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.