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

Social media as part of a new professionalism : #GMCConf

Add caption

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.

Ethical responsibilities of leaders of tweetchats?

That way by justinbaeder
Over a year a go, Natalie Lafferty and I hosted the first #meded chat on Twitter. Ours was between 9-10pm UK time, and 5 hours later a similar chat was held for participants in the US.

We had some really great and very wide-ranging discussions. In the UK we had a lot of participation from students and doctors in training. This made for particularly rich and informative debates, for example on portfolios and competency. Over the summer we wound the chats down and didn't get them started again, although the US chat has kept running. But thanks to some calls on Twitter we have got some momentum building again and it looks as if our first session will be announced soon.

In advance of this I wanted to clarify what someone who participates in these chats could expect. I am not so interested in etiquette. We didn't really have any problems before, and participants seemed to be relatively sophisticated users of Twitter, so saying 'be nice' would seem to be a bit superfluous, and a little prissy.

But there are some other issues that I think we should address. The first is the issue of archiving. Anyone can archive anything on Twitter, but I think we should be clear with users that we ourselves will be archiving tweets and the implications of that. Up to now we had been using Symplur's archiving tool but we need to check whether individual tweets can be removed if they breached the confidentiality of patients or others. Again this did not arise before, but it is a serious enough governance issue that I think we should draw attention to it.

Next is the issue of research. As we are forming a community with the participants we would not consider researching the community without making participants aware. However, others outside our community might make us an object of research without making us aware. We can not do anything to stop that but we can make participants aware at least.

So given all that, here is a first draft. It is a fully editable document so please leave a comment here or directly on the document. What else do you think we need to add?

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.