Wishful thinking in medical education: 2014

Thursday, 9 October 2014

The ethics of health organisations monitoring social media...#justiceforlb

Sara Ryan is a learning disabilities researcher. She is also a mother. She kept a blog about the joy that her son, Connor, who was affectionately called LB (Laughing Boy) brought into her family's life. Last year, Connor became unwell and was admitted to an assessment and treatment centre. 107 days later he drowned in the bath. He had epilepsy and Sara had noticed an increase in his seizures and alerted staff. But he was allowed to bathe unsupervised. Now her blog is about what Sara is learning since his death.

This is Sara talking about LB and the campaign for #justiceforLB.

Today's post on Sara's blog is about the memo that was circulated the day after Connor's death by the communications department of the health trust, to brief staff about Sara's blog and provide a summary of posts with the aim that it might "help in shaping a tailored media response". Sara obtained this memo today through a Freedom of Information request. It details how Sara's blog had been monitored by the comms team from as soon as they were aware of it in March 2013 shortly after his admission to the unit. It specifically mentions this post in May 2013 just over half way through Connor's admission, where Sara described her distress at realising that Connor had a seizure but not being able to convince the staff that this was the case. Last week Sara was told by the Chairman of the Board that there had been no monitoring of her blog.

Four years ago there were blog discussions in the UK about the ethics of monitoring social media. There was a particular case of a patient who had had a renal transplant, described here by Dan O'Connor. I made comments here, and in another blog (it was on posterous but hopefully has been rescued and is retrievable elsewhere) that I thought that health organisations should not monitor social media unless they had clear policies agreed by staff throughout the organisation on what they would do in various scenarios, including if a matter came to attention which needed clinical input. I think that Sara's post in May describing Connor's seizure is such a post.

If a health organisation is monitoring social media they should consider in whose interests they are undertaking this monitoring and how they will respond to posts like Sara's.

Connor's death was a tragedy. As the independent report into his death found, it was preventable. This should never happen again.

Link: An excellent post by Tim Turner on the data protection aspect of this social media monitoring.

Wednesday, 8 October 2014

The unwritten rules of stethoscope placement....and what you wear when.

Learned that because doctors and medstudents don't wear uniform in UK, you can identify one from t'other by stethoscope position. Who knew?!
— AnneMarie Cunningham (@amcunningham) October 8, 2014

I'm quite fascinated by the culture around what different health professionals wear in hospital, and also what different health professionals wear around campus. In the UK, medical students do not wear uniforms on placements; they wear their own clothes. They no longer wear white coats. When I was a medical student I am sure we were identifiable on wards by our ill-fitting white coats, before anyone saw our university name badges.

Cardiff University medical students are given lanyards to hold their university IDs, and I heard recently that there may be an unwritten rule that this lanyard should not be worn around campus... or people might just think you were showing off.

Of course doctors in the UK don't wear white coats now either, so fitting vs not fitting white coats are not a way to quickly visually distinguish doctors from medical students. Instead, I learnt today that the position of your stethoscope is now an unwritten rule about your seniority in the medical profession. Some (doctors and students) think that only doctors should wear stethoscopes around their necks. Some have even suggested that the unwritten rule might be that you shouldn't wear a stethoscope around your neck until you are a little bit further up the ranks... maybe having passed professional exams! Even more curious, there is a rumour that this unofficial way of distinguishing medical students from doctors may be sabotaged by infection control guidance preventing ANYONE from wearing a stethoscope round their neck.

It's also worth noting that from a patient's perspective just knowing someone is a doctor is not enough.

@amcunningham Stethoscope meant DR, but emergency med, or general med, or cardiology, or haematology? When parked/oncology ward? Confusing.
— Tricia Murphy-Black (@Pogster) October 8, 2014

We need to remember to always say #hellomynameis and explain who we are and why we are talking to the patient on this occasion.

So I was wondering... should it be easier to identify medical students? Should doctors and medical students wear uniforms too? How do patients visually distinguish medical students from doctors, as I'm sure they are pretty unlikely to know these rules, and does it matter? And has the significance of stethoscopes to doctors in the UK gone up as they've stopped wearing white coats?

Edit : Some doctors in the UK do wear uniform! @sally_bobs is a respiratory consultant in Chesterfield. All doctors and medical students in @royalhospital wear navy scrubs which indicate if they are consultants.

@amcunningham pic.twitter.com/z6yu8PlmM5
— HellomynameisSally (@sally_bobs) October 8, 2014

And ENT consultant, John McGarva, @IamChirurgicus, even designed his own which highlights his specialty.

@amcunningham @sally_bobs I unilaterally invented my own when moved to new build. Saves hassle but am yet to see copy pic.twitter.com/0qFpmJ8jk5
— John McGarva (@IamChirurgicus) October 8, 2014

More about the importance of the lanyard... some have colour coding to distinguish role. In this particular case they were brought in to help distinguish staff at the time of a cardiac arrest. But interestingly lanyards are seen as an infection control risk in some trusts as well.

.@e_hothersall @amcunningham So do we (& colour coded): dark blue for cons, light blue ST3+, yellow CT1-2, green Fs pic.twitter.com/8TOFTDgSG1
— Philip Pearson (@respirologist) October 8, 2014

Saturday, 4 October 2014

Let's not medicalise exercise. Inactivity, not exercise, is risky!

