Thank you!

Over the next few posts I am going to tell the story of doing a survey using Twitter, and of the results. But I thought I would start with saying a great big thank you.

 I opened the short survey at 6.01pm BST on 19/4/2012. Initially I was using a free Survey Monkey account which limited responses to 100. They started coming in fast and furiously and I realised that the free version didn't even allow export of data. So I splashed out £24 to get the next level of account which allowed me 1000 responses for each survey in 1 month. This morning there were almost 500 responses. I set myself the challenge of trying to get 1000 responses in 24 hours.

At 6.01pm BST 20/4/2012 there were 997 responses. At 6.07pm there were 1000. 

(EDIT 21/4/2012 Actually I started designing the survey at 6.01pm but it only was finished and was published at 6.18pm. Therefore 1000 responses were in fact collected in 24 hours!!)

What does it all mean? The survey questions were about how people would like their doctors to introduce themselves and how they would like to be addressed by their doctors. After this survey how much more do we know? Should this have been a 'proper' research study? Should I have sought institutional ethics approval? I will try and answer these questions and any others that you think are important along with you.

You are my co-researchers. We managed to get this response because you participated and you recruited people into the survey. Now we can do the analysis together as well. 

Within an hour of the survey closing I started tweeting some of the main quantitative findings. I also made the decision to make the results available to participants after they took part so that they had a sense of the project they were working in.

Today I deliberately targeted male followers and asked them to share the survey. We managed to move from 65% of respondents being female to 57% at the end. We also managed to increase the percentage of older participants during the day. I has asked Age UK to share the survey and they did. I'm sure that helped.

So there are a lot of questions to be answered but now I just want to thank you for your help so far.

"What is evidence?" - tweets from a #amee2011 symposium

After 2 weeks of conferences I have a lot of SoMe activity to catch up with! This storify is for @mikey3982. Luckily I had set up a tweet archive of #amee2011 tweets with FoxePractice. I then have a scoopit chrome plugin that makes it quite easy to move tweets from the archive to a storify. A lot of my tweets contain images of slides but scoopit doesn't detect and embed these automatically as keepstream does- BUT- keepstream doesn't embed nicely (last time I checked anyway) and there isn't a chrome plugin.

I've also added in some tweets from the afternoon synposium on the contribution of the social sciences to medical education research. Greenhalgh was also present for this.

Intimate examinations without consent- it's still happening.

Image: Exam Room by Maggie Osterburg

Having an intimate examination can be uncomfortable enough, but the thought that a medical student might be examining you without your clear consent is hard to accept in 2011.Although Canada only introduced guidance that explicit consent from patients was needed for pelvic examinations  less than six months ago (and following much dissent in the press), in the UK and Australia this has been established policy for many years. But researchers from Cardiff and Dundee universities who were exploring UK and Australian  medical students 'professionalism dilemmas' found that the students often told stories of performing intimate examinations without consent. Sometimes they challenged being asked to perform an examination by a doctor-tutor, but more often the stories were of going along with requests despite knowing it was against their school's policy.
The researchers conclude that having a policy is not enough to change the behaviour of doctors who request students to practice examinations of patients without consent despite clear guidance which says this is wrong.
So where next? To try and quantify how common some of the professionalism dilemmas such as this are, the researchers are now carrying out a survey of all medical students in the UK which can be found here, and have set up a Facebook group to support the research. They also hope to study why the policies have not had the impact on doctor-tutors that would be expected.

Press Release from University of Dundee.

EDIT: Annabel Bentley has suggested that action needs to be taken. What do you think?

Rees CE, & Monrouxe LV (2011). Medical students learning intimate examinations without valid consent: a multicentre study. Medical education PMID: 21251051

You can see some of the discussion about this on twitter via @storify here. 





















































































































































































Edit 7/2/2013: This paper got a lot of press coverage especially in Australia. Here the authors, Lynn and Charlotte, respond to the media coverage of their research. There were shocked at the reaction and decided not to engage in the media storm. Right decision?

What is more important: behaving badly or being seen to behave badly?

Doctors behaving badly
Yesterday, CNN carried a story ("Photos of drinking, grinning aid mission doctors cause uproar")
that doctors from Puerto Rico, volunteers in Haiti, may be disciplined because pictures of them holding soldiers' guns, drinking alcohol and with patients (possibly without their consent) have been posted on Facebook. The comments on the story are interesting, as some say the doctors are being treated too harshly. They may be traumatised by events and should be allowed to relax. Others who have seen all of the photos are in no doubt that the activities of the doctors are unprofessional. But in nearly all cases, commenters are talking about the act of taking the photo, rather than the sharing of the photo in social media.I have not read all 1411 comments but there does not seem to be anyone advocating that the photos could be OK in private, but inappropriate in public.


