practioner research
....Erica Frank
....Jean McNiff
....Berry Wellman

I also wanted to get a Del.ic.ious cloud tag for my blog but couldn't manage it. You can find me here.

Tuesday, 18 November 2008

Quality Counts

My colleague, Lynn Knight, organised a very successful one-day conference in Cardiff today. I was particularly interested in a keynote address by Glenn Regehr and a presentation by Alan Bleakely.

Glenn's presentation focussed on what I would call a complexity thinking approach to medical education. He was clear that just answering 'does it work' is not enough. Instead we need to know about the processes along the way which lead to our successes and failures. I can't help thinking that the format of journals and conferences at the moment do not really facillitate this kind of knowlege sharing and generation.

Alan's presentation "Medical Education Research at a Crossroads" discussed his work developing a new postgraduate medical education research programme at Peninsula Medical School. He predicted that we are moving towards a Multitude model of power, with power resting in the flows of networks and meshworks. I am still fascinated by how as an outsider one accessed and finds these networks. Without transparency it can not really be democratic.

If their presentations become available I will link to them.

Me at Machu Picchu, just a little exhausted and exhilarated.

Wednesday, 29 October 2008

Massive discussion forums

A colleague in CU suggested to me yesterday that really what we needed to foster links in the institution was a massive discussion forum; something as big as digitalspy where we could be as high or low-brow as we liked. I think that's a great idea and I wonder why it hasn't happened yet.
It also made me think about this clip of an interview with Clay Shirky. He makes the observation that we have to almost become 'bored' with a technology before we can go on to become imaginative with uses for the masses. Maybe discussion boards have reached that stage of familiarity for enough of us now.
So how do we get it set up?

My blog hasn't died yet.

It's just that I am off to Peru tomorrow so haven't had time to write in the last few days. But I'll be back mid-November!

Friday, 24 October 2008

health 2.0, medicine 2.0, learning 2.0

How do they come together?

Web 2.0 and Me....

The networks and communities (professionally) I could be linked with:

Staff in GP Practice
Colleagues in other GP surgeries in Caerphilly/Wales/UK/World

Colleagues in Public Health and Primary Care
Colleagues in College of Medicine
Colleagues in Cardiff University
Colleagues in UK Universities
Colleagues in Global Universities



I spent a while yesterday evening trying to get to grips with Twitter. One of the most interesting things is its searchability through sites such as Twitter Search. I searched for "medical education" (without the quotes) and managed to find a few of the people I had come across on other sites. I could therefore access their blogs and twitters although it is harder to find networks on Twitter. But I did find tags to the Medicine 2.0 conference so that brought more links to interesting people and interesting blogs. I've added those blogs to the list on the side.
Now, beyond acting as a database in this way, I'm not so sure how useful it actually is. But I will learn!

Thursday, 23 October 2008

Is blogging dead?

Well, mine has only been started a week and already people are talking about blogging (and all web 2.0) as being passe. I read in comments to this post ( about a medicine and web 2.0 course) that we are already moving on to web 3.0. Someone mentioned it to me in an email and 30 minutes ago my husband mentioned reading something about blogging being dead on the BBC. Well, I don't think it is yet. I think that is ways it's potential is only just starting. I'm also being asked more about Twitter, but I haven't really figured out microblogging yet. My Facebook status updates are going to Friendfeed and I have even joined Twine. Surely enough connection for one day and to ensure that I can keep up with things if blogging is dead.

Surveymonkey for Blackboard feedback

Yesterday I came across mention of surveymonkey as a way to get quick feedback to a question someone raised in a comment about a blog post. So I had a look at surveymonkey and thought I would try and use it to get some quick feedback about the way I have started using Blackboard tools in my part of the course.

First, some background. I teach in a 5 year medical course in the Cardiff, UK. I co-ordinate a course which is delivered to 2nd year (pre-clinical) students called the Family Case Study. Pairs of students are assigned a family to visit 3 times between October and March. Many of the families have young children, and some are older families (at least one member over 60). The focus of the visits and conversations with the family is meant to be health rather than illness. This is the first opportunity students will have to longitudinally visit a family and to experience moving from being a lay student to a student doctor. The students are based in another part of the campus so it is not easy for them to call into my office. So, over the past few years I have been trying to maximise the potential of Blackboard.

