Social media as part of a new professionalism : #GMCConf

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Two years ago I attended a GMC education conference in the London. The conference had no hashtag so I and some others decided to use #GMCEd11 . The GMC didn't have their @gmcuk account at that time but they did have a @gooddoctoruk account launched around the time of initial consultation on the updating of Good Medical Practice. Altogether there were just over 300 tweets made on the day and about half of those were by me. Most of this activity probably bypassed those who were attending except when I had a chance to ask a question to an afternoon panel on behalf of Alastair McLellan, editor of the Health Services Journal. Alastair had posed the question to me in a tweet. I remember a frisson of laughter that a question was coming via twitter and I think that it was Fergus Walsh who joked that at least 140 characters created  usefully brief and succinct questions.

Fast forward to 2013 and the first national GMC conference on 'Medical professionalism : whose job is it anyway?' is held today in Manchester with 400 attendees- over 50% of them medical students and jobbing doctors, but with other stakeholders including patients well represented. There is an official conference hashtag #gmcconf and it is used more than 1500 times today. Throughout the day there is reference to taking questions from tweets and no-one seems to be in any way surprised.

I make about 1/2 the tweets I do at the last event, in part because this time I was giving a lunch-time seminar with Gareth Williams from the GMC office in Cardiff on the social media in practice. A strong conference theme is the nature of professionalism in a post Berwick and Francis report world and so my part of the session focussed on how social media is being used to drive improvement and ensure patient safety by doctors in the UK today.



I concentrated on a few stories - Elin Roddy's experiences of learning and reflecting in social media which lead to her taking on the role of lead for End of Life care in her trust ; raising patient safety through openness and transparency of sharing the #Wrongfooted storify ; NHS Change Day ; the FOAMed initiatives of ECGClass, Gasclass and TeamHaem ; and Kate Granger's #HelloMyNameIs campaign.

A few years ago I was not confident that I could justify urging every doctor to explore social media. But it is now beyond doubt that some of the most innovative, creative and transformative conversations about improving the care of and with our patients are happening within social media.

We must ask ourselves what we can do to help our colleagues and students be part of these conversations.

Balancing personal and professional presence in social media.

During the week I was talking to some of the doc2doc team and they asked me what I thought about the GMC guidance on social media.

I think that the guidance is good in that it states that the use of social media can very positive and worthwhile for any doctor. I think that it is likely to increase engagement with social media for doctors, and through that provide many opportunities for learning. It doesn't provide guidance on some of the issues which I think are important, for example, what responsibilities does a doctor have before encouraging patients to engage in a social media space. We will have to wait for future iterations to deal with these scenarios.
But within the twittersphere and blogosphere the reaction has been dominated by controversy over the  statement that "If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name."
I still hear people talking about the guidance being impossible to operationalise because how will the GMC identify these pseudonymous doctors? But why would they be trying to? No one would know if that person was really a doctor or not. The GMC have clearly said that the guidance does not "change the threshold for investigating concerns about a doctor's fitness to practice". This means that being anonymous/pseudonymous will never be an issue in itself. But if it was established that a doctor was for example bullying a colleague, or breaking patient confidentiality, then the fact that they were doing this without revealing their identity might be seen as being an aggravating factor.
Some people say that the guidance can't protect the public from charlatans who represent themselves as doctors when they are not. Well, in a way it does. If it is good practice to identify yourself then we can tell the public that they should not trust the authority of any one who represents themselves as a doctor, but  does not identify themselves, and then tries to give them advice.

When I tweeted the link to this interview earlier, Phil replied

@amcunningham @scoopit interesting - raises issue of @gmcuk believing drs can separate their medical & personal presence on twitter
— Phil Williams (@scottishphil83) May 4, 2013

Is it possible to separate medical and personal presence on Twitter? Why would you want to? Are doctors concerned that their personal interests or feelings will affect their relationships with colleagues or patients? If so then they may wish to try and separate our these different parts of their identity by setting up more than one account. But personally  I'm happy enough to tweet about going to a gig from my @amcunningham twitter account. Why would or could a tweet like the one that follows be an issue?

The very lovely @efterklang at the @fleecebristol twitter.com/amcunningham/s…
— AnneMarie Cunningham (@amcunningham) April 21, 2013

A few weeks ago I was asked to write a few paragraphs on how I think about how I present myself online for this ebook on "Social Media and Mental Health Practice".

