Monday, May 30, 2011

You think Twitter serves no practical purpose except starting revolutions? Read on

This my first attempt at using Storify, a wonderful tool to create stories from various social media sites.

Resources mentioned here
1. Storify

Friday, May 27, 2011

Express yourself by typing a video!

There are many things about medicine that make us throw up our hands in frustration, bring tears to our eyes or rarely have us in splits.  A wonderful and easy way to share these is a simple tool call Go!Animate that is now available via YouTube.  You can create upto a 10 piece dialog for free.  This is generally adequate as it will make a 90-120 second video and anything longer will probably get boring.

How do you do this?

  1. Create a YouTube Account if you dont already have one
  2. Click on upload in the upper right corner
  3. Click on the Try Now link in the create your own animation box.
  4. Click on the Go!Animate button.

Here are 3 videos that I created.
The Adventures of Dr. Newbie:

The first 2 are now part of a series that most doctors can relate to.

Part 1
Part 2

The setting of the third one is a bit more obscure.

  • As online doctor rating sites are flourishing, doctors and making patients sign gag agreements that waive their rights to post comments about or rate the doctor on online sites.
  • Recently there was a big brouhaha in the blogosphere and Twitterverse about an anesthesiologist tweeting about a patient with priapism.  This is rich material for a workshop on Professionalism in the age of Social Media.

Give this a try.  Bring out the film director (or at least the script writer) in you!

Thursday, May 26, 2011

A workshop for medical students on Professionalism in the age of Social Media.

I have been asked to do a workshop for 3rd year medical students (just starting clinical years) on professionalism in the age of Social Media.  The recent brouhaha in the social media world gave me the material I was looking for this workshop (resources listed at bottom).  Unless you just got off the spaceship from Mars, you are aware of this story.

A very concise summary:

A physician posted on Twitter about a male patient's genital problem.
  • The physician is a female (Let us call her Doc T for twitter)
  • Doc T was writing under a Twitter handle that does not directly identify her.
  • Doc T does not identify the patient in the tweet
  • Doc T tweets that she feels sorry for the patient
  • Someone else (non-physician?) makes a sexually loaded comment 
  • Doc T responds to this person with a comment that could be interpreted as having sexual overtones.
  • All this seems to occur even before she sees the patient (my interpretation of the Twitter posts).
A very well known academic physician blogger (Let us call him Doc B for blogger) 

  • Posts the entire Twitter thread (5-6 posts) on his blog and comments about this being unprofessional.
  • His post includes the Twitter handle of the physician.  
  • This blog is very widely read and creates a flurry of comments where people take different sides.  

Plan for the workshop:

  • Have the students organize in small groups and present this case.
  • Each group will be assigned one of the following questions (bold).  They will be asked to discuss among themselves and report back to the main group.  
  • Hope they will not come back with a Black/White answer.  Hopefully they will raise more questions about each question.  Some of the sub-questions that might come up are listed below each main question.  
  • This should lead to a lively discussion and hopefully to a consensus that is close to the professional values of putting the interests of the patient before those of oneself.

These are the questions and sub-questions:

  1. Is it OK to post information about our patients in the public space 
    1. What if the patient consents to it?
    2. Why do you want to post patient information in the cloud?  Does it serve the patient's interest in anyway?  Does it serve the poster's personal interest? Does it serve societal interest?
    3. What if their is an educational value to this post - to help other physicians or patients?
    4. What if the patient is not identifiable? 
    5. What if the patient reads this and realizes this is him they are talking about?
    6. What if another patient of yours is a follower on Twitter?
    7. What if you are the patient, your physician makes a sexual comment in the context of this Twitter thread?
    8. What is the role of Institutional Review Boards?
  2. Is it all about HIPAA vs. the freedom of speech or are physicians held to a higher standard? What about our professional code and values?
    1. Will the professional values change because of Social Media? Or have they already?  Who decides?  Does anyone need to? 
    2. Do physicians have a responsibility to uphold the image of the physician community?
    3. When students enter the medical profession, they are asked to taken on the "burden" of wearing a white coat and all the responsibility that comes with this.  This can create a lot of stress for some students who feel they are living double lives.  Is this good?  Are we asking for too much?
    4. Should physicians just be who they are, in private and public, and let the patients and society accept them as such (or reject them).
    5. Can we ever succeed in getting all our physicians to go from TRYING to be professional to TRULY BECOMING professional and thus resolve the stress of dual identities?
  3. What do you think about people (professionals) posting anonymously?
    1. Have you heard of the Flea Incident? 
    2. Can you ever truly stay anonymous in this age?  
    3. Does posting anonymously lead to posting irresponsibly?
    4. Should physicians take the attitude that they are their online personality and they should be proud or comfortable of what is attached to that personality?
    5. Should readers take the attitude that "I don't care who you are but if what your write is good, I will read it"?
    6. Are there instances where posting anonymously is the best or only option? 
  4. Did Dr. B do the right thing?
    1. Should Dr. B have sent a direct message to Dr. T instead of posting it on his blog?
    2. Should Dr. B have hidden the Twitter handle of Dr. T when posting on his blog?
    3. Did it matter that Dr. T was using a Twitter handle and not her real name?
    4. Will the intense flurry of discussions and chats and comments help improve the level of professionalism? 
  5. Is it OK to use humor when Blogging and Tweeting?
    1. What if there is potential for misinterpretation?
    2. What is the risk for this when blogging vs. Tweeting?
    3. What is the difference between laughing at incidents vs. laughing at patients?

#MDChat transcript - a twitter group discussion on this topic -

Sunday, May 22, 2011

Putting the Pedagogy horse before the Education cart- a collaborative exercise for EdTech learners.

One of the problems with simple and attractive technology is that educators may jump in and start creating content before thinking about the pedagogical aspects.  This leads to the use of a technology in education because it is there instead of because it is the right tool to facilitate learning.

I was struggling to find a way to reinforce this concept for a workshop on Education Technology.  I thought of this collaborative exercise using Linoit.  Linoit is a dynamic online sticky note tool with a simple interface. Another similar tool is Wallwisher.  The two are very similar and this YouTube video does a nice job comparing the two.

If the participants will have access to the online Linoit site during the workshop, then follow these steps.  Otherwise, the facilitator will be doing all the note creation live based on feedback from the class.


  1. Create an account on Linoit.
  2. Create a new canvas
  3. Set up the preferences to allow anyone to post stickies
  4. Uncheck the box to list this as a Public Canvas
  5. You can create a short URL for the canvas and share with the class (
  6. If you like you can review a basic Linoit tutorial on YouTube.
  7. There is also a nice short document for some ideas and tips regarding setting this up the preferences in different ways and tracking who posted the stickies.
Instructions to the participants:
  1. You could share with them the same basic Linoit video but starting at 3 min 15 sec so they know how to create a sticky note.
  2. Ideally send this by e-mail prior to the workshop so they can click the link and review it before hand.
During the Workshop:
  1. Share the URL for your canvas with the participants
  2. In a large group discussion ask what the various steps for using technology in education should be. As participants make suggestions, create a sticky for each one.  Then lead a discussion on developing consensus on these steps and ordering them.  Once consensus is reached, pin these notes in place. 
  3. Now ask each participant (or pairs) to create stickies related to any of the steps.  The stickies will be signed as guest (so they are anonymous)
  4. Once everyone is done, lead a large group discussion on organizing the various stikcies under the appropriate steps.
  5. You could end up with something that looks like this.  Feel free to add more ideas if you want and place them under the appropriate step. 
  6. Remember this is about a collaborative exercise and not necessarily the final product.  The learning happens in the process and not in looking at the end product. 
You can go to the full screen canvas by clicking the link below (Not fully compatible with IE)
Steps For Creating eLearning
Play right here
  • Hover over the blue "Steps for creating ..." bar to get a sticky.
  • Drag an empty portion of the canvas around to navigate.

Friday, May 20, 2011

Family History, Genomics and Proteomics - What I learned this week.

This was an interesting week, first we had a department grand rounds on Personalized Healthcare including a demonstration of the right way to take a Family history and then we had a Medical Informatics grand rounds on Practical Proteomics.

