Category Archives: Social Media

Utilising the improvement from healthcare social movement #MedX

I am pretty sure it is impossible to change the world alone. You may be innovative, provocative, and inspirational. But even our greatest leaders will cite key influencers to their success

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Hello – My name is Damian. I am a paediatrician. I am also a father and when my second daughter was 8 weeks old she was admitted to hospital with suspected meningitis. I saw the best that healthcare has to offer patients and their families during that worrying time. Compassion, dedication and great skill. To the colleague who expertly performed procedures on Bella’s delicate veins I will always be grateful.

But I also saw the worst of healthcare. A failure of senior staff to introduce themselves, the neglect of staff not washing their hands and the public display of hierarchy for the benefit of an individual needing to assert their authority.

There are many things I wish I could change about Bella’s stay in hospital. What would you change in healthcare? If you are a patient what frustrates you most? As a health care professional, how would you like your service to be run? Sadly change can become somewhat of a dirty word.

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Max Davie, a paediatrician, once said to me, “we are fed up of change, but not of improvement

There are many things we can improve with robust research and the scientific method. The dose of chemotherapy, the type of surgery or the treatment of infections with new generation of antibiotics. But what of personal change, system change, cultural change? For these we need movements.

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Social Movements are collective actions by large, but sometimes informal, groups of individuals or organisations to carry out, resist, or undo a social change. When we think about resources for change we tend to think about economic resources (budgets, technology, individuals etc). These resources are limited and finite whereas social movements can release resources in the form of social capital which is vital in environments where monetary intervention is not possible.

Within healthcare there are many shared values, both for patients and professionals, so achieving common goals through a movement has an obvious appeal. For example, the Institute for Health Care Improvement’s (IHI) “5 million lives” campaign aimed to reduce medical harm in American hospitals. The movement generated considerable publicity and the IHI claimed they surpassed their target.

Social Movements are not a new idea. They have been occurring for centuries. However in the last decade there has been a seismic change though the accessibility and reach of social media.

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Social media is increasingly seen as credible and accepted medium by which to disseminate information, decrease the knowledge translation gap and allow professional and patient engagement in a meaningful way. It has hugely increased the momentum and motivation behind social movements. I’d like to discuss some social media derived movements I have been involved in, or aware of, and share some learning.

NHS Change Day was about harnessing the power of collective action. It was a grass roots frontline movement for improvement in health and care and 98% of the activity was undertaken by volunteers. It asked for a simple action. To pledge to perform a healthcare intervention on a single day (March 13th 2013). It became single biggest day of collective action for improvement in the history of the NHS with 189000 pledges made. Change Day has been replicated across the world and is now in its 4th year.

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Change day started with a tweet that enable a first conversation between junior doctors and an improvement leader. From that first conversation a timeline can be drawn that resulted in a national event that impacted on the lives of patients.

Change day taught me about the power of stories. My pledge in the first year to try some of the medications that I prescribe to children. One, an antibiotic, was absolutely vile. It was truly disgusting. It made me realise that this wasn’t something you could give to parents and expect them to religiously give to their child. I realised you need to provide clear guidance on how to hide the taste and encourage adherence.

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Importantly the process created a story of my experiences. The staff in my department know about my pledge. They have seen the video of the odd contortions my face made when I tried to swallow it. The narrative a powerful back drop in promoting change in others.

This year Kate Granger, a doctor, passed away having been diagnosed with a rare form of cancer. She was responsible for #hellomynameis. A social movement that clearly begins with her encapsulation of how frustrating it is when health care staff don’t introduce themselves. Her campaign started on twitter and with now 1300 million impressions continues to spread throughout the world. A powerful personal narrative with meaning for others.