How do I present myself online?

I first started using social media because I wanted to network so that I could do my job in medical education better. Yes, I am also a GP but I did not see social media as something that would help me to be a better doctor. I’m still not sure that it does, although I certainly do not think that it makes me a worse one. But I am very aware that most of what I say and do within social media is public. I want it to be that way. I do not aim what I say at my patients (or students) but I’m aware that they might read it, and I do not want them to be shocked or upset or worried by anything that they see me write. I aim to be professional, and I aim to respect professional boundaries.


When I am in the consulting room I reveal very little personal information. I doubt that patients are really interested. They walk in to see me and want and need to talk about them, not me. They often politely ask how I am. If I’m running late, I might smile and say, ‘Busy!’ But I would not share my own personal woes and worries with a patient. It would be wrong for me to burden them with my personal concerns. Of course, if they ask did I enjoy my holiday we might chat briefly about that. I don’t close down these conversations but I would never initiate talk about myself.

I share very little personal information online. I do not usually talk about my friends or family publicly online, and this is often to protect their privacy. However, this year I am sharing a photo that I take every day. In some ways this often reveals more personal information about me that what I write. It is something that I am aware of but rarely feel constrained by. I think that in many ways I am quite a private person, so this maybe more than being ‘professional’ defines how I am online.

Of course I might share some difficulties online, for example struggling to make technology work just the way I want it to! I don’t think that is a problem. It shows a different side of me and it is unlikely to impact in any way on the professional relationships which are important to me.I have thought about how I present myself online over the years. I try to be calm, collected, honest and independent. I hope that I come across as I do when I am offline. I am proud that when I meet people offline, who have first known me through social media, they often say that they feel as if they know me already. I would be unhappy if my online presence was considered inauthentic, so this pleases me.

 How do you manage the boundaries between personal and professional? What are the issues for you?

Response and clarification from GMC to criticism of their social media guidance

Last Monday the GMC published this response to the discussion of their new social media guidance on their Facebook page.  I'm posting it here in case some people do not want to access it through Facebook, and because my previous blog post on the topic has over 100 comments.

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Jane O'Brien from the GMC's standards and ethics team on our new social media guidance.

On the 25  March 2013 we published new explanatory guidance on Doctor's use of social media (PDF) alongside the new edition of Good medical practice for all UK doctors.

The response from the  profession has been lively — particularly about the phrase:

'If you identify yourself as a doctor in publicly accessible  social media, you should also identify yourself by name.'

Like all our  guidance, Doctors' use of social media describes good practice, not minimum standards.  It's not a set of rules.

But the response from the profession shows that doctors are unclear or uncertain about:

• Why  we included this in the guidance
• What  'identify yourself as a doctor' means in practice
• Whether  this curtails doctors' rights to express their views
• Whether  the GMC would take disciplinary action against a doctor because they used a  pseudonym
• Why  doctors shouldn't raise concerns anonymously

We’ve answered these questions below and also provided some background information about how the guidance was developed.

Why identifying yourself as a doctor is good practice?

Patients and  the public generally respect doctors and trust their views — particularly about  health and healthcare. Identifying yourself as a member of the profession gives  credibility and weight to your views. Doctors are accountable for their actions  and decisions in other aspects of their professional lives - and their behaviour must not undermine public trust in the profession. So we think  doctors who want to express views, as doctors, should say who they are.

What does 'identifying yourself as a  doctor' mean in practice?
There is a bit of judgement involved here. For  example, if you want to blog about football and incidentally mention that  you're a doctor, there is no need to identify yourself if you don't want to.

If  you're using social media to comment on health or healthcare issues, we think it's  good practice to say who you are.

In the guidance we say 'you should' rather than 'you must'. We use this language to  support doctors exercising their professional judgement. This means we think it  is good practice but not that it is mandatory.

We've  explained the difference in our use of these terms in paragraph 5 of Good medical practice, and at:http://www.gmc-uk.org/guidance/good_medical_practice/how_gmp_applies_to_you.asp

Does this restrict doctors' freedom  of expression?
We are not  restricting doctors' right to express their views and opinions except:

• Where  this would breach patient confidentiality 
• Where  comments bully, harass or make malicious comments about colleagues on line. (A  colleague is anyone a doctor works with, whether or not they are also doctors).

