New horizons...

In the next few months I will be leaving my post as a clinical lecturer and academic lead for elearning in the undergraduate medical course in Cardiff University to become a primary care clinical director in Aneurin Bevan University Health Board.

I am absolutely delighted that I will be joining a fantastic clinical leadership team (including Sally Lewis and Alastair Roeves) and having the chance to participate in many different levels of the health board's work to help make sure that we can deliver sustainable primary health care.

Many years ago I didn't know whether I wanted to be a GP or a public health physician. I had a wonderful GP trainer in Belfast,  Fergus Donaghy, who is I think still the most committed clinician educators that I have ever met. But I was still uncertain so I came to Bristol to do a six month SHO job in public health in Avon Health Authority. After a few months working in public health I realised that I did not want to leave clinical work behind.

A chance came to join the Department of General Practice in the then University of Wales College of Medicine in an innovative new Academic Fellow scheme with the twin aims of developing general practice in the South Wales valleys and also developing young academic GPs.  I decided not to return to Northern Ireland My head of department was Professor Helen Houston, who is still a wonderful colleague, and has provided much support to me in the last 13 years.

In Wales I was very lucky to meet and work in Professor Jonathan Richard's practice in Merthyr Tyfdil. In his incredibly generous and nurturing way, when Jonathan realised that I was interested in Public Health he invited me to come along to one of the meetings of a Public Health and Primary Care Steering group of the Welsh Assembly. It helped me to realise that my interests in primary care and public health could sit well together and shortly afterwards I started my Masters in Public Health.

I then moved to Gelligaer Practice and have worked there as a salaried GP ever since.  Kathrin Thomas was also a big inspiration to me. Welsh, she moved back from Liverpool to work with us and always managed to keep a balance between the perspectives of caring for individual patients and for populations in her work. It wasn't really a surprise when she later trained as a public health specialist, and she is now lead for public health primary care in Public Health Wales.

Gradually I became more involved in medical education in the medical school which merged with Cardiff University in 2004. For the past few years as we have been developing a new curriculum I got to use my interest in the use of tech to develop our use of technology in the course.

Back in 2008 I started my social media journey with this blog and a twitter account. I have learnt so very much from those I have met online and face-to-face in this time. I will be very sorry to leave my good colleagues throughout Cardiff University but as Bon Stewart writes these days our membership of academic networks does not have to depend on membership of institutions.

In short, I am very lucky because when I was a medical student a role with the scope of a primary care clinical director in Wales, and which would allow me to continue working as a GP, did not exist. But if it did I would have aimed to get here.  And I am very lucky to have been able to work with many wonderful people through the university, and to learn and share my learning with people all over the world through social media. Thank you every one!

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.

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

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

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?

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

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