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Free Open Access Medical Education (FOAM) is an international movement that has brought together people from many backgrounds and specialties. It describes the production of educational materials in a variety of forms that are openly accessible. The concept of FOAM started in a pub (much like all great innovations!). Mike Cadogan coining the term during an international emergency medicine conference. It has come to represent a focus point for critical care and emergency medicine communities in particular. The term encompassing not just the materials produced but the bringing together of enthusiasts who design and digest them. It has developed into a true digital community of practice as demonstrated by examination of the hashtag #FOAMed. FOAM, along with patient derived digital communities such as #chroniclife, are social movements almost entirely derived within social media yet have all the attributes of a community of practice with the potential benefits they confer on professional and patient outcomes.

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We are now at the beginning of a new approach to social movements. One in which anyone: pubic, patient or professional can contribute to the challenge that is change.

A very public social movement can inspire others to feel passionate about what they are doing. To do this we must:

  • Learn to tell and share stories, always keeping in mind the event(s) that prompted the initial story
  • Let these stories build communities

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I am sure it is impossible to change the world alone. But with others we can achieve great things. The 21st century social media enhanced social movement will continue to teach us about connectivity and community. I for one am very glad to be part of it.

Huge thanks to Helen Bevan, Jackie Lynton, Daniel Cabrera, Jesse Spur, Chris Nickson, Mike Cadogan and many others who have impacted on my thinking in some way. 

This is a shortened version of my presentation at #MedX 2016

Networking: Twitter doesn’t build communities, stories do…

This blog posting is based on my talk to the #HSJRisingStars. It’s good to have the opportunity to expand on my thoughts as it’s clear from feedback that this didn’t quite touch the nerve I was expecting. Raising concerns about twitter, within twitter, is an interesting experience…

In the run up to NHS Change Day 2014 a number of constructive criticisms had been voiced on the type of pledges made. How can it be that health care professionals are pledging to “deliver safe care”, “create caring cultures”? Aren’t these pledges just paying lip service to the broader purpose? Are people just jumping on a bandwagon?

I wrote a blog in response to these concerns. It centred around my acknowledgement that on a busy shift I had forgotten to introduce myself to the parents/child I had just seen. I had essentially failed Kate Granger

I am not a prolific blog writer, I’m probably not even a good one, but Kate tweeted the blog post and in the space of 3 hours it had received 1300 views. This was dissemination on a pretty impressive scale and in fact far more powerful than any previous networking opportunity I had been engaged in. It made me really think about reach and how I had communicated in and out of networks.

Change Day has taught us a lot about the NHS. There seems to be a unmet need to publicly discuss and celebrate core values; reports by Francis and Berwick have removed the taboo of some of these issues. It has taught me personally a great deal about my role in change and the roles of other networks. The story of Change Day began with a discussion about junior doctors and at the very first Change Day meeting I told a story inspired by Helen Bevan, describing how it is the new generation who are most likely to bring about radical change. Interestingly, though, one of the groups least involved in Change Day (in terms of raw numbers) were junior doctors (probably second only to GPs).

How did that happen? Did my networks fail to understand to the message? Was I wrong in my belief that Change Day can – and will – be a powerful instrument for cultural change? I think the reasons are subtle but well worth exploring.

Change Day was in essence about individual people. The real narrative was the reasons behind the individual pledges; the event itself was more like a big scrap book recording and highlighting more than half a million stories. My biggest transformation of thought in the last couple of years has been about the power of narrative. It’s personal narrative which drives us. The networks you are part of, represent, lead or create, contain people who share parts of that narrative. But I wonder how often your (or your network’s) narrative is shared by others. Just because I know ‘x’ doesn’t necessarily mean that an e-mail to their “network” will spread to a wider “network” and will be effective at spreading the message.

I’m sure I am as guilty as anyone at pushing the ‘send all’ button. Similarly asking friends  “can you send to your networks?” is something I have realised may not really add value. In fact the use of networks in this way may, in fact, create silos due to the lack of proper dialogue between them. “Nobody talks anymore” is oft quoted but there is some danger that it really is a little too easy not talk. By all means use technology – Hangout, FaceTime and Skype have enabled conversations to take place that weren’t possible previously. They are conversations with animation of expression and vocal nuance. But the real essence of good narrative goes beyond the physical conversation to the nature of what is being spoken. My story of failing at #hellomynameis is much more powerful than telling people how important Change Day is. Similarly describing my personal pledge is a much better vehicle to create interest than a newsletter about the day itself.