Have you ever been told by a gym to check with your GP first if it is OK to exercise? Wondering how common this is.
— AnneMarie Cunningham (@amcunningham) October 4, 2014

I asked this because it is reported that gyms ask many people, but particularly those with long-term conditions to get advice from a health professional before starting exercise. The wiki 'GANFYD' (Get a note from your doctor) even has a template letter for GPs to use when gyms seemingly insist on a letter from a GP to say that exercise is safe.

The above statement is taken from a leaflet published by ExerciseWorks. The leaflet starts by giving advice on how to start exercising but just over half way through is what seems like a disclaimer advising all who are new to exercise to check with a health professional before starting any new exercise activity.

When I asked @exerciseworks why they advised this, because I could find no basis for it, they said that it was 'industry standard' advice.

@amcunningham that's because that is the industry's guidance. I am not risk averse and covered in liability anyway by insurance...
— Exercise Works! (@exerciseworks) October 4, 2014

I could not establish where this industry standard advice is published but if it becomes available I will publish the link. (edit: thanks to +Lindsay Jordan for directing me to PAR-Q, and info on how its use is suggested by industry training. Note this does not suggest that all people increasing physical activity should see a health professional.) But I am concerned because this not fit with general advice from the NHS or from the Chief Medical Officers of Wales, Scotland, Northern Ireland and England on the safety of exercise. In their document "Start Active, Stay Active' they state that previously inactive people who increase their activity are unlikely to encounter significant risks.

There is therefore no justification for the advice that all who are new to exercise, or even those with longterm conditions, should see a health professional before starting to increase their activity.

If you want to start exercising follow the advice on the NHS Choices website. Exercise in not risky, but inactivity is. If the fitness industry really is advising that you need to see a health professional before starting exercise they need to catch up with the NHS!

EDIT : The Faculty for Sports and Exercise Medicine discuss risk stratification for exercise in this document but this is not referred to in the CMO guidance. I will attempt to update as I find out more!

@amcunningham @FSEM_UK yes. CMO can't detail all the risk...inactivity is the issue. More support for LTC patients where risk is higher
— Niall Elliott (@dundeesportsmed) October 4, 2014

Tuesday, 23 September 2014

What should open educational resources (aka #FOAMed) 'replace' in university education?

. @AmboFOAM asked if #FOAMed should be incorporated into uni degrees. #spa2014conf #PAIC2014
— Jess (@EMS_Junkie) September 20, 2014

I thought that all of us agreed on the answer to this question. Surely... surely... it must be acceptable for Open Educational Resources (OER) to be incorporated into university education? But this tweet produced a lot of discussion. You can see many of the tweets here but some of the issues raised were :

1. Is it acceptable for students to pay for a course where free content is used? My first thought was why wouldn't it be? But I suppose this question is hinting at a similar distinction to a creative commons license which allows reuse for commercial purposes and one which does not. It used to be that we thought of OER as coming primarily from institutions (and possibly being re-used by them too) whilst social media tools have allowed more and more OER to be produced by individuals and disseminated through networks. Some of this is #FOAMed and it is maybe not surprising if the individuals producing it don't feel so happy about institutional re-use.

2. Can we identify the best lecture on congestive heart failure (CHF) in the world? This supposes that across the world we have shared concepts of what is the best lecture? Treatments and management might vary throughout the world but maybe we could find the best 'lecture' on pathophysiology? Maybe it is this 13 min long video from Vanderbilt University?

Maybe the students and teachers on your course could get together to try and identify some of the best resources for their course as we are doing here with our curation project.

3. Is the reuse of materials like the lecture above a threat to local pedagogical practice? I struggled most with this question. I happen to think that reuse of materials like the short video above opens up so many possibilities for local pedagogical practice. The video could be remixed using TedEd with questions relevant to local practice, and links to local guidelines or formularies. It could be remixed using Mozilla Popcorn maker in an infinte number of ways. And the remix could be remixed again by other local colleges or by students. We are not talking here about people sharing content through MOOCs which often aren't really very open at all, though of course there are exceptions! .

4. What can OER replace? If lectures (like textbooks) were about information transmission then OER selected (and remixed) for local relevance might replace them. And do a better job. But I can't see why teachers will be replaced.

Thank you to everyone who participated in the discussion so far. What other questions should be be asking about OER and do you have any different answers to those I have asked above?

Wednesday, 28 May 2014

The need for a #1care forum... who will lead?

Saturday, 3 May 2014

Why social media is not a waste of time for a doctor - infographic, slides, video and paper!

In Decemeber 2013 - Professor Matt de Camp and I were asked to debate whether social media was a waste of time for doctors in the Journal of the Royal College of Physicians of Edinburgh. You can read the full paper here and see some discussion on PubMed commons about it here. This is my part of the paper with hyperlinks. I should mention that JRCPE is an open access journal who allowed me to retain my copyright. This is therefore published here, along with the infographic and my slides, under a creative commons license so feel free to reuse and remix as you wish.

Why does a twittering doctor tweet? - 10 reasons for a social media presence from Anne Marie Cunningham
These are the slides I used when giving my talk on this at #Dotmed13 in Dublin last December. You can watch a video of the talk below.

