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

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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.

Digital divide, health records access and online security

Oxford Internet Study 2011 http://oxis.oii.ox.ac.uk/blog/non-users-and-ex-users-looking-lifestage-education-and-income

The 'digital divide' is very real. The Oxford Internet study is conducted every two years and the above chart is from their most recent survey in 2011. Level of income here relates to household income rather than individual outcome. If you live in a household with an income above £40K it is almost guaranteed that you will have online access. If you live in a poor household with an income of less that £12.5K it is most likely that you won't. There are also stark divisions related to age and educational levels described here.

I've just been having an interesting discussion with Amir Hannan, a GP who is a very strong advocate of patient access to their own health records, about how the digital divide means that those who are most likely to have health problems are least likely to be online... bringing us in the direction of a digital 'inverse care law'.

So if you are a GP and are encouraging patients to access their records online what would you say to those who lack the means to be online? Amir said that patients who are not yet online are directed to a course run by the local library which helps to get people online. But what if you can not afford to have your own access at home, should patients be encouraged to access their medical records from public places such as libraries or internet cafes? What are the risks? Or what about using a computer at the house of friends or family?

Of course, it's not only those who don't have their own computers at home who may use other computerss that they do not own themselves. What issues should you be concerned about if accessing your records from a computer that is also shared with your family or from your work place? Or a hotel lobby when on holiday?

A quick search does not reveal guidance about these issues for people in the UK. Here is the log-in page for the EMIS general practice records access. There is no link to information about online security. Contrast this with information which is available from online banking websites on what to look out for when using their services, for example here is a page on online security from Intelligent Finance.

If there are issues around the online security of accessing health records online, then those who don't have their own internet access at home, are more likely to be at risk. Do you have any examples of links to information in easy to understand forms which will help people to understand and address these issues? Or is it not an issue at all?

EDIT: some great guidance from BCS on accessing records http://www.bcs.org/upload/pdf/social-care-records.pdf <- they state if possible not to access from public computers, but if you do to clear browsing history.*** note this guidance is draft and NOT FOR CIRCULATION but I found it through Google ;-) ***

Should the NHS be on Yahoo Answers?

Last week Leigh Blackall and I agreed that patients needed access to high quality information on the internet but we disagreed on how that would happen. He mentioned Yahoo Answers and I and many of those I know on twitter responded sceptically. Why would ANYONE look to Yahoo Answers??!! But my experience of looking for information online is most often centred around knowing the diagnosis. If you are trying to make sense of your symptoms then it is a whole different ballgame. So I decided to make a short screencast to show what the experience might be like.
What should we do about this? Make the existing NHS websites more user-friendly when checking symptoms? Develop better tools for symptom sorting? Make sure that the relevant NHS pages are serach optimised? Or should the NHS be patrolling Yahoo Answers?
I'd love to know your thoughts and feel free to share any stories. But remember this is a public site and others will be able to read it after you!
EDIT: After Fi's comment below I feel I should add that I think it is unlikely that patients will find a diagnosis online but they should in a sense get good triage information. Is this a serious symptom that I need to go to the doctor with, or can I leave it for a few months to see if it goes away?
I've blogged about fear of Dr Google before. We should be helping Dr Google to perform better, and we should be able to give guidance to patients on where they can get sensible information online.