None of us wish to create silos as I’m sure we share the same the values. The translation of those values into a vision is probably different between our networks though. So in this time of social media and electronic interfaces, maybe we all need to be a bit more personal. We need to reconnect with each other with personal stories and communications that unite networks – not just transfer information between them.

“In this age of omniconnectedness, words like ‘network,’ ‘community’ and even ‘friends’ no longer mean what they used to. Networks don’t exist on LinkedIn. A community is not something that happens on a blog or on Twitter. And a friend is more than someone whose online status you check.” – Simon Sinek

This (admittedly controversial) quote was really brought home to me when I attended #SMACCGold, a social media and critical care conference. I thoroughly recommend watching the talks when realeased as they are all very much personal stories. Undoubtedly it was twitter, google and blogs that brought people in the #FOAMed community together but the real benefit for me was meeting the people there and engaging directly with them. As I said after the #HSJRisingStars event:

 

(Thanks to Natalie May for pre-publication proof-reading and editing)

#SMACCGOLD – It hurts..

Too often we enjoy the comfort of opinion without the discomfort of thought

The 2nd SMACC (social media and critical care conference) has just finished. A packed 4 days (including pre-conference) with over 1000 delegates developed by a few brilliant individuals who have envisioned a different way of learning and collaborating.

This is no ordinary conference, with fantastic topics discussed and innovative events. See Salim Rezaie’s great blog for the detail. There are few conferences where professionally executed simulation debriefings occur in front of an entire auditorium, speakers’ cry in a context that feels appropriate and delegates give standing ovations in some of the break out sessions.

I sit writing this approaching Doha on the second stage of my journey home. I am a SMACC virgin, utterly humbled by the invitation to speak in Brisbane. I have met and listened to some extraordinary people but my over-riding emotion at the moment is one of sadness. I am truly sad it has finished. Don’t get me wrong, my youngest developed chicken pox during my journey away, I do want to go home. I am sad though that I know I will be attending other conferences (unfortunately SMACC Chicago is over a year away!) where I will sit and listen, I may learn some additional clinical information, I may meet a future research collaborator, if I am really lucky something may inspire me to change practice.

What is unlikely to happen is that there will be a tangible excitement when the first speaker takes to the stage, that over coffee break all the delegates will be smiling, that I will witness carefully constructed slide sets that support (not deliver) the stories the speakers are telling.

The attention to detail in the narratives delivered at SMACC was brilliant. It’s likely those reading this who weren’t at SMACC will probably be a little sceptical of this hyperbole. Please, please, watch the video casts when they are released. Watch how Cliff Reid and Iain Beardsell bring their emotional talks together full circle. Natalie May delivers to a packed crowd on “paediatric tips you won’t find in a book” using slides with no text and Tamara Hills received a standing ovation for her PK presentation.  Listen to Victoria Brazil deliver a 20 minute presentation in exactly 20 minutes with no timing aids (ok – I admit this is only probably considered really cool by geeks like me).

The hierarchical nature of academic events is not present at SMACC. It was brilliant to see a mix of professionals, grades, and specialities mucking in. Medical students and junior doctors delivering lectures and being part of the panel discussions. And so I could go on….

If there was one thing that encapsulated SMACC it was the patient centered approach to challenging dogma. I am struck that although the patient should be at the heart of everything we do – I often don’t see that at conferences. I hear people ‘talk’ about it but during lectures on new treatments or methods it’s about stats and facts. It’s about why the speaker thinks something is wrong. What SMACC did was deliver lectures where the speakers understood the challenges of normal practice. That patients are humans, that the things we do in critical and emergency care have an impact on them. That if we do what we always did, we will get where we are going – and is some cases that is simply not acceptable. Challenging Dogmalyis, championed by Prof. Simon Carley is uncomfortable. It hurts sometimes to be challenged.