Introduction

Should you have a strong social media presence? I am going to give you ten reasons why I think you need one. Social media provides an opportunity to publish your thoughts and ideas and to share your experiences without having to go through a middleman. And many people are taking advantage of this. Globally half a billion tweets are posted every day. (1) Surely it must be possible to find something of value that could make it worthwhile for a doctor to start exploring these spaces? It is not nearly as difficult as you might think, because these pieces of information are not just floating unconnected to each other; they are disseminated and linked to through networks of your peers. Developing networks, and figuring out who and what to pay attention to, are some of the key learning skills we need in the twenty-first century. (2) I will convince you that it is worth developing these skills.

10 Reasons to have a social media presence

To connect

The landmark report on ‘Health professionals for a new century’ suggested that we need ‘locally responsive but globally connected teams’ 3 but lamented that ‘most institutions are not sufficiently outward looking to exploit the power of networking and connectivity for mutual strengthening’.(3) But this is changing. It is now rare to attend a forward-thinking event without being encouraged to tweet with the conference hashtag. We are our institutions, and we are leading the way; we are making the connections.

To engage

Social media is not just about getting your message out. It is also about listening. We can learn with patient leaders.( 4 )As Gilbert and Doughty, co-directors of the Centre for Patient Leadership, describe ‘[w]hen patients can both manage their own health and go on to develop the confidence and skills to lead and influence others, something special happens: new collaborative systems of healthcare take shape and positive solutions emerge to healthcare problems, locally and nationally.’ (4) Through their blogs and tweets you can engage with them.

To inform

If you are trying to do things differently, changing the way you and your team work, where can you tell people about this? Consultant endocrinologist Partha Kar uses his blog, NHS Sugar Doc, to communicate how an award-winning team is involving patients in redesigning their service, meeting the challenges of modern healthcare.(5)

To reflect

Elin Roddy is a respiratory consultant. She also tweets (@elinlowri). During ‘dying matters’ awareness week, and prompted by discussions of end-of-life care on Twitter, she decided to write her first blog post: a reflection on how, during her working life, she has ‘been involved with death in many different guises and in many different ways.’ (6) Thirty eight people – health professionals and patients – left comments to say how they had been moved by her eloquent writing. She is now lead for end-of-life care in her trust and says this would not have happened without her learning through social media.

To share

In a hospital in London a patient has the wrong foot operated on because they put a compression stocking on the wrong side. The checks and balances which the nominally implemented surgical checklist should have provided did not happen. (7) Fortunately the other foot needed operating on too. After investigations were completed the medical director of the trust gave permission for an account to be shared through social media. The story ‘Wrongfooted’ by anaesthetist Helgi Johnannson has been viewed more than 17,000 times. (7) When surgeon and medical director, Dermot Riordan, read the story he wrote on his blog that he felt ‘déjà vu, sadness and even anger’. (8)

.@traumagasdoc This make me both sad & cross. We had near identical case. Reported externally but no learning dissemination by @NHSEngland
— Dermot O'Riordan (@dermotor) October 19, 2013

A year ago nearly exactly the same mistake had occurred where he works. He describes the transparent and open approach that his team took to learning about this incident but he personally regrets that he did not share this learning with others in the way that ‘Wrongfooted’ showed it could be done. Social media is changing how we conceive of dissemination.

To be challenged

Often the best way to learn is to be challenged. Earlier this year people who had experienced mental health care started tweeting their experiences using the tag #DearMentalHealthProfessionals. (9) Along with appreciation and thanks there were also tweets which expressed how it felt to be let down by a system that is supposed to help. To be able to change systems for the better we need to work towards understanding, and that starts with shifting our perspectives. Social media can help us to do this.

To be supported

Sometimes we just need to know that we are not alone. #TipsForNewDocs are short messages of advice for newly graduated medics from doctors, other health professionals and patients. Like many social media activities it is hard to say who started this trend but Guardian healthcare(10)and the GMC(11) have both used the tag to support this important transition.

To lead

How much impact can you achieve through social media? NHS Change Day has been lauded as the ‘biggest ever day of collective action to improve healthcare that started with a tweet’. (12) A conversation between some junior doctors on Twitter was the catalyst for a project which saw 189,000 people take action on 13 March 2013 to improve the care of the patients they served. (12)

To learn

Free open access medical education – otherwise known as FOAMed (13) is on the rise. In the past we used databases to store and find these resources, but now we are increasingly depending on the power of distributed networks to help filter the best content for our needs. New educational initiatives are starting every week in social media. The case-based discussions of ECGclass (14) and Gasclass for anaesthesia (15) can give you a flavour of what is achievable.

To inspire

Kate Granger is a doctor training in elderly medicine; she is also terminally ill with a rare aggressive abdominal sarcoma. During a recent hospital admission (16) she noticed that too many of the staff she met did not introduce themselves. She decided that something needed to be done, so she wrote a blog post with a simple idea – when health professionals meet patients they should say ‘hello, my name is’. (17) People started talking about her idea and doing what she asked. The campaign has reached so many people that it is mentioned in the Government’s response to the Francis Inquiry. (18)

Conclusion

Is social media a professionalism quagmire? Could your professional reputation hang on as few as 140 characters? Yes, norms are still being established but that means you can shape them. The truth is that if you respect your patients and your colleagues, like these pioneering physicians, you have little to fear. Instead, you should be feeling optimistic and excited that you can now easily tap into a global community who can help you to be a better doctor in a better system with your patients.

