Using patient decision aids in the consultation

A few months ago I asked Jon Brassey of Tripdatabase, a clinical search engine or metasearch, if he could ask patient decision aids to the database. Patient decision aids (PDAs) are tools that are made with the aim of helping patients make decisions about treatment options through considering the risks and benefits of options. They are produced by the UK National Prescribing Centre (NPC) and NHS Direct, amongst others. The advantage of having them listed in a metasearch is that I don't have to go round several sites checking if they might have a decision aid on the topic I am interested in.

Tripdatabase is a small but dynamic organisation and it makes great use of social media. Jon uses a Facebook page to get feedback from users, and I was able to give him my suggestion my sending him a tweet. You can see how quickly he responded here, but the short version is that in less than 3 weeks PDAs were added to Trip!

I've recorded the following screencast to show how I used Tripdatabase to share decison making with a patient. In this case the decision to start warfarin to reduce the risks of stroke in atrial fibrillation had been made in secondary care but we were able to review the evidence for this together. We also used the NPC patient decision aid to review the risks and benefits of warfarin treatment.



As you can see the NPC decision aid is not perfect. I don't think that a PDF is the ideal format for exploring this information online. And I don't have access to a colour printer in the surgery so if printing it might be good to have the option to print a version that was not so dependent on colour graphics.

Have you any thoughts on how PDAs can be incorporated into consultations? Please leave a comment!

EDIT 7/2/2012 As I mention in the audio here I explicitly asked this patient's consent to share this story.

EDIT 7/12/2015 Key learning for me in this was that the patient had different concerns to that which I assumed they had. I thought they were worried about inconvenience of warfarin (for given benefit), but they were actually concerned about risk of harm. The decision aid reassured them about risk of harm.

On being public : How social media reshapes professional identity.

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

Social Media Monitoring in Healthcare

Search Privacy by Mushon

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

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

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

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

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

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

Governmentality and Professionalism

This is an essay that I wrote last year on changing concepts of professionalism for a module on the Cardiff EdD. The ideas need a lot more work but there may be some parts that are of wider interest including a history of medical professionalism in the UK.
Governmentality refers to a Foucauldian concept of the "art of governing". If you have any thought on what I have written then please leave a comment. I'm publishing it today as a follow-up to some discussion with Cl are Gerada. Governmentality and Medical Professionalism

Social media, black humour and professionals...

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

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

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

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

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

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

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

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

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

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

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

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

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

My #altc2011 presentation.

View more presentations from Anne Marie Cunningham

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

A story needs a story-teller...

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

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

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

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

"What is evidence?" - tweets from a #amee2011 symposium

After 2 weeks of conferences I have a lot of SoMe activity to catch up with! This storify is for @mikey3982. Luckily I had set up a tweet archive of #amee2011 tweets with FoxePractice. I then have a scoopit chrome plugin that makes it quite easy to move tweets from the archive to a storify. A lot of my tweets contain images of slides but scoopit doesn't detect and embed these automatically as keepstream does- BUT- keepstream doesn't embed nicely (last time I checked anyway) and there isn't a chrome plugin.

I've also added in some tweets from the afternoon synposium on the contribution of the social sciences to medical education research. Greenhalgh was also present for this.

Social media, organisations, identity and anonymity- an interview

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

So you're a public service organisation thinking of starting a twitter account?...

Although this story is about a police account - who have been very quick to start using social media, very well- I think it is also equally applicable to health organisations who might make the move.

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!

Study author joins #twitjc discussion

The Twitter journal club was started by Dr. Natalie Silvey, and Fi Douglas, a medical student, from the UK in 2011. It is going from strength to strength.

Near-patient googling.... any thoughts?

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.

Why I realised the importance of the psychosocial in medicine...

Women of the world by robynejay

Students often don't seem to understand why the social sciences are important to understanding health and the way that we organise health services. The relevance has always seemed rather obvious to me but then I have to wonder if this doesn't have something to do with my own personal circumstances. Or else wouldn't all medical students think the same? So a few facts about me, the person who entered medical school in Belfast aged 18:

• I grew up on a small farm in Northern Ireland
• I'm the eldest of 4 children
• My maternal grandmother died in childbirth
• My mother's aunt started living with us when I was 6. My mother cared for her for 25 years until she died aged 103
• My family had a great interest in politics and my father was elected as a local councillor
• My father died suddenly when I was 14
• The family income fell as a result of my father's death but we were no longer entitled to free school meals
• I took a GCSE in sociology when at school. My coursework project considered why although the school was predominantly female, we only made up 1/3 of the a-level physics class.

I don't usually write about personal things here and there is a lot more I could say about what might have shaped my identity as a doctor. I am left wondering if many students don't question the structures and practice of medicine (insights that can be gained from the social sciences) because nothing in their own personal lives has sensitised them to the way that we organise society. 