SMACC hurt.

But until SMACC Chicago this type of hurt is so much better than the pain of any other conference you will go to….

Post Blog note:

Have already started getting messages saying but what about…..? Will start adding 🙂

How I let @GrangerKate down and what you can do about it..

It was not a particularly busy shift. The patients were not any more sick than other evenings I have worked. I may have been a little more tired than normal, I don’t think I was anymore distracted, but as I walked out of the consulting room I realised I hadn’t #hellomynameis.

I’m pretty thorough by nature. I have always felt my communication skills were at least ok and I certainly think I’ve introduced myself to patients/parents since being a junior doctor. I actually felt everyone else did as well. It wasn’t until Kate Granger‘s #hellomynameis campaign really took off that I realised this might not actually be common practice. It’s interesting what is perceived as common practice or ‘assumed’ to be normal. You would think most people or systems would deliver at the minimum a style of care that at least doesn’t harm people but we know from some tragic events this is not always the case. We know for a fact that there must be pretty huge differences in the way things are done from variation in many healthcare outcomes (atlas of variation in care in children being one example).

It always upset me, and the term upset is correct, when I was a trainee representative for the RCPCH and AoMRC and senior medical leader or educator made a pronouncement on what trainees must be able to do. “It’s ridiculous trainees can’t get their WPBA signed off by consultants. At my hospital there is always a consultant available” Yes – at your hospital perhaps. Your world and training environment is very different from others.

And so I raised a wry smile at this tweet this evening

I’ve never met Partha but he sounds like a pretty awesome bloke. Cruelly overlooked in the HSJ Rising Stars awards he clearly has a great vision and passion for health care. He also seems to insist on calling NHS Change Day – pledge day but I’ll let him off that. It’s worth following the chain this tweet produced. I make no secret of my support for NHS Change Day and I’m happy to accept and defend criticism about it (Partha – I know your weren’t criticising but your tweet was perfect for this blog!). “What’s the point?” is a common question. “You had 3500 people pledge to smile last year. Don’t they do that anyway?” is another. For the answer to the latter reflect on when was the last time you spent an entire shift in public view and at no point looked like you weren’t upset, annoyed, bored or frustrated. How do you think your patients felt when they saw you looking like that?

Yes someone has pledged they want to keep patients safe. And yes this is a fundamental part of a healthcare professional’s role. But, unfortunately, sometimes the healthcare service doesn’t always keep patients safe. Yes – its fairly obvious that you should introduce yourself at the beginning of every consultation. But, unfortunately, even someone who has been supporting #hellomynameis passionately can fall short.

In some ways it is a shame it is ‘change’ and it is ‘day’ because it’s not always about ‘change’ and hopefully its not about one ‘day’. But if you can find a better mechanism that brings the NHS together and say look – lets just think about this – then please let me know. Because until I find one I will continue to support people pledging what they feel is important to them however obvious that might seem to you.

Post Blog Note (23.2.14)

A subsequent comment from @parthaskar following this post deserves mention as it is something I strongly support and given I gave the poor chap no notice about using his original tweet think it is only fair I utilise his wise words!

Beyond the ‘why’ of twitter: Remember there are lots of ‘hows’

A recent tweet got me thinking

There are many reasons for health care professionals to use twitter (all described well elsewhere). One of the things that puts people off is the feeling that they have to constantly, and actively, participate. When introducing someone to twitter it is worth demonstrating that you can simply just watch timelines of hashtags. Examples of this are in the NHS Employers app which contains the @nhsemployers twitter feed. Anyone downloading the app can get a sense of what happens on twitter without having to create a username or password. A more bespoke way of doing this is using a hashtag website such as http://twubs.com. You can simply type in a hashtag and follow all the conversations related to it (also useful for twitter journal clubs).