References

1 Naughton J. What’s Twitter’s real value? Don’t ask an economist. The Observer.2013 Nov 24.
2 Rheingold H. Net smart: how to thrive online. Cambridge: MIT Press; 2012.
3 Frenk J, Chen L, Bhutta ZA et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet2010; 376:1923–58. http://dx.doi. org/10.1016/S0140-6736(10)61854-5
4 Gilbert D, Doughty M. Quality: why patient leaders are the new kids on the block. Health Serv J2012; 122:26–7.
5 Kar P. Game-changer III: ward priority and transparency[Internet}. Partha Kar 2013 Nov 16 [cited 2013 Nov 27]. Available from: http:// nhssugardoc.blogspot.co.uk/2013/11/game-changer-iii-ward-priority-and.html
6 Lowri E. Dying matters[Internet]. Elin Lowri 2013 May 13 [cited 2013 Nov 27]. Available from: http://elinlowri.wordpress.com/2013/05/11/ dying-matters/
7 Wrongfooted[Internet]. 2013 Oct 13 [cited 2013 Nov 27]. Available from: http://storify.com/traumagasdoc/wrongfooted
8 O’Riordan D. Failure to learn[Internet]. Dermot O’Leary 2013 Oct 20 [cited 2013 Nov 27]. Available from: http://oriordan.co.uk/blog/ files/Failing%20to%20learn.html
9 Betton V. #DearMentalHealthProfessionals[Internet]. Victoria Betton 2013 Aug [cited 2013 Nov 27]. Available from: http:// storify.com/VictoriaBetton/dearmentalhealthprofessionals
10 Guardian Healthcare. #TipsForNewDocs[Internet]. 2012 [cited 2013 Nov 27]. Available from: http://storify.com/GdnHealthcare/ tipsfornewdocs
11 General Medical Council. #tipsfornewdocs[Internet]. 2013 [cited 2013 Nov 27]. Available from: http://storify.com/GMCUK/tips-for-new-doctors.
12 Bevan H, Roland D, Lynton J et al. Biggest ever day of collective action to improve healthcare that started with a tweet [Internet]. 2013 June 14 [cited 2013 Nov 27]. Available from: http://www. mixprize.org/story/biggest-ever-day-collective-action-improve-healthcare-started-tweet-0
13 Life in the fastlane. FOAM – Free Open Access Medical Education [Internet]. 2013 [cited 2013 Nov 27]. Available from: http:// lifeinthefastlane.com/foam/
14 Wetherell H. Keeping ECGs simple[Internet]. 2013 [cited 2013 Nov 27]. Available from: http://hcwetherell.blogspot.co.uk/
15 Gasclass. Gasclass: the web school of anaesthesia[Internet]. 2013 [cited 2013 Nov 25]. Available from: http://gasclass.wordpress.com/
16 Granger K. The other side live![Internet]. Kate Granger 2013 Aug [cited 2013 Nov 27]. Available from: http://storify.com/katemgranger/ the-other-side-live
17 Granger K. #hellomynameis[Internet]. Kate Granger 2013 Sept 4 [cited 2013 Nov 27]. Available from: http://drkategranger. wordpress.com/2013/09/04/hellomynameis/
18 Department of Health. Hard truths: the journey to putting patients first. Volume one of the Government response to the Mid Staffordshire NHS Foundation Trust Public Inquiry[Internet]. London: Department of Health; 2013 [cited 2013 Nov 27]. Available from: https://www. gov.uk/government/uploads/system/uploads/attachment_data/ file/259648/34658_Cm_8754_Vol_1_accessible.pdf

Wednesday, 2 April 2014

PollEverywhere Higher Education License Pricing

PollEverywhere is a 'bring your own device' audience response system. Your audience can respond by SMS or web (or Twitter!). Although we have access to clickers we found that they were not used as much as they could be - in part because of the extra effort of getting the clickers, handing them out and then getting them back. Last year one of my colleagues suggested that we look into PollEverywhere as it had been used by the university for public engagement events.

A free PollEverywhere license allows up to 40 responses to any question or poll. But we have over 300+ students in the 5 years of our undergraduate course so I approached PollEverywhere last year to find out how much a HigherEd license would be for 1500 students. I was advised that pricing was based on maximum number of responses not on students. This made sense since we would not actually be registering or tracking individual students on the system. So we purchased a license which allowed us to have up to 330 responses to each poll. This was priced at $3.50 per student response. The pricing model made sense because it felt as if we were buying 330 virtual clickers. This license allowed us to have an unlimited number of tutor accounts. We started with 50 but haven't needed to go beyond that yet.

We've been learning a lot as we have gone through the year about the pros and cons of using the various question types and I and others have used this license at various public events with great success. Last week we were contacted by PollEverywhere to inform us that we had gone outside the terms of our license. I have spoken to the PollEverywhere team today and they estimate that we have had 829 unique responders/students to our polls in the last 2 months. They do this by applying an algorithim looking at IP addresses and unique mobile numbers. This isn't in any way surprising as we had a public engagement event a few weeks ago and have also been demonstrating PollEverywhere at teaching events and conferences.

PollEverywhere say that there has been a misunderstanding and that we have been purchasing unique accounts for our students not a maximum number of responses to a given poll. I asked about public engagement activities- would be need to purchase a separate license for these? They say that we don't need to if we email them in advance and let them know that we will be using the license to a public audience.

By the end of the week PollEverywhere are going to clarify the terms of the Higher Education license to us in writing. This documentation is being written now. They don't plan to put this on their website as they say that there has not been a need as there have been no other misunderstandings about this. Since I told many people about what I thought was the terms of our existing license I thought I would write this blog post to explain that my understanding of the license has now changed.