Medical students behaving badly
The conduct of medical students in social networking sites has been recieving increasing press. In September 2009,  Chrieten et al. published the reults of a survey in JAMA which found that the majority of US medical schools has had to take disciplinary action against some students because of their activities on social networking sites. And in November 2009, Farnen et al. described a case where first-year medical students posted a sketch from a medical talent show on YouTube. The sketch was of a hip-hop song accompanied by medical students playing  with plastic skeletons and  body bags. It was removed when a more senior student complained that it portrayed the medical school poorly, although there was student resistance to that action as the video had been very popular with students. The author's state:
" Our students' video has become our digital liaison. Prospective medical school applicants often comment on viewing it before their interview day. Alumni and senior faculty responded with significant concerns about the video's representation of the medical profession and how patients may react to this depiction of physicians' training. " (my emphasis) Students do not seem to have been disciplined for any unprofessional conduct in the production of the video,instead it is the sharing of the activity through social media which is the focus of the article. This seems to suggest that activities may be acceptable in private but not in public. In a further response to letters on their work, Chrieten et al. state "the medical profession is responsible for maintaining the public's trust. It is necessary to understand how online behavior is viewed by the public and how that affects trust in the medical profession."
Hayter (2006) has wrote about the medical student show. He says that it has various functions including "the collective ventilation of emotional reactions to the process of becoming a doctor". There are links to some of the skits from these shows in this Slate article. What we do not know is how the general public views these shows. Did they know of them? Did they think the conduct was appropriate? Since medical faculty often participate, and attend, they may be seen to approve of the content. If this is the case then why is it not appropriate to share the content publicly.


What does it mean to bring the profession into disrepute?
In the UK, both nursing ("You must uphold the reputation of the profession at all times") and pharmacy (where one should report any circumstances that may "bring the pharmacy professions into disrepute") bodies imply that not upholding the reputation of the profession is in itself something that a member may be disciplined for. For UK doctors, the GMC document "Good Medical Practice", states that "You must make sure that your conduct at all times justifies your patients' trust in you and the public's trust in the profession." But it is not clearly stated what conduct may contravene that trust. Older GMC guidance, prior to the first publication of Good Medical Practice in 2005, states that "convictions for drunkenness or other offences arising from misuse of alcohol (such as driving a motor car when under the influence of drink) indicate habits which are discreditable to the profession". Although this terminology is no longer used in Good Medical Practice, when discussing the case of a doctor convicted of driving with a blood alcohol level three times above the upper legal limit, it is stated that, "Public confidence in the medical profession is likely to be undermined by such conduct." The doctor was suspended for three months, in order to "send the right message to the public". In the case of medical students, GMC guidance states that drunk driving and "alcohol consumption that affects clinical work or the work environment" is unacceptable.There is no mention of drunkenness away from patients.


What do patients think?
Research conducted by Mori for the Royal College of Physicians in the UK consistently shows that doctors are the profession thought most likely to be telling the truth. This is routinely reported as "Public Still Trust Doctors". Smith (2001) distinguishes between trust, which exists at the level of individual interaction, and confidence, which relates to abstract systems.  Boudreau et al (2008) asked members of the public about the attributes of the ideal physician. They were reformulating the medical curriculum and wanted patient input. Patients wanted doctors who listened to them and didn't treat them as a 'number'. When asked "If I said to you that a doctor was very professional, what would that mean to you?", some patients responded negatively suggesting that it might mean someone 'stuffy-nosed' or who didn't want to bother with 'menial things'. But generally being professional was associated with behaviours that concerned individual interaction with the patient: bedside manner and interpersonal skills. 
But what of trust (or confidence) in the wider medical profession?  It is understudied. Hall et al.(2002) found, using a new scale, that trust in one's own physician is higher than trust in the physicians generally. They say that might not be a surprise as one might settle with a doctor one trusts, after experience of others who are less good. Calnan and Sanford (2004) in the UK, sudied general trust in the healthcare system rather that trust in the 'medical profession', and found that trust that patients would be provided with patient-centred care, was strongly associated with trust in the system. 


Conclusions
Professional bodies still talk about individuals conducting themselves at all times in a way that does not reduce trust in the profession. But the very limited studies which look at how the public view the medical profession suggest that it is the interactions with individual doctors in the healthcare setting which determine trust. Patients value patient-centred doctors.
Pattison and Wainright (2010) suggest that the ethics of a profession should be determined in conjunction with the wider public. It is not something that a profession can do alone. But I think that after that  behaviour is either unacceptable because it is unprofessional, and therefore should be disciplined, or it is acceptable. If it is acceptable it can be shared through social media.The use of social media is a secondary consideration.


Questions
But what do you think?

1. How do you feel about medical student shows?
2. Are medical student shows appropriate to share online?
3. Would seeing photos or videos of doctors, nurses or pharmacists in a state of drunkenness on Facebook affect your view of the profession as a whole?
4. Would it affect your view of the individuals involved as professionals?
5. What determines your trust of the medical profession as a whole?

Feel free to answer these questions or leave any other comments.


(This post resulted from a rather long discussion with @psweetman, @bitethedust, @drmarcustan and @mtnmd earlier today. I am currently studying for a module on Changing Modes of Professionalism for my EdD course, and writing an essay on deprofessionalisation in medicine. This writing is only tangentially related... as yet!)