Those who are not typical ‘social media’ types (trying not to be discriminatory here :-/ ) usually come across twitter at conferences. The ability to see ongoing debate without actually having to sign up for something can be appealing; and so the above methods provide a ‘way in’. Technically your ‘interaction’ with twitter could stop there. For those whose interest is peaked they then probably do need to create an account. I try to explain to novices that twitter users fall into one of three categories [There is absolutely no science behind this but if you want an equally anedoctal breakdown but from someone with more credibility see here.]

i) Observers      [the Outpatients]

ii) Engagers        [the Wards]

iii) Captivators  [the Emergency Department]

Basically some people (observers) just watch others, learn from conversations and favourite the occasional interesting link. You then may engage in some conversations, tweet some stuff that appeals to you or join in in the odd tweet chat or journal club. Engagers may only be on twitter at certain times, or leave it alone for days/weeks on end. There is probably a spectrum of engagers however some will end up  captivated by the whole experience. Providing the material for observers and engagers, the captivators provide the material for the twitter to work. Taking in, and then throwing out ideas, at an outstanding rate.

No type of person is any better or any worse. They are just participants to varying degrees. So there is not just one way of engaging with twitter and by not being clear about this, to those dismissive or curious about it, is doing it a disservice. There are lots of reasons to be on twitter, there are even more ways of being on it.

 

COI: I was involved in the design of the NHS Employers app via www.quackapps.com

Tweets, Text and Trolling

The recent dreadful events surrounding Caroline Criado-Perez @ccridoperez and abusive tweets has now reached the UK Parliament (see here). It’s a sad story and represents a dark undercurrent to the way some humans choose to communicate and act. Although clearly not in anyway the same league as the dreadful comments made to @ccriadoperez a number of recent twitter conversations have given me reason to reflect on what people say, and the context in which they do it.

Sir Bruce Keogh was recently quoted in the Daily Mail that the NHS should emulate the retail model of high street chains Dixons and PC World. This comment didn’t go down particularly well to some on twitter leading to a very interesting tweet from one of his clinical fellows

To some, the content of the Daily Mail needs to be taken with a pinch of salt. I suspect many were willing to the give the NHS Medical Director the benefit of the doubt.

But what about this example? Emergency Medicine in the UK has recently been described as being in crisis with a serious shortfall of trainees completing trainees leaving many rota unfilled.  I was amazed to find a headline in a scottish newspaper “Doctors avoiding hard work in A&E” [and it’s not because the papers still haven’t worked out it’s Emergency Medicine not A&E!]. The second paragraph reads,

The claim from David Caesar, clinical director for emergency medicine at NHS Lothian, that young life-savers are lazy has thrown the harsh working conditions they face again under the microscope.”

The bold is my emphasis, but the term rankled with many, see the comments, and lead me to say this.

A reasonable response was:

But my concern was how much was spin, versus some underlying truth.

Often the problem with twitter is the originator of a discussion isn’t on the discussion to defend themselves. The doctrine of  “be careful what you say” has been blogged, commented on, and researched numerous times over the last century. I am not covering new ground here but twitter has opened the ability to respond, in a public manner, in a striking way.

So I have paused to reflect to my response to this tweet. First I have no idea why I used “Alan” in my tweet. I don’t really know Alan, we have certainly never met him. Did calling him by his first name somehow balance the antagonistic nature of my response? And was my response antagonistic – I was not alone in my opinion…

To his credit Prof. Alan Maynard responded but I came back with:

In the cold light of day this is a harsher response than perhaps I had originally intended. I still posted it though, in the wake of a ‘storm’ about communication and trolling on the internet my reflex was to go straight for the jugular. I am fairly certain my actions do not constitute aggression or violate any law (and I note did immediately post a tweet saying this wasn’t directly aimed at Alan). This does not let me off the hook though. Could I have approached things in a different way – I am fairly sure I could. Could I have done so in 140 characters  though? (waiting for the research that the character limits encourages a more direct, and potentially more aggressive approach)

The abuse received by  @ccriadoperez was unacceptable but from a small minority of twitter uses. However maybe everyone should remember the words of Laurence J. Peter:

“Speak when you are angry – and you’ll make the best speech you’ll ever regret.”