We now have to decide whether we want to purchase this license again considering that it will be 3-4times as expensive next year as this year. We will review other options such as Participoll. It may be back to clickers after all!

Thursday, 20 March 2014

very quick survey about Facebook in education

social media in medical education... it's all about the network

What is the role of Twitter in medical education?

I started using Twitter (and this blog) because I wanted to connect with people who I didn't know how to connect with otherwise. I wanted to connect to people who worked in medical education but I got a lot more than I bargained for. I found a wonderful network of people who I continually learn from. I can share, and get feedback, dip in and out, refine my thoughts, and the rest.

But do I think that we should use it in our courses? What for?

Last week I attended a workshop lead by Claudia Megele on social media in higher education. She has done tremendous work in establishing several 'knowledge networks' including #mhchat (mental health chat). She then introduced a group of social work students to social media including Twitter. They used pseudonyms but participated in regular Twitter chats and discussed topics online.

It seems to me that the most powerful thing that Claudia did was to introduce her students to her networks. She helped them to become part of a community discussing mutual topics of interest online.

So how can we, committed to health professional education, help our students? I think we can do the same thing. We can give our students access to our knowledge networks.

Wednesday, 12 March 2014

The challenge of feedback and the burden of accountability in clinical medical education

Have you received good feedback in a clinical setting as a doctor or medical student?

Some of the best feedback I received was during my GP reg training year when my trainer reviewed most of my consultations with me every day for the first 4 or 5 months. I knew it would be a chance to ask what he thought about a patient, and also that I would have to justify some of the decisions I had made or hadn't made. It was above and beyond any feedback I have ever had before or since on my clinical work.

We know what makes good feedback. Here is a great paper about this from 31 years ago. There was no talk about eportfolios or skills logs or apps at that time. 16 years later when I was during my GP trainee year we didn't have the burden of documenting our feedback either.

So do current moves to use technology, including smart phones, to try and document feedback in clinical settings enhance the quality of feedback given? Do they make it more likely to happen? If they don't why do we do them?

Is there a risk that in an effort to be accountable, we are making it harder for learners to achieve good feedback because of the burden of documentation? If you want to read more about this I strongly recommend Onora O'Neill on 'Intelligent Accountability in Education'.

Thursday, 27 February 2014

Politicians badly briefed about data issues too?

At the end of the Parliamentary meeting on 'Patient rights and access to NHS data',
Parliamentary Under Secretary of State for Public Health, Jane Ellison MP made the following statement:

"I should actually just before we close put on the record Mr Emerson, forgive me, but I think it is useful for colleagues, just in regard to the Faculty of Actuaries and the data there, and I think actually the Shadow Minister also alluded to this; just to put on the public record that the data that they used was publicly available, non-identifiable and in aggregate form."

This data as described in this blog post was not publicly available or in aggregate form. It was individual-level data that had to be specifically asked for from the NHSIC.

Jane Ellison may have been referring to the report generated from the research done which is indeed publicly available, with aggregate analyses from which it would be impossible to identify an individual. But no one has concerns about the report.

You can watch her statement here at 16.16.30

Wednesday, 26 February 2014

We need data literate journalists.

So what do you think happened recently with NHS data? Do you think that the NHS handed over the records of millions of patients to insurers who then looked up their credit records and suggested that their insurance premiums should be changed?

That would be awful wouldn't it? Just as well it didn't happen.

I came back from visiting family on Sunday night to see the Telegraph story "Hospital records of all NHS patients sold to insurers" being tweeted. It was picked up by many other papers including the Guardian.

The story is about research done by a group of actuaries, the Critical Illness Definitions and Geographical Variations Working Party . You can find the full report here. It's a 200 page plus document written to explain to other actuaries how 'geodemographic' data might help predict how likely someone is to develop a critical illness. If you have ever applied for life insurance or critical illness cover or an income protection policy you would know that you your policy is priced based on what your risk is... your age, weight, smoking status, what illnesses you have. If you know anything about health inequalities you will know that beyond our own personal risk factors( age, weight etc) our social circumstances are important in determining how long we will live and if we will get sick. And you can tell a lot about our social circumstances from where we live. The relationship is so strong that there is a postcode mortality lottery Your postcode *might* reflect your lifestyle, your wealth, your education- all the things that predict how likely you are to get sick or to live long.

Geodemographics , CACI's Acorn, and Experian's Mosaic , classify postcodes into strange-sounding groups like 'happy families' and 'twilight subsistence' based on information obtained from public and commercial sources. The research by the actuaries was about whether these postcode classifications could predict when people developed serious illnesses. You can read the report to find out more but the short answer is that they do.

You may disagree with the idea that you postcode should be used to predict your risk to insurers. Is it a smart way of doing things? You can read some discussion of this in Tony Hirst's blog post here.

Most of the discussion was not about this though. It was about the fact that 'hospital records' were given to insurers.

So what actually happened in the research?

"patients' medical histories, identified by date of birth and postcode, were combined with credit ratings data" http://t.co/oRhzGgazvt
— roger kline (@rogerkline) February 24, 2014

The above tweet by Roger quotes the Guardian's coverage of this story. Are Acorn and Mosaic 'credit ratings data'? Well, yes, they may have been originally developed to predict how likely you were to be able to pay back a loan. But as we can see they can also predict how likely you are to get sick or to die.