Some take home points and highlights from this week:
  1. Lynch Syndrome is relatively common and very much underdiagnosed. 
  2. "Old" docs can still learn new tricks on how to take a good family history!
  3. Doing this the right way (see below) could significantly impact our patients' lives
  4. The lab mouse and humans have the same number of genes.  The complexity of the phenotype is determined not by the genes but the proteins these genes code for. 
  5. Thus our Genome is just a script but the proteome is the actor that makes or breaks the show.
So "What is this about the right way to take a family history"?

A routine patient interview could go something like this:
Dr. Jomes: Ms Smith, lets talk about any family history of medical problems.  Did anyone in your family have any cancers?
Ms. Smith: Oh yes, my dad had colon cancer and my aunt had breast cancer. 
Dr. Jones:  Is that your paternal aunt?
Ms. Smith: No that was my mom's sister. 
Dr. Jones:  I see.  Ok any other cancers like that of the ovary or uterus or lung?
Ms. Smith:  Not that I know of.
And then Dr. Jones would go on to cover other conditions like Diabetes, CAD etc.

The summary note would something like this:
Pt with family h/o colon ca in father and breast ca in aunt.

You can see the process is quite haphazard and focuses on conditions rather than the family tree and could easily miss early deaths, critical conditions and does not give an overall picture that can help give us clues to heritable conditions.

So what should the ideal process look like?

Dr. Jones: So Ms. Smith, lets talk about your family history.  Do you have any brothers or sisters?
Ms Smith:  Yes, I have a brother who is 45
Dr. Jones:  And does he have any medical concerns?
Ms. Smith:  No he is doing well.
Dr. Jones:  Do you have any children? 
Ms. Smith: Yes, a son, he is 14 and a daughter she is 12 and they are well.
Dr. Jones:  Good.  Does your brother have any children?
Ms. Smith:  Yes he has 2 sons and they are well.
Dr. Jones:  Now tell me about your parents
Ms. Smith:  My dad is 65 and he had colon cancer and my mom is 62 and she has high blood pressure and high cholesterol. 
Dr. Jones:  Tell me about your father's side of the family.  Does he have brothers or sisters?
After completing the father's side, Dr. Jones would probe into the mother's side of the family.  The key difference is asking about sibs, children and parents and then asking about their health; and probing on one side of the family and then moving to the other side.
Ideally, Dr. Jones would be creating a family tree as he goes along.

This is an example of what it could look like in a family with Lynch syndrome (Hereditary non-polyposis colorectal cancer):
(From David G. Jagelman Inherited Colo-rectal Cancer Registries at the Cleveland Clinic)

What should lead one to suspect this syndrome?
There are well defined Amsterdam criteria which require early onset of colon cancer, successive generations with colon cancer and multiple family members with colon cancer. A simple intervention like creating a family tree can help lead to diagnosing this with genetic testing and could impact the lives of multiple members of the family.

So what are the barriers?
  1. Time:  It could take a good 10-15 minutes to create a simple family tree and longer for large families with multiple conditions.  In the context of the 15-20 minute office visits this is challenging.
  2. Lack of specific electronic tools that support doing this within the EHR
  3. Patients often may not know details of their family members' medical history.
  4. Family members may not want to divulge their medical details.
Potential solutions:
Patients should create family trees before their office visit using some simple genealogy tools like Geni.  They could then print out the family tree and write in what they know of the medical histories of their family.
A tool that could be used for this on a handheld device like an Android tablet or an iPad would also be very helpful.  Patients could use this in the waiting room.  There should be a way of importing this into the EHR.

Thursday, May 19, 2011

Making a case for importance of clinical skills - PollEverywhere + Human Histogram

Setting:A course for Educators in the Health Professions.
Some of the audience was international and some did not have a clinical background.
There were about 75 people in the audience.

I was trying to make a case for the importance of clinical skills in helping make the correct diagnosis - this was to be done in about 10 min before moving on to some tools to help teach clinical skills. What would be the best way to make a convincing case while engaging the audience?