The #FOAMed universe – normal laws of evaluation don’t work here

I try and write blogs which can be accessed by anyone, at anytime, with minimal prior knowledge. However in this case you probably do need a understanding of what #FOAM and it would be useful to also read @boringEM‘s thought provoking commentary on methods to evaluate #FOAMed sites. Essentially he proposes a number of metrics to evaluate, and potentially, rank #FOAMed resources. A number of tweets about this got me thinking of a potential conceptual challenge that may inhibit the debate:

I have spent the last three years looking at the evaluation of practice changing interventions, in particular educational ones, as part of my PhD (see summary here). Part of this involved an analysis of the term evaluation, which is different from assessment and effectiveness. One of the things that happens when medics start evaluating things is that they often apply the same measures to a variety of different environments. As soon as discussions started on judging #FOAMed content inevitable comparisons with the process of evaluating academic literature arose (some of my previous comments on this here). The problem with that is:

i) Not only are #FOAM sites, by definition, designed to share learning in an OPEN access fashion but

ii) The methodology of engagement with #FOAMed was always going to be different from that of an academic paper.

To set some context the naysayers and skeptics for #FOAMed have always stated there is no quality control of resources. How do you know if the content holds up to current evidence? What if the authors are not credible or has a conflict of interest? Well – think of the last journal you read? Did you go away and practice immediately what it told you? I am fairly sure you didn’t, probably for a variety of reasons, but ultimately because critical evaluation has been ingrained in most clinicians from early in their training. This criticism  is a particular bug-bear of mine and puts people off receiving information via Social Media (see here for previous thoughts). The lack of peer-review of #FOAM material makes it more vital that the reader is aware of potential error (if I was to change one think it would be a universal alert statement is placed on site highlighting this – this would also act as a very useful #FOAM brand) but the reader can still make their judgement. As an example this paper on Early Warning Scores in Emergency Departments has been a cited on a number of occasions but is neither peer reviewed or commissioned, ultimately it should have no more value than anything else lifeinthefastlane.com or St.Emlyn’s have produced. Why does being in a journal make it have more value?

But I suppose I digress slightly, what is different about the evaluation? Well academic literature is spread by publication in journals, promoted by citations and only recently  encouraged by social media. #FOAM has always been essentially reliant on word-of-mouth. The route to #FOAM is rarely discussed. Think of the last #FOAMed site you went to – why did you go there? Did you just find it? I suspect (and please comment and say I have got this wrong) it’s because it is from a source you already follow or someone has directed you there. And who was that person? My guess it is someone  you trust,  follow or is a leader in #FOAM. Not really sure how you define a leader in #FOAM but I stake trust in the sites that key #FOAM supporters recommend. So if @sandnsurf@emmanchester, @_nmay, @predordialthump, @boringem, @jvrbntz or @tessardavis mention a site I take a look. Others may have a completely different list – but it probably doesn’t matter who they are. There is a different form of peer review in process here – that of trusted followership.

Could there be mistakes in the process – well yes there could. But the process of academia and publication has not been risk free . So when it comes to evaluation the metric is at stake is the spread of information. The more recommendations leading to website hits being a proxy measure of word of mouth assessment of the perceived quality of site. Problems still exist if you want to be pedantic- hits to sites can be manipulated (but this can be controlled for) and the “quality”, in terms of readability and evidence, if you are determined to measure this as well has still not formally been assessed. But if you are evaluating  the primary purpose of FOAM then it is metrics like hits which have value. How this reflects the sharing ability of some of the FOAM leaders is open to question? This also prompts the question about what is the ultimate aim of #FOAM and whether it wishes to be constrained by old paradigms of evaluation or maybe create new ones.