One of the  key messages in the guidance is that although social media changes the means of  communication, the standards expected of doctors do not change when  communicating on social media rather than face to face or through other  traditional media (see paragraph 5 of the social media guidance). 

Will the  GMC take disciplinary action if I decide not to identify myself online?
This is  guidance on what we consider to be good practice. Failure to identify yourself  online in and of itself will not raise a question about your fitness to  practise.

Any concern  raised is judged on its own merits and the particular circumstances of the case.  But a decision to be anonymous could be considered together with other more  serious factors, such as bullying or harassing colleagues, or breaching  confidentiality (or both) or breaking the law. The guidance doesn't change the  threshold for investigating concerns about a doctor's fitness to practise. 

Does this guidance apply to personal use?
The GMC has no interest in doctors' use of social media in their personal lives —  Tweets, blogs, Facebook pages etc. But doctors mustn’t undermine public trust  in the profession. Usually this means breaking the law, even where the  conviction is unrelated to their professional life. 

For an example, read the recent Fitness to Practise Panel decision on the MPTS web page (PDF).

Why can't  I raise concerns anonymously in social media?
We are not trying to restrict discussion about important issues relating  to patient safety and certainly don't want to discourage doctors from raising  concerns.

However, we wouldn't encourage doctors to do so via social media because  ultimately it's not private and it might well be missed by the people or organisations who are able to take action to protect patients.

Our confidential helpline — where you can speak to  an advisor anonymously — enables doctors to seek advice on issues they may be dealing  with and to raise serious concerns about patient safety when they feel unable  to do this at local level. Our Confidential Helpline number is 0161 923 6399.

If  you want to talk to an independent organisation, we work with Public Concern at  Work whose legal advisors are trained in managing whistleblowing calls. They  can support and direct doctors who wish to raise concerns.

Why do publications like the BMJ  allow anonymous blogs/letters articles? Does the guidance mean they can't do  that anymore?
BMJ is entirely  independent of the GMC, and it is a matter for them to decide what is  appropriate for their website. However the Committee on Publication Ethics  considered a case and published their conclusions athttp://publicationethics.org/case/anonymity-versus-author-transparency. 

Many blogs  are published without formal editorial or publisher control — although there  may be moderation on some sites. Using your name (or other identifying  information) provides some transparency and accountability.

Background

How did we consult on the guidance?
We consulted  on the explanatory guidance in 2012 and wrote to all registered doctors via our publication GMC News in May 2012 asking them to tell us their thoughts on the  draft social media guidance. 

As part of this  public consultation, we received 80 responses from organisations and  individuals (with 49 of the individual respondents identifying themselves as  doctors). Specifically we asked whether it was reasonable for us to say that  doctors should usually identify themselves when using social media in a  professional capacity and 63% (49 respondents) agreed while 16 respondents  disagreed and 13 were unsure. 39 of those who responded commented on this  point.

Some of the responses from doctors in the consultation included: 

'Doctors should take ownership of  information given in a professional capacity as it is important that we are  accountable for our professional actions.'

'Too often, people hide behind  usernames on internet and on social media — if you have something to say,  don't be a coward.'

Patients groups also felt that being  open and honest when communicating online was important saying:

'Doctors should also be conscious of the widespread access to much social media, e.g. Twitter, which could mean that their social media engagement could endanger public confidence in the profession.'

Of course, some expressed the opposite view including:

'A doctor should be able to state that they are a medical professional without having to publicise their personal data. For example, when commenting on an online article it may be relevant that the comments come from a doctor but it should not require full identity disclosure. Where a comment is formal and part of a professional role, it would be more reasonable to expect identity disclosure.'

What does the final guidance say?
So after  careful consideration of all the views and the arguments on both sides the  final guidance says:

If you identify yourself as a doctor in publicly  accessible social media, you should also identify yourself by name. Any  material written by authors who represent themselves as doctors is likely to be  taken on trust and may reasonably be taken to represent the views of the  profession more widely.

What's happened since we published?
e-petition
We  acknowledge the level and strength of feeling the petition represents. However,  there is nothing in the guidance that restricts doctors' freedom of speech  online or stops them from raising concerns. The guidance is a statement of good  practice, and the paragraph on anonymity in the guidance is framed as 'you should'; rather than 'you must'; to support doctors exercising their professional judgement.