If this is so, what can we do about it? If I am wrong, then what can we do about it? Either way we need to do something to shake things up.

How education could learn from games.....

Many thanks to Dom Rodwell, a first year medical student at UEA for sending me the link to this. There are lots of comments here. But how do you think any of the lessons here might be relevant to medical education?

Clinical learning in the open: the strengths of social media.

Image: Open by Justin Marty

Last night I had quite a few learning episodes on Twitter. It started with Christian Assad's post about how Twitter could be used for learning. He is training in cardiology and is aware that troponin (a protein measured to assess damage to the cardiac muscle) levels are often elevated in those with poor renal function. But seemingly this is still a hot topic, and is not acknowledged yet by labs or many doctors. So Christian tweeted an eminent cardiologist to see what he thought and got an ambivalent response. But the key was that it was ambivalent. He didn't just state that, 'No, there is no evidence that renal function is related to troponin levels', he hedged his bets.

Christian saw this as an illustration of how cardiologists could learn on Twitter. But I think it tells us a lot more about learning in the open. I am not a cardiologist. I'm a generalist. I don't diagnose NSTEMI ( a type of heart attack in which diagnosis is partly dependent on troponin levels) but I do manage little old ladies who are discharged on multiple medications after having NSTEMI diagnosed in hospital. So I was interested in this and through commenting on Christian's blog I was able to discuss this issue with him.

And of course patients and the wider public will also be able to gain insights into how many of the things which seem certain in medicine are perhaps not so certain. And that I hope can only be for the good.

I was just recovering from that clinical learning experience when I saw a medical student from Manchester tweet that she had found a tablet somewhere that she didn't recognise. Neil Mehta has done a great job of documenting the learning that came out of that episode on his blog, which you can read here.

There was a suggestion that the pink, oval tablet with EC stamped on it might be aspirin. Out of this rose a very interesting discussion with Jessica Ote, who is training as a family doctor. She asked if there was any evidence that taking NSAIDs (drugs like ibuprofen) with food helped to protect the stomach. I've saved our twitter discussion here using Keepstream, but unfortunately it doesn't embed well (you need greater customisation of embedding, Keepstream!), so you'll have to go to the site directly.

What these examples show is that social media allows us to document our clinical learning, and more importantly the questions we are asking, in the open. These questions don't have to remain in our heads. Next our networks can help us to answer these questions. And then the real benefit is that the learning is there in the open for everyone else to access. These networks can cross medicine (specialists and generalists), other professions (pharmacy, nursing, midwifery, OT), students and the patients and public.

We might even go and find the relevant wikipedia articles and decide to make them better!

PS Another great example of clinical learning in the open is Twitter Journal Club (#TwitJC) which starts tomorrow evening Sunday, 5th June.
And if you want a simple way to record your clinical learning that is happening in the open, have a look at TILT (Today I learned that...) from Jon Brassey, and the Tripdatabase team.

And I should point out that in the initial version of this post I stated that troponins were hormones. This was lazy. I was thinking of kinases (which are also measured to determine cardiac damage, but in any case are enzymes not hormones.) Christian kindly sent me a private message through Twitter pointing out that troponins are proteins, which along with actin and tropomyosin, are needed for cardiac muscle contraction. I've now corrected above (and added the wikipedia link so you can learn more) but I thought in the spirit of openness that I should document my mistake. Thanks Christian!

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.

Chatting on Twitter about Medical Education

Image: Coversations at Vermillion by JeanineAnderson

A few years ago when I started blogging and tweeting my aim was to try and connect with other people interested in medical education. It was hard to find people, and still the bulk of those involved in medical education- educators, students and doctors are not active in social media.

But there are enough of us here to make it reasonable to consider sketching out some spaces to interact and find each other. For the past year or so I've been pulling together people who are interested in medical education into a twitter list which you can find here.

There has also been talk over the last year or so about having a #meded chat. What is a tweetchat? It's a set time when people try to come together, usually over an hour, to discuss different topics which are usually agreed in advance. Medical education happens all over the world, so time zones (as well as language) become issues when trying to organise synchronous social media events.

In the US, Ryan Madanick is hosting the first #meded chat at 9pm EST or 1am UK time. Many of us will be in bed by then so we thought that it would be sensible to have a very informal chat at 9pm BST (8pm GMT) tonight about what the way forward might be for those of us in this timezone.

Personally, I think that tweetchats have quite a few limitations. Think of the limitations of twitter as a communication medium- 140 chts, unthreaded- and then square that for a tweetchat! They can seem noisy and confusing. So why bother? The main benefit is that you might get to know people who are interested in the same things as you, or who have different perspectives to you. You can decide to follow them on twitter, to visit their blog, to catch up on Skype, to meet up at a conference, or to write a paper together. The possibilities are endless, but essentially this is about networking.