What did the hospital records look like? There were Hospital Episode Statistics. This is what the data looked like (from this presentation)

Is that what you thought the 'hospital records' would look like?

Did the researchers have full postcodes and dates of birth? It was a bit hard to tell this from the report. I presumed they didn't because I didn't see why they needed it. And I didn't think that the NHS was likely to give away information that would make it easy for individuals to be re-identified. But the full postcode was needed to be able to assign a 'geodemographic profile' to each person in the dataset. The following screenshot is from page 10 of the report.

I read this as meaning that the geodemographics were added to the HES dataset by the NHSIC who provided the dataset to the insurers. But others, including Tony Hirst, first read this as meaning that it was the researchers that did the datalinking. Who did the datalinking was important because who ever did it needed the full postcode.

Today after reading an article by Wired in which it is stated the hospital data was given to the Institute and Faculty of Actuarie IFOA and "was then combined with secondary sources, including Experian credit ratings data, in order to influence insurance premiums." I decided that I had to find out. So I phoned the press office of the Institute and Faculty of Actuaries (IFOA) on the number I found on the press release of their rebuttal to the Telegraph article.

I got straight through. The press officer directed me to page 10 above. I asked who had done the datalinking and they said it was the NHSIC. This made sense and fitted with their statement that they had no identifiable information for the individuals in the dataset. They only had an age group, and the 1st part of their postcode.

So how many people do you think contacted the IFOA to try and make the same clarifications as me? Every journalist that had written a story about this perhaps? No 3 people. The BBC and two bloggers. I was one of them.

Why didn't other journalists get in touch with them? Didn't they understand the significance of this? Didn't they care?

In the next few months and years we are going to be having many conversations about big data. We need to have journalists who know how to ask the right questions. And at the moment it looks as if we haven't.

If you think that the problem is that actuaries were given NHS data at all then see this.
EDIT In the past GPRD data was provided to actuaries. This is no longer the case although at least one application was made recently to CPRD. They rejected this.

Thursday, 20 February 2014

The benefits of social media for researchers...

You can vote here

Sunday, 16 February 2014

How to create a great curriculum map without wasting a lot of time : Repost from @mededportal by @one45software

All of MedEd Portals resources are creatives commons licensed but you have to register for a free account and log-in to license them. I thought I would share this brief 'fact sheet' on curriculum mapping because it is something that has come up a lot in the LinkedIn group on technology in medical education that I started. Here are some of the threads discussing curriculum mapping from that group.
The factsheet is written by Brian Clare, CEO of One 45 software. I like the style that it is written in and the acknowledgement that curriculum maps are rarely started from the desire to make it easier for students to find content which seems a downright tragedy.
What are your thoughts on what he says?
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From MedEd Portal

Curriculum mapping is a process that holds the potential for great rewards, but it carries many risks. One of the biggest risks is that it will be a giant waste of time. In our work with clients, we often see ambitious curriculum mapping projects fail because the final result was just not useful enough. In this guide we will share some practices that will help ensure your curriculum map is not only LCME-compliant, but is continually updated and useful too.

Make the curriculum map useful for students

To some, the curriculum map is purely administrative overhead to ensure LCME compliance. To others it is a useful planning and reporting database used to inform curriculum changes. But almost never is it a tool for students to find and reference content and learning objectives.
This is a mistake. In our experience, schools that make their curriculum map useful for students enjoy a map that is more comprehensive, updated more frequently, and used more by faculty and administration. This occurs because of the natural adjustments that faculty and administration make to match their processes up with student behavior.
To begin making your map more useful to students, a great place to start is with exam objectives. Survey your students and ask them which reports about the curriculum would help them study for their exams. Or, ask them which parts of finding curriculum content they find frustrating. These answers will help you discover valuable curriculum mapping changes to make. You could include a question about this on your end-of-course survey.
Once you’ve got an idea what students are looking for, try mapping a course or two to its exam objectives. Have a small group of students report and search before their next exam and see if the new mappings addressed their issues. After a few rounds of this process, you’ll have an idea of a valuable set of curriculum mappings to make. This will lower the risk of creating mappings that no one uses.

Use data on report usage to drive updates to the curriculum map

Our data shows that users perform curriculum searches far more than they navigate the curriculum. If your system allows for it, gather data on the types and frequency of searches users are performing. Periodically, ask the users doing these searches what other data they’d like to find. This feedback is invaluable at curriculum committee meetings as it provides qualitative and quantitative data to help justify changes to the curriculum map.
For example, if someone suggests linking competencies to session objectives, and the usage data suggests this might be a good idea, start small. Link the competencies to the objectives for one course and see if the changes increase search usage or user satisfaction. If they do, fantastic! You have a compelling reason to change your map. If not, fantastic! Now you can work on a different initiative that will have more value and you haven’t wasted any time.

Add more detail in small increments

If you focus on making the curriculum map valuable for stakeholders at every step, you’ll have an enviable problem: people will want you to make the system even more valuable for them. For students and faculty, this may mean making reports easier to generate, or more specific. For your curriculum committee, this may mean adding more detail to the map.
If you are considering changes to your curriculum map, focus first on testing that the changes will produce value for your users at a small scale before rolling them out full-scale. This means mapping one course instead of 10, or having a few students generate reports while you watch them work, or creating a test installation of your curriculum map where you can play around without worrying about making mistakes. Your goal with these small scale experiments is to get the users excited about the results. Whenever a suggestion is made to change the curriculum, try and ask “how can we test that this will add value?”
Proceed carefully, and try and match your curriculum mapping efforts with the most valuable use-cases for those efforts. We hope that by doing this you’ll find greater success and buy-in from students, faculty, and administrators. Good luck!