This is what I came up with:
Step 1. 
Do a poll asking the audience
"What percentage of cases in an ambulatory practice can be correctly diagnosed with a good medical interview and physical examination?"
Here are the results of the poll (done on

Create your own sms poll at Poll Everywhere

Step 2. 
Provide some references that show that the correct answer is 70-80%.

Step 3. 
Do a Human Histogram - I learned this simple but very effective tool from Ken Locke a clinican educator from Toronto - he used this at a recent Society of General Internal Medicine workshop.  The following slides show how I used it.  FIRST ASK EVERYONE TO STAND UP.  (make a wisecrack about this being "active" learning")
Everyone stayed standing

2-3 people sat down

Almost everyone sat down

I asked the audience to interpret what they had just observed.  There was no doubt in anyone's mind how one or two critical bits of information can help confirm a diagnosis and rule out another.  They also saw how medical interviewing is a very dynamic process of deductive reasoning and how the physician is constantly matching the story with patterns of disease and looking for pieces to complete the jigsaw puzzle.  This is very different from the checklist approach of history of present illness, review of symptoms etc. that we teach our medical students. 
This helped set the stage for discussing various options for making sure our medical trainees get to learn this deductive approach.

Looking back I was struck by how using a web-based polling system where the audience submitted their responses using laptops, smartphones and SMS and combining it with a simple classroom technique of the Human Histogram worked out so well. 

In case you are wondering, Poll Everywhere is a free tool for limited audience sizes and has some great features for submission of responses via web, sms, twitter, and for starting and stopping the poll, clearing results and sharing the data.  You can also embed the poll on a blog and share results with the readers.

Monday, May 9, 2011

Reflections on "Why do I blog?"

Fresh from a very invigorating SGIM (Society of General Internal Medicine) meeting, waiting at the Phoenix airport for my flight back gave me some time to reflect.

One of the workshops some colleagues and I have conducted for the past 2 sessions is on "Web 2.0 in Medical Education".  We try to do some needs assessment prior to the workshop and there has generally been more interest in learning about Wikis (as opposed to blogs).  This year this trend continued but I was struck by how many people approached me for help in setting up their first blog.  These are very bright, thoughtful, creative physicians and educators and thought leaders who have been prolific writers in the print literature.  But somehow have been hesitant to take the plunge into the blogosphere.

As I helped them create their Google accounts and create their first blog I could sense their excitement and got me wondering what their reason was for blogging.

After I had helped then get started, that evening lying on my hotel bed I wondered, "Why do I blog?"  I know I got started as a matter of curiosity, to understand what a blog is and to explore how it could be useful in education.  I have now been blogging for many years.  It has somehow become a self-sustaining activity.  So what keeps me going?

  1. Reflection:  I find that as I force myself to write, I get more clarity in my thoughts.  I often realize a new meaning for a subject or topic that I had understood more superficially.  Often when I go back and read an old post, I am surprised to see how clearly I had understood something even for a brief window of time.  
  2. It is a great way to share my thoughts.  More and more frequently, when asked a question about technology or just during a discussion, I find myself saying, "I blogged on that" and then getting asked to share a hyperlink to the blog post.
  3. It serves as a portfolio for an area of expertise that does not have degrees or diplomas. It says in a unique manner that I am constantly trying to learn and apply what I learn.
  4. While somewhat scary, it has been very instructive to open myself up to anonymous comments by posting on the web.  People are not generally "mean" and when I have been "attacked" it is because I had unknowingly offended someone or some group.  Reading the comments has helped me to understand another view point and learn more.  While these are not fun interactions, looking back I can honestly say, they were very educational.  
  5. I don't think I blog because it helps me write.  I don't know if I am writing any better now then when I started.  I don't think I blog because I have a thousand followers who need a daily dose of my writing.  It is definitely not a revenue source.  
  6. I think one key reason why I blog is because it has become a habit.  When I get a new idea or read something that interests me and I explore it further and discover a new personal meaning about that something, I automatically turn to my blog to write it down before I lose that meaning or idea.  
  7. Most of all, I enjoy blogging, it is fun and it is not a chore.  I do it for myself as writing it and reading it helps me learn something about my thoughts, it gives me an insight into myself, it is like meditating.