Thursday, 18 February 2010

Social Media and Medicine: Let's get #hyperlocal!

So after 16 months of blogging, twittering and social bookmarking how do I find social media to be useful to my work as a GP? Ummm. Well, I don't really....yet. Let me explain.

Early 2009: Phil Bauman's post on 140 Healthcare Uses for Twitter caused a lot of excitement. Then there was talk about surgeons twittering from operating theatres. It all left me a little bit cold. I couldn't see how I would use social media to support my work as a GP. But then I came across a review by Richard Smith from the BMJ in 1996, "What Clinical Information do Doctors Need" which helped me understand my resistance and the potential. To summarise there are three kinds of informations that doctors need
  1. Information about the patient
  2. Information about disease and management
  3. Information about local services to help manage the patient's condition.
I could (and might) do a whole other blog post about how social media might be useful in direct interactions with patients. In medicine we are trained almost exclusively for synchronous communication with patients. When I am in the same room as a patient we can usually communicate so much better. Speaking on the telephone is the next best thing and has the added bonus that it is much more convenient for the patient.  But as I say this needs a lot more room to explore so I'm not going to focus on this now, but safe to say, I am unclear as to see social media could help me gain information about patients at the moment.

Next, there is information about diseases and management. I'm a generalist, and I work in the UK and in a practice with several other doctors. For many conditions such as diabetes or cardiovascular disease, my management is determined by national guidelines, which are then tailored to individual patients through shared decision making. I will often look for information about these more common and less common conditions, and I will use sites such as TripDatabase which will find me relevant research papers and guidelines quickly. But I don't bookmark the information I find there. Why would I? The next time I need some information about that condition, which may not be for a few months, I will search again because the evidence may have changed. Now, this is different to how I use social bookmarking for my work as an educator or as a student (I'm registered for an EdD). Social bookmarking is useful for infomation that I have come across through serendipity (perhaps through Twitter), or because I am specifically looking for information that I don't have time to completely study now but want to be able to find again. But my infomation needs in clinical medicine tend to be more just-in-time. I don't think that I am so alone in this and it probably explains why I have found it hard to find delicious doctors
(Should I be reading generalist journals to keep up to date? The RSS feeds of the BMJ, NEJM and the Lancet swamped my google reader and made me feel inadequate! But here is somewhere where social media is useful. If you have any interest in what is happening in the big medical journals sign up to the RSS feed from Richard Lehman's Journal Watch blog. He writes with wit, and cuts to the chase.)

And lastly there is how social media could be useful with regards to information about healthcare services locally. This is where I currently feel the largest gap, and not uncoincidentally, where I feel social media could contribute most. Back in 1996, Richard Smith pointed out that this information is often diffuse and rapidly changing. Doesn't that sound like something that social media could grapple with? Well, next month I am going up to Glasgow to meet people interested in gathering information that is diffuse and rapidly changing and that could help people living with long-term conditions. 

I'll tell you more about the ALISS project and what they are hoping to achieve when I get back. Then we can start thinking about how we can all get useful #hyperlocal information. What do you think?

PS. By last summer @drves was referring to me as a "Web 2.0 sceptic". But I was so enthused about this last year that I actually started a new blog to try and get some discussion going.

Monday, 1 February 2010

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. 

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.

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!)

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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
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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
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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