Sunday, 9 February 2014

Asking women to speak at events...

I have been involved in organising a few events recently - Digital Doctor and NHS Hack Day Both are a bit techy and geeky - and I have been acutely aware of issues of gender balance. Men tend to volunteer to speak. Women more often have to be asked.

People are doing something about this. Last year I spoke at the first 300 seconds -an initiative to get more women speaking up on tech- started by Sharon O'Dea, Ann Kempster and Hadley Beeman. It was a great experience. It took me out of my comfort zone. Speaking to a digital/techy audience about why I was personally driven to engage in a social media as a doctor was a new challenge, but the audience and atmosphere was supportive and all I had to do was volunteer (after being tipped off about by the lovely Louise Kidney who I have still to meet).

My friend Nicholas Whyte, an independent diplomat, wrote last year about his awkwardness at turning up at a conference, chairing a session and finding that no women were amongst the 22 panelists and moderators at the event. So he says that he will not participate in an event where this happens again. There have been other calls for men to take this action.

The biggest medical education conference in Europe is AMEE in Milan this summer. The provisional programme includes 3 plenary sessions with 7 speakers. All the speakers are men. Only one of the 3 plenary sessions is chaired by a woman: Trudie Roberts, President of AMEE.

I think that as women we have to take responsibility for this too. We have to make the organisations that we are part of aware that we think that having women prominently represented at the events that we attend is important. If we are organising events we should make clear to our co-organisers that having women speaking is important.

And if we are asked to speak we should try and say yes. It is easy to think that we are not qualified, or there is someone better. Say yes and have a good chat with the organiser; ask them to tell you about why you will be a great person to speak to their audience.

This isn't about having women speaking just for the sake of it. It's about having the best people speaking. The best people are very likely to be women so if your event doesn't have women speakers something has gone wrong.

Everyone who speaks at 300 seconds deserves a wider audience. And it's not just the tech sector that have to think about this. Watch Lily Dart!

Edit: Response from AMEE twitter feed

@e_hothersall @amcunningham Careful consideration is given to the choice of speakers from nominatations, we aim to balance gender if we can.
— AMEE Online (@AMEE_Online) February 10, 2014

@e_hothersall @amcunningham We are sorry that male plenary speakers have dominated the #amee2014 prog. We are reviewing for #amee2015
— AMEE Online (@AMEE_Online) February 10, 2014

And 'female conference speaker' bingo

Monday, 13 January 2014

Social media and medical professionalism : Commentary in Medicial Education February 2014

This is a pre-publication version of the following paper. Cunningham, A. (2014), Social media and medical professionalism. Medical Education, 48: 110–112. doi: 10.1111/medu.12404

In this issue, Jain et al. (1) are undoubtedly correct when they suggest that the focus on social media in the medical education literature to date has been a worry about threats to professionalism. In conducting their study, they set out to explore how students, faculty and university staff (presumed to represent the public) view the posting of certain materials to public Facebook profiles. They found agreement on the most serious transgressions such as breaching patient confidentiality. There was more disagreement, however, about other issues such as appearing in photographs with alcohol, or as part of what the authors described as ‘same sex couples’. In general, students were more tolerant than their faculty or the public.

The focus on social media in the medical education literature has concerned threats to professionalism

What does this research on online professionalism tell us about our deeper uncertainties about what it means to be a doctor in the 21^st century? Hafferty has described the confusion between the various conceptions of professionalism (2), indicating that to some professionalism is an identity and set of values, whereas to others it is a set of attitudes and behaviours. Medical students also employ different discourses when considering professionalism with some focussing on more superficial aspects such as how they act or appear, whilst other students have more complex and embodied understandings(3).

To some professionalism is an identity and set of values, whereas to others it is a set of attitudes and behaviours

Let us consider the portrayal of alcohol consumption by medical students in social media. We know that excessive alcohol consumption has a long history in the culture of medical schools. The Pithotomy Club, a John Hopkins Medical School student society formed in Sir William Osler’s time(4), had a cherub on a beer keg as its emblem, and an annual revue, the Pithotomy Show, which ended in a ‘beer slide’(5). (Forthcoming) research by Black and Monrouxe (6) finds that some medical students in the UK feel compelled or coerced by their fellow students to drink alcohol or take more than they had intended. Although there are concerns about the alcohol consumption of medical students and doctors (7-9), the culture in medical schools which facilitates this is rarely examined. An online survey of medical students in the UK in 2012(10) found that only 22% thought that their medical school promoted a healthy attitude to alcohol. Is it surprising that some of the students thought that medical schools were more concerned about image than student well-being given the preponderance of messages about not sharing images of alcohol consumption through social media combined with a tacit acceptance of a pro-alcohol culture? Students sensed that being seen to behave badly may be considered worse than actually behaving badly. That is, the portrayal of a ‘professional demeanour’(11) was seen as more important that the actual behaviours of medical students. So when we consider the portrayal of alcohol by students in social media, might students have a more complex understanding of this than the restricted discourses often promulgated by their schools?

Is it surprising that some students think that medical schools are more concerned about image than about student well-being?