If you want to join in the discussion just add #meded to your tweets between 9 and 10 pm tonight. I've tentatively started a google spreadsheet where we might enter topics that we want to discuss, but I'd be happy for us to discuss what way we want to run this tonight. Here is the spreadsheet.

Please feel free to leave any comments here, or just join in!

Health professionals, social media and identity- more thoughts.

Talking to medical students about social media and medicine

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

Policing YouTube: Medical Students, Social Media and Digita Identity

View more presentations from Anne Marie Cunningham

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

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

"Who needs med school when you have Twitter?;-)"

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

Empathy by The Shopping Sherpa

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

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

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

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

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

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

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

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

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

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

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

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

Reflection and Portfolios

Do you agree with these medical students and young doctors?

What happens when you have a brilliant website but you don't have search and google doesn't seem to know about you?

Answer: your content can't be accessed and most people don't know about your website. EDIT Unless they search tripdatabase.

Behind the headlines is an excellent service. Here you can find the background to the latest health stories that you find reported in the UK press. The problem is that it is hard to find what is there. The NHS Choices website seems to exclude BtH from its search. Google doesn't seem to know about the content of the BtH website. Infact, the only way of getting to BtH content seems to be through Tripdatabase, the excellent metasearch.

But, BtH does have it's own twitter feed! Yes, you can follow @NHSNewsUk!

Maybe NHSChoices thinks that content in BtH is of no interest after a few days and that no-one will ever want to look past what is on their front page. They are wrong.

To me this is evidence why anyone who produces content should think about search first and social media later. Get the basics right.

New Post

I'm very pleased to announce that I have been offered a part-time secondment within Cardiff University School of Medicine to look at how we can make best use of technology to support learning throughout the undergraduate medical course.

I go into this post having learned so much from my personal learning network. In the next few years I hope to keep learning and sharing with you.

Thanks.

Storify: the story of a single tweet

Location and Learning

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

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

So what can we do?

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

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

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

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

Lies, damned lies and statistics: How do you turn 61% into 95%?

Image from "Working together for a stronger NHS" Crown Copyright

Edit: 13/05/11 An analysis of the BSA 2007 dataset by Siobhan Farmer, Mark Hawker and myself has been published today in the new publication Lancet UK Policy Matters. You can find it here. We conclude that it is not possible to conclude that 95% of respondents wished for more choice. Using the kind of suppositions given below it may be possible to infer that between 61% and 72% may have thought there should be more choice, but the survey was not designed to answer this question. 

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Edit: 17/4/11 I and a colleague have independently tried to verify Mark's analysis. We have reached similar conclusions but they don't corroborate Mark's results. Unfortunately he is currently outside the UK. We will update with our own results in the UK. We are in agreement that there is still no justification for claiming that "95% of people want more choice in healthcare". 

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Today many of you will have read Ben Goldacre's excellent  analysis of the leaflet which the Department of Health issued last week to help the public understand why they were pursuing reforms of the NHS which are facing widespread opposition. 

Page 11 of the leaflet contains the graphic above stating that 95% of those surveyed in the 25th British Social Attitudes Survey  wanted MORE choice in the NHS. When Ben looked at the published reports he found that 'Do you want more choice in the NHS?' was not a question in the survey. Instead respondents were asked 'How much choice do you think you should have?' and 'How much choice do you actually have?'  But if you could establish how many people thought they should have choice but who currently think that they don't have choice then you might be able to say how many people think that they should have more choice. As Ben points out to answer this you would need to have individual level data. When he asked the DOH for the dataset they unfortunately pointed him to a book chapter.

But fortunately the day this leaflet was published, April 6th, 2011, Mark Hawker  started wondering if he could find out more about this dataset. And he did find more. The individual level data is available to download. So Mark did that. Then he analysed it. And what did he find?  Well, you can read a lot more in the blog post that he published on April 7th but here is a summary.

13% thought they had more choice that they thought they should have.

46% thought they had just the right amount of choice.

41% thought they should have more choice that they had.

So how did the DOH manage to get this so wrong? How did they confuse 41% with 95%? Why weren't they able to direct Ben Goldacre to the correct data source? And why have they decided not to fund this survey in the future?

Hopefully someone can help make the correct data look just as pretty as the incorrect infographic in the leaflet. In the meantime I think I'd like to thank Mark for his work, and to agree with this tweet:

#1care : crowd sourcing a hashtag for primary care

hashtags, a photo by halfbrown on Flickr.

Don't Think Websites, think data

What the non-geeks including me, need to understand. Check out this SlideShare Presentation:

Don't Think Websites, think data

View more presentations from Mike Ellis.

A medical student's thoughts on empathy and #meded

Patient + Wife a photo by polaroid667 on Flickr.

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

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

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

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

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

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

Thank you, Gautam.