To read the new edition of the Good medical practice for UK doctors, please visit GMC website.

GMC guidance- doctors online should reveal their identity

"je digitale alter ego" by verbeeldingskr8

Yesterday, March 25th the GMC published the updated version of Good Medical Practice.  And for the first time, supplementary explanatory guidance on the use of social media is also included. The "doctors and social media" guidance was issued in draft last year, was relatively uncontroversial and didn't provoke a lot of discussion. This is what I wrote prior to the publication of the draft guidance.

One line in the final version has received a lot of attention on the twittersphere : "If you identify yourself as a doctor in publicly
accessible social media, you should also identify yourself by name."

Below is the full section from which this comes, followed by the wording of the draft guidance.

Final
17  If you identify yourself as a doctor in publicly accessible social media, you should also identify
yourself by name.Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely.
18  You should also be aware that content uploaded anonymously can, in many cases, be traced back to its point of origin.

Draft
17 If you are writing in a professional capacity, you should usually identify yourself. Any material written by authors who represent themselves as doctors are likely to be taken on trust and/or to represent the views of the profession more widely. You should also be aware that content uploaded anonymously can, in many cases, be traced back to its point of origin.

Why has the wording been changed? The GMC have tweeted that the guidance applies "if you are tweeting as a doctor.Then you should identify yourself. Being open+honest helps maintain trust."

The draft guidance was more ambiguous. What was writing in a 'professional capacity'? And you should 'usually' identify yourself. The final guidance is very clear. For people who have not yet started a blog or joined Twitter this clarity may be useful.

But I don't think that many of us who are online already expected this. The RCGP published the final version of its social media highway code last week where they say that as a general principle doctors should use their professional name online if portraying themselves as a registered doctor, but that use of a pseudonym might be reasonable in some circumstances eg moderating a forum, writing about a sensitive subject, or for when comedy or satire.

What happens if a doctor is currently tweeting under a pseudonym and does not start using their real name before April 22nd when the guidance is enacted? Will they be disciplined or reported? How will the GMC respond? Usually most doctors are confident that they are working within the bounds of good medical practice but this is making some with existing pseudonymous twitter accounts, or blogs, feel uncomfortable. They are now deciding what steps they should take.

I have seen some doctors who tweet in their own names suggest that some might use the anonymity of the internet to raise concerns about patient safety or whistle-blow. Personally, I think that writing a blog post to raise concerns about patient safety would be a last resort after taking the steps which the  GMC recommend.
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What does this guidance mean to you? I allow anonymous comments on this blog.

(By the way, I was glad to see that doctors are not going to be obliged to 'encourage' ill patients back to work -this had been one of the consultation controversies.)

EDIT: reaction from around the web
@GilulaArc, an orthopaedic surgeon, feels that anonymity is essential to protect those dissenting. She wrote a letter to a magazine in her own name which she feels stalled her career. Read more here.
@JobbingDoctor writes that the government sees the professions as people to be controlled. Ensuring doctors only contribute to social media in their own name is part of this. Read more here.
Other reaction collated here.

Doctors’ use of social media - some thoughts prior to publication of GMC guidance

This is taken from the GMC website. The GMC have published draft guidance on social media here. Take part in the consultation here.

This month, Dr Anne-Marie Cunningham (@amcunningham), a GP and Clinical Lecturer at Cardiff University, writes on the role of social media in doctors’ lives.

More than half the UK population now use Facebook. And more new users are over 50 rather than under 50. The dominance of Facebook means that if you are not there you are likely to miss out on what is happening with your family or friends. For most of us our use of Facebook has nothing to do with being a doctor. It is about being a mother, nephew, or friend. And it is because we want to protect these people that we care about, and ourselves, that we check our privacy settings and make sure that we are not publishing photos of our nearest and dearest to the world.

So if most of our social media use is about who we are when we are not at work do we need guidance from the GMC? What does using social media have to do with being a doctor at all?

Useful guidance or ‘moral panic’?