I started with the use of the discussion boards in 2005. I made a board to ask me questions about the project, and others where students could talk to each other about how to meet the learning outcomes. I took a course in e-moderating like this one, but I found that I was not going to be able to set up small groups as Gilly Salmon suggests. Instead all 300 students had access to the boards together. But in the main they did use them. In the first year there was no relationship between participation in the discussion forums and mark, but I made some changes and have to repeat the analysis for subsequent years.

This year I set up some wikis and asked students to use them to sign up for the age group of family that they would like to visit. 75% of them managed to do this. But I wasn't sure why the others hadn't although I knew that some had simply missed the deadline.

I then set up some other wikis to allow students to post the questions that they were planning to ask the families in the visits. These questions are essentially the products of the buzz groups that we used in their first tutorial. There are 16 different tutorial groups and 5 buzz groups in each one so we should have had nearly 80 contributors to the wikis. So far there has been contributions from 3 of the tutorial groups. But the contributions are good.

I also started a blog where I could give tips to students, send them interesting links and generally try and keep in contact with them.

So yesterday evening in about 20 minutes I drew up a 7 question survey through surveymonkey to get some feedback on the way I was trying to use Blackboard. You can have a look at the survey here.

By this morning I had 23 responses. Wow! So I learned that generally students found the wiki easy to use but some still weren't sure how to use it. Most said that they hadn't used the wiki for tutorial feedback yet because they hadn't had time, but interestingly nearly all those students accessed Facebook every day. They also suggested I made things a little more organised on Blackboard so I had a tidy-up. I then used my blog to tell them about the findings so far and let them know what I was doing to try and get things moving in a better direction.

It feels quite exciting to be able to get feedback from students so easily.

Blogging as learning...

I really realised the power of blogging in the last few weeks when I started checking Robert Peston's blog every day. I've stopped for now. So his blog is so powerful that is was accused of setting the news agenda rather than just commenting on it. I have no aspirations to reach such dizzy heights. Instead I thought that I would like to record my own journey in learning how to use these new media. I also hoped that I might inspire people who really have something to say to join me. Networking takes time and energy. This should make it easier and over the next few weeks I will be able to report if it does!
This morning I bumped into a colleague at the bottom of the stairs. He works in the School of Postgraduate Medical and Dental Education. I told him I had started blogging and he told me he had too! I'll post a link later. Blogging could help forge links between our departments.
I hadn't realised that there is discussion about whether or not all learning professionals should be blogging but there is.

Wednesday, 22 October 2008

Networking results!

Today through IVIMEDS NING I have been introduced to another NING community, Work Literacy. Their subtitle is Web 2.0 for Learning Professionals. It is a 6 week course that introduces blogs, wikis, social marketing etc. I have missed the start but there is a lot of interesting stuff there. My first thought was that Work Literacy must be a government initiative. But it isn't. It seems to be a different kind of organisation: a network.
More later..

Tuesday, 21 October 2008

Getting the most out of Blackboard

Within my module I have instigated wikis and today a new blog, by me, and the discussion boards that I have used before.

I also rediscovered TED and have linked to a few talks on there in my new Blackboard blog. I wonder what the students will make of them. Here they are- Dean Ornish and Jill Bolte Taylor.

Gonna get myself connected....

Since last week I have joined two NING communities. I found Medical Education Evolution through Deirdre Bonnycastle's blog. This is a very interesting concept- radical people in medical education. But I guess it isn't as busy as I might have hoped. Still I will keep checking in and see how it develops.

Next, I was invited to join the IVIMEDS NING community. This is just in it's infancy but it will be interesting to see how it takes off too. It seems that NING is where it's at.... for now!

Friday, 17 October 2008

Finding the medical education community

So how do you do it? ASME and AMEE don't have a presence on Facebook.... searching for "medical education" + blog, turns up http://blogs.usask.ca/medical_education/ which is excellent.... but there must be more out there. I just haven't found you yet!

Thursday, 16 October 2008

Starting out!

I am a clinical lecturer in Cardiff University. I'm a GP and work in a Department of Primary Care and Public Health in the university, and in a GP practice in the South Wales valleys.

I want to link up with other people in medical and health sciences education so that we can learn together.