References
Boudreau JD, Jagosh J, Slee R, Macdonald ME, & Steinert Y (2008). Patients' perspectives on physicians' roles: implications for curricular reform. Academic medicine : journal of the Association of American Medical Colleges, 83 (8), 744-53 PMID: 18667888
Calnan MW, & Sanford E (2004). Public trust in health care: the system or the doctor? Quality & safety in health care, 13 (2), 92-7 PMID: 15069214
Checkland K, Marshall M, & Harrison S (2004). Re-thinking accountability: trust versus confidence in medical practice. Quality & safety in health care, 13 (2), 130-5 PMID: 15069221
Chretien KC, Greysen SR, Chretien JP,  Kind T (2009). Online posting of unprofessional content by medical students. JAMA : the journal of the American Medical Association, 302 (12), 1309-15 PMID: 19773566
Chretien KC, Greysen SR,  Kind T (2010). Medical Students and Unprofessional Online Content—Reply JAMA : the journal of the American Medical Association, 303 (4) 329
Farnan JM, Paro JA, Higa JT, Reddy ST, Humphrey HJ,  Arora VM (2009). Commentary: The relationship status of digital media and professionalism: it's complicated. Academic medicine : journal of the Association of American Medical Colleges, 84 (11), 1479-81 PMID: 19858794
Hall MA, Camacho F, Dugan E, & Balkrishnan R (2002). Trust in the medical profession: conceptual and measurement issues. Health services research, 37 (5), 1419-39 PMID: 12479504
Hayter CR (2006). Medicine's moment of misrule: the medical student show. The Journal of medical humanities, 27 (4), 215-29 PMID: 17123173
Pattison, S., Wainwright, P. (2010). Is the 2008 NMC Code ethical? Nursing Ethics, 17 (1), 9-18 DOI: 10.1177/0969733009349991
Smith, C. (2001). Trust and confidence: possibilities for social work in 'high modernity' British Journal of Social Work, 31 (2), 287-305 DOI: 10.1093/bjsw/31.2.287

Web 2.0 tools and medical education - more sceptical comments

Last week, @drves described me as a web2.0 skeptic. Those who know me in 'real-life' would certainly agree that I ask many questions, and may doubt received wisdom. Now it seems this facet of my personality is more apparent in the online world too!



Lemley, T., & Burnham, J. (2009). Web 2.0 tools in medical and nursing school curricula*EC Journal of the Medical Library Association : JMLA, 97 (1), 50-52 DOI: 10.3163/1536-5050.97.1.010

The above paper was published in January 2009. It has been talked about a lot on twitter today because it was mentioned in a student BMJ article, which was then picked up in a blog post by Dr Ves. The finding that '45% of medical schools use Web 2.0 tools in their curricula' is that most often cited in twitter and elsewhere. So what does this mean and how did the authors draw their conclusions?

Method
A survey was conducted using Survey Monkey. Participants were identified by emailing a link to the survey to 3 different email lists:
DR-ED (for those involved in medical education) 1383 subscribers
AACN (for those involved in nursing education) 150 subscribers
AAHSL (for academic health librarians- who were asked to forward the survey to those responsible for curricula in their institution) 146 subscribers

The questionnaire is given in an appendix.Although the title and background to the article talk about web 2.0, the first questions asks about use of the following 'web 2.o/social networking tools':

• Blog
  
• Del.icio.us or some type of social bookmarking resource
  
• Flickr or some type of photo-sharing resource
  
• Moodle
  
• MySpace, Facebook, or some type of online community
  
• Podcasts
  
• Videocasts
  
• Wiki
  
• YouTube or some type of video-sharing resource

I don't know why Moodle, which is an open-source,and flexible learning management system (LMS) or virtual learning environment (VLE) is included as a web 2.0 or social networking tool. Moodle does support the use of web 2.0 tools, but so can other VLEs, so it is unclear why it is listed here.

Results

There was no way of tracking how those who responded to the survey found it, ie did they find it on a list themselves, or was it passed to them by a librarian? In any case there were responses from 36 individuals involved in medical school education, and 19 individuals involved in nursing school education.

The response rate from the medical school list is no higher than 36/1383 or 2.6%, amd possibly lower if some of the responses came via the librarians' list.

Several responses may have came from individuals in the same medical or nursing school as responses were anonymous.

Despite this the authors go on to report results as the percentage of medical schools which are engaging in the use of web 2.0 tools, rather than the percentage of medical educator respondents. The individuals who responded that they did not use these tools may work in institutions where many others do, and the individuals who responded positively may be the sole educators in the institution to use the tools out of several hundred or more.

The questionnaire did contain a question ("Please briefly describe how these tools are incorporated into your instruction.") which allowed free-text response and could have provided some information for a qualitative data analysis, but no results are given.

My conclusion

Does this paper tell us anything about the use of web 2.0 tools in medical and nursing schools in the US? No.


Is the author's justification of validity despite low response rate, because the study is "to gain insight into an issue", appropriate? No, because exclusively quantitative results are published.

This paper is short. It is open-access. I think that with a cursory look, most people would have reached similar conclusions to me. So why were so many people referring to this paper today without any criticism of the severe weaknesses in methodology?

Thanks to @drcolinmitchell for drawing my attention to this research.
He has also published a great post about this paper.