Some might think that the development of this guidance is a response to a near moral panic about what may be seen as the portrayal of unprofessional behaviour by doctors and medical students in their use of Facebook and other social networking sites. Breaking patient confidentiality is always wrong but these days what does it take to reduce trust in ourselves or the medical profession? Research seems to indicate that the main determinant of trust in doctors is their interaction with patients in consultations. Patients value doctors who listen to them and take their concerns seriously. They trust them. So are we worrying excessively about how the public may respond to the depiction of minor misdemeanours and hijinx which may not reflect how well an individual will carry out their professional role?

Blurred boundaries

In the past, the private life of a doctor living in a small community may have been well known to her patients. Social media facilitates this same kind of blurring of boundaries. We all have to consider how much of our private and personal lives should be revealed to the public and patients. Will ‘professional distance’ be a meaningful or helpful term in the 21st century? Medical decision making is no longer seen as objective and the role of the doctor, but as a shared task with the patient which acknowledges their values and subjectivities. Might this process be helped or hindered if patients understood our values and subjectivities too?

Doctors may also choose to use new technologies to interact with patients. What then are our responsibilities? As we have a duty to protect patients’ confidentiality we must assure ourselves of the appropriateness of any communications platform. If there are risks then we must make these clear to patients.

The importance of maintaining trust

We might also use social media to connect with other professionals. There can be many benefits to opening up the flow of knowledge within networks. Again, discussing the details of any clinical case should be done with patient consent. In the past when considering if a patient may be identifiable we tended to focus on whether others would be able to recognise the individual concerned. But if discussing a case in near real-time in a public space we have to consider whether the patient will be able to identify themselves even if no one else can. Without their explicit permission, this in itself may reduce trust in us as practitioners.

Looking forward

Will social media have a major impact on the practice of medicine? We do not know yet, but the pace of change is rapid. It took 100 years from invention of the telephone for it to reach 50% of UK households in the mid-1970s. Has the telephone radically changed medical practice? Facebook reached 50% of the UK population in 5 years. Will it be a more powerful disruptor?

When discussing technological change we have to remember that social divides also exist. Julian Tudor Hart coined the phrase the ‘inverse care law’ for his observation that those who most need good medical or social care are least likely to get it. The digital divide describes inequalities in access to information and communication technologies. In 2011, 99% of those with a household income above £40,000 had internet access, whilst only 43% of those with household income below £12,500 did. The gaps are narrowing, but if we change our practices we need to consider how the digital divide will impact on access for the poorest, and most vulnerable.

So do we need guidance on the use of social media and networks? If the publication gives us cause to reflect on how use of these technologies fit with our professional roles and our professional practice then this can only be a good thing.

Doctors getting people back to work

The YouTube video above was shared by the GMC as part of their pre-consultation on updating the guidance on Good Medical Practice(GMP).

Reward to doctors for getting patients back to work is not mentioned in the draft version of Good Medical Practice.  However, for the first time the GMC guidance to doctors includes specific mention of encouraging patients to stay in or to return to employment. I am not aware of the reason why this has been included at this time. The wording is

"51 You must support patients in caring for themselves to empower them to improve and maintain their health. This may include encouraging patients, including those with long-term conditions, to stay in or return to employment or other purposeful activity. You may also advise patients on the effects of their life choices on their health and well-being and the possible outcomes of their treatments."
(my emphasis)

This is specifically raised in the consultation questionnaire:

"At paragraph 51 of this section, we advise doctors that they must support patients in caring for themselves to empower them to improve and maintain their health. This is essentially the same as GMP 2006. But we also now say that such support may include ‘encouraging patients, including those with long term conditions, to stay in or return to employment or other purposeful activity’. 
30 Do you agree this is a reasonable expectation of doctors "

What do you think of this guidance to doctors? The consultation closes on Friday 10th February 2012. Any member of the public can take part.  Find out more here including the link to the e-consultation.


"Doctors to encourage long-term sick to return to work" Daily Mail 1/11/2011
"Who is in charge of doctors and consultants- the DWP?" Twisted News 1/11/2011

"New section of the Department of Health" Jobbing Doctor 1/11/2011

"Work guidance for long-term sick" Guardian 1/11/2011 

EDIT Full GMC guidance published on 25/3/2013 The requirement to encourage patients back to work is absent. Full wording of para 51 is 
"51 You must support patients in caring for themselves to empower them to 
improve and maintain their health. This may, for example, include:
a advising patients on the effects of their life choices and lifestyle on 
their health and well-being 
b supporting patients to make lifestyle changes where appropriate."