A twitter conversation with UK medical students about empathy

Antidepressant prescribing in England: variation may not be as great as Guardian map suggests.

The Guardian published a story on March 5th, 2011, showing that the crude rate of anti-depressant prescribing in some areas of England was more than 3 times higher than in others.The highest rate of prescriptions was in Blackpool, and the lowest in Kensington and Chelsea.
The data was from publicly available sources and is linked to from the Guardian website. The journalists give this description of their method :
"How did we arrive at our figures? First, we gathered prescription data from the online database managed by the NHS Information Centre.

This quarterly information was compiled to get annual numbers covering 1 April 2009 to 31 March 2010 – the most recent full year with available data. In order to make the numbers comparable, we then linked the raw prescription numbers to the ONS mid-year population estimates.

This allowed us to calculate the prescriptions per 100,000 figure in the data below, which controls for the different sizes of PCTs, if not their different levels of wealth, employment and general illness."

The data is also not age standardised. In the comments section some have suggested that in areas with low numbers of prescriptions doctors may be prescribing several months prescriptions at one time. I have looked at the most recent data set available (July-August 2010). Data is available on the total cost of the prescriptions as well as the number of prescriptions and these are plotted below.


This shows a clear correlation between number of prescriptions and cost. However when one looks at individual PCTs the average cost of an antidepressant prescription in Kensington and Chelsea PCT is £7.01, whilst in Blackpool PCT it is £3.48. This does suggest that either more expensive antidepressants are being prescribed in Kensington and Chelsea, or more months prescriptions are being given at one time. Since the absolute number of prescriptions in Kensington and Chelsea is so much lower than in Blackpool, it may be that more antidepressants are being prescribed in each prescription. 


When looking at datasets it's good to make use of all that is available.


You can find my spreadsheet here.


EDIT 4.20pm 6/3/11 I've calculated a rate of prescribing of antidepressants per 1000 of population over 19. (This is not ideal as some teenagers may be prescribed antidepressants, but more accurate than using the total population including children). This has been plotted against average cost of antidepressant prescription. This shows that Blackpool and Kensington and Chelsea are outliers. 

There is not a strong relationship between cost of prescriptions and number of prescriptions. This may explain some of the variation between north and south of England, but the long-established relationships between deprivation and depression are likely to have greater explanatory power.


Here is a link to some papers on that relationship and a very interesting report (via @coxar) on the relationship between antidepressant prescribing, poisoning by antidepressants and deprivation.

If something is shared do you value it less?

Image: Sharing the juice by zummersweet

If you listened only to those I know online, who are interested in learning, you would think that the world believed in trying to make and share educational content as easily as possible. But that is not always true.  I have participated in discussions where it has been suggested that students might think that a course has less value if the content is freely available. The usual response is that  a student should sense more value in participating in a course,  than that which can be derived from easily shared online content. There should be more to it than a few lectures.

This morning I saw a tweet about a lecture on health inequities in the London School of Hygiene and Tropical Medicine. My immediate thought, which I tweeted back, was that it was a pity that the lecture wasn't more widely available (recorded, shared and able to be embedded in a blog) since the topic is so important. The things is that I've started getting a little spoiled. Last week I was able to watch sessions from the Foundation for Informed Medical Decision Making (FIMDM) conference in Washington DC here, live as they were being streamed, and for free. Last year, I watched many of the sessions in a 2 day conference on "Innovation in the Age of Reform" and you can too now, because those sessions are still available here. That conference was organised by Swedish . I had never heard of them before but I have now and so have you.

Lecture capture is becoming so easy to do that most universities have started already. And if you have the lecture then why not share it? Many are. iTunesU is one way of  sharing your content freely with others. Cambridge, Oxford, Harvard and Yale are some of the universities already sharing with iTunesU. MIT have a whole website devoted to sharing 2000 of their courses. So all of these institutions have decided that there is something to be gained from making some of their content freely available. Maybe they believe that it is morally right to share, or that is will garner them positive coverage, or attract future students.

Anyway, the doctor I was speaking to thought that it wouldn't be appropriate to share material from a post-graduate course that someone was paying for. I asked if she thought it would devalue the course and she said yes. So, away from the echo chamber that I seem to inhabit more often I wanted to ask how you would feel about paying to attend a course where some of the materials were made freely available to others. Would it put you off? Would you feel proud that others could see the high standard of teaching you were receiving? Would you feel glad that your fees were helping to share knowledge around the world? Or would you feel cheated?

Intimate examinations without consent- it's still happening.

Image: Exam Room by Maggie Osterburg

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

Press Release from University of Dundee.

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

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

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





















































































































































































Edit 7/2/2013: This paper got a lot of press coverage especially in Australia. Here the authors, Lynn and Charlotte, respond to the media coverage of their research. There were shocked at the reaction and decided not to engage in the media storm. Right decision?