Next let us consider whether we should be concerned that personal information, not usually revealed in the consultation, may be self-disclosed through social media profiles. Thompson et el. (12) in their 2008 study of the Facebook profiles of medical students and residents in Florida were the first to postulate that the revealing of sexual orientation and political views through social media could be construed as unprofessional. Professional boundaries are normally seen as either crossed (when no harm is done to the patient) or violated (where harm does occur), but we have no evidence that online self-disclosure through social media profiles affects subsequent consultations (13). Still, the warnings persist. In the study reported this month, Jain et al. (1) looked at perceptions of the expression of sexual orientation. We know that homophobia exists within medical cultures (14, 15) and that young people use social media to form networks to support them in dealing with the homophobia they meet in offline life (16). It would, therefore, be quite concerning if we were to recommend without good reason that medical students should be cautious about expressing their sexual identity online.

We have no evidence that online self-disclosure through social media profiles affects subsequent consultations

More generally, discomfort over the disclosure of personal information is in keeping with the tensions Frost and Regehr (17) describe between the discourses of standardisation and diversity in medical professional identity. Is concern over releasing one’s sexual orientation or other personal information evidence that those leading medical schools, implicitly or otherwise, believe we can (or desire to) produce ‘neutral doctors’ (18) or ‘vanilla physicians’(19) who are able to leave behind their own personal values and socio-cultural backgrounds? If so, then it is no wonder that social media is seen as a threat to a process of socialisation which Beagan (18) describes as in part involving isolation from all wider networks who might remind students of their previous identities.

Discomfort over the disclosure of personal information is in keeping with tensions between the discourses of standardisation and diversity in medical professional identity

When we are online, just as when we are offline, we must always respect the dignity of our patients and colleagues. Beyond this, regulating and advising on behaviour in social media risks appearing, as Lerner states, ‘alarmist’(20). There are alternatives. McCartney suggests that ‘doctors, like other citizens, are entitled to express opinions online and one effect of the undoing of the medical god-complex has been to humanise medicine and populate it with doctors who are fallible but professional’(21). Ballick describes such an approach as ‘rather thoughtful and subtle’ and acknowledging of ‘the complexity of online life’ (22).

If we recognise that ‘becoming a professional is an interpersonal and complex activity’(3) then we should aspire to research and guidance on social media and professionalism which reflects this.

Key quotes:

So when we consider the portrayal of alcohol by students in social media, might students have a more complex understanding of this than the restricted discourses often promulgated by their schools?

It would, therefore, be quite concerning if we were to recommend without good reason that medical students should be cautious about expressing their sexual identity online.

Is concern over releasing one’s sexual orientation or other personal information evidence that those leading medical schools, implicitly or otherwise, believe we can (or desire to) produce ‘neutral doctors’ (18) or ‘vanilla physicians’(19) who are able to leave behind their own personal values and socio-cultural backgrounds?

When we are online, just as when we are offline, we must always respect the dignity of our patients and colleagues.

If we recognise that ‘becoming a professional is an interpersonal and complex activity’(3) then we should aspire to research and guidance on social media and professionalism which reflects this.

1. Jain A, Petty E, Bjaber R, Tackett S, Pukiss J, Fitzgeral J, et al. What is Appropriate to Post on Social Media? Ratings from Students, Faculty and the Public. Medical Education. 2013.

2. Hafferty FW. Professionalism and the socialization of medical students. In: Cruess R, Cruess S, Steinert Y, editors. Teaching medical professionalism. New York: Cambridge University Press; 2009. p. 53-73.

3. Monrouxe LV, Rees CE, Hu W. Differences in medical students' explicit discourses of professionalism: acting, representing, becoming. Med Educ. 2011 Jun;45(6):585-602. PubMed PMID: 21564198.

4. Jarrett WH. The Pithotomy Club: RIP. Proceedings (Baylor University Medical Center). 2011;24(1):35.

5. Harrell R. History of The Pithotomy Club 2009 [29/9/2013]. Available from: http://www.pithotomy.com/history.html.

6. Black L, Monrouxe LV. ‘Being sick a lot, often on each other’: students’alcohol-related provocation. Medical Education. in press.

7. Boland M, Fitzpatrick P, Scallan E, Daly L, Herity B, Horgan J, et al. Trends in medical student use of tobacco, alcohol and drugs in an Irish university, 1973–2002. Drug and Alcohol Dependence. 2006;85(2):123-8.

8. Keller S, Maddock J, Laforge R, Velicer W, Basler H. Binge drinking and health behavior in medical students. Addictive Behaviors. 2007;32(3):505-15.

9. Thakore S, Ismail Z, Jarvis S, Payne E, Keetbaas S, Payne R, et al. The perceptions and habits of alcohol consumption and smoking among Canadian medical students. Academic Psychiatry. 2009;33(3):193-7.

10. Rourke E. Work hard, play hard: Medical students; and schools' attitudes to alcohol. Student BMJ [Internet]. 2012 29/9/2013. Available from: 10.1136/sbmj.e5326.

11. Snyder L. American College of Physicians Ethics ManualSixth Edition. Annals of Internal Medicine. 2012;156(1_Part_2):73-104.

12. Thompson L, Dawson K, Ferdig R, Black E, Boyer J, Coutts J, et al. The Intersection of Online Social Networking with Medical Professionalism. Journal of General Internal Medicine. 2008;